Pediatric Emergency Physician Opinions on Ankle Radiograph Clinical Decision Rules

Abstract

Objectives: The Low Risk Ankle Rule (LRAR) is a validated clinical decision rule (CDR) about the indications for ankle radiographs in children with acute blunt ankle trauma. Although application of the LRAR has the potential to safely reduce the rate of ankle radiography by 60%, current x-ray rates in most emergency departments (EDs) in the United States and Canada remain unnecessarily high (85%-100%). To evaluate this gap between knowledge and practice, physicians who treat pediatric ankle injuries in EDs were surveyed to determine physician awareness and use of the LRAR, acceptability of the LRAR as measured by the Ottawa Acceptability for Decision Rules Scale (OADRS), and perceived barriers to the use of a validated pediatric ankle x-ray rule.Methods: An on-line survey of members of two national pediatric emergency medicine (PEM) physician associations in the United States and Canada was conducted using a modified Dillman technique.Results: Response rates were 75.6% (149 ⁄ 197) in Canada and 45.7% (352 ⁄ 770) in the United States, yielding an aggregate rate of 51.8%. Only 119 of 478 respondents (24.9%) had heard of the LRAR, and 53 of 432 (12.3%) were sufficiently familiar with the LRAR to apply it. The LRAR scored a mean (± standard deviation [SD]) OADRS score of 4.28 out of 6 (±0.67), comparable to published OADRS scores for two well-known CDRs used in adults. Of the respondents, 434 of 471 (92.1%) at least ''slightly agreed'' that ankle x-ray CDRs would be useful in their practice, with no significant differences between the two sides of the border (p = 0.28). Ankle x-ray rules were felt to save time by 342 (72.6%) of the participants, and the pediatric ankle exam was considered easy enough to apply a CDR by 306 (65.0%). The most common barriers reported for use of any ankle x-ray rule included perceived reduction in family satisfaction without imaging in 380 (80.7%), nurse-initiated x-ray protocols not based on ankle x-ray rules in 285 (60.5%), concerns about missing a significant fracture in 248 (52.7%), and a preference for own clinical judgment in 246 (52.2%). Conclusions:Although the LRAR had a high acceptability score among respondents in this survey, this validated CDR is not widely known and is even less frequently applied by PEM physicians in the United States and Canada. Barriers were identified that will guide efforts to improve the knowledge translation of the LRAR into pediatric EDs.ACADEMIC EMERGENCY MEDICINE 2010; 17:709-717 ª

Emergency Physicians’ Knowledge and Attitudes of Clinical Decision Support in the Electronic Health Record: A Survey‐based Study

“…This observation was further bolstered by responses to attitudinal questions that demonstrated generally favorable opinions of CDS and clinical prediction rules, and various means of incorporating them into the EHR. Our results support the concept of active knowledge translation of evidence rather than relying on passive diffusion, which has previously been shown to be incomplete and variable . Of note in this respect, 24% of respondents to our survey reported never having heard of the PECARN prediction rules—despite these rules having been published in a leading journal a year and a half prior to the time of survey administration.…”

Evidence into Practice

“…However, our response rate of 68% exceeds other similar published physician surveys (53% to 54%), [28][29][30] respondents represented a wide geographic area in the United States and Canada, and nonrespondent/nonsampled surgeons working in the same clinic/institution are more likely to be similar than different from each other in their practices. One issue with this survey's results is the potential for self-selection bias.…”

Effect of the Low Risk Ankle Rule on the frequency of radiography in children with ankle injuries

“…6 This power simulation required the following estimates derived from site administrative data: no secular trends were present in the radiography rates; an average of 4.5 ankle injuries per week per site or 2100 injuries across 78 weeks and 6 sites; and 97% radiography of these injuries. Using these methods, test power was estimated to be 95%.…”

“…Phase 1 served as an internal control at these sites with no measures to encourage rule use. In phase 2, a multimodal intervention strategy was introduced to encourage use of the Low Risk Ankle Rule based on knowledge of barriers to implementing strategies, 6,8,9 available evidence 7,10-17 and consultation with knowledge transfer experts. Emergency physicians underwent a teaching session and were provided with pocket cards that outlined the use of the ankle rule.…”