• Taryn Bessen, Robyn Clark, Sepehr Shakib, and Geoffrey Hughes.
• Department of Medical Imaging, Royal Adelaide Hospital, Adelaide, SA 5000, Australia. Taryn.Bessen@health.sa.gov.au
• BMJ. 2009 Jan 1; 339: b3056.

ProblemDespite widespread acceptance of the Ottawa ankle rules for assessment of acute ankle injuries, their application varies considerably.DesignBefore and after study.Background And SettingEmergency departments of a tertiary teaching hospital and a community hospital in Australia.Key Measures For ImprovementDocumentation of the Ottawa ankle rules, proportion of patients referred for radiography, proportion of radiographs showing a fracture.Strategies For ChangeEducation, a problem specific radiography request form, reminders, audit and feedback, and using radiographers as "gatekeepers."Effects Of ChangeDocumentation of the Ottawa ankle rules improved from 57.5% to 94.7% at the tertiary hospital, and 51.6% to 80.8% at the community hospital (P<0.001 for both). The proportion of patients undergoing radiography fell from 95.8% to 87.2% at the tertiary hospital, and from 91.4% to 78.9% at the community hospital (P<0.001 for both). The proportion of radiographs showing a fracture increased from 20.4% to 27.1% at the tertiary hospital (P=0.069), and 15.2% to 27.2% (P=0.002) at the community hospital. The missed fracture rate increased from 0% to 2.9% at the tertiary hospital and from 0% to 1.6% at the community hospital compared with baseline (P=0.783 and P=0.747).Lessons LearntAssessment of case note documentation has limitations. Clinician groups seem to differ in their capacity and willingness to change their practice. A multifaceted change strategy including a problem specific radiography request form can improve the selection of patients for radiography.

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