Effect of Triage-Based Application of the Ottawa Foot and Ankle Rules on Treatment in an Emergency Department: A Pilot Study

Date of Award


Degree Type


Degree Name

Master of Science (MS)

First Advisor

Fred Goldstein PhD, FCP

Second Advisor

Marna Greenberg DO, MPH

Third Advisor

Bryan Kane MD, FACEP

Fourth Advisor

Richard Pascucci DO, FACOI


Context: Reducing unnecessary testing is required to lessen the cost burden of medical care but decreasing utilization will depend on consistently following evidence-based clinical decision rules. The Ottawa Foot and Ankle Rules (OFAR) are evidence-based clinical decision rules employed to predict fractures. Frequently, radiographs are automatically ordered for acute ankle injuries despite OFAR exam findings suggesting no fracture. This clinical investigation was designed to assess (1) baseline OFAR use before radiographs were ordered and (2) length of stay (LOS). Then, after intervention (OFAR education), there was an assessment of utilization of radiographs and LOS. In addition, patient expectations and satisfaction regarding x-ray utilization was evaluated as well as the documentation of the OFAR.

Methods: A prospective, two-stage sequential designed pilot study was implemented using a before and after model. Triage nurses and emergency medicine providers (advanced practicing clinicians, residents and attending physicians) performed their usual practice procedures for radiograph use in the first arm. In the second arm these health providers subsequently were educated to apply appropriately the OFAR before ordering a radiograph. Subjects who were OFAR positive at triage had radiographs ordered by nursing staff. Those who were OFAR negative at triage were assessed by the provider and had the OFAR applied again. Radiographs were ordered at the discretion of the provider. LOS was monitored for all patients. All subjects and providers were surveyed regarding their expectations and satisfaction.

Results: Sixty-two patients were consented and enrolled in the study. Two withdrew prematurely (which excluded them from analysis), leaving 30 subjects in each arm. Fifty-eight of the 60 patients were radiographed (97%) and 51 (85%) responded that they expected a radio graph. ED LOS decreased from 103 minutes to 96.5 minutes (p=0.297) for all patients after OFAR was applied. There was also a decrease in LOS in the sub-group of patients with a fracture (137 minutes versus 103 minutes [p=0.112]). Patients were equally satisfied amongst the groups (90%) with no difference between arms and 95% of emergency medicine providers felt subjects were satisfied with their treatment. OFAR documentation for nurses increased from 3% to 7% (p=0.29) after education. Documentation from emergency medicine providers increased from 20% to 83% (p<0.0001) after OFAR education.

Conclusions: There was no statistical evidence that application of OFAR decreased the number of radiographs ordered or LOS. This suggests that even when providers are being observed and instructed to use decision rules, their evaluation bias tends toward assessments that result in testing. The application of OFAR does not appear to alter patient expectations or satisfaction. Basic education regarding documentation does appear to alter physician's habits regarding clinical decision rule documentation but not that of the nursing staff.

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