Review
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

https://doi.org/10.1016/j.ijnurstu.2016.08.016Get rights and content

Abstract

Background

The Ottawa Ankle Rules provide guidelines for clinicians on the recommendation of radiographic tests to verify fractures in patients with ankle injuries. The use of the Ottawa Ankle Rules by emergency nurses has been suggested to minimise unnecessary radiographic-test requests and reduce patients’ length of stay in emergency departments. However, the findings of studies in this area are inconsistent.

Design

A systematic review was conducted to synthesise the most accurate evidence available on the extent to which emergency nurses’ use of the Ottawa Ankle Rules to initiate radiographic tests improves healthcare outcomes for patients with ankle injuries.

Data sources

The systematic review attempted to identify all relevant published and unpublished studies in English and Chinese from databases such as Ovid MEDLINE, EMBASE, ProQuest Health and Medical Complete, EBM Reviews, SPORTDiscus, CINAHL Plus, the British Nursing Index, Scopus, the Chinese Biomedical Literature Database, China Journal Net, WanFang Data, the National Central Library Periodical Literature System, HyRead, the Digital Dissertation Consortium, MedNar and Google Scholar.

Review methods

Two reviewers independently assessed the eligibility of all of the studies identified during the search, based on their titles and abstracts. If a study met the criteria for inclusion, or inconclusive information was available in its title and abstract, the full text was retrieved for further analysis. The methodological quality of all of the eligible studies was assessed independently by the two reviewers.

Results

The search of databases and other sources yielded 1603 records. The eligibility of 17 full-text articles was assessed, and nine studies met the inclusion criteria. All nine studies were subjected to narrative analysis, and five were meta-analysed. All of the studies investigated the use of the refined Ottawa Ankle Rules. The results indicated that emergency nurses’ use of the refined Ottawa Ankle Rules minimised unnecessary radiographic-test requests and reduced patients’ length of stay in emergency departments. However, the use of these rules in urgent-care departments did not reduce unnecessary radiographic-test requests or patients’ length of stay. The implementation of the refined Ottawa Ankle Rules by emergency nurses with different backgrounds, including nurse practitioners or general emergency nurses was found to reduce patients’ length of stay in emergency departments.

Conclusions

The results of the systematic review suggested that a nurse-initiated radiographic test protocol should be introduced as standard practice in emergency departments.

Section snippets

What is already known about the topic?

  • It is difficult to distinguish an ankle strain or sprain from a fracture without radiographic assistance so that radiographic tests are requested for most patients with ankle injuries, although only a small proportion of these patients have actually sustained fractures.

  • The Ottawa Ankle Rules provide guidelines for clinicians on the recommendation of radiographic tests to verify fractures in patients with ankle injuries.

  • The implementation of the Ottawa Ankle Rules by emergency nurses has been

What this paper adds

  • The implementation of the refined Ottawa Ankle Rules by emergency nurses was found to minimise unnecessary radiographic-test requests and reduce patients length of stay in emergency departments, but did not reduce unnecessary radiographic-test requests or patients length of stay in an urgent-care department.

  • The implementation of the refined Ottawa Ankle Rules by emergency nurses with different backgrounds, including nurse practitioners and general emergency nurses was found to reduce patients

Background

Ankle injuries are common among emergency-department patients. Approximately 15% of 117 million emergency-department patients in the United States report lower-extremity injuries (Niska et al., 2010). The ankle is the second most common area of lower-extremity injury (20%), and the most common types of ankle injury are strain and sprain (72%) (Lambers et al., 2012). It is difficult to distinguish an ankle strain or sprain from a fracture without radiographic assistance (Singh-Ranger and

Aim

The aim of the systematic review was to synthesise the most accurate information available on the extent to which emergency nurses’ use of the OARs to initiate radiographic tests improves healthcare outcomes for patients with ankle injuries.

Design

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist was used to identify essential components of the review.

Eligibility criteria

The participants of interest were patients (≥1 year old) who visited emergency or urgent care departments to obtain

Retrieval and selection of studies

The processes of retrieving and selecting the studies are depicted in Fig. 1. A search of databases and other sources yielded 1603 records, with 1584 in English and 19 in Chinese. After removing duplicates, 1406 records were screened. The eligibility of 17 full-text articles was assessed, and nine were found to meet the inclusion criteria. Eight full-text articles were excluded because of irrelevant types of participants, interventions, outcome measures, or studies. All nine studies were

Radiographic-test requests

Pooled analysis of the results reported by Allerston and Justham (2000b), Lee et al. (in press) and Mann et al. (1998) implies that the use of the OARs by emergency nurses can minimise the proportion of radiographic-test requests in emergency departments. Similarly, the results reported by Gwilym et al. (2003) imply that the use of the OARs by medical and nursing staff minimises the proportion of radiographic-test requests in emergency departments.

Lau et al. (2013) and Salt and Clancy (1997)

Conclusions

This systematic review summarises the best available evidence of the extent to which emergency nurses’ use of the OARs to initiate radiographic tests improves the healthcare outcomes for patients with ankle injuries. The implementation of the refined OARs by emergency nurses was found to minimise unnecessary radiographic-test requests and reduce patients’ length of stay in emergency departments, but did not reduce unnecessary radiographic-test requests or patients’ length of stay in an

Conflicts of interest

None declared.

Sources of funding

None declared.

Ethical approval

None.

References (26)

  • S. Dowling et al.

    Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: a meta-analysis

    Acad. Emerg. Med.

    (2009)
  • J. Fan et al.

    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)
  • S.E. Gwilym et al.

    The impact of implementing the Ottawa Ankle Rules on ankle radiography requests in A & E

    Int. J. Clin. Pract.

    (2003)
  • Cited by (16)

    • Effect of triage nurse-led application of the ottawa ankle rules on pain and patient satisfaction with emergency department care

      2020, Clinical Epidemiology and Global Health
      Citation Excerpt :

      One of the effective strategies that have been used to improve patient outcomes in the ED and other clinical settings is the implementation of standing orders that can be utilized by nurses and other health providers. In the ED, this has been found to be cost effective and reduces patients’ length of stay.5,6 Nurses working in the ED provide a unique and reliable resource that can be used to improve the quality of ED care through implementation of standing orders or protocols for acute conditions commonly seen in the ED such as ankle injury, chest pain, abdominal pain and others.

    • ACR Appropriateness Criteria® Acute Trauma to the Ankle

      2020, Journal of the American College of Radiology
      Citation Excerpt :

      Including an added criterion of swelling has been shown to increase the sensitivity and specificity for fracture to 100% and 55% for the malleolar region. Recent implementation of nurse triage programs using the radiographic OAR protocol have shown a reduction in emergency room patient stay by up to 20 minutes [3,15-17]. In an effort to decrease the use of radiographs, other rules, including the Bernese Ankle Rules, have been evaluated but have shown lower sensitivity to the OAR [18,19].

    • Damage localization in hydrogen storage vessel by guided waves based on a real-time monitoring system

      2019, International Journal of Hydrogen Energy
      Citation Excerpt :

      A number of methods and techniques have been developed for assessing and detecting defects in pressure equipment [6–8]. Conventional non-destructive evaluation techniques, such as radiographic testing [9], magnetic particle testing [10], penetrant testing [11], fiber optics [12,13], and eddy current testing [14], have been used for safety inspection of a wide range of structures. However, they are a point-to-point inspection method, and hence, the safety inspection is usually time consuming and not applicable to inaccessible locations of structures.

    • Nurse-initiated radiographic-test protocol for ankle injuries: A randomized controlled trial

      2018, International Emergency Nursing
      Citation Excerpt :

      Selection bias could be observed because randomization or allocation concealment was lacked in quasi-experimental studies. Apart from this, none of the previous studies evaluated the requests for ankle and foot radiographic tests separately and the actual reason for the reduction of patients’ LOS in EDs [11]. Therefore, this randomized controlled trial was performed to evaluate whether the implementation of a nurse-initiated radiographic-test protocol compared with the conduct of the usual practice could reduce unnecessary ankle and foot radiographic-test requests and shorten the patients’ LOS in an ED by reducing their waiting time for physician reassessment.

    • Reliability of Triage Nurses and Emergency Physicians for the Interpretation of the C-3PO Rule for Head Trauma in Children

      2018, Journal of Emergency Nursing
      Citation Excerpt :

      On a clinical ground, the use of the C-3PO rule by nurses at triage could improve patient flow through the emergency department because patients will already have had their radiologic evaluations when seen by the treating physicians. This has been demonstrated for the use of the Ottawa ankle rule in a recent study in which the nurse-initiated protocol, using the Ottawa ankle and foot rule, was associated with a significant decrease in the median length of stay.30 In addition, a systematic review reported 4 other studies confirming the reduced length of stay associated with the nurse-initiated use of the Ottawa ankle rule.31

    View all citing articles on Scopus
    View full text