Minimising negative ankle and foot X-rays in the Emergency Department -- are the Ottawa ankle rules good enough?

OBJECTIVES: To review fracture rates in patients who had X-rays of either the ankle or foot or both in the Emergency Department of a district hospital. METHOD: A retrospective review of 2589 Emergency Department patients who had X-rays of the ankle or foot or both over a 12-month period. RESULTS: There were 1199 ankle X-rays taken of which 193 (16%) showed a significant fracture. There were 1081 patients who had a foot X-rayed of which 165 (15%) showed a significant fracture. Younger patients had more X-rays but older patients were more likely to have a fracture. There were 309 patients who had an ipsilateral ankle and foot X-rayed at the same time, and of these 42 (14%) showed one fracture and just two (0.6%) showed a significant fracture of both ankle and foot. CONCLUSIONS: The approach to X-raying ankle and feet in this study is probably widespread, and Ottawa Ankle Rules still seem to be of limited use in diagnosing fractures. This low yield of positive X-ray could be accepted or a more sophisticated ankle rule introduced.

Using computerised patient-alert system.

SThe information technology systems used in most modern emergency departments alert staff to patients who require special management, including those with infections or histories of violence, or children on the child protection register. These systems can improve care for patients, protect staff and prevent infection, although their benefits must be weighed against the risks involved in storing sensitive data on computers. It is essential, therefore, that such systems are professionally maintained and updated. This article reports how one UK emergency department uses a computerised alert system to improve patient care.

Transporting major trauma patients from the margins of a UK trauma system.

OBJECTIVE: For serious motor vehicle crashes (MVC) occurring in a rural area to quantify: how many occur more than 45 min by road to a major trauma centre (MTC); how many occur more than 45 min by helicopter to an MTC; and how many patients might have to be taken to a local trauma unit if their incident occurs more than 45 min by road from an MTC and when the helicopter cannot fly. METHODS: MVC occurring in Shropshire, in which patients were killed or seriously injured during 2006-9 (inclusive) were analysed using the following parameters: distance from MTC by road; distance from MTC by air; weather and visibility-related factors that affect the operation of a helicopter emergency medical service. RESULTS: 722 serious MVC occurred, of which 626 (87%) occurred more than 45 min by road from the MTC. Of these 626 incidents, 408 occurred in conditions in which the helicopter could fly. There were 218 incidents (30%), which were more than 45 min by road from the MTC and which occurred when the helicopter could not fly. CONCLUSIONS: The transportation of patients from remote and rural areas to MTC remains problematical. Further work is required to develop more efficient systems of retrieval and transfer, and in particular to consider how emergency medical helicopters might operate safely at night.