Alam, Sarfraz

Ashurst, John V, DO

Delpais, Paul, BSN, RN, CEN

DiGiambattista, Stephanie, MD

Gl-Porter, Bernadette, BS

Greenberg, Marna R, DO, MPH, FACEP

Kambhampati, Avinash, DO

Kane, Bryan G, MD

Kurt, Anita, PhD, RN

Nappe, Thomas M, DO

Ortiz, Michele, RN

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksDepartment of Emergency MedicineThe Effect of Triage-Based Application of theOttawa Ankle and Foot Rules (OAR/OFR) on theNumber of Radiographs Ordered: A Pilot StudyJohn V. Ashurst DOLehigh Valley Health Network, John_V.Ashurst@lvhn.orgStephanie DiGiambattista MDLehigh Valley Health Network, Steph.Digiambattista@lvhn.orgThomas M. Nappe DOLehigh Valley Health Network, Thomas_M.Nappe@lvhn.orgAvinash Kambhampati DOLehigh Valley Health Network, Avinash.Kambhampati@lvhn.orgSarfraz AlamLehigh Valley Health Network, Sarfraz.Alam@lvhn.orgSee next page for additional authorsFollow this and additional works at: http://scholarlyworks.lvhn.org/emergency-medicinePart of the Emergency Medicine CommonsThis Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by anauthorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtAshurst, J., Digiambattista, S., Nappe, T., Kambhampati, A., Alam, S., Ortiz, M., Delpais, P., Porter, B., Kurt, A., Kane, B., & Greenberg,M. (2014, April 7-9). The effect of triage-based application of the ottawa ankle and foot rules (OAR/OFR) on the number of radiographsordered: A pilot study. Poster presented at: The PaACEP Scientific Assembly, Harrisburg, PA.AuthorsJohn V. Ashurst DO; Stephanie DiGiambattista MD; Thomas M. Nappe DO; Avinash Kambhampati DO;Sarfraz Alam; Michele Ortiz RN; Paul Delpais BSN, RN, CEN; Bernadette Gl-Porter BS; Anita Kurt PhD,RN; Bryan G. Kane MD; and Marna R. Greenberg DO, MPH, FACEPThis poster is available at LVHN Scholarly Works: http://scholarlyworks.lvhn.org/emergency-medicine/262Lehigh Valley Health Network, Allentown, PennsylvaniaThe Effect of Triage-Based Application of the Ottawa Ankle and Foot Rules (OAR/OFR) on the Number of Radiographs Ordered: A Pilot StudyJohn Ashurst, DO, Stephanie Digiambattista, MD, Thomas Nappe, DO, Avinash Kambhampati, DO, Sarfraz Alam, MD, Michelle Ortiz, RN, BSN, Paul Delpais, RN, MSN, Bernadette Porter, BS, Anita Kurt, PhD, RN, Bryan Kane, MD, Marna Rayl Greenberg, DO, MPHIntroduction:© 2014 Lehigh Valley Health NetworkReducing 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 long-standing evidence-based rules used to predict fractures. However, radiographs are frequently ordered for acute ankle injuries despite OFAR exam findings suggesting no fracture.  Study Objectives:We set out to assess baseline OFAR use before radiographs were ordered. Then, after intervention (OFAR education), we assessed utilization of radiographs and length-of-stay (LOS). Secondarily, patient expectations and satisfaction were assessed.Methods:A prospective, two-stage, sequential designed pilot study was implemented. Triage nurses and providers performed their usual practice habits for radiograph use in the first arm. They subsequently were educated to appropriately apply the OFAR before radiograph ordering. 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 for patients enrolled was monitored, and subjects and providers were surveyed regarding their expectations and satisfaction.Results:Sixty-two patients were consented and enrolled in the study, and two withdrew prematurely (not included in analysis), leaving 30 subjects in each arm. Fifty-eight of the 60 patients were radiographed (97%) and 85% of patients responded that they expected a radiograph. ED LOS decreased from 103 minutes to 96.5 minutes (p=0.297) for all patients after OFAR education. There was also a decrease in LOS in 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 providers felt subjects were satisfied with their treatment.Conclusion:There was no statistical evidence that application of the OFAR results in a decrease in the number of X-rays ordered or decreased 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. Public campaigns to ensure the correct tests are ordered may have to emphasize the necessary conversations between provider and patient that change patient expectations. Table 1. Patient Demographics Before and After Application of the Ottawa Foot and Ankle Rules at Triage Control OFAR OverallAGE (years)N 30 30 60Mean +/- SD 36.5+/-17.87 36.4+/-15.48 36.5+/-16.58Median 33.5 38.5 36.5Range 16-85 16-70 16-85GENDER Male [n (%)] 12 (40.0) 11 (36.7) 23 (38.3)Female [n (%)] 18 (60.0) 19 (63.3) 37 (61.7)  Table 2. Median Length of Stay in Minutes Before and After Application of the Ottawa Foot and Ankle Rules at TriageLength of Stay Control OFAR P-valueFracture 137 103 0.112No Fracture 96 85 0.751Total 103 96.5 0.297  Funding: Funding for this project was provided, in part, by the Dorothy Rider Health Care Trust Fund; a nonprofit community foundation unrestricted grant.

The Effect of Triage-Based Application of the Ottawa Ankle and Foot Rules (OAR/OFR) on the Number of Radiographs Ordered: A Pilot Study

https://scholarlyworks.lvhn.org/cgi/viewcontent.cgi?article=1262&context=emergency-medicine

The Effect of Triage-Based Application of the Ottawa Ankle and Foot Rules (OAR/OFR) on the Number of Radiographs Ordered: A Pilot Study

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