Adequacy of clinical information with reference to the Pittsburgh knee rules in cases of traumatic knee pain

Adequacy of clinical information provided by Emergency Department (ED) with reference to the Pittsburgh knee rules. The Pittsburgh knee rules help in triaging patients with traumatic knee pain and evidence has shown that it could help in reducing the number of referrals for unnecessary radiographs. It is also well proven to have a better specificity compared to the Ottawa knee rules [1].

The Pittsburgh knee rules state that knee radiographs are only required if there is traumatic knee pain in patients if they meet at least one of the following criteria:

• <12 years

• >50 years

• an inability to weight bear in the ED for 4 steps

The standard: 

All Knee x-ray requests for traumatic knee pain should provide adequate clinical information with reference to the Pittsburgh knee rules.

Target: 

100%

Indicators: 

Percentage of request cards providing adequate clinical information with reference to the Pittsburgh knee rules.

Data items to be collected: 

Request cards to assess clinical information provided by ED clinicians.

Suggested number: 

100

1. Presentation of results at ED education meeting highlighting areas for improvement

2. Identify referrers with poor record of completing requests and discuss benefits of improved clinical information

3. Re-audit after introduction of ED knee injury proforma, which specifies the Pittsburgh knee rules under examination findings, to assess if there was improvement in clinical information provided

4. An educational reminder as a report macro reiterating the Pittsburgh knee rule is an (evidence-based) effective intervention

• Patient list compilation by clerical staff: 2 hours

• Radiologist analysis of request card clinical information: 2 hours

1. Seaberg DC1, Jackson R, Clinical decision rule for knee radiographs, Am J Emerg Med. 1994 Sep;12(5):541-3.

2. Seaberg DC1, Yealy DM, Lukens T, Auble T, Mathias S. Multicenter comparison of two clinical decision rules for the use of radiography in acute, high-risk knee injuries. . Ann Emerg Med. 1998 Jul;32(1):8-13

3. Towards evidence based emergency medicine:PRIVATE best BETs from the Manchester Royal Infirmary. BET 1: predicting the need for knee radiography in the emergency department: Ottawa or Pittsburgh rule? Emerg Med J. 2012 Jan;29(1):77-8. doi: 10.1136/emermed-2011-200980.

4. Cheung TC1, Tank Y, Breederveld RS, Tuinebreijer WE, de Lange-de Klerk ES, Derksen RJ. Diagnostic accuracy and reproducibility of the Ottawa Knee Rule vs the Pittsburgh Decision Rule. Am J Emerg Med. 2013 Apr;31(4):641-5. doi: 10.1016/j.ajem.2012.11.003. Epub 2013 Feb 8.

Dr Umme Sara Zishan

Co-authors

Dr Khalid Ali