As a medical officer and clinical researcher I have found it worthy to conduct an audit and carry out a research on the Ottawa Ankle Rules and how effective they are in ruling out the need for an x-ray examination. X-rays are a very important and crucial medical examination because it is used to determine the nature of all broken limbs in the body and all the other related issues. My field of work deals a lot with X-ray patients and also with broken limbs and therefore I have a huge interest in researching on any rules and laws affecting the x-rays and related examinations. The Ottawa Ankle Rules affect the x-ray examination and therefore affects my field of expertise.
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The Ottawa ankle rules are the regulations that help a medical officer or a physician to decide whether there is need for an x-ray examination after someone suffers and injury at the ankles or at their mid foot. I am interested in carrying out this research because of different varied reasons such as the results of a previous audit done on the same issue giving credible results, healthcare issues, political and social issues. There have been previous audits or researches conducted on this issue before for example the audit conducted on children.
The Ottawa ankle rules are supposed to be applied to adults only but in the audits, they were conducted to children and there were credible results that an x-ray examination is not necessary for patients with broken limbs or mid foot injuries. A previous audit has shown that in case of a broken limb, there are other clinical instruments that can be used to examine the injury and determine whether it is a fracture or it is just a swelling. Physical examination can also be done effectively to determine the nature of the injury whether it is fractured deeply, lightly or whether it is not fractured at all. These results prompted my interest in the study of whether those rules really do away with the need for x-ray examinations. The audits also show that the Ottawa Ankle Rules does not apply to only adults but even children.
The children who were tested or examined gave positive results of examination of an injury of a broken limb or mid foot injury without the need for an x-ray. Healthcare issues are another reason why I decided to carry on an audit in this matter. Clinical or medical officers need to be very careful, accurate and sure of what they are doing to their patients and also be very accurate with their examinations. (Ellis, 2010, p. 89) The x-ray examination though not very important as stated by the Ottawa Ankle rules, it should still be performed so as to be very sure of what the problem is. The x-ray examination has a higher chance of being very accurate because it is electronically carried out unlike other examinations like a physical examination by an expert which might not be correct because humans are subject to errors
Search strategy
The research or audit could be carried out in the internet by viewing various documented resources on the topic or related topic, using electronic journals, peer reviewed articles, opinions of credible and influential persons on the same topic and documented facts on the same topic. The topic in question to be researched on is the Ottawa Ankle Rules and whether they propose that the X-ray examination is not necessary. The search was based on the facts based on the case, ideas of different people and their ideas. There are various facts about the Ottawa Ankle Rules and whether they propose that the X-ray examination is not necessary. The research on these facts was to determine the truth in the need for X-ray examinations and whether it is really necessary for injuries and whether there is any truth in the Ottawa rules. The research on the facts was also to determine whether the Ottawa Ankle rules have worked before on any previous cases and if indeed true that X-ray examination is not necessary. The search was also based on the opinions of influential people in the field of medicine and also experts and physicians dealing in that field.
The search strategy took the form of texts, graphics and charts. The charts were from the primary data collected during the audit. The audit was carried out using two sources which are the primary and the secondary sources. The secondary sources were from already documented sources or audits on the same topic and on opinions of experts in the area where the topic falls. The secondary sources were to help in determining the popular opinion about different experts on the topic and what they think about it. (Ellis, 2010, p. 115) The audit was also based on the primary sources. These were the sources that were based on the personal search or primary data that I personally collected.
Outcomes
I used the databases from previous audits of some experts because of their credibility and their results which were reliable and almost the same meaning there was a high chance that they are accurate. Some of the outcomes from secondary sources that in searched on the relevance of the Ottawa Ankle rule are as follows. A research done by Chande on 68 patients who were aged between two to eight years shows that x-rays were performed on all the participants to determine whether x-ray was necessary if Ottawa Ankle Rules were applied. All types of fractures were included in the search. The fractures excluded in the search were open fractures, the patients with follow up sensitivities. The results for the search were 100% sensitivity and specificity of 32%. The weakness of the audit was a small sample size.
Another documented research on the Ottawa Ankle Rules was the research done by McBride on 318 adults and children with the number of children being 37. The study was to determine the ability of Ottawa Ankle Rules to decrease the need for an x-ray examination after giving instructions to the family practitioners on the use of these rules. The fractures included in the study were the fractures which are less than 3 millimeters. The ones excluded were open injuries, patients presenting themselves more than a week after the injury. The results were 100% sensitivity and 28% specificity. The limitations encountered during this research were the lack of children less than nine years old as participants.
Another secondary source documenting the necessity of the x-ray examination when the Ottawa Ankle Rules are applicable is the Audit done by Libetta on 761 patients who were aged between the ages of one and fifteen. The search was carried out to determine whether a historical control group was included before the Ottawa Ankle Rules were implemented in this exercise as a comparison to find out the need for x-ray examination. The patients included were those that were able to walk before the injury. Those excluded from the search were the ones in the month of August so that the staff could have a month to learn and implement the Ottawa Ankle Rules. The outcome from the audit was a sensitivity rate of 98% and a specificity of 46%. The limitations of this search was the small number of children and the inclusion of the mid foot injuries in the study
Data analysis
I computed the effects Meta analysis model on the proportions of the weights based on variances. In finding the sensitivity and specificity percentages I used a pooled estimate of all the studies instead of individual estimates of each study. Pooled estimates are usually meant to ensure the accuracy of the results. (Ellis, 2010, p. 135) I used the Meta library to do the statistical calculations. The overall sensitivity level for all the studies was found to be 97% and that of specificity was found to be 295 and this shows the accuracy of the findings
Findings
During my research of the primary and the secondary sources, I found out that the Ottawa Ankle rules that there is usually tenderness over the lateral malleoli which results in the patient being unable to bear any weight in the injured section and also the tenderness over the posterior distal tibia and fibula. I found out that a patient who had one or all of these characteristics were to have an X-ray examination performed on them. From my audit and research I was able to determine that the Ottawa Ankle Rules have been made valid to be applied when screening adults who have injuries at the ankle or mid foot injuries. I also determined that application of the Ottawa Ankle rules on children is less certain because they may not be reliable in verbal history and because the children should be able to walk without difficulty before an injury if the Ottawa Ankle Rules are to be applied on them and therefore the Ottawa Ankle Rule criteria will be positive on the children and radiographs should be obtained for injuries that resemble sprains or that are treated like sprains
Critical evaluation of the types of audit or research designs and data collection methods
There have been various research studies that have been undertaken by other researchers and experts on the topic in question. Various research methods have been used and there have been both qualitative and quantitative researches that have been carried out. The qualitative research is the kind of research where there is in-depth analysis of the data at hand. (Ellis, 2010, p. 160) The researcher will analyze the data deeply and consider human behavior and also look at how and why decisions are made regarding the particular topic under research.
The research samples used during qualitative research is small to allow for easy analysis and sampling of the data. Quantitative research on the other hand is where there is no much in-depth analysis and the data collected is literally interpreted without deep analysis. The sample size here is big. The aim of the qualitative research is a complete and detailed description and in most cases the researcher always has just a faint idea of what he is looking for. Qualitative research is also characterized by the researcher being the instrument of data gathering and data is usually in the form of words, pictures or charts. It is also usually characterized by subjectivity where the individuals or researchers interpret the events at hand and the researcher usually uses observation of the participant and interviews.
Qualitative research is time consuming and the data obtained is very rich and detailed. The research usually involves the analysis of data such as words. Quantitative research on the other hand involves analysis of numerical data. It is not in-depth. The aim of a quantitative data is to try and group features, count them and to create a model which is statistical in nature. (Cormack, 2000, p. 76) Here the researcher explains what he has observed and does not go further to explain why what he has observed is the way it is or why the results of his observation are the way they are. Here the researcher also knows what he is researching about in advance and the researcher is not the gathering instrument but instead he uses the research tools such as questionnaires.
Qualitative research is very objective in nature because the researcher only seeks measurement and analysis of target concepts like surveys. The researchers who carried out a research on the Ottawa Ankle Rules used both qualitative and quantitative research methods during their research. Qualitative research methods are usually done at the early phase of the research while quantitative research methods are used in the later phases of the study. An example of previous research done by other researchers is the research carried out by the children’s mercy hospital and clinics doctors Myers, Canty and Nelson. They carried out a research on twenty seven studies where six were related directly to children. However they focused on eight studies where six were included in the systematic review and two had been previously published. In the study both qualitative and quantitative research was used. They however dwelled on the quantitative research more.
This is because the researchers already knew and were aware of what they were researching on and that is whether the Ottawa Ankle Rules were reliable in eliminating the need for an X-ray examination on a patient without the risk of missing out on a possible fracture. The researchers did not dwell on a single study but they took on many different studies to ensure that they were accurate and to get different views and results and if the results from all the studies were similar or close to similar then they would know that the results are credible. They carried out a quantitative research on different studies that had been performed earlier and they analyzed the data found in the studies and came out with their own results.
The first study that they researched on was the study by boutis which was a study on about 607 patients who were of the age of three to sixteen. The study was carried out in two similar urban emergency departments and the participants were the fellow researchers and the staff of the emergency departments. The people carrying out the study were under instructions from the orthopedic surgeons on the use of the Ottawa Ankle Rules before they started the study. The results of the study were that there was 100% sensitivity and 13% specificity. (Boutis 2001, 326) The fractures which were included in the study were the isolated ankle trauma within 72 hours of the injury. Those excluded from the study were the musculoskeletal disease that had existed before and the patient is of ages less than thirteen years and less than sixteen years old. Other exclusions included any history of surgery or any recent injury of affected ankle and by recent they meant less than three months. In this study the patients were divided into risk groups of high risk and low risk. The low risk groups consisted of pain that was isolated and tenderness or both with or without oedema or ecchymosis of the distal fibula just below the ankle. (Boutis, 2001, p. 326) The rest of the findings were however classified as high risks. The study also examined whether there was need of reducing radiographs when trying to compare the findings of the low risk cases with the Ottawa Ankle Rules.
Another study that the researchers dwelled on was the study by Chande on 68 patients which was carried out on patients between the ages of two and eighteen. The study was carried out by performing x-rays on the participants with the investigator not aware that the Ottawa Ankle Rules are necessary for evaluation of the necessity of the x-ray examination. The results of the study were a sensitivity of 100% and a specificity of 32%. (Chande, 1995, p. 149) The study included all fractures and excluded the open fractures and patients without a follow up. There was a small sample size used which qualifies the qualitative research methods.
Another study that was considered by the researchers was the study by Clarke Garcia. He conducted the study on 11 patients who were of the ages between three and eighteen years. The method used was the evaluation of the patients by the nurses and the residents who had stayed in the area for three years. The Ottawa Ankle rules were applied and x-rays were obtained when the expert saw a need for one. The results were a 96% sensitivity rate and specificity of 6%. (Garcia, 2004, p. 60) The ones included were salter-harris two to five fractures. The ones excluded from the study were multiple traumas which were less than seven days from the event, the bony disease, the salter-harris one fractures and the patients who came to be reevaluated. The patients were then given a follow up after one month through a call and none of the patients depicted any complications. (Garcia, 2004, p. 60)
Another study was the study by Karpas on 190 patients who were aged between five and nineteen. The method included the application of the Ottawa Ankle Rules after two training sessions. The results were a sensitivity of 96% and a specificity of 27%. (Karpas, 2002, p. 9) The inclusions were the patients who presented themselves within 48 hours of injury and all fractures and the ones excluded were the open fractures, multiple traumas, the patients who were referred with x-rays and those who visited recurrently with the same injury for two weeks. The study included a patient with salter-harris one fracture and the results were negative.
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Another study was by Libetta who conducted the study on 761 patients and a historical control group was included before the Ottawa Ankle Rules were implemented when the participants were being evaluated as a comparison in predicting the need for x-ray. The results were a sensitivity of 98% and a specificity of 46%. (Libetta, 1999, p. 16) The people included in the study were the ones who had ability to walk to walk before the injury. The patients were excluded in the month of August to give the nurses time to go and learn how to implement the Ottawa Ankle Rules. In this study there were a small number of children despite the big number of participants that were evaluated during the exercise. The mid foot injuries were also included in the study even though they were not required.
Another study was by Plint who conducted the study on 670 patients who were aged between two and sixteen. The patients were evaluated by the staff of the place and the people trained in the Ottawa Ankle Rules. In this study there were x-rays performed according to the policies of the hospital in question and data forms were filled without performing the x-rays. The data forms were used to evaluate whether there was need of applying the Ottawa Ankle Rules. The results of the study were a sensitivity of 100% and a specificity of 27%. (Plint, 1999, p. 6) The inclusions of the study were those who were having injuries within 48 hours and those who had fractures which are less than 3 mm. The ones excluded were the salter-harris 1 fractures and open injuries.
Another study that the researchers dwelled on was by McBride who conducted the study on 37 patients aged between nine and sixteen. The study was to determine the ability of the Ottawa Ankle Rules in reducing the need for x-ray examination. The results were a sensitivity of 100% and specificity of 28%. (McBride, 1997, p. 16) The patients who were included were those who were pregnant, those with open fractures and those who presented themselves more than one week after the injury. The researchers used all these studies to evaluate the applicability of the Ottawa Ankle Rules and how they would be applied and also the circumstances under which they were to be applied. The researchers then went ahead and analyzed the data so as to determine any similarities in the results of the study and also so that they could come up with a conclusion on whether the topic they were researching on was true or false.
They still used the quantitative methods in analyzing the data, doing the calculations and coming up with a conclusion. The researchers calculated the overall sensitivity of all the studies to be 97% and specificity to be 29%. They also calculated a prevalence rate of 12 % on all fractures. They realized that one of the articles had five patients with negative results when considering evaluation of patients with fractures only. The other articles had one or no patient in this category. They also found out that a small number of patients that were not allowed to take x-ray examination based on the Ottawa Ankle Rules were having fractures. It is however a low percentage of the patients. They also found out that the choice of applying the Ottawa Ankle Rules depended on the individual doctor and also the hospital rules. The nature of injury or fracture also mattered in the application of the rules. This approach by the researchers was fit for the research because it answered their questions and helped them understand the topic well
Methodologies
The choice of methodology used by these researchers was appropriate for the research. This is because it covered all the concepts of the research which was on the relevance and applicability of the Ottawa Ankle Rules. The aim of the researcher was to identify whether the Ottawa Ankle Rules were relevant in doing away with x-ray examinations. The methodology makes sense because from the studies analyzed by the researchers because they found out that indeed there are cases where x-ray examinations are not necessary but not all cases. They found out that indeed the Ottawa Ankle Rules could be applied so that the x-ray examination was not necessary. This however depended on the type of fractures and injuries being dealt with and also the policies and practices of the person applying the rules and the institution for example they determined that the nurses who had no experience or knowledge of the Ottawa Ankle Rules could not apply it until they had learnt it. Another example is that the rules applied to children who could walk properly before they were injured.
The researchers could have used other alternative methods to carry out the research for example they could have used primary data or performed qualitative research which means that they could have applied the Ottawa Ankle Rules personally. They could have done this by evaluating the patients on their own by taking in patients with similar injuries and fractures and performing x-ray examination on half of those patients and doing away with the examination on the other half and then seeing if the x-ray examination will make a difference or if the lack of it will make a little or no difference. This approach would have answered the question of whether x-ray examinations are necessary to an injured patient with a fracture. This is because this approach is direct and it determines whether x-rays are necessary or not.
This approach also answers the question of whether a patient with an injury or a fracture needs an x-ray examination before being treated or if they can be examined and diagnosed and later treated without the need of an x-ray examination. This methodology could also answer the question of the relevance of the Ottawa Ankle Rules to experts. The researchers could also have used a mixed methodology of both primary and secondary data. This means that apart from examining the patients on their own, they could also interview patients who have been examined under the Ottawa Ankle Rules and determine whether the application of the rules on them gave positive or negative outcome. This would help them to compare their results with the results from the interviews and determine whether there are any similarities of differences in the outcomes and hence determine the relevance of the rules
Data collection tools
The researchers used different data collection methods. They used documented sources from the studies that they were analyzing. The studies had already been collected and what they did was to collect the different studies and analyze them together. The data was collected by the people who were doing the study and the researchers only gathered the data together and analyzed it. The researchers used this method because it was easy and cheap. Carrying out the studies on their own would be very expensive because they would have to evaluate all the patients for free and even carry out x-ray examinations on some participants which would be very expensive.
The studies would also be time consuming because in some studies the number of participant was large and some evaluations would also take time to be completed. The methodology however was fir for the research because the data from the studies were credible. They might have used interviews and questionnaires to collect data. This would give them direct information from the patients on what they were researching on hence making their research accurate and true. They could have also used other previously documented references that are credible
Conclusion
If I was examining the topic on the Ottawa Ankle Rules I would use a different methodology and ask different questions. The first question that I would ask is what do the Ottawa Ankle Rules state. This will ensure that the Rules are clearly understood first. This means that what the rules stand for, what they say would be clearly understood. Another question I would ask is why the Ottawa Ankle Rules were drafted. This will give a deeper understanding on the Rules and help iron out any misunderstandings that may be experienced by the users. This will ensure that the rules are applied by those who understand it and apply it where necessary. Another question would be where the Ottawa Ankle Rules are applicable. This will determine the situations under which the rules should be applied.
This is because their application has been questioned before and therefore I have to determine why their application has been questioned and identify whether there are specific situations in which they are supposed to be applied. When examining the topic I would be very concerned with how the Ottawa Ankle Rules affects the x-ray examination and whether it proposes that the x-ray be done away with or whether it should be applied but to specific cases. I would want to determine if the Ottawa Ankle Rules has been applied before and how it has affected the applicants and also the people who applied. I would also determine whether its application has been successful in any cases that it has been applied to.
The application of the rules would mean that the x-ray examination has a possibility of being done away with during the treatment process of injured patients with fractures and related injuries because it states that you can perform treatment and diagnosis without necessarily doing an x-ray. I would want to determine if there are any documented cases that have proved the applicability of the Ottawa Ankle Rules and it has become successful on the cases where it has been applied. I would also want to determine whether there have been cases where the x-ray examination has not been performed and diagnosis and treatment done and how the treatment was administered. If am examining the topic I would also find out whether the Ottawa Ankle Rules should be applied after all or whether they are valid.
Given the question at hand to be examined I would research using both qualitative and quantitative research methods. These methodologies would help me in answering the questions that I have concerning the topic directly and give possible explanations to my answers and my concerns. The quantitative methodology that I would use is researching on previously documented cases or studies on the Ottawa Ankle Rules or any previous secondary sources that were talking about the rules. These would help me in building my research problem and help me get a broader aspect of the problem or the topic. It would also help me in understanding the topic better and to determine the nature of my questions and whether they are relevant and need answers.
The quantitative research methodology would help me in getter a better sense of what the topic was about that is a better sense of whether the Ottawa Ankle Rules were applicable in all cases and whether it proposed doing away with the x-ray examination in all cases or whether here were any exceptions with the rules. The methodology would also help me in looking at and understanding the opinions of other researchers who have conducted researches and studies in the same topic. Different views are good for a research because it helps you understand the topic better but in different aspects. You get to know the positive and negative sides of that topic and you get to evaluate the criticisms set towards it.
The qualitative methodology would also help me in analyzing the data from the secondary sources. Through this analysis I will be able to learn about how data can be collected and summarized so as to come up with a conclusion on whether the data collected is relevant to the topic at hand and whether the questions asked have been answered. In the case of Ottawa Ankle Rules, a quantitative search or methodology will help me determine the applicability of the rules and whether they have been applied before and have been implemented successfully and whether the need for an x-ray examination has indeed been done away with when the rules were applied. I would also use qualitative research methodology when trying to understand the topic deeply.
This methodology is also very credible and accurate because the researcher goes to the field personally to carry out the evaluations on his own. This methodology would also help me analyze the data and try and understand why the rules were drafted in the first place. This means that I would determine the reasons for the rules being put up and how and why the rules should be applied. Since this methodology involves the researcher directly, it would help in ensuring the accuracy of the findings of the researcher
I would collect data through the use of interviews, questionnaires and personal evaluations. Personal evaluations would be my first choice because that way I would nail the problem in the head. I will carry out evaluations on patients with injuries and fractures and apply the rules to some patients and not to some and determine whether the rules indeed support the doing away with x-ray examinations or whether the examinations are still important to the patients
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