Assessing Compliance With Ottawa Foot and Ankle Rules in the Emergency Department: A Closed-Loop Quality Improvement Project
Bibliographic record
Abstract
Introduction Traumatic foot and ankle injuries are frequent presentations to the emergency department (ED). The Ottawa Foot and Ankle (F&A) Rules are to help clinicians in decision making whether an X-ray of the foot or ankle is justified. Methods A retrospective analysis of ankle and foot X-ray requests from a South London Hospital ED was performed. Consecutive requests for both foot and ankle X-rays were assessed chronologically until n=100 for each cohort. The clinical documentation of each ED clerking and the X-ray request clinical details were then compared to the Ottawa Rules of that respective request. The presence of a midfoot or ankle fracture was recorded. Several interventions were implemented to improve compliance; this included distributing the results of the first audit cycle and a handout containing the Ottawa F&A rules to ED staff. A teaching session for ED Junior Doctors on assessing, documenting, and requesting X-rays for foot and ankle injuries was delivered within the department. An identical second retrospective audit cycle for both ankle and foot X-rays was then completed three weeks after implementation of the above interventions. Results The compliance of Ottawa Foot Rules in documenting foot injuries significantly improved from 48% to 78% (p<.001). Foot X-ray request compliance significantly improved from 32% to 54% (p<.01). Documentation compliance of ankle injuries significantly improved from 74% to 87% (p<.05). Ankle injury X-ray request compliance improved from 43% to 57% (p<.05). Fracture rate did not significantly change; ankle fractures increased from 17% to 22% (p=.372), foot fracture rate remained 15% in both cycles. Significance was assessed using the Chi-square test throughout. Conclusion This two-cycle Quality Improvement Project demonstrated significant improvement in compliance with Ottawa F&A Rules for ED clerking documentation and X-ray request clinical details in a South London Hospital. Compliance with Ottawa F&A Rules has the potential to reduce costs, facilitate faster discharge, and reduce unnecessary radiation exposure.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.120 | 0.136 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.005 | 0.004 |
| Science and technology studies | 0.002 | 0.002 |
| Scholarly communication | 0.004 | 0.002 |
| Open science | 0.003 | 0.006 |
| Research integrity | 0.001 | 0.001 |
| Insufficient payload (model declined to judge) | 0.001 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".