A multifaceted strategy for implementation of the Ottawa ankle rules in two emergency departments

EDITOR - Bessen et al should be congratulated on their successful
efforts to reduce unnecessary ankle radiographs in acute ankle injuries.
It should, however, be noted that from reading the description of their
methods it clearly took an enormous amount of time, effort and
organization by many people to achieve this. What they have not
demonstrated, as they readily admit, is any benefit to cost, length of
stay or patient satisfaction.(Ref 1)

While the Ottawa ankle rules will always have their sceptics, the
evidence in their favour is compelling. Since their conception and
introduction 25 years ago their high sensitivity (almost 100%) and ability
to reduce unnecessary radiography by up to 40% has been demonstrated
clearly (Ref 2,3,4,5). Given the strength of this evidence, why are they
not being used? There is no simple answer.

While I agree wholeheartedly with the reduction of unnecessary
investigations, this is on the assumption that doing so will save
resources. If the resources required to promote the use of the Ottawa
ankle rules prove greater than the saving from the reduction in
radiography, is it worth it? We need to find a simpler way to ensure their
use.

Competing Interests: None

References:
1: Taryn Bessen, Robyn Clark, Sepehr Shakib, and Geoffrey Hughes. A
multifaceted strategy for implementation of the Ottawa ankle rules in two
emergency departments
BMJ 2009; 339: b3056

2: Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I,
Worthington JR. A study to develop clinical decision rules for the use of
radiography in acute ankle injuries.
Ann Emerg Med. 1992 Apr;21(4):384-90

3: Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Reardon
M, Stewart JP, Maloney J. Decision rules for the use of radiography in
acute ankle injuries. Refinement and prospective validation. JAMA. 1993
Mar 3;269(9):1127-32

4: Stiell IG, McKnight RD, Greenberg GH, McDowell I, Nair RC, Wells
GA, Johns C, Worthington JR. Implementation of the Ottawa ankle rules.
JAMA. 1994 Mar 16;271(11):827-32

5: Lucas M Bachmann, Esther Kolb, Michael T Koller, Johann Steurer,
and Gerben ter Riet. Accuracy of Ottawa ankle rules to exclude fractures
of the ankle and mid-foot: systematic review. BMJ Feb 2003; 326: 417

Competing interests:
None declared