Skip to main content
×
×
Home

Accuracy of the Ottawa Ankle Rules applied by non-physician providers in a pediatric emergency department

  • Joe MacLellan (a1) (a2) (a3), Teya Smith (a4), Jason Baserman (a3) and Shawn Dowling (a2)
Abstract
Objective

The Ottawa Ankle Rules (OAR) are a clinical decision tool used to minimize unnecessary radiographs in ankle and foot injuries. The OAR are a reliable tool to exclude fractures in children over 5 years of age when applied by physicians. Limited data support its use by other health care workers in children. Our objective was to determine the accuracy of the OAR when applied by non-physician providers (NPP).

Methods

Children aged 5 to 17 years presenting with an acute ankle or foot injury were enrolled. Phase 1 captured baseline data on x-ray use in 106 patients. NPPs were then educated on the usage of the OAR and completed an OAR learning module. In phase 2, NPPs applied the OAR to 184 included patients.

Results

The sensitivity of the foot rule, as applied by NPP’s, was 100% (56-100% CI) and the specificity was 17% (9-29% CI) for clinically significant fractures. The sensitivity of the ankle portion of the rule, as applied by NPP’s, was 88% (47-99 CI) and the specificity was 31% (23-40% CI) for clinically significant fractures. The only clinically significant fracture missed by NPP’s was detected on physician assessment. Inter-observer agreement was κ=0.24 for the ankle rule and κ=0.49 for the foot rule.

Conclusion

The sensitivity of the OAR when applied by NPP’s was very good. More training and practice using the OAR would likely improve NPP’s inter-observer reliability. Our data suggest the OAR may be a useful tool for NPP’s to apply prior to physician assessment.

Objectif

La Règle d’Ottawa pour la cheville (ROC) est un outil de décision clinique visant à réduire le nombre de radiographies inutiles dans les cas de blessures au pied ou à la cheville. Il s’agit d’un outil digne de confiance pour exclure les fractures chez les enfants de plus de 5 ans lorsqu’il est appliqué par les médecins. Il existe toutefois peu de données étayant son utilisation par d’autres catégories de professionnels de la santé chez les enfants. L’étude visait donc à déterminer l’exactitude de la ROC lorsque celle-ci est appliquée par des fournisseurs de soins non médicaux (FSNM).

Méthode

Ont participé à l’étude des enfants de 5 à 17 ans qui sont allés au service des urgences pour la survenue de blessures au pied ou à la cheville. À la phase I, on a recueilli des données de base sur le recours à la radiographie chez 106 patients. Par la suite, les FSNM ont reçu une formation sur l’application de la ROC, complétée par un module d’apprentissage. À la phase II, les FSNM ont appliqué la ROC chez 184 patients.

Résultats

La sensibilité de la règle relative au pied, telle qu’elle a été appliquée par les FSNM, était de 100 % (IC : 56-100 %) et la spécificité, de 17 % (IC : 9-29 %) pour les fractures importantes sur le plan clinique. Quant à la sensibilité de la règle relative à la cheville, telle qu’elle a été appliquée par les FSNM, elle était de 88 % (IC : 47-99) et la spécificité, de 31 % (IC : 23-40 %) pour les fractures importantes sur le plan clinique. La seule fracture importante sur le plan clinique qui a échappé aux FSNM a été décelée à l’examen médical. La fiabilité interévaluateurs (κ) était égale à 0,24 pour la partie de la règle concernant la cheville, et égale à 0,49 pour celle concernant le pied.

Conclusion

La sensibilité de la ROC, lorsqu’elle était appliquée par les FSNM, était très bonne. Toutefois, une formation approfondie sur l’application de la ROC et une pratique accrue de celle-ci permettraient sans doute d’améliorer la fiabilité interévaluateurs parmi les FSNM. Enfin, les résultats de l’étude donnent à penser que la ROC serait un outil utile aux FSNM avant l’examen médical.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Accuracy of the Ottawa Ankle Rules applied by non-physician providers in a pediatric emergency department
      Available formats
      ×
      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Accuracy of the Ottawa Ankle Rules applied by non-physician providers in a pediatric emergency department
      Available formats
      ×
      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Accuracy of the Ottawa Ankle Rules applied by non-physician providers in a pediatric emergency department
      Available formats
      ×
Copyright
Corresponding author
Correspondence to: Dr. Shawn Dowling, Department of Emergency Medicine, Rockyview General Hospital–Holy Cross Ambulatory Care Centre, 7007 14th Street SW, 5th Floor, Room 5A105, Calgary, Alberta T2V 1P9; Email: skdowling@gmail.com
References
Hide All
1. Conrad, EU, Rang, MC. Fractures and sprains. Pediatr Clin North Am 1986;33(6):1523-1540.
2. Boutis, K, Plint, A, Stimec, J, et al. Radiograph-negative lateral ankle injuries in children: occult growth plate fracture or sprain? JAMA Pediatrics 2016;170(1):e154114.
3. Boutis, K, Komar, L, Jaramillo, D, et al. Sensitivity of a clinical examination to predict need for radiography in children with ankle injuries: a prospective study. Lancet 2001;358(9299):2118-2121.
4. Al Omar, MZ, Baldwin, GA. Reappraisal of use of x-rays in childhood ankle and midfoot injuries. Emerg Radiol 2002;9(2):88-92.
5. Cockshott, WP, Jenkin, JK, Pui, M. Limiting the use of routine radiography for acute ankle injuries. Can Med Assoc J 1983;129(2):129-131.
6. Gleadhill, DN, Thomson, JY, Simms, P. Can more efficient use be made of x ray examinations in the accident and emergency department?. Br Med J (Clin Res Ed) 1987;294(6577):943-947.
7. Stiell, IG, Greenberg, GH, McKnight, RD, et al. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA 1993;269:1127-1132.
8. Anis, AH, Stiell, IG, Stewart, DG, Laupacis, A. Cost-effectiveness analysis of the Ottawa Ankle Rules. Ann Emerg Med 1995;26(4):422-428.
9. Fan, J, Woolfrey, K. The effect of triage-applied Ottawa Ankle Rules on the length of stay in a Canadian urgent care department: a randomized controlled trial. Acad Emerg Med 2006;13(2):153-157.
10. Dohin, B, Lubanziado, D. Validation of the Ottawa Ankle Rules for varus ankle trauma in children: A prospective study of 160 cases. 2004. J Bone Joint Surg–British Volume 2002;86(Supp 20).
11. Plint, AC, Bulloch, B, Osmond, MH, et al. Validation of the Ottawa Ankle Rules in children with ankle injuries. Acad Emerg Med 1999;6(10):1005-1009.
12. Libetta, C, Burke, D, Brennan, P, Yassa, J. Validation of the Ottawa ankle rules in children. J Accid Emerg Med 1999;16(5):342-344.
13. Auleley, GR, Kerboull, L, Durieux, P, et al. Validation of the Ottawa ankle rules in France: a study in the surgical emergency department of a teaching hospital. Ann Emerg Med 1998;32(1):14-18.
14. Yuen, MC, Sim, SW, Lam, HS, Tung, WK. Validation of the Ottawa ankle rules in a Hong Kong ED. Am J Emerg Med 2001;19(5):429-432.
15. Springer, BA, Arciero, RA, Tenuta, JJ, Taylor, DC. A prospective study of modified Ottawa ankle rules in a military population. Interobserver agreement between physical therapists and orthopaedic surgeons. Am J Sports Med 2000;28(6):864-868.
16. Dowling, S, Spooner, CH, Liang, Y, et al. Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: a meta-analysis. Acad Emerg Med 2009;16(4):277-287.
17. Gravel, J, Hedrei, P, Grimard, G, Gouin, S. Prospective validation and head-to-head comparison of 3 ankle rules in a pediatric population. Ann Emerg Med 2009;54(4):534-540; e1.
18. Lau, LH, Kerr, D, Law, I. Nurse practitioners treating ankle and foot injuries using the Ottawa Ankle Rules: A comparative study in the emergency department. Australas Emerg Nurs J 2013;16:110-115.
19. Meena, S, Gangary, SK. Validation of the Ottawa Ankle Rules in Indian Scenario. Arch Trauma Res 2015;4(2):e20969.
20. Dowling, S, Wishart, I. Use of the Ottawa Ankle Rules in the Pediatric Population: A Survey of Physician Practice. CAEP. Ottawa: Poster Presentation; 2008.
21. Allerston, J, Justham, D. Nurse practitioners and the Ottawa Ankle Rules: comparisons with medical staff in requesting X-rays for ankle injured patients. Accid Emerg Nurs 2000;8(2):110-115.
22. Derksen, RJ, Bakker, FC, Geervliet, PC, et al. Diagnostic accuracy and reproducibility in the interpretation of Ottawa ankle and foot rules by specialized emergency nurses. Am J Emerg Med 2005;23(6):725-729.
23. Fiesseler, F, Szucs, P, Kec, R, Richman, PB. Can nurses appropriately interpret the Ottawa Ankle Rule? Am J Emerg Med 2004;22(3):145-148.
24. Salt, P, Clancy, M. Implementation of the Ottawa Ankle Rules by nurses working in an accident and emergency department. J Accid Emerg Med 1997;14(6):363-365.
25. Scheaffer, RL, Mendenhall, W, Ott, L. Elementary survey sampling. Duxbury Press; 1979.
26. Karpas, A, Hennes, H, Walsh-Kelly, CM. Utilization of the Ottawa ankle rules by nurses in a pediatric emergency department. Acad Emerg Med 2002;9(2):130-133.
27. Rowe, BH, Willa-Roel, C, Guo, X, et al. The role of triage nurse ordering on mitigating overcrowding in emergency departments: a systematic review. J Accid Emerg Med 1998;15(5):315-316.
28. Brehaut, JC, Stiell, IG, Visentin, L, Graham, ID. Clinical decision rules “in the real world”: How a widely disseminated rule is used in everyday practice. Acad Emerg Med 2005;12(10):948-957.
29. Gravel, J, Roy, M, Carrière, B. 44-55-66-PM, a mnemonic that improves retention of the Ottawa Ankle and Foot Rules: a randomized controlled trial. Acad Emerg Med 2010;17(8):859-864.
30. Stiell, IG, McKnight, RD, Greenberg, GH, et al. Implementation of the Ottawa Ankle Rules. JAMA 1994;271(11):827-832.
31. Silveira, PC, Ip, IK, Sumption, S, et al. Impact of a clinical decision support tool on adherence to the Ottawa Ankle Rules. Am J Emerg Med 2016;34(3):412-418.
32. Ho, JK, Chau, JP, Cheung, NM. Effectiveness of emergency nurses’ use of the Ottawa Ankle Rules to initiate radiographic tests on improving healthcare outcomes for patients with ankle injuries: A systematic review. Int J Nurs Stud 2016;63:37-47.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Canadian Journal of Emergency Medicine
  • ISSN: -
  • EISSN: 1481-8035
  • URL: /core/journals/canadian-journal-of-emergency-medicine
Please enter your name
Please enter a valid email address
Who would you like to send this to? *
×

Keywords

Type Description Title
WORD
Supplementary materials

MacLellan et al supplementary material 1
Appendices

 Word (226 KB)
226 KB

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed