Department of Pediatrics, Hospital for Sick Children, University of Toronto, Ontario, Canada.
Acad Emerg Med. 2010 Jul;17(7):709-17. doi: 10.1111/j.1553-2712.2010.00787.x.
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.
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.
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%).
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.
低风险踝关节法则（LRAR）是一种经过验证的临床决策规则（CDR），用于确定儿童急性钝性踝关节创伤时进行踝关节 X 光检查的指征。虽然应用 LRAR 有可能安全地将 X 光检查率降低 60%，但目前美国和加拿大大多数急诊部（ED）的 X 光检查率仍然过高（85%-100%）。为了评估知识与实践之间的差距，对治疗 ED 中儿童踝关节损伤的医生进行了调查，以确定医生对 LRAR 的认知和使用情况、用渥太华决策规则接受度量表（OADRS）衡量的 LRAR 的可接受性，以及使用经过验证的儿科踝关节 X 光规则的感知障碍。
使用改良的 Dillman 技术，对美国和加拿大两个国家的儿科急诊医学（PEM）医师协会的成员进行了在线调查。
加拿大的回应率为 75.6%（149/197），美国为 45.7%（352/770），总回应率为 51.8%。在 478 名受访者中，只有 119 名（24.9%）听说过 LRAR，而在 432 名受访者中，只有 53 名（12.3%）对 LRAR 足够熟悉，可以应用它。LRAR 的平均（+/-标准差[SD]）OADRS 得分为 4.28（+/-0.67），与成人中使用的两个知名 CDR 的已发表 OADRS 评分相当。在回答者中，471 名中的 434 名（92.1%）至少“稍微同意”在他们的实践中使用踝关节 X 光 CDR 会很有用，边境两侧之间没有显著差异（p=0.28）。342 名参与者（72.6%）认为踝关节 X 光规则可以节省时间，306 名参与者（65.0%）认为儿科踝关节检查足够简单，可以应用 CDR。报告的最常见使用任何踝关节 X 光规则的障碍包括在没有影像学检查的情况下，380 名患者（80.7%）认为会降低家庭满意度，285 名患者（60.5%）认为护士启动的 X 光协议不是基于踝关节 X 光规则，248 名患者（52.7%）担心会漏诊重要骨折，246 名患者（52.2%）更倾向于自己的临床判断。
尽管这项调查中 LRAR 的可接受性评分很高，但这种经过验证的 CDR 并不广为人知，甚至在美国和加拿大的 PEM 医生中也很少应用。确定了一些障碍，将指导努力改善 LRAR 在儿科 ED 中的知识转化。
