IMPLEMENTATION OF THE OTTAWA ANKLE RULES

Objective.-To assess the impact on clinical practice of implementing t he Ottawa ankle rules. Design.-Nonrandomized, controlled trial with be fore-after and concurrent controls. Setting.-Emergency departments of a university (intervention) hospital and a community (control) hospita l. Patients.-All 2342 adults seen with acute ankle injuries during 5-m onth periods before and after the intervention. Intervention.-The impl ementation of the Ottawa ankle rules by emergency department physician s. Main Outcome Measure.-Proportions of patients referred for standard ankle and foot radiographic series. Results.-There was a relative red uction in ankle radiography by 28% at the intervention hospital but an increase by 2% at the control hospital (P<.001). Foot radiography was reduced by 14% at the intervention hospital but increased by 13% at t he control hospital (P<.05). Compared with nonfracture patients who ha d radiography during the after period at the intervention hospital, th ose discharged without radiography spent less time in the emergency de partment (80 minutes vs 116 minutes; P<.0001), had lower estimated tot al medical costs for physician visits and radiography ($62 vs $173; P< .001), but did not differ in the proportion satisfied with emergency p hysician care (95% vs 96%) or undergoing subsequent radiography (5% vs 5%). The rules were found to have sensitivities of 1.0 (95% confidenc e interval [Cl], 0.95 to 1.0) for detecting 74 malleolar fractures and 1.0 (95% Cl, 0.82 to 1.0) for detecting 19 midfoot fractures. In the following 12 months at the intervention hospital, use of radiography d id not increase. Conclusions.-Implementation of the Ottawa ankle rules led to a decrease in use of ankle radiography, waiting times, and cos ts without patient dissatisfaction or missed fractures. Future studies should address the generalizability of these decision rules in a vari ety of hospital settings.