Audit of Ottawa Knee Rules Compliance in the Emergency Department: A Two-Cycle Quality Improvement Study at a General Hospital.

BACKGROUND: The Ottawa Knee Rules (OKRs) are validated clinical decision-making guidelines designed to reduce unnecessary radiography in acute knee trauma. Adherence to the OKRs ensures appropriate imaging, reduces patient radiation exposure, decreases the burden on radiology departments, and improves documentation standards. OBJECTIVE: To assess compliance with OKRs among non-consultant hospital doctors (NCHDs), namely registrars and senior house officers working in the emergency department (ED) of St. Luke's General Hospital, Kilkenny, Ireland, and evaluate improvements following targeted interventions. METHODS: A two-cycle audit was conducted. Data from February 2025 (cycle 1, n=70) and August 2025 (cycle 2, n=79) were reviewed. Interventions included educational sessions, dissemination of OKR leaflets, and display of posters in the ED area. Compliance with OKRs, documentation practices, imaging yield, and radiology resource burden was analyzed. RESULTS: Compliance with the OKRs improved between audit cycles, increasing from 50 cases (72.5%) in cycle 1 to 66 cases (83.5%) in cycle 2; however, it was not statistically significant (χ²=2.05, df=1, p=0.15). Correspondingly, the number of non-compliant X-rays decreased from 19 cases (27.5%) to 13 cases (16.5%). Documentation of suspected fracture or bone injury also showed improvement, rising from 23 cases (32.9%) to 44 cases (55.7%), which was statistically significant (χ²=6.56, df=1, p=0.01). The proportion of pathology-negative X-rays declined from 37 cases (52.9%) in cycle 1 to 30 cases (38.0%) in cycle 2, though this reduction was not statistically significant (χ²=3.04, df=1, p=0.08). Osteoarthritis was the most frequently reported finding in cycle 1, accounting for 15 patients (21.4%), whereas joint effusion was the predominant finding in cycle 2, observed in 33 patients (41.8%). Estimated unnecessary radiation exposure was reduced from 19 patients (~0.095-0.19 mSv) in cycle 1 to 13 patients (~0.065-0.13 mSv) in cycle 2. Additionally, the radiographer's workload was reduced by approximately 60-90 minutes between the two audit cycles. CONCLUSION: Educational interventions improved adherence to OKRs, reduced unnecessary imaging, and alleviated the radiology department's workload. Continuous reinforcement of guideline-based practice is essential to sustain improvements and optimize patient safety.