Assessing Compliance With Ottawa Foot and Ankle Rules in the Emergency Department: A Closed-Loop Quality Improvement Project

Introduction Traumatic foot and ankle injuries are frequent presentations to the emergency department (ED). The Ottawa Foot and Ankle (F&A) Rules are to help clinicians in decision making whether an X-ray of the foot or ankle is justified. Methods A retrospective analysis of ankle and foot X-ray requests from a South London Hospital ED was performed. Consecutive requests for both foot and ankle X-rays were assessed chronologically until n=100 for each cohort. The clinical documentation of each ED clerking and the X-ray request clinical details were then compared to the Ottawa Rules of that respective request. The presence of a midfoot or ankle fracture was recorded. Several interventions were implemented to improve compliance; this included distributing the results of the first audit cycle and a handout containing the Ottawa F&A rules to ED staff. A teaching session for ED Junior Doctors on assessing, documenting, and requesting X-rays for foot and ankle injuries was delivered within the department. An identical second retrospective audit cycle for both ankle and foot X-rays was then completed three weeks after implementation of the above interventions. Results The compliance of Ottawa Foot Rules in documenting foot injuries significantly improved from 48% to 78% (p<.001). Foot X-ray request compliance significantly improved from 32% to 54% (p<.01). Documentation compliance of ankle injuries significantly improved from 74% to 87% (p<.05). Ankle injury X-ray request compliance improved from 43% to 57% (p<.05). Fracture rate did not significantly change; ankle fractures increased from 17% to 22% (p=.372), foot fracture rate remained 15% in both cycles. Significance was assessed using the Chi-square test throughout. Conclusion This two-cycle Quality Improvement Project demonstrated significant improvement in compliance with Ottawa F&A Rules for ED clerking documentation and X-ray request clinical details in a South London Hospital. Compliance with Ottawa F&A Rules has the potential to reduce costs, facilitate faster discharge, and reduce unnecessary radiation exposure.