Ottawa Guidelines Implementation for a Local Government Run Hospital

The incidence of lower extremity injury that present to emergency departments in the United States yearly is unknown. But, due to the high numbers of lower extremity injuries seen at Emergency Departments (ED), overutilization of resources such as radiology can occur. Approximately 30% of patients receive unnecessary radiographic imaging for lower extremity injury. X-ray radiation causes known deleterious effects on cellular structure called cutaneous radiation injuries. Between 43-72% of these injuries are strains and sprains and should not require radiographic imaging. Due to the volume of patient's who visit and are evaluated at ED's for lower extremity injury, Registered Nurses (RN) initiate radiographic imaging orders for these patient's, prior to the patient's injury evaluated by a physician. However, many nurses do not have the clinical background or training to properly determine if a patient meets criteria requiring x-rays. The aim of this project was to provide evidenced based guidelines, as an assessment tool for RN's to be able to evaluate and order x-rays effectively. The Ottawa Rules are a well-established tool with a high sensitivity to rule out fracture without the need of radiographic imaging. Studies have shown that RN's are capable of employing this tool successfully, and the use of Ottawa rules can decrease ED length of stay, and decrease unnecessary x-rays by up to 30%. A reduced length of stay at the ED also has shown an increase in patient satisfaction. Evidenced based guidelines were developed for rapid assessment of lower extremity orthopedic injury. Twenty-three triage RN's, a majority of female (53%), aged of 52.9 (SD ± 13.4) years and a majority with a Bachelors degree, were instructed the use of Ottawa rules via an instructional power point. The nurses were evaluated pre and post instruction to determine their understanding of Ottawa rules. The nurses understanding pre and post-test were evaluated using a paired t-test and the intervention was found to be significant with a p-value of <0.01. The preliminary efficacy of guideline implementation was evaluated via data collected for all patients seen in ED with ICD 10 codes for lower extremity injuries for two weeks prior to, and for two weeks after intervention. Seventeen patients were identified for that time period, all were male with a mean age of 71 (SD ± 9.8), fourteen were Caucasian, 2 were Hispanic and 1 was Asian/Pacific Islander. The data was analyzed for x-rays ordered pre and post intervention using demographics and comparative statistics; results indicated 66% (5/9) of patients received x-rays prior to the education, and 50% (4/8) received x-rays after the intervention. Data was analyzed with a t-test, the p-value was 0.517, and indicating the difference was not significant. Radiographic imaging is an important tool for use in emergency medicine, but due to the costs associated and potential cellular damage, it is important that it be ordered responsibly. As a result of this project, there was a statistically significant increase in RN knowledge, and a decrease in the amount of x-rays ordered. The implementation of Ottawa rules as demonstrated in this project could be utilized in other emergency departments and private practices to encourage responsible use of radiography.