P0138 - Low Risk, High Reward – Using Quality Improvement and the Low Risk Ankle Rule to Decrease X-rays in the Pediatric Emergency Department

Background
Pediatric ankle injuries account for over 2 million Emergency Department (ED) visits a year in North America, and up to 95% of these patients receive ankle radiographs although only a minority reveal fractures. Unnecessary imaging in these cases increases radiation exposure for individual patients, as well as both direct and indirect healthcare costs. The Low Risk Ankle Rule (LRAR) is a highly sensitive clinical decision tool which can reduce unnecessary imaging of these patients, without affecting detection of clinically important injuries, or patient and physician satisfaction. Despite the fact that this rule was developed and validated at our institution, an audit of practice in our ED showed that 91% of patients presenting with acute ankle injuries received ankle radiography.

Aim
This was a quality improvement study aimed at reducing the proportion of ankle x-rays in children presenting with acute ankle injuries by 30%. We also evaluated the sustainability of this change after 24 months.

Methods and Interventions
A fishbone diagram was used to identify factors contributing to high ankle radiography rates in our ED. Using Plan-Do-Study-Act (PDSA) cycles, we implemented several interventions to increase use of the LRAR, including: 1) staff (medical, nursing) education around the LRAR, 2) LRAR reference posters, 3) development of a new mandatory diagnostic imaging requisition encouraging use of the LRAR and 4) a hard stop from diagnostic imaging if the new requisition was not used.

We calculated ankle x-ray and LRAR documentation rates from 8 months before and 24 months following these interventions by reviewing the medical records of all children ages 3 to 18 years who presented to our pediatric ED with an isolated acute ankle injury. We excluded patients who presented with outside imaging, greater than 72 hours after the injury, or who had a previous visit for the same injury. Rates of return visits and orthopedic referrals were calculated as balancing measures.

Results
Prior to any interventions, 91% of patients presenting to our ED with ankle injuries received ankle x-rays. Following our interventions, this percentage decreased significantly to 59% (p<0.0001), without an increase in rates of return visits or orthopedic referrals (Figure 1). This lower rate was sustained even 24 months following completion of the interventions, when ongoing actions were limited to educational posters and yearly departmental updates, and despite regular staff turnover.

Discussion and Conclusion
We achieved a significant reduction of 32% in the percentage of ankle x-rays ordered for patients presenting to our ED with acute ankle injuries, without increasing the rate of return visits or orthopedic referrals. This decrease was sustained 24 months following completion of the active interventions and despite staff turnover, suggesting a change in culture resulting from the QI initiative and periodic educational updates.