Uptake of Validated Clinical Practice Guidelines

Experience With Implementing the Ottawa Ankle Rules

HOLROYD, BRIAN R. MD
WILSON, DEBORAH MN
ROWE, BRIAN H. MD, MSc
MAYES, DAMON C. MSc
NOSEWORTHY, THOMAS MD, MSc, MPH

^*Division of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada
†Department of Public Health Sciences, University of Alberta, Edmonton, Alberta, Canada
‡Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
§Alberta Clinical Practice Guidelines Program, Edmonton, Alberta, Canada
¶Department of Community Medicine and Epidemiology, University of Calgary, Calgary, Alberta, Canada

Address correspondence to Brian H. Rowe, MD, MSc, Research Director, Division of Emergency Medicine, Room 1G1.43 WMC, 8440-112 Street, Edmonton, Alberta, Canada T6G 2B7. E-mail: [email protected]

Presented in part at the 7th International Conference of Emergency Medicine, Vancouver, BC, March 1998, and the Annual Society for Academic Emergency Medicine (SAEM) Meeting, Chicago, IL, May 1998.

Supported by the Capital Health Authority, Alberta Medical Association (AMA) Clinical Practice Guideline Program, and the AMA-Medical Services Branch Grant Program. Dr Rowe is supported by the Canadian Institute of Health Research (CIHR; Ottawa, Ontario) as a Canada Research Chair.

Manuscript received March 30, 2003; accepted April 22, 2003

American Journal of Emergency Medicine 22(3):p 149-155, May 2004.

This study examined whether emergency physicians (EPs) exposed to multiple dissemination strategies for the Ottawa Ankle Rules (OARs) would reduce extremity radiography use. We conducted a prospective cohort study comparing intervention (n = 2) with control (n = 2) hospitals over a 2-year period. All EPs received the paper-based rules during the run-in phase; EPs in the intervention hospitals were also subjected in sequence to valid dissemination approaches. Provincewide dissemination of the OARs did not decrease radiography during the run-in period (92% vs. 93%; P = .36). Sequential directed education and personalized feedback strategies failed to reduce radiographic ordering rates (P = .54) or the ordering of both foot and ankle radiographs (P = .11) over time. The use of radiography did not decrease despite the use of a variety of dissemination strategies. Additional research is required to determine the most effective methods of incorporating guidelines into emergency practice.