Dr. Ian Stiell’s emergency department rulebook

Picture this: you’re an emergency department physician. A patient has come in with an ankle injury, and it’s your job to determine whether the ankle is broken, sprained, or just sore. How do you decide whether to send the patient for an x-ray?

Cue the Ottawa Ankle Rules. Developed by Ottawa-based researcher and emergency physician Dr. Ian Stiell, the Ottawa Ankle Rules are a series of guidelines to indicate whether an x-ray is needed in the case of ankle injuries.

“When I started out as a young emergency physician, there was virtually no research in the field,” says Dr. Stiell, now a senior scientist at The Ottawa Hospital and professor at the University of Ottawa. “In the case of ankle injuries, we didn’t really assess patients. We just ordered the x-rays.”

Dr. Stiell developed the Ottawa Ankle Rules more than 30 years ago, initially as his master’s thesis project, and they remain the standard of care in emergency departments worldwide, known for their reliability and simplicity. Based on research findings, these rules now ensure that patients with broken ankles receive the imaging they need while reducing unnecessary, costly, and time-consuming imaging for patients with milder injuries.

The Ottawa Ankle Rules aren’t the only clinical decision rules pioneered by Dr. Stiell. He also developed the Canadian C-Spine Rule to help health care providers decide whether patients with head or neck trauma require imaging of the cervical spine – the neck area of the spine. The Canadian CT Head Rule guides the use of computed tomography (CT) imaging for minor head injuries, and the Ottawa Knee Rule indicates when knee injuries require an x-ray.

Dr. Stiell’s greatest challenge? Encouraging his fellow health care providers to adopt these guidelines. “Busy emergency department physicians will often take the expeditious route of ordering imaging rather than a systematic assessment of the patient,” he says. In an uphill battle, through a number of implementation studies, Dr. Stiell and his colleagues have succeeded in coaxing health care providers to turn to these sets of rules.

“Things have changed greatly over the past 30 years,” notes Dr. Stiell. These clinical decision rules are now recognized and taught worldwide, streamlining emergency care and ensuring patients receive quick, evidence-based treatment.

At a glance

Issue

Diagnostic imaging including x-rays and computed tomography (CT) scans are costly, time-consuming, and often unnecessary, contributing to long emergency room wait times.

Research

Dr. Ian Stiell has developed clinical decision rules to indicate when imaging is needed for patients with conditions including ankle and knee injuries and head or neck trauma.