Impact of clinical decision rules on clinical care of traumatic injuries to the foot and ankle, knee, cervical spine, and head

Impact of Computerized Physician Order Entry (CPOE) Coupled With Clinical Decision Support (CDS) on Radiologic Services

Medical imaging is an essential component of healthcare, enabling accurate diagnoses and facilitating effective treatment plans. However, the field is not without its challenges, including medical imaging errors, overutilization of procedures, and adverse reactions to contrast agents. This review explores the impact of computerized physician order entry (CPOE) systems coupled with clinical decision support (CDS) on radiologic services. By analyzing the findings from various studies, this paper highlights how CPOE coupled with CDS can significantly reduce inappropriate imaging, enhance adherence to clinical guidelines, and improve overall patient safety. The implementation of CPOE with CDS optimizes the utilization of radiologic procedures, thereby reducing healthcare costs and minimizing patients' exposure to unnecessary radiation. Despite its benefits, the adoption of CPOE with CDS encounters challenges such as high implementation costs, changes in workflow, and alert fatigue among healthcare providers. Addressing these challenges requires careful system design, including the customization of alerts to reduce override rates and improve the specificity of CDS recommendations. This review underscores the potential of CPOE with CDS to transform radiologic services, enhancing both the quality and safety of patient care. Further research is needed to explore the system's effectiveness in preventing adverse reactions to contrast media and to identify best practices for overcoming the barriers to its broader adoption.

Quality and transparency of reporting derivation and validation prognostic studies of recurrent stroke in patients with TIA and minor stroke: a systematic review

BACKGROUND

Clinical prediction models/scores help clinicians make optimal evidence-based decisions when caring for their patients. To critically appraise such prediction models for use in a clinical setting, essential information on the derivation and validation of the models needs to be transparently reported. In this systematic review, we assessed the quality of reporting of derivation and validation studies of prediction models for the prognosis of recurrent stroke in patients with transient ischemic attack or minor stroke.

METHODS

MEDLINE and EMBASE databases were searched up to February 04, 2020. Studies reporting development or validation of multivariable prognostic models predicting recurrent stroke within 90 days in patients with TIA or minor stroke were included. Included studies were appraised for reporting quality and conduct using a select list of items from the Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis (TRIPOD) Statement.

RESULTS

After screening 7026 articles, 60 eligible articles were retained, consisting of 100 derivation and validation studies of 27 unique prediction models. Four models were newly derived while 23 were developed by validating and updating existing models. Of the 60 articles, 15 (25%) reported an informative title. Among the 100 derivation and validation studies, few reported whether assessment of the outcome (24%) and predictors (12%) was blinded. Similarly, sample size justifications (49%), description of methods for handling missing data (16.1%), and model calibration (5%) were seldom reported. Among the 96 validation studies, 17 (17.7%) clearly reported on similarity (in terms of setting, eligibility criteria, predictors, and outcomes) between the validation and the derivation datasets. Items with the highest prevalence of adherence were the source of data (99%), eligibility criteria (93%), measures of discrimination (81%) and study setting (65%).

CONCLUSIONS

The majority of derivation and validation studies for the prognosis of recurrent stroke in TIA and minor stroke patients suffer from poor reporting quality. We recommend that all prediction model derivation and validation studies follow the TRIPOD statement to improve transparency and promote uptake of more reliable prediction models in practice.

TRIAL REGISTRATION

The protocol for this review was registered with PROSPERO (Registration number CRD42020201130 ).

Elbow rehabilitation using intelligent medical devices

The purpose of this paper is to demonstrate that the process of elbow joint rehabilitation can be monitored and improved using intelligent medical devices. During the study, an orthosis-type medical device was developed that monitors the mobility of the elbow joint in case of pathology. This device is useful in monitoring flexion movements (forward and backward), as well as internal and external rotation. For this purpose, a set of sensors were used that will capture the necessary and specific information, and the extracted data will be transmitted to a microcontroller for processing. The orthosis is one that can be customized according to the patient's pathology because it will analyse the data collected and interpret the values according to the calibration performed on the patient. The orthosis can be used both in the evaluation of joint dysfunctions at the elbow and in a rehabilitation program to avoid vicious positions. The positioning of the orthosis will be done together with the specialist doctor or in the presence of a physiotherapist, following the detailed clinical examination, so that the calibration of the sensors can be performed correctly. The device can emit warning sequences that will depend on the movements that the patient will perform, movements that can be sudden or accidental. Keywords: elbow joint, orthesis, physiokinetotherapist, rehabilitation, health improvement,

A validation study for a clinical decision rule for acute wrist injury

PURPOSE

Acute wrist injury is a common reason for visiting the emergency department. To date, there are no implemented clinical decision rules to predict a fracture in this group of patients. We previously identified six clinical predictors in adult patients with acute wrist trauma. The aim of this study was to validate these predictors as a decision rule in a validation cohort.

METHODS

This prospective cohort study was conducted in the emergency department at five hospitals in the Netherlands and included adults with acute wrist injury. All collaborating physicians performed a standardized physical examination and data were collected in a case report form. The main outcome was defined as the radiographic presence of a wrist fracture. Six clinical variables that were significantly associated with a fracture (ρ < 0.01) were included in a model to develop the clinical decision rule.

RESULTS

A total of 493 fractures in 724 patients were identified by radiographic assessment. Almost all of the clinical variables were associated with the presence of a fracture. Our decision rule had a sensitivity of 0.97 (95% CI 0.96-0.99) with a specificity of 0.26 (95% CI 0.20-0.32) in this validation cohort. Application of the decision rule resulted in a reduction in radiographic assessment rate of 10% at the cost of missing 2% of the fractures.

CONCLUSION

The decision rule showed a high sensitivity and low specificity, possible due to the high pre-test probability of a wrist fracture in the cohort. Our study needs further validation in other populations.

Mobile Clinical Decision Tools Among Emergency Department Clinicians: Web-Based Survey and Analytic Data for Evaluation of The Ottawa Rules App

BACKGROUND

The Canadian CT Head Rule (CCHR), the Canadian Transient Ischemic Attack (TIA) Score, and the Subarachnoid Hemorrhage (SAH) Rule have all previously demonstrated the potential to significantly standardize care and improve the management of patients in emergency departments (EDs). On the basis of user feedback, we believe that the addition of these rules to the Ottawa Rules App has the potential to increase the app's usability and user acceptability.

OBJECTIVE

This study aimed to evaluate the perceived usefulness, acceptability, and uptake of the enhanced Ottawa Rules App (which now includes CCHR, TIA, and SAH Rules) among ED clinicians (medical students, residents, nurses, and physicians).

METHODS

The enhanced Ottawa Rules App was publicly released for free on iOS and Android operating systems in November 2018. This study was conducted across 2 tertiary EDs in Ottawa, Canada. Posters, direct enrollment, snowball sampling, and emails were used for study recruitment. A 24-question Web-based survey was administered to participants via email, and this was used to determine user acceptability of the app and Technology Readiness Index (TRI) scores. In-app user analytics were collected to track user behavior, such as the number of app sessions, length of app sessions, frequency of rule use, and the date app was first opened.

RESULTS

A total of 77 ED clinicians completed the study, including 34 nurses, 12 residents, 14 physicians, and 17 medical students completing ED rotations. The median TRI score for this group was 3.38, indicating a higher than average propensity to embrace and adopt new technologies to accomplish goals in their work or daily lives. The majority of respondents agreed or strongly agreed that the app helped participants accurately carry out the clinical rules (56/77, 73%) and that they would recommend this app to their colleagues (64/77, 83%). Feedback from study participants suggested further expansion of the app-more clinical decision rules (CDRs) and different versions of the app tailored to the clinician role. Analysis and comparison of Google Analytics data and in-app data revealed similar usage behavior among study-enrolled users and all app users globally.

CONCLUSIONS

This study provides evidence that using the Ottawa Rules App (version 3.0.2) to improve and guide patient care would be feasible and widely accepted. The ability to verify self-reported user data (via a Web-based survey) against server analytics data is a notable strength of this study. Participants' continued app use and request for the addition of more CDRs warrant the further development of this app and call for additional studies to evaluate its feasibility and usability in different settings as well as assessment of clinical impact.

The Applicability of New Orleans Criteria for Head Computed Tomography in Inpatient Falls With Injury

Background

Inpatient falls are a patient safety concern. Limited data exist on the utility of head computed tomography (CT) for inpatient falls. The New Orleans Criteria (NOC) is a validated tool to determine the appropriateness of neuroimaging in the emergency department for falls with minor head injury. This study aimed to evaluate whether the NOC could be applied to inpatient falls.

Methods

This retrospective cohort study assessed 1 year of inpatient falls with injury at 5 inpatient facilities. Records were reviewed for demographic data, fall circumstances, laboratory results, components of the NOC, and head CT results. Cohorts included positive NOC (≥1 NOC finding) and negative NOC. Sensitivity and specificity were calculated for the NOC alone, NOC plus coagulopathy, and NOC or coagulopathy for acute intracranial process.

Results

Of 332 inpatient falls with injury, 188 (57%) received a head CT. Of the 250 (75.3%) NOC-positive cases, 159 (63.6%) received a head CT. Of all patients who received a head CT, 7 (2.1%) showed a significant acute intracranial process. The NOC was positive in 6 of the 7 cases (sensitivity 85.7% and specificity 23.8%); the other case had a significant coagulopathy. New Orleans Criteria or coagulopathy had 100% sensitivity and 23.4% specificity.

Conclusions

Our findings show that use of the NOC to evaluate potential intracranial injury in inpatient falls is limited. Adding criteria to the NOC may improve its test characteristics, with a sensitivity of 100% for the NOC or coagulopathy, suggesting potential clinical utility.

Acceptability of a Mobile Clinical Decision Tool Among Emergency Department Clinicians: Development and Evaluation of The Ottawa Rules App

Background

The Ottawa Ankle Rules, Ottawa Knee Rule, and Canadian C-Spine Rule—together known as The Ottawa Rules—are a set of internationally validated clinical decision rules developed to decrease unnecessary diagnostic imaging in the emergency department. In this study, we sought to develop and evaluate the use of a mobile app version of The Ottawa Rules.

Objective

The primary objective of this study was to determine acceptability of The Ottawa Rules app among emergency department clinicians. The secondary objective was to evaluate the effect of publicity efforts on uptake of The Ottawa Rules app.

Methods

The Ottawa Rules app was developed and publicly released for free on iOS and Android operating systems in April 2016. Local and national news and academic media coverage coincided with app release. This study was conducted at a large tertiary trauma care center in Ottawa, Canada. The study was advertised through posters and electronically by email. Emergency department clinicians were approached in person to enroll via in-app consent for a 1-month study during which time they were encouraged to use the app when evaluating patients with suspected knee, foot, or neck injuries. A 23-question survey was administered at the end of the study period via email to determine self-reported frequency, perceived ease of use of the app, and participant Technology Readiness Index scores.

Results

A total of 108 emergency department clinicians completed the study including 42 nurses, 33 residents, 20 attending physicians, and 13 medical students completing emergency department rotations. The median Technology Readiness Index for this group was 3.56, indicating a moderate degree of openness for technological adoption. The majority of survey respondents indicated favorable receptivity to the app including finding it helpful to applying the rules (73/108, 67.6%), that they would recommend the app to colleagues (81/108, 75.0%), and that they would continue using the app (73/108, 67.6%). Feedback from study participants highlighted a desire for access to more clinical decision rules and a higher degree of interactivity of the app. Between April 21, 2016, and June 1, 2017, The Ottawa Rules app was downloaded approximately 4000 times across 89 countries.

Conclusions

We have found The Ottawa Rules app to be an effective means to disseminate the Ottawa Ankle Rules, Ottawa Knee Rule, and Canadian C-Spine Rule among all levels of emergency department clinicians. We have been successful in monitoring uptake and access of the rules in the app as a result of our publicity efforts. Mobile technology can be leveraged to improve the accessibility of clinical decision tools to health professionals.

Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline

This guideline aimed to advance current understandings regarding the diagnosis, prevention and therapeutic interventions for ankle sprains by updating the existing guideline and incorporate new research. A secondary objective was to provide an update related to the cost-effectiveness of diagnostic procedures, therapeutic interventions and prevention strategies. It was posited that subsequent interaction of clinicians with this guideline could help reduce health impairments and patient burden associated with this prevalent musculoskeletal injury. The previous guideline provided evidence that the severity of ligament damage can be assessed most reliably by delayed physical examination (4-5 days post trauma). After correct diagnosis, it can be stated that even though a short time of immobilisation may be helpful in relieving pain and swelling, the patient with an acute lateral ankle ligament rupture benefits most from use of tape or a brace in combination with an exercise programme.New in this update: Participation in certain sports is associated with a heightened risk of sustaining a lateral ankle sprain. Care should be taken with non-steroidal anti-inflammatory drugs (NSAIDs) usage after an ankle sprain. They may be used to reduce pain and swelling, but usage is not without complications and NSAIDs may suppress the natural healing process. Concerning treatment, supervised exercise-based programmes preferred over passive modalities as it stimulates the recovery of functional joint stability. Surgery should be reserved for cases that do not respond to thorough and comprehensive exercise-based treatment. For the prevention of recurrent lateral ankle sprains, ankle braces should be considered as an efficacious option.

The Optimal Screening for Prediction of Referral and Outcome (OSPRO) in patients with musculoskeletal pain conditions: a longitudinal validation cohort from the USA

PURPOSE

There is an increased need for determining which patients with musculoskeletal pain benefit from additional diagnostic testing or psychologically informed intervention. The Optimal Screening for Prediction of Referral and Outcome (OSPRO) cohort studies were designed to develop and validate standard assessment tools for review of systems and yellow flags. This cohort profile paper provides a description of and future plans for the validation cohort.

PARTICIPANTS

Patients (n=440) with primary complaint of spine, shoulder or knee pain were recruited into the OSPRO validation cohort via a national Orthopaedic Physical Therapy-Investigative Network. Patients were followed up at 4 weeks, 6 months and 12 months for pain, functional status and quality of life outcomes. Healthcare utilisation outcomes were also collected at 6 and 12 months.

FINDINGS TO DATE

There are no longitudinal findings reported to date from the ongoing OSPRO validation cohort. The previously completed cross-sectional OSPRO development cohort yielded two assessment tools that were investigated in the validation cohort.

FUTURE PLANS

Follow-up data collection was completed in January 2017. Primary analyses will investigate how accurately the OSPRO review of systems and yellow flag tools predict 12-month pain, functional status, quality of life and healthcare utilisation outcomes. Planned secondary analyses include prediction of pain interference and/or development of chronic pain, investigation of treatment expectation on patient outcomes and analysis of patient satisfaction following an episode of physical therapy.

TRIAL REGISTRATION NUMBER

The OSPRO validation cohort was not registered.

Diagnostic error in the Emergency Department: follow up of patients with minor trauma in the outpatient clinic

Background

The Emergency Department (ED) is prone to diagnostic error. Most frequent diagnostic errors involved “minor” trauma. Our goal was to determine how frequently a missed diagnosis was detected during follow up and to determine the frequency and causes of primary missed diagnosis and diagnostic error.

Methods

A retrospective single centre study review, during 6 months including all patients presenting to the outpatient clinic after ED admission with a minor trauma. We defined primary missed diagnosis versus diagnostic error. Demographic data were collected in Excel file and analyzed using Χ² and unpaired T-test.

Results

Inclusion of 56 patients leading to 57 missed diagnoses representing 1.39% of all minor trauma patients presenting to the ED. History and physical examination notes were incomplete or inadequate in respectively 17/56 and 20/56. Most frequently missed diagnoses were ankle (13/57), wrist (8/57) and foot (7/57) fractures. Causes for diagnostic error could be categorized into two main groups: failure to perform adequate history taking and/or physical examination and failure to order or correctly interpret technical investigation. In 6 cases (0.14%) diagnostic error was confirmed. All other cases were defined as primary missed diagnosis.

Discussion

Emergency physicians have to remain vigilant to prevent and avoid primary missed diagnosis (PMD) and diagnostic error (DE), certainly in case of minor trauma patients, representing a large proportion of ED patients. We observed a prevalence of 1.39% of missed diagnoses within a six month study period. This is comparable to previous studies (1% ). However in our study both primary missed diagnoses and DE were included. Using this definition we saw that only one case could be attributed to negligence and DE had a prevalence of 0.14% (6 cases). X-rays remain the mainstay investigation for minor trauma patients, however in certain selected cases (pelvic and spinal trauma) we advise early CT-scan.Follow up in an outpatient clinic or other forms of planned follow up have to be provided and help to reduce PMD and DE.

Conclusion

Both primary missed diagnosis and diagnostic error have relatively low prevalence but have a serious impact on patients, hospitals and medical services. Planned follow up after adequate explanation can help to prevent diagnostic error and detect primary missed diagnosis, thereby reducing time to final diagnosis and risks for medico legal litigation. Reassessment of diagnostic error on a timely basis can be used as a key performance indicator in a quality assessment program.

Weber B Distal Fibular Fracture Diagnosed by Point-of-care Ultrasound

We report the case of a 45-year-old woman who presented to the emergency department (ED) after an acute ankle inversion injury. After history and physical exam suggested a potential fracture, point-of-care ultrasound (POCUS) demonstrated a cortical defect of the distal fibula, consistent with fracture. Plain radiography failed to demonstrate a fracture. Later, the fracture was identified as a Weber B distal fibular fracture by stress-view radiography. This case reviews the evaluation of acute ankle injuries in the ED and the utility of POCUS as a supplemental imaging modality in the evaluation of ankle fracture.

Diagnostic validity of physical examination tests for common knee disorders: An overview of systematic reviews and meta-analysis

INTRODUCTION

More evidence on diagnostic validity of physical examination tests for knee disorders is needed to lower frequently used and costly imaging tests.

OBJECTIVE

To conduct a systematic review of systematic reviews (SR) and meta-analyses (MA) evaluating the diagnostic validity of physical examination tests for knee disorders.

METHODS

A structured literature search was conducted in five databases until January 2016. Methodological quality was assessed using the AMSTAR.

RESULTS

Seventeen reviews were included with mean AMSTAR score of 5.5 ± 2.3. Based on six SR, only the Lachman test for ACL injuries is diagnostically valid when individually performed (Likelihood ratio (LR+):10.2, LR-:0.2). Based on two SR, the Ottawa Knee Rule is a valid screening tool for knee fractures (LR-:0.05). Based on one SR, the EULAR criteria had a post-test probability of 99% for the diagnosis of knee osteoarthritis. Based on two SR, a complete physical examination performed by a trained health provider was found to be diagnostically valid for ACL, PCL and meniscal injuries as well as for cartilage lesions.

CONCLUSION

When individually performed, common physical tests are rarely able to rule in or rule out a specific knee disorder, except the Lachman for ACL injuries. There is low-quality evidence concerning the validity of combining history elements and physical tests.

Putting Meaning into Meaningful Use: A Roadmap to Successful Integration of Evidence at the Point of Care

Pressures to contain health care costs, personalize patient care, use big data, and to enhance health care quality have highlighted the need for integration of evidence at the point of care. The application of evidence-based medicine (EBM) has great promise in the era of electronic health records (EHRs) and health technology. The most successful integration of evidence into EHRs has been complex decision tools that trigger at a critical point of the clinical visit and include patient specific recommendations. The objective of this viewpoint paper is to investigate why the incorporation of complex CDS tools into the EMR is equally complex and continues to challenge health service researchers and implementation scientists. Poor adoption and sustainability of EBM guidelines and CDS tools at the point of care have persisted and continue to document low rates of usage. The barriers cited by physicians include efficiency, perception of usefulness, information content, user interface, and over-triggering. Building on the traditional EHR implementation frameworks, we review keys strategies for successful CDSs: (1) the quality of the evidence, (2) the potential to reduce unnecessary care, (3) ease of integrating evidence at the point of care, (4) the evidence’s consistency with clinician perceptions and preferences, (5) incorporating bundled sets or automated documentation, and (6) shared decision making tools. As EHRs become commonplace and insurers demand higher quality and evidence-based care, better methods for integrating evidence into everyday care are warranted. We have outlined basic criteria that should be considered before attempting to integrate evidenced-based decision support tools into the EHR.

Knowledge Translation and Barriers to Imaging Optimization in the Emergency Department: A Research Agenda

Researchers have attempted to optimize imaging utilization by describing which clinical variables are more predictive of acute disease and, conversely, what combination of variables can obviate the need for imaging. These results are then used to develop evidence-based clinical pathways, clinical decision instruments, and clinical practice guidelines. Despite the validation of these results in subsequent studies, with some demonstrating improved outcomes, their actual use is often limited. This article outlines a research agenda to promote the dissemination and implementation (also known as knowledge translation) of evidence-based interventions for emergency department (ED) imaging, i.e., clinical pathways, clinical decision instruments, and clinical practice guidelines. We convened a multidisciplinary group of stakeholders and held online and telephone discussions over a 6-month period culminating in an in-person meeting at the 2015 Academic Emergency Medicine consensus conference. We identified the following four overarching research questions: 1) what determinants (barriers and facilitators) influence emergency physicians' use of evidence-based interventions when ordering imaging in the ED; 2) what implementation strategies at the institutional level can improve the use of evidence-based interventions for ED imaging; 3) what interventions at the health care policy level can facilitate the adoption of evidence-based interventions for ED imaging; and 4) how can health information technology, including electronic health records, clinical decision support, and health information exchanges, be used to increase awareness, use, and adherence to evidence-based interventions for ED imaging? Advancing research that addresses these questions will provide valuable information as to how we can use evidence-based interventions to optimize imaging utilization and ultimately improve patient care.

Rehabilitation after lower limb injury: development of a predictive score (RALLI score)

BACKGROUND

The purpose of our study was to identify the risk factors associated with the need for inpatient rehabilitation after lower limb injury to develop a predictive scoring tool for early identification of such patients.

METHODS

We followed a prospective cohort of patients admitted to a level 1 trauma centre. Data were collected through chart review and a self-administered questionnaire on sociodemographics, patient living environment, pretrauma status, injury and treatment received. We compared patients who were discharged home with those going to rehabilitation after acute care. Analysis consisted of bivariate comparisons and logistic regression.

RESULTS

Our study included 160 patients with a mean age of 56 years. A total of 40% were discharged to an inpatient rehabilitation centre. Factors associated with inpatient rehabilitation were low preinjury physical health status, concomitant injury of the upper limbs, bilateral lower limb injury, the use of a walking aid before injury, head injury and femur or pelvic fractures. We created a predictive score using the top 3 risk factors: upper limb injury, bilateral lower limb injury and presence of femoral or pelvic fractures. The chance of needing inpatient rehabilitation rose from 14% with 0 factors to 47% with 1 factor and 96% with 2 factors.

CONCLUSION

Rehabilitation planning should begin for patients exhibiting at least of 3 risk factors at the time of admission to acute care. Prospective validation of the tool is needed, but it has the potential to orient the multidisciplinary team's decision on rehabilitation needs postdischarge.

A pilot study to identify clinical predictors for wrist fractures in adult patients with acute wrist injury

BACKGROUND

To date, no clinical decision rules for acute wrist injuries are available. In the past, clinical decision rules for the knee, ankle and spine injuries have been developed and validated. Implementation of these rules resulted in standardised clinical assessment at the emergency department and a substantial reduction of radiographic diagnostics. The objective of the study was to identify predictors for wrist fractures in patients with acute wrist injury which might potentiate a clinical decision rule in the future. This is a prospective pilot study in adult patients presenting with acute wrist injury at the emergency department of the Canisius-Wilhelmina Hospital in the Netherlands.

METHODS

Clinical variables were collected in a case report file by emergency physicians. Radiography was ordered according to common practice to confirm or rule out the presence of fractures. Independent associations between the presence of clinical variables and wrist fractures were calculated. Multivariable analysis was performed in order to quantify sensitivity and specificity for fracture prediction.

RESULTS

A total of 63 wrist fractures were detected in the study population of 95. Age over 55 years, inability to carry weight directly after trauma, support of injured wrist by the contralateral hand for pain relief, presence of swelling and/or hematoma, visible wrist deformity and reduced range of motion were associated with the presence of a wrist fracture.

CONCLUSIONS

Our study identified clinical predictors for wrist fractures in patients with acute wrist injury. Future studies are needed for justification of evidence-based wrist assessment and identification of a 100% sensitive decision rule for wrist fractures.

Is there a need for a clinical decision rule in blunt wrist trauma?

BACKGROUND

Blunt wrist trauma is a very common injury in emergency medicine. However, in contrast to other extremity trauma, there is no clinical decision rule for radiography in patients with blunt wrist trauma.

OBJECTIVE

The purpose of this study is to describe current practice and to assess the need and feasibility for a clinical decision rule for radiography in patients with blunt wrist trauma.

METHODS

All patients with blunt wrist trauma who presented to our Emergency Department (ED) during a 6-month period were included in this study. Basic demographics were analysed and the radiography ratio was determined. The radiography results were compared for different demographic groups. Current practice and the need and feasibility for a decision rule were evaluated using Stiell's checklist for clinical decision rules.

RESULTS

A total of 1019 patients with 1032 blunt wrist injuries presented at our ED in a period of 6 months. In 91.4% of patients, radiographs were taken. In 41.6% of those radiographed, a fracture was visible on plain radiography. Fractures were most common in the paediatric and senior age groups. However, even in the lower-risk groups we observed a fracture incidence of about 20%.

CONCLUSION

There is no need for a clinical decision rule for radiography in patients with blunt wrist trauma because the fracture ratio is high. Neither does it seem feasible to develop a highly sensitive and efficient decision rule. Therefore, the authors recommend radiography in all patients with blunt wrist trauma presenting to the ED.

Knowledge Translation Tools are Emerging to Move Neck Pain Research into Practice

Development or synthesis of the best clinical research is in itself insufficient to change practice. Knowledge translation (KT) is an emerging field focused on moving knowledge into practice, which is a non-linear, dynamic process that involves knowledge synthesis, transfer, adoption, implementation, and sustained use. Successful implementation requires using KT strategies based on theory, evidence, and best practice, including tools and processes that engage knowledge developers and knowledge users. Tools can provide instrumental help in implementing evidence. A variety of theoretical frameworks underlie KT and provide guidance on how tools should be developed or implemented. A taxonomy that outlines different purposes for engaging in KT and target audiences can also be useful in developing or implementing tools. Theoretical frameworks that underlie KT typically take different perspectives on KT with differential focus on the characteristics of the knowledge, knowledge users, context/environment, or the cognitive and social processes that are involved in change. Knowledge users include consumers, clinicians, and policymakers. A variety of KT tools have supporting evidence, including: clinical practice guidelines, patient decision aids, and evidence summaries or toolkits. Exemplars are provided of two KT tools to implement best practice in management of neck pain—a clinician implementation guide (toolkit) and a patient decision aid. KT frameworks, taxonomies, clinical expertise, and evidence must be integrated to develop clinical tools that implement best evidence in the management of neck pain.

Diagnostic accuracy of history, physical examination, and bedside ultrasound for diagnosis of extremity fractures in the emergency department: a systematic review

OBJECTIVES

Understanding history, physical examination, and ultrasonography (US) to diagnose extremity fractures compared with radiography has potential benefits of decreasing radiation exposure, costs, and pain and improving emergency department (ED) resource management and triage time.

METHODS

The authors performed two electronic searches using PubMed and EMBASE databases for studies published between 1965 to 2012 using a strategy based on the inclusion of any patient presenting with extremity injuries suspicious for fracture who had history and physical examination and a separate search for US performed by an emergency physician (EP) with subsequent radiography. The primary outcome was operating characteristics of ED history, physical examination, and US in diagnosing radiologically proven extremity fractures. The methodologic quality of the studies was assessed using the quality assessment of studies of diagnostic accuracy tool (QUADAS-2).

RESULTS

Nine studies met the inclusion criteria for history and physical examination, while eight studies met the inclusion criteria for US. There was significant heterogeneity in the studies that prevented data pooling. Data were organized into subgroups based on anatomic fracture locations, but heterogeneity within the subgroups also prevented data pooling. The prevalence of fracture varied among the studies from 22% to 70%. Upper extremity physical examination tests have positive likelihood ratios (LRs) ranging from 1.2 to infinity and negative LRs ranging from 0 to 0.8. US sensitivities varied between 85% and 100%, specificities varied between 73% and 100%, positive LRs varied between 3.2 and 56.1, and negative LRs varied between 0 and 0.2.

CONCLUSIONS

Compared with radiography, EP US is an accurate diagnostic test to rule in or rule out extremity fractures. The diagnostic accuracy for history and physical examination are inconclusive. Future research is needed to understand the accuracy of ED US when combined with history and physical examination for upper and lower extremity fractures.

Electronic decision support for diagnostic imaging in a primary care setting

METHODS

Clinical guideline adherence for diagnostic imaging (DI) and acceptance of electronic decision support in a rural community family practice clinic was assessed over 36 weeks. Physicians wrote 904 DI orders, 58% of which were addressed by the Canadian Association of Radiologists guidelines.

RESULTS

Of those orders with guidelines, 76% were ordered correctly; 24% were inappropriate or unnecessary resulting in a prompt from clinical decision support. Physicians followed suggestions from decision support to improve their DI order on 25% of the initially inappropriate orders. The use of decision support was not mandatory, and there were significant variations in use rate. Initially, 40% reported decision support disruptive in their work flow, which dropped to 16% as physicians gained experience with the software.

CONCLUSIONS

Physicians supported the concept of clinical decision support but were reluctant to change clinical habits to incorporate decision support into routine work flow.

Diagnostic classification in patients with suspected deep venous thrombosis: physicians' judgement or a decision rule?

BACKGROUND

Clinical decision rules can aid in referral decisions for ultrasonography in patients suspected of having deep venous thrombosis (DVT), but physicians are not always convinced of their usefulness and rely on their own judgement.

AIM

To compare the performance of a clinical decision rule with the probability of DVT presence as estimated by GPs.

DESIGN OF STUDY

Cross-sectional survey.

SETTING

Primary care practices in The Netherlands.

METHOD

GPs (n = 300) estimated the probability of the presence of DVT (range 0-100%) and calculated the score for the clinical decision rule in 1028 consecutive patients with suspected DVT. The clinical decision rule uses a threshold of three points and so, for the GP estimates, thresholds were introduced at 10% and 20%. If scores were below these estimates, it was not considered necessary to refer patients for further examination. Differences between the clinical decision rule and the GP estimates were calculated; this is discrimination (c-statistic) and classification of patients.

RESULTS

Data of 1002 patients were eligible for analysis. DVT was observed in 136 (14%) patients. Both the clinical decision rule and GP estimates had good discriminative power (c-statistic of 0.80 and 0.82 respectively). Fewer patients were referred when using the clinical decision rule compared with a referral decision based on GP estimates: 51% versus 79% and 65% (thresholds at 10% and 20% respectively). Both strategies missed a similar and low proportion of patients who did have DVT (range 1.4-2.0%).

CONCLUSION

In patients suspected of DVT both GP estimates and a clinical decision rule can safely discriminate in patients with and without DVT. However, fewer patients are referred for ultrasonography when GPs rely on a clinical decision rule to guide their decision making.

Evaluation and economic impact analysis of different treatment options for ankle distortions in occupational accidents

RATIONALE, AIMS AND OBJECTIVES

Appropriate use of diagnostic and treatment modalities are essential for rational use of resources. The aim of this study is to evaluate the use of diagnostic modalities and different treatment options and their economic impacts following an acute ankle distortion resulting from an occupational accident. We evaluated the type-of-treatment impact on the victims' course of recovery as well as its impact on the associated accident costs. Research was carried out in Belgium.

METHODS

An ankle distortion victims' database consisting of 200 cases of (Belgian) occupational accidents during the period 2005-2007 was analysed.

RESULTS

Patients who were prescribed immobilization or the use of adjuvant support or physical therapy (118 cases) were not employed during a period of 37 days on average, with a mean total cost of 3140.14 Euros caused by the ankle sprain. Patients without any adjuvant therapy (82 cases) were characterized by an unemployment rate of 15 days on average, and a total cost of 1077.86 Euros. Cast immobilization, although its application is not supported by evidence-based literature, was still applied in 36% of the population studied and resulted in the longest average absence of work of 42 days with an obvious significant increase in medical and total costs.

CONCLUSIONS

Our results show a high rate of inappropriate use of cast immobilizations for ankle distortions. From an economic point of view and for the same clinical endpoint (being full resumption of the occupational activities), simple conventional treatment, consisting of rest, ice, compression and elevation at diagnosis with allowance of early weight bearing in the further clinical course, leads to the quickest full resumption of activities in combination with the lowest medical costs, if compared with any other kind of treatment.

Sideline evaluation and treatment of bone and joint injury

Athletes can sustain a large variety of injuries, from simple soft-tissue sprains to complex fractures and dislocations. This article reviews and provides the most recent information for sports medicine professionals on the initial assessment and treatment from the sports sidelines without the benefit of imaging of bone and joint injuries (excluding facial injuries). This information will aid sports medicine professionals by giving them basic suggestions that may allow for the safe and prompt return of athletes to the field of play.

Knowledge translation: putting the "practice" in evidence-based practice

Knowledge translation (KT) is an iterative process that involves knowledge development, synthesis, contextualization, and adaptation, with the expressed purpose of moving the best evidence into practice that results in better health processes and outcomes for patients. Optimization of the process requires engaged interaction between knowledge developers and knowledge users. Knowledge users include consumers, clinicians, and policy makers. KT is highly reliant on understanding when research evidence needs to be moved into practice. Social, personal, policy, and system factors contribute to how and when change in practice can be accomplished. Evidence-based practitioners need to understand a conceptual basis for KT and the evidence indicating which specific KT strategies might help them move best evidence into action in practice. Audit and feedback, knowledge brokering, clinical practice guidelines, professional standards, and "active-learning" continuing education are examples of KT strategies.

Elbow extension test to rule out elbow fracture: multicentre, prospective validation and observational study of diagnostic accuracy in adults and children

OBJECTIVE

To determine whether full elbow extension as assessed by the elbow extension test can be used in routine clinical practice to rule out bony injury in patients presenting with elbow injury.

DESIGN

Adults: multicentre prospective interventional validation study in secondary care. Children: multicentre prospective observational study in secondary care.

SETTING

Five emergency departments in southwest England.

PARTICIPANTS

2127 adults and children presenting to the emergency department with acute elbow injury.

INTERVENTION

Elbow extension test during routine care by clinical staff to determine the need for radiography in adults and to guide follow-up in children.

MAIN OUTCOME MEASURES

Presence of elbow fracture on radiograph, or recovery with no indication for further review at 7-10 days.

RESULTS

Of 1740 eligible participants, 602 patients were able to fully extend their elbow; 17 of these patients had a fracture. Two adult patients with olecranon fractures needed a change in treatment. In the 1138 patients without full elbow extension, 521 fractures were identified. Overall, the test had sensitivity and specificity (95% confidence interval) for detecting elbow fracture of 96.8% (95.0 to 98.2) and 48.5% (45.6 to 51.4). Full elbow extension had a negative predictive value for fracture of 98.4% (96.3 to 99.5) in adults and 95.8% (92.6 to 97.8) in children. Negative likelihood ratios were 0.03 (0.01 to 0.08) in adults and 0.11 (0.06 to 0.19) in children.

CONCLUSION

The elbow extension test can be used in routine practice to inform clinical decision making. Patients who cannot fully extend their elbow after injury should be referred for radiography, as they have a nearly 50% chance of fracture. For those able to fully extend their elbow, radiography can be deferred if the practitioner is confident that an olecranon fracture is not present. Patients who do not undergo radiography should return if symptoms have not resolved within 7-10 days.

CT utilization: the emergency department perspective

CT scan utilization in the pediatric emergency department (ED) has dramatically increased in recent years. This likely reflects the improved diagnostic capability of CT, as well as its wider availability. However, the utility of CT is tempered by the high radiation exposure to patients as well as cost. In this review we will consider the magnitude of changes in CT use in the pediatric ED, and we will examine some of the driving forces behind these increases. In addition, we will consider strategies to limit growth in CT scan utilization or even result in reductions in CT use in the future. These strategies include better physician and patient education, application of existing clinical decision rules to reduce CT utilization and development of new rules, technical alterations in CT protocols to reduce per-exam exposures, use of alternative imaging modalities such as US and MRI that do not expose patients to ionizing radiation, and expanded use of clinical observation in place of immediate diagnostic imaging. Reform of liability laws might alleviate another driving force behind high CT utilization rates. Protocols must be designed to maximize patient safety by limiting radiation exposures while preserving rapid and accurate diagnosis of time-sensitive conditions.

International survey of emergency physicians' priorities for clinical decision rules

OBJECTIVES

One of the first stages in the development of new clinical decision rules (CDRs) is determination of need. This study examined the clinical priorities of emergency physicians (EPs) working in Australasia, Canada, the United Kingdom, and the United States for the development of future CDRs.

METHODS

The authors administered an e-mail and postal survey to members of the national emergency medicine (EM) associations in Australasia, Canada, the United Kingdom, and the United States. Results were analyzed via frequency distributions.

RESULTS

The total response rate was 54.8% (1,150/2,100). The respondents were primarily male (74%), with a mean age of 42.5 years (SD +/- 8), and a mean of 12 years of experience (SD +/- 7). The top 10 clinical priorities (% selected) were: 1) investigation of febrile child < 36 months (62%); 2) identification of central or serious vertigo (42%); 3) lumbar puncture or admission of febrile child < 3 months (41%); 4) imaging for suspected transient ischemic attack (39%); 5) admission for anterior chest pain (37%); 6) computed tomography (CT) angiography for pulmonary embolus (30%); 7) admission for suicide risk (29%); 8) ultrasound for pain or bleeding in the first trimester of pregnancy (28%); 9) nonspecific weakness in elders (26%); and 10) CT for abdominal pain (25%). Between study countries, there was consistency in identification of clinical problems, but variation in prioritization.

CONCLUSIONS

This international survey identified the sampled EPs' priorities for the future development of CDRs. The top priority overall was investigation of the febrile child < 36 months. These results will be valuable to researchers for future development of CDRs in EM that are relevant internationally.

Diagnostic imaging practice guidelines for musculoskeletal complaints in adults--an evidence-based approach: introduction

PURPOSE

Imaging technology can improve patient outcomes by allowing greater precision in diagnosing and treating patients. However, there is evidence that overuse, underuse, and misuse of imaging services occur. The purpose of this project was to develop evidence-based diagnostic imaging practice guidelines for musculoskeletal complaints for use by doctors of chiropractic and other primary health care professionals.

METHODS

An electronic search of the English and French language literature (phase 1) was conducted on several databases. Cross references, and references provided by clinicians, were also used. Independent assessment of the quality of the citations used to support recommendations in the guidelines was performed using the QUADAS, the AGREE,and the SPREAD evaluation tools. A first draft of a diagnostic imaging practice guideline was produced, using the European Commission's Referral Guidelines for Imaging document as a template. Results were sent to 12 chiropractic specialists for a first external review. A modified Delphi process, including 149 international experts, was used to generate consensus on recommendations for diagnostic imaging studies. The reliability of proposed recommendations was further tested on field chiropractors and on a group of specialists both in chiropractic and in medicine in both Canada and the United States. All recommendations were graded according to the strength of the evidence.

RESULTS

The research procedure resulted in the recommendations for diagnostic imaging guidelines of adult extremity and spine disorders supported by more than 685 primary and secondary citations. High levels of agreement among Delphi panelists were reached for all proposed recommendations. Comments received by specialists were generally very favorable and reflected high levels of agreement with the proposed recommendations, perceived ease of use of guidelines, and implementation feasibility.

CONCLUSIONS

These evidence-based diagnostic imaging practice guidelines are intended to assist chiropractors and other primary care providers in decision making on the appropriate use of diagnostic imaging for specific clinical presentations. In all cases, the guidelines are intended to be used in conjunction with sound clinical judgment and experience. Application of these guidelines should help avoid unnecessary radiographs, increase examination precision,and decrease health care costs without compromising the quality of care. All guidelines are documents to be refined and modified regularly with new information and experience.