The scientific study of animal welfare has generated a welter of complex, equivocal and often contradictory results. Consequently, there is little agreement about how impairment of welfare should be measured. While some solutions to this have been suggested, these have usually relied on more sophisticated versions of, or more control over, existing measures. However, we argue that the difficulties arise because of questionable assumptions in the definition and measurement of welfare, in particular the measurement of suffering and the assumed importance of individual well-being. We contend that welfare can be interpreted only in terms of what natural selection has designed an organism to do and how circumstances impinge on its functional design. Organisms are designed for self-expenditure and the relative importance of self-preservation and survival, and the concomitant investment of time and resources in different activities, varies with life history strategy. The traditional notions of coping and stress are anthropomorphisms based on homeostatic mechanisms of self-preservation in a long-lived species. Suffering-like states are viewed as generalized subjective states that are geared to avoiding deleterious circumstances with which the organism does not have specific adaptive mechanisms to deal. Attempts to measure suffering-like states directly are likely to remain inconclusive, at least for the foreseeable future, because such states are private and subjective, may take many forms fundamentally different from our own and are likely to depend on the operation of phenotype-limited priorities and decision rules. However, measuring the impact of circumstances on functional design via the organism ‘s decision rules provides a practicable means of giving benefit of the doubt by indicating when suffering, or an analogous subjective state, is likely.

Introduction: Our tertiary care institution embarked on the Choosing Wisely campaign to reduce unnecessary testing, and selected the reduction of ankle x-rays as part of its top five priority initiatives. The Low Risk Ankle Rule (LRAR), an evidence-based decision rule, has been derived and validated to clinically evaluate ankle injuries which do not require radiography. The LRAR, is cost-effective, has 100% sensitivity for clinically important ankle injuries and reduces ankle imaging rates by 30-60% in both academic and community setting. Our objective was to significantly reduce the proportion of ankle x-rays ordered for acute ankle injuries presenting to our pediatric Emergency Department (ED). Methods: Medical records were reviewed for all patients presenting to our tertiary care pediatric ED (ages 3- 18 years) with an isolated acute ankle injury from Jan 1, 2016-Sept 30, 2016. Children with outside imaging, an injury that occurred >72 hours prior, or those who had a repeat ED visit for same injury were excluded. Quality improvement (QI) initiatives included multidisciplinary staff education about the LRAR, posters placed within the ED highlighting the LRAR, development of a new diagnostic imaging requisition for ankle x-rays requiring use of the LRAR and collaboration with the Division of Radiology to ensure compliance with new requisition. The proportion of patients presenting to the ED with acute ankle injuries who received x-rays was measured. ED length of stay (LOS), return visits to the ED and orthopedic referrals were collected as balancing measures. Results: At baseline 88% of patients with acute ankle injuries received x-rays. Following our multiple interventions, the proportion of x-rays decreased significantly to 54%, (p<0.001). This decrease in x-ray rate was not associated with an increase in ED LOS, ED return visits or orthopedic referrals. There was an increase uptake of the dedicated x-ray requisition over time to 71%. Conclusion: This QI initiative to increase uptake of the LRAR, resulted in a significant reduction of ankle x-rays rates for children presenting with acute ankle injuries in our pediatric ED without increasing LOS, return visits or need for orthopedic referrals for missed injuries. Just as in the derivation and validation studies, the reductions have been sustained and reduced unnecessary testing and ionizing radiation.

This paper is Part I of a 2-part series to describe the background and methodology for the Canadian C-Spine Rule study to develop a clinical decision rule for rational imaging in alert and stable trauma patients. Current use of radiography is inefficient and variable, in part because there has been a lack of evidence-based guidelines to assist emergency physicians. Clinical decision rules are research-based decision-making tools that incorporate 3 or more variables from the history, physical examination or simple tests. The Canadian CT Head and C-Spine (CCC) Study is a large collaborative effort to develop clinical decision rules for the use of CT head in minor head injury and for the use of cervical spine radiography in alert and stable trauma victims. Part I details the background and rationale for the development of the Canadian C-Spine Rule. Part II will describe in detail the objectives and methods of the Canadian C-Spine Rule study.