• I Stiell, G Wells, A Laupacis, R Brison, R Verbeek, K Vandemheen, and C D Naylor.
• Clinical Epidemiology Unit, Loeb Medical Research Institute, Ottawa, Ontario, Canada.
• BMJ. 1995 Sep 2;311(7005):594-7.

ObjectiveTo assess the feasibility and impact of introducing the Ottawa ankle rules to a large number of physicians in a wide variety of hospital and community settings over a prolonged period of time.DesignMulticentre before and after controlled clinical trial.SettingEmergency departments of eight teaching and community hospitals in Canadian communities (population 10,000 to 3,000,000).SubjectsAll 12,777 adults (6288 control, 6489 intervention) seen with acute ankle injuries during two 12 month periods before and after the intervention.InterventionMore than 200 physicians of varying experience were taught to order radiography according to the Ottawa ankle rules.Main Outcome MeasuresReferral for ankle and foot radiography.ResultsThere were significant reductions in use of ankle radiography at all eight hospitals and within a priori subgroups: for all hospitals combined 82.8% control v 60.9% intervention(P < 0.001); for community hospitals 86.7% v 61.7%; (P < 0.001); for teaching hospitals 77.9% v 59.9%; (P < 0.001); for emergency physicians 82.1% v 61.6%; (P < 0.001); for family physicians 84.3% v 60.1%; (P < 0.001); and for housestaff 82.3% v 60.1%; (P < 0.001). Compared with patients without fracture who had radiography during the intervention period those who had no radiography spent less time in the emergency department (54.0 v 86.9 minutes; P < 0.001) and had lower medical charges ($70.20 v $161.60; P < 0.001). There was no difference in the rate of fractures diagnosed after discharge from the emergency department (0.5 v 0.4%).ConclusionsIntroduction of the Ottawa ankle rules proved to be feasible in a large variety of hospital and community settings. Use of the rules over a prolonged period of time by many physicians of varying experience led to a decrease in ankle radiography, waiting times, and costs without an increased rate of missed fractures. The multiphase methodological approach used to develop and implement these rules may be applied to other clinical problems.

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