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Lê A, Bierry G, Willaume T. The 'nutcracker' spino-laminar fracture: evaluation as a sentinel lesion of a hyperextension mechanism in cervical spine trauma. Skeletal Radiol 2024; 53:1125-1134. [PMID: 38082141 DOI: 10.1007/s00256-023-04533-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 11/23/2023] [Accepted: 11/23/2023] [Indexed: 04/10/2024]
Abstract
OBJECTIVE We hypothesised that the orientation of the fracture line in the cervical vertebral arch depends on the traumatic mechanism, specifically focusing on frontal oblique spino-laminar fractures to determine if this pattern can serve as an indicator of a hyperextension mechanism of injury of the cervical spine. MATERIALS AND METHODS We reviewed the imaging records of 114 adult patients admitted to the emergency department of the Strasbourg University Hospital for severe polytrauma between January 2016 and December 2021 and who presented with a fracture of the posterior vertebral arch of the lower cervical spine on the whole-body CT scan. A radiology resident (R1) and a musculoskeletal radiologist (R2) independently read the CT scans to determine the type of vertebral arch fracture; inter- and intra-observer agreements were calculated using Cohen's Kappa test. Two musculoskeletal radiologists (R2 and R3) then reviewed the CT scans and possible MRIs to identify specific hyperextension injuries of the cervical spine. The association between frontal oblique spino-laminar fracture and hyperextension injuries was assessed using chi2 test. RESULTS Thirty-five patients had frontal oblique spino-laminar fractures of the cervical spine. These fractures were significantly associated (p = 0.001) with hyperextension injuries of the cervical spine. The inter- and intra-observer agreements for the identification of these spino-laminar fractures were very good (0.86 (0.75-0.96) and 0.90 (0.81-0.99)). CONCLUSION Frontal oblique spino-laminar fractures are easily recognisable on CT scans and significantly associated with other traumatic injuries known as resulting from hyperextension. Their identification should lead to a search for potential associated unstable vertebral disco-ligamentous injuries with MRI.
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Affiliation(s)
- Alexandre Lê
- Department of Radiology, Strasbourg University Hospital, 1 Avenue Moliere, 67098, Strasbourg, France
| | - Guillaume Bierry
- Department of Radiology, Strasbourg University Hospital, 1 Avenue Moliere, 67098, Strasbourg, France
| | - Thibault Willaume
- Department of Radiology, Strasbourg University Hospital, 1 Avenue Moliere, 67098, Strasbourg, France.
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Tavender E, Eapen N, Wang J, Rausa VC, Babl FE, Phillips N. Triage tools for detecting cervical spine injury in paediatric trauma patients. Cochrane Database Syst Rev 2024; 3:CD011686. [PMID: 38517085 PMCID: PMC10958760 DOI: 10.1002/14651858.cd011686.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
BACKGROUND Paediatric cervical spine injury (CSI) after blunt trauma is rare but can have severe consequences. Clinical decision rules (CDRs) have been developed to guide clinical decision-making, minimise unnecessary tests and associated risks, whilst detecting all significant CSIs. Several validated CDRs are used to guide imaging decision-making in adults following blunt trauma and clinical criteria have been proposed as possible paediatric-specific CDRs. Little information is known about their accuracy. OBJECTIVES To assess and compare the diagnostic accuracy of CDRs or sets of clinical criteria, alone or in comparison with each other, for the evaluation of CSI following blunt trauma in children. SEARCH METHODS For this update, we searched CENTRAL, MEDLINE, Embase, and six other databases from 1 January 2015 to 13 December 2022. As we expanded the index test eligibility for this review update, we searched the excluded studies from the previous version of the review for eligibility. We contacted field experts to identify ongoing studies and studies potentially missed by the search. There were no language restrictions. SELECTION CRITERIA We included cross-sectional or cohort designs (retrospective and prospective) and randomised controlled trials that compared the diagnostic accuracy of any CDR or clinical criteria compared with a reference standard for the evaluation of paediatric CSI following blunt trauma. We included studies evaluating one CDR or comparing two or more CDRs (directly and indirectly). We considered X-ray, computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine, and clinical clearance/follow-up as adequate reference standards. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts for relevance, and carried out eligibility, data extraction and quality assessment. A third review author arbitrated. We extracted data on study design, participant characteristics, inclusion/exclusion criteria, index test, target condition, reference standard and data (diagnostic two-by-two tables) and calculated and plotted sensitivity and specificity on forest plots for visual examination of variation in test accuracy. We assessed methodological quality using the Quality Assessment of Diagnostic Accuracy Studies Version 2 tool. We graded the certainty of the evidence using the GRADE approach. MAIN RESULTS We included five studies with 21,379 enrolled participants, published between 2001 and 2021. Prevalence of CSI ranged from 0.5% to 1.85%. Seven CDRs were evaluated. Three studies reported on direct comparisons of CDRs. One study (973 participants) directly compared the accuracy of three index tests with the sensitivities of NEXUS, Canadian C-Spine Rule and the PECARN retrospective criteria being 1.00 (95% confidence interval (CI) 0.48 to 1.00), 1.00 (95% CI 0.48 to 1.00) and 1.00 (95% CI 0.48 to 1.00), respectively. The specificities were 0.56 (95% CI 0.53 to 0.59), 0.52 (95% CI 0.49 to 0.55) and 0.32 (95% CI 0.29 to 0.35), respectively (moderate-certainty evidence). One study (4091 participants) compared the accuracy of the PECARN retrospective criteria with the Leonard de novo model; the sensitivities were 0.91 (95% CI 0.81 to 0.96) and 0.92 (95% CI 0.83 to 0.97), respectively. The specificities were 0.46 (95% CI 0.44 to 0.47) and 0.50 (95% CI 0.49 to 0.52) (moderate- and low-certainty evidence, respectively). One study (270 participants) compared the accuracy of two NICE (National Institute for Health and Care Excellence) head injury guidelines; the sensitivity of the CG56 guideline was 1.00 (95% CI 0.48 to 1.00) compared to 1.00 (95% CI 0.48 to 1.00) with the CG176 guideline. The specificities were 0.46 (95% CI 0.40 to 0.52) and 0.07 (95% CI 0.04 to 0.11), respectively (very low-certainty evidence). Two additional studies were indirect comparison studies. One study (3065 participants) tested the accuracy of the NEXUS criteria; the sensitivity was 1.00 (95% CI 0.88 to 1.00) and specificity was 0.20 (95% CI 0.18 to 0.21) (low-certainty evidence). One retrospective study (12,537 participants) evaluated the PEDSPINE criteria and found a sensitivity of 0.93 (95% CI 0.78 to 0.99) and specificity of 0.70 (95% CI 0.69 to 0.72) (very low-certainty evidence). We did not pool data within the broader CDR categories or investigate heterogeneity due to the small quantity of data and the clinical heterogeneity of studies. Two studies were at high risk of bias. We identified two studies that are awaiting classification pending further information and two ongoing studies. AUTHORS' CONCLUSIONS There is insufficient evidence to determine the diagnostic test accuracy of CDRs to detect CSIs in children following blunt trauma, particularly for children under eight years of age. Although most studies had a high sensitivity, this was often achieved at the expense of low specificity and should be interpreted with caution due to a small number of CSIs and wide CIs. Well-designed, large studies are required to evaluate the accuracy of CDRs for the cervical spine clearance in children following blunt trauma, ideally in direct comparison with each other.
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Affiliation(s)
- Emma Tavender
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Australia
- Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Australia
| | - Nitaa Eapen
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Australia
| | - Junfeng Wang
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Vanessa C Rausa
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Australia
| | - Franz E Babl
- Emergency Research, Murdoch Children's Research Institute, Melbourne, Australia
- Departments of Paediatrics and Critical Care, University of Melbourne, Melbourne, Australia
- Emergency Department, The Royal Children's Hospital, Melbourne, Australia
| | - Natalie Phillips
- Emergency Department, Queensland Children's Hospital, Children's Health Queensland, Brisbane, Australia
- Child Health Research Centre, University of Queensland, Brisbane, Australia
- Biomechanics and Spine Research Group, Centre for Children's Health Research, School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, Australia
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Gangathimmaiah V, Drever N, Evans R, Moodley N, Sen Gupta T, Cardona M, Carlisle K. What works for and what hinders deimplementation of low-value care in emergency medicine practice? A scoping review. BMJ Open 2023; 13:e072762. [PMID: 37945299 PMCID: PMC10649718 DOI: 10.1136/bmjopen-2023-072762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 10/26/2023] [Indexed: 11/12/2023] Open
Abstract
OBJECTIVES Low-value care can harm patients and healthcare systems. Despite a decade of global endeavours, low value care has persisted. Identification of barriers and enablers is essential for effective deimplementation of low-value care. This scoping review is an evidence summary of barriers, enablers and features of effective interventions for deimplementation of low-value care in emergency medicine practice worldwide. DESIGN A mixed-methods scoping review was conducted using the Arksey and O'Malley framework. DATA SOURCES Medline, CINAHL, Embase, EMCare, Scopus and grey literature were searched from inception to 5 December 2022. ELIGIBILITY CRITERIA Primary studies which employed qualitative, quantitative or mixed-methods approaches to explore deimplementation of low-value care in an EM setting and reported barriers, enablers or interventions were included. Reviews, protocols, perspectives, comments, opinions, editorials, letters to editors, news articles, books, chapters, policies, guidelines and animal studies were excluded. No language limits were applied. DATA EXTRACTION AND SYNTHESIS Study selection, data collection and quality assessment were performed by two independent reviewers. Barriers, enablers and interventions were mapped to the domains of the Theoretical Domains Framework. The Mixed Methods Appraisal Tool was used for quality assessment. RESULTS The search yielded 167 studies. A majority were quantitative studies (90%, 150/167) that evaluated interventions (86%, 143/167). Limited provider abilities, diagnostic uncertainty, lack of provider insight, time constraints, fear of litigation, and patient expectations were the key barriers. Enablers included leadership commitment, provider engagement, provider training, performance feedback to providers and shared decision-making with patients. Interventions included one or more of the following facets: education, stakeholder engagement, audit and feedback, clinical decision support, nudge, clinical champions and training. Multifaceted interventions were more likely to be effective than single-faceted interventions. Effectiveness of multifaceted interventions was influenced by fidelity of the intervention facets. Use of behavioural change theories such as the Theoretical Domains Framework in the published studies appeared to enhance the effectiveness of interventions to deimplement low-value care. CONCLUSION High-fidelity, multifaceted interventions that incorporated education, stakeholder engagement, audit/feedback and clinical decision support, were administered daily and lasted longer than 1 year were most effective in achieving deimplementation of low-value care in emergency departments. This review contributes the best available evidence to date, but further rigorous, theory-informed, qualitative and mixed-methods studies are needed to supplement the growing body of evidence to effectively deimplement low-value care in emergency medicine practice.
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Affiliation(s)
- Vinay Gangathimmaiah
- Department of Emergency Medicine, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Natalie Drever
- Department of Obstetrics and Gynaecology, Cairns Hospital, Cairns, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Cairns, Queensland, Australia
| | - Rebecca Evans
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Nishila Moodley
- Department of Emergency Medicine, Townsville University Hospital, Townsville, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Tarun Sen Gupta
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Magnolia Cardona
- A/Prof Implementation Science, Faculty of Health and Behavioural Sciences, School of Psychology, The University of Queensland, Brisbane, Queensland, Australia
- Honorary A/Prof of Research Translation, Institute for Evidence Based Healthcare, Bond University, Gold Coast, Queensland, Australia
| | - Karen Carlisle
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
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Luckhurst CM, Wiberg HM, Brown RL, Bruch SW, Chandler NM, Danielson PD, Draus JM, Fallat ME, Gaines BA, Haynes JH, Inaba K, Islam S, Kaminski SS, Kang HS, Madabhushi VV, Murray J, Nance ML, Qureshi FG, Rubsam J, Stylianos S, Bertsimas DJ, Masiakos PT. Pediatric Cervical Spine Injury Following Blunt Trauma in Children Younger Than 3 Years: The PEDSPINE II Study. JAMA Surg 2023; 158:1126-1132. [PMID: 37703025 PMCID: PMC10500431 DOI: 10.1001/jamasurg.2023.4213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 06/16/2023] [Indexed: 09/14/2023]
Abstract
Importance There is variability in practice and imaging usage to diagnose cervical spine injury (CSI) following blunt trauma in pediatric patients. Objective To develop a prediction model to guide imaging usage and to identify trends in imaging and to evaluate the PEDSPINE model. Design, Setting, and Participants This cohort study included pediatric patients (<3 years years) following blunt trauma between January 2007 and July 2017. Of 22 centers in PEDSPINE, 15 centers, comprising level 1 and 2 stand-alone pediatric hospitals, level 1 and 2 pediatric hospitals within an adult hospital, and level 1 adult hospitals, were included. Patients who died prior to obtaining cervical spine imaging were excluded. Descriptive analysis was performed to describe the population, use of imaging, and injury patterns. PEDSPINE model validation was performed. A new algorithm was derived using clinical criteria and formulation of a multiclass classification problem. Analysis took place from January to October 2022. Exposure Blunt trauma. Main Outcomes and Measures Primary outcome was CSI. The primary and secondary objectives were predetermined. Results The current study, PEDSPINE II, included 9389 patients, of which 128 (1.36%) had CSI, twice the rate in PEDSPINE (0.66%). The mean (SD) age was 1.3 (0.9) years; and 70 patients (54.7%) were male. Overall, 7113 children (80%) underwent cervical spine imaging, compared with 7882 (63%) in PEDSPINE. Several candidate models were fitted for the multiclass classification problem. After comparative analysis, the multinomial regression model was chosen with one-vs-rest area under the curve (AUC) of 0.903 (95% CI, 0.836-0.943) and was able to discriminate between bony and ligamentous injury. PEDSPINE and PEDSPINE II models' ability to identify CSI were compared. In predicting the presence of any injury, PEDSPINE II obtained a one-vs-rest AUC of 0.885 (95% CI, 0.804-0.934), outperforming the PEDSPINE score (AUC, 0.845; 95% CI, 0.769-0.915). Conclusion and Relevance This study found wide clinical variability in the evaluation of pediatric trauma patients with increased use of cervical spine imaging. This has implications of increased cost, increased radiation exposure, and a potential for overdiagnosis. This prediction tool could help to decrease the use of imaging, aid in clinical decision-making, and decrease hospital resource use and cost.
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Affiliation(s)
- Casey M. Luckhurst
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston
| | | | - Rebeccah L. Brown
- Division of Pediatric Surgery at Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Steven W. Bruch
- Division of Pediatric Surgery at University of Michigan Medical Center, Ann Arbor
| | - Nicole M. Chandler
- Division of Pediatric Surgery, Johns Hopkins All Children’s Hospital, St Petersburg, Florida
| | - Paul D. Danielson
- Division of Pediatric Surgery, Johns Hopkins All Children’s Hospital, St Petersburg, Florida
| | - John M. Draus
- Division of Pediatric Surgery at Kentucky Children’s Hospital, Lexington
| | - Mary E. Fallat
- Division of Pediatric Surgery at Norton Children’s Hospital, Louisville, Kentucky
| | - Barbara A. Gaines
- Division of Pediatric Surgery at University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jeffrey H. Haynes
- Department of Pediatric Surgery, Children’s Hospital of Richmond at Virginia Commonwealth University Health, Richmond
| | - Kenji Inaba
- Division of Trauma, Emergency Surgery, and Surgical Critical Care at University of Southern California Medical Center, Los Angeles
| | - Saleem Islam
- Division of Pediatric Surgery at University of Florida Health, Gainesville
| | - Stephen S. Kaminski
- Department of Surgery at Santa Barbara Cottage Hospital, Santa Barbara, California
| | - Hae Sung Kang
- Department of Surgery, Virginia Commonwealth University Health, Richmond
| | | | - Jason Murray
- Department of Surgery, University of Texas Health Tyler, Tyler
| | - Michael L. Nance
- Division of Pediatric Surgery at Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Faisal G. Qureshi
- Division of Pediatric Surgery at Children’s Medical Center Dallas, Dallas, Texas
| | - Jeanne Rubsam
- Division of Pediatric Surgery at Morgan Stanley Children’s Hospital of New York-Presbyterian, New York
| | - Steven Stylianos
- Division of Pediatric Surgery at Morgan Stanley Children’s Hospital of New York-Presbyterian, New York
| | | | - Peter T. Masiakos
- Division of Pediatric Surgery, Massachusetts General Hospital, Boston
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5
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Saris TFF, van Bergen CJA, The B, Boele van Hensbroek P, Schep NWL, van Boekel LC, Eygendaal D. Development and validation of the paediatric elbow trauma (PET) rules as a decision rule for radiography in traumatic elbow injuries: a study protocol. BMJ Paediatr Open 2023; 7:10.1136/bmjpo-2022-001833. [PMID: 37105597 PMCID: PMC10151907 DOI: 10.1136/bmjpo-2022-001833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 04/10/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Traumatic elbow injuries in children occur frequently and are among the most common traumatic injuries seen in the emergency department (ED) and in general practice. The use of a validated decision rule to enhance selective radiography in paediatric patients with possible elbow fractures may reduce unnecessary exposure to radiation in children. METHOD AND ANALYSIS This study is designed as a multicentre prospective cohort study. An expert panel of orthopaedic elbow surgeons, paediatric orthopaedic surgeons and trauma surgeons will initially determine clinical parameters that provide a possible predictive value for elbow fractures. Four hundred children between the ages of 2 and 17 years visiting the ED with pain following elbow trauma will then be included. The clinical parameters will be collected via patient history and physical examination. Elbow radiographs will be obtained in all patients to identify fractures. The data will be processed in a multivariable logistic regression analysis to determine which clinical parameters predict the presence of an elbow fracture. Only the clinical parameters that predict a fracture will be used to formulate the new decision rule: the paediatric elbow trauma (PET) rules. Internal validation of the prediction model will take place after inclusion is complete and by means of a bootstrap analysis on the acquired data. A calculation will be made to determine how many radiographs can potentially be reduced by applying the PET rules and a cost analysis will be performed. ETHICS AND DISSEMINATION The study will be conducted according to the principles of the Declaration of Helsinki and in accordance with the Medical Research Involving Human Subjects Act. The Medical Research Ethics Committees United stated on 16 May 2022 that The Medical Research Involving Human Act (WMO) does not apply to this study and an official approval by the committee is not required, reference number; project W22.086.
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Affiliation(s)
| | | | - Bertram The
- Orthopedic Surgery, Amphia Hospital, Breda, The Netherlands
| | | | - Niels W L Schep
- Trauma Surgery, Maasstad Hospital, Rotterdam, The Netherlands
| | | | - Denise Eygendaal
- Orthopedic Surgery and Sports Medicine, Erasmus MC, Rotterdam, The Netherlands
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Roberts T, Carlton E, Booker M, Voss S, Vaillancourt S, Jafar AJN, Benger J. Cross-cultural adaptation and its impact on research in emergency care. Emerg Med J 2023; 40:396-403. [PMID: 36941034 DOI: 10.1136/emermed-2022-212337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 03/05/2023] [Indexed: 03/22/2023]
Abstract
The perspective of patients is increasingly recognised as important to care improvement and innovation. Patient questionnaires such as patient-reported outcome measures may often require cross-cultural adaptation (CCA) to gather their intended information most effectively when used in cultures and languages different to those in which they were developed. The use of CCA could be seen as a practical step in addressing the known problems of inclusion, diversity and access in medical research.An example of the recent adaptation of a patient-reported outcome measure for use with ED patients is used to explore some key features of CCA, introduce the importance of CCA to emergency care practitioners and highlight the limitations of CCA.
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Affiliation(s)
- Tom Roberts
- Doctoral Fellow, The Royal College of Emergency Medicine, London, UK
- Faculty of Health and Life Sciences, University of the West of England, Bristol, UK
| | - Edward Carlton
- Faculty of Health and Life Sciences, University of the West of England, Bristol, UK
- Emergency Department, North Bristol NHS Trust, Westbury on Trym, UK
| | - Matthew Booker
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Sarah Voss
- Faculty of Health and Life Sciences, University of the West of England, Bristol, UK
| | - Samuel Vaillancourt
- St Michael's Hospital, Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
- Emergency Department, St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Jonathan Benger
- Faculty of Health and Life Sciences, University of the West of England, Bristol, UK
- University of the West of England, Bristol, UK
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7
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McCallum J, Eagles D, Ouyang Y, Ende JV, Vaillancourt C, Fehlmann C, Shorr R, Taljaard M, Stiell I. Cervical spine injuries in adults ≥ 65 years after low-level falls - A systematic review and meta-analysis. Am J Emerg Med 2023; 67:144-155. [PMID: 36893628 DOI: 10.1016/j.ajem.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 01/10/2023] [Accepted: 02/06/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Adults ≥ 65 are at risk of cervical spine (C-spine) injury, even after low-level falls. The objectives of this systematic review were to determine the prevalence of C-spine injury in this population and explore the association of unreliable clinical exam with C-spine injury. METHODS We conducted this systematic review according to PRISMA guidelines. We searched MEDLINE, PubMed, EMBASE, Scopus, Web of Science, and the Cochrane Database of Systematic reviews to include studies reporting on C-spine injury in adults ≥ 65 years after low-level falls. Two reviewers independently screened articles, abstracted data, and assessed bias. Discrepancies were resolved by a third reviewer. A meta-analysis was performed to estimate overall prevalence and the pooled odds ratio for the association between C-spine injury and an unreliable clinical exam. RESULTS The search identified 2044citations, 138 full texts were screened, and 21 studies were included in the systematic review. C-spine injury prevalence in adults ≥ 65 years after low-level falls was 3.8% (95% CI: 2.8-5.3). The odds of c-spine injury in those with altered level of consciousness (aLOC) v/s not aLOC was 1.21 (0.90-1.63) and in those with GCS < 15 v/s GCS 15 was 1.62 (0.37-6.98). Studies were at a low-risk of bias, although some had low recruitment and significant loss to follow-up. CONCLUSIONS Adults ≥ 65 years are at risk of cervical spine injury after low-level falls. More research is needed to determine whether there is an association between cervical spine injury and GCS < 15 or altered level of consciousness.
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Affiliation(s)
- Jessica McCallum
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada.
| | - Debra Eagles
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Department of Emergency Medicine, The University of Ottawa, Ottawa, Ontario, Canada.
| | - Yongdong Ouyang
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Jamie Vander Ende
- College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
| | - Christian Vaillancourt
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Department of Emergency Medicine, The University of Ottawa, Ottawa, Ontario, Canada.
| | - Christophe Fehlmann
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Department of Anaesthesiology, Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals, Geneva CH-1211, Switzerland.
| | - Risa Shorr
- Learning Services, The Ottawa Hospital, Ottawa, Ontario, Canada.
| | - Monica Taljaard
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Ian Stiell
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Department of Emergency Medicine, The University of Ottawa, Ottawa, Ontario, Canada.
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8
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Implementation of the Modified Canadian C-Spine Rule by Paramedics. Ann Emerg Med 2023; 81:187-196. [PMID: 36328852 DOI: 10.1016/j.annemergmed.2022.08.441] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 07/26/2022] [Accepted: 08/11/2022] [Indexed: 01/25/2023]
Abstract
STUDY OBJECTIVE The Canadian C-spine rule was modified and validated for use by the paramedics in a multicenter study where patients were assessed with the Canadian C-spine rule yet all transported with immobilization. This study evaluated the clinical impact of the modified Canadian C-spine rule when implemented by paramedics. METHODS This single-center prospective cohort implementation study took place in Ottawa, Canada (from 2011 to 2015). Advanced and primary care paramedics were trained to use the modified Canadian C-spine rule, collect data on a standardized study form, and selectively transport eligible patients without immobilization. We evaluated all consecutive low-risk adult patients (Glasgow Coma Scale [GCS] 15, stable vital signs) at risk for a neck injury. We followed all patients without initial radiologic evaluation for 30 days. Analyses included descriptive statistics with 95% confidence intervals (CI), sensitivity, specificity, and kappa coefficients. RESULTS The 4,034 enrolled patients had a mean age of 43 (range 16 to 99), and 53.4% were female. Motor vehicle collisions were the most common mechanism of injury (55.1%), followed by falls (23.9%). There were 11 clinically important injuries. The paramedics classified these injuries with a sensitivity of 90.9% (95% CI, 58.7 to 99.8) and specificity of 66.5% (95% CI, 65.1 to 68.0). There was no adverse event or resulting spinal cord injury. The kappa agreement between paramedics and investigators was 0.94. A total of 2,583 (64.0%) immobilizations were avoided using the modified Canadian C-spine rule. CONCLUSION Paramedics could accurately apply the modified Canadian C-spine rule to low-risk trauma patients and significantly reduce the need for spinal immobilization during transport. This resulted in no adverse event or any spinal cord injury.
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Dayan PS, Ballard DW, Shelton RC, Kuppermann N. Implementation Trials That Change Practice: Evidence Alone Is Never Enough. Ann Emerg Med 2022; 80:344-346. [PMID: 35965161 DOI: 10.1016/j.annemergmed.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 06/03/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Peter S Dayan
- Department of Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York City, NY.
| | - Dustin W Ballard
- Department of Emergency Medicine, Kaiser Permanente Northern California, Oakland, CA; Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, CA
| | - Rachel C Shelton
- Department of Sociomedical Sciences, Mailman School of Public Health, and Columbia's Irving Institute for Clinical and Translational Research, New York City, NY
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, CA
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10
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Bailey RS, Klein R, de Los Cobos D, Geraud S, Puryear A. A Retrospective Look at a Cervical Spine Clearance Protocol in Pediatric Trauma Patients at a Level-1 Trauma Center. J Pediatr Orthop 2022; 42:e607-e611. [PMID: 35297387 DOI: 10.1097/bpo.0000000000002146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Adult studies have demonstrated the efficacy of written protocols for clearance of the cervical spine. However, less than half of recently surveyed pediatric trauma centers report using a documented protocol. Little data exists on such protocols in pediatric populations, but interest remains because of potential reductions in radiation exposure, time to clearance, hospital stay, and specialist referral. However, missed injury can have devastating consequences. The purpose of this study is to examine the efficacy in detecting injury of an implemented cervical spine clearance protocol at a level-1 pediatric trauma hospital. METHODS A retrospective review was performed on pediatric patients presenting as activated traumas to the emergency department of a single level-1 pediatric trauma hospital between May 2010 and October 2018. This institution has utilized a written cervical spine clearance protocol throughout this time. Presence of cervical spine injury, documented clearance, cervical spine imaging, and follow-up documentation were reviewed for any missed injuries. RESULTS There were no missed cervical spine injuries. Five-hundred sixty-three clinically significant cervical spine injuries were identified, representing 16.5% of patients. Of these, 96 were fractures, dislocations, or ligamentous injuries, representing 2.8% of all patients. Most cervical spine clearances were performed by trauma surgery. Advanced imaging of the cervical spine was ordered for 43.2% of patients overall and trended down over time. CONCLUSION Documented cervical spine clearance protocols are effective for detection of significant injury in pediatric trauma patients. This study suggests these protocols minimize risk of missed injury and may prevent unnecessary radiation exposure, delayed clearance, prolonged hospitalization, or unnecessary specialist referral. CLINICAL RELEVANCE Utilization of a standard written protocol for cervical spine clearance likely prevents missed injury and helps to minimize radiation exposure in pediatric populations. Further research is needed on evaluation and management of pediatric cervical spine trauma.
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Affiliation(s)
- Ryan S Bailey
- Department of Orthopaedic Surgery, Saint Louis University, St. Louis, MO
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RAFF-3 Trial: A Stepped-Wedge Cluster Randomized Trial to Improve Care of Acute Atrial Fibrillation and Flutter in the Emergency Department. Can J Cardiol 2021; 37:1569-1577. [PMID: 34217808 DOI: 10.1016/j.cjca.2021.06.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 06/21/2021] [Accepted: 06/23/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND We sought to improve care of patients with acute atrial fibrillation (AF) and flutter (AFL) in the emergency department (ED) by implementing the CAEP AAFF Best Practice Checklist. METHODS We conducted a stepped-wedge cluster randomized trial at 11 large community and academic hospital EDs, in five Canadian provinces and enrolled consecutive AF/AFL patients. The study intervention was the introduction of the CAEP Checklist using a knowledge translation-implementation approach that included behavior change techniques and organization/system level strategies. The primary outcome was length of stay in ED and secondary outcomes were discharge home, use of rhythm control, adverse events, and 30-day status. Analysis used mixed effects regression adjusting for covariates. RESULTS Patient visits in the control (N=314) and intervention (N=404) periods were similar with mean age 62.9, 54% male, 71% onset <12 hours, and 86% atrial fibrillation, 14% atrial flutter. We observed a reduction in length of stay of 20.9% (95% CI 5.5 to 33.8%, P=0.01), an increase in use of rhythm control (adjusted odds ratio (OR 4.5, 1.8-11.6; P=0.002), and decrease in use of rate control medications (OR 0.5, 0.2 to 0.9; P=0.02). There was no change in adverse events and no strokes or deaths by 30 days. CONCLUSIONS The RAFF-3 Trial led to optimized care of AF/AFL patients with decreased ED lengths of stay, increased ED rhythm control by drug or electricity, and no increase in adverse events. Early cardioversion allows AF/AFL patients to quickly resume normal activities. CLINICALTRIALS. GOV IDENTIFIER NCT03627143.
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12
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Leonardo F, Galindo GFDC, Pagamisse OST, Rodrigues JMDS. ALGORITHMS FOR CLINICAL ASSESSMENT OF THE CERVICAL SPINE IN PATIENTS WITH SEVERE TRAUMA: A MIXED-METHOD ANALYZIS. COLUNA/COLUMNA 2021. [DOI: 10.1590/s1808-185120212002242209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objective: Cervical trauma is an important cause of morbidity and mortality, affecting 2% of patients admitted to emergency units. Therefore, this study aims to compare the use of two clinical cervical spine evaluation algorithms, the Canadian C-Spine Rule (CCR) and the National Emergency X-radiography Utilization Study (NEXUS). Methods: A descriptive study of the use of the two algorithms by medical residents in the initial assessment of severely traumatized patients admitted to the regional emergency unit was conducted. The evaluation of the indication for imaging tests and the positive predictive value of the algorithms were the parameters analyzed. Finally, the residents answered a questionnaire evaluating the applicability, degree of confidence and advantages of both flowcharts. Results: There was no significant difference between the number of indications for imaging or their predictive values. In the analysis of the questionnaires, the CCR proved to be more reliable and the NEXUS more applicable, and the positive and negative points of applying each of them were highlighted. Conclusion: It is concluded that the two methods are similar in detecting injuries and optimizing the use of imaging exams, being equally indicated to evaluate cervical trauma. However, the technical specifics of each must be taken into account when deciding which to use. Level of evidence IV; Descriptive Study.
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13
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Rousseau JF, Ip IK, Raja AS, Schuur JD, Khorasani R. Can emergency department provider notes help to achieve more dynamic clinical decision support? J Am Coll Emerg Physicians Open 2020; 1:1269-1277. [PMID: 33392531 PMCID: PMC7771753 DOI: 10.1002/emp2.12232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/31/2020] [Accepted: 08/05/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Assess whether clinical data were present in emergency department (ED) provider notes at time of order entry for cervical spine (c-spine) imaging that could be used to augment or pre-populate clinical decision support (CDS) attributes. METHODS This Institutional Review Board-approved retrospective study, performed in a quaternary hospital, included all encounters for adult ED patients seen April 1, 2013-September 30, 2014 for a chief complaint of trauma who received c-spine computed tomography (CT) or x-ray. We assessed proportion of ED encounters with at least 1 c-spine-specific CDS rule attribute in clinical notes available at the time of imaging order and agreement between attributes in clinical notes and data entered into CDS. RESULTS A portion of the clinical note was submitted before imaging order in 42% (184/438) of encounters reviewed; 59.2% (109/184) of encounters with note portions submitted before imaging order had at least 1 positive CDS attribute identified supporting imaging study appropriateness; 34.8% (64/184) identified exclusion criteria where CDS appropriateness recommendations would not be applicable. 65.8% (121/184) of encounters had either a positive CDS attribute or an exclusion criterion. Concordance of c-spine CDS attributes when present in both notes and CDS was 68.4% (κ = 0.35 95% CI: 0.15-0.56; McNemar P = 0.23). CONCLUSIONS Clinical notes are an underutilized source of clinical attributes needed for CDS, available in a substantial percentage of encounters at the time of imaging order. Automated pre-population of imaging order requisitions with relevant clinical information extracted from electronic health record provider notes may: (1) improve ordering efficiency by reducing redundant data entry, (2) help improve clinical relevance of CDS alerts, and (3) potentially reduce provider burnout from extraneous alerts.
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Affiliation(s)
- Justin F. Rousseau
- Center for Evidence‐Based ImagingBrigham and Women's HospitalHarvard Medical SchoolBostonMassachusettsUSA
- Department of RadiologyBrigham and Women's HospitalHarvard Medical SchoolBostonMassachusettsUSA
- Department of Population HealthDell Medical School, The University of Texas at AustinAustinTexasUSA
- Department of NeurologyDell Medical School, The University of Texas at AustinAustinTexasUSA
| | - Ivan K. Ip
- Center for Evidence‐Based ImagingBrigham and Women's HospitalHarvard Medical SchoolBostonMassachusettsUSA
- Department of RadiologyBrigham and Women's HospitalHarvard Medical SchoolBostonMassachusettsUSA
- Department of MedicineBrigham and Women's HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Ali S. Raja
- Center for Evidence‐Based ImagingBrigham and Women's HospitalHarvard Medical SchoolBostonMassachusettsUSA
- Department of RadiologyBrigham and Women's HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Jeremiah D. Schuur
- Department of Emergency MedicineBrigham and Women's HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Ramin Khorasani
- Center for Evidence‐Based ImagingBrigham and Women's HospitalHarvard Medical SchoolBostonMassachusettsUSA
- Department of RadiologyBrigham and Women's HospitalHarvard Medical SchoolBostonMassachusettsUSA
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Baker M, Jaeger C, Hafley C, Waymack J. Appropriate CT cervical spine utilisation in the emergency department. BMJ Open Qual 2020; 9:bmjoq-2019-000844. [PMID: 33028655 PMCID: PMC7542617 DOI: 10.1136/bmjoq-2019-000844] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 07/30/2020] [Accepted: 09/18/2020] [Indexed: 12/03/2022] Open
Abstract
Introduction Over 40 000 CT scans are performed in our emergency department (ED) annually and utilisation is over 80% capacity. Improving medical appropriateness of CT scans may reduce total number of scans, time, cost and radiation exposure. Methods Lean Six Sigma methodology was used to improve the process. A National Emergency X-Radiography Utilisation Study (NEXUS)-based PowerForm was implemented in the electronic health record and providers were educated on the criteria. Results The rate of potentially medically inappropriate CT C-spine scans decreased from 45% (19/42) to 22% (90/403) (two-proportion test, p=0.002). After the intervention, there was no longer a difference between midlevel providers and physicians in the rate of medically inappropriate orders (19% vs 22%) (two-proportion test, p=0.850) compared with that before the intervention (56% vs 31%) (two-proportion test, p<0.01). Overall rates of CT C-spine scans ordered decreased from 69.3 to 62.6/week (t-test, p=0.019). Conclusion A validated clinical decision-making tool implemented into the medical record can improve quality of care. This study lays a foundation for other imaging studies with validated support tools with similar potential improvements.
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Affiliation(s)
- Mark Baker
- Department of Emergency Medicine, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Cassie Jaeger
- Department of Operations Improvement, Memorial Health System, Springfield, Illinois, USA
| | - Carol Hafley
- Midwest Healthcare Quality Alliance, Memorial Health System, Springfield, Illinois, USA
| | - James Waymack
- Department of Emergency Medicine, Southern Illinois University School of Medicine, Springfield, Illinois, USA
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Abstract
Injuries to the subaxial cervical spine are increasing and have a high risk for neurological injury in comparison to the thoracic and lumbar spine. The current treatment recommendations according to the recommendations of the section spine of the German Society for Orthopaedics and Trauma (DGOU) and the S1 guidelines of the German Society for Trauma Surgery are summarized in this article. High-energy as well as low-energy trauma can cause a significant injury to the cervical spine. If there is a suspicion of a cervical spine injury, a tomographic imaging modality (CT/MRI) is the procedure of choice. Injuries should be classified according to the AOSpine classification for subaxial injuries. Based on this classification, a decision on a conservative or operative treatment regimen as well as individual details of the treatment can be made.
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16
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Elliott JM, Smith AC, Hoggarth MA, Albin SR, Weber KA, Haager M, Fundaun J, Wasielewski M, Courtney DM, Parrish TB. Muscle fat infiltration following whiplash: A computed tomography and magnetic resonance imaging comparison. PLoS One 2020; 15:e0234061. [PMID: 32484835 PMCID: PMC7266316 DOI: 10.1371/journal.pone.0234061] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 05/18/2020] [Indexed: 01/17/2023] Open
Abstract
Here we present a secondary analysis from a parent database of 97 acutely injured participants enrolled in a prospective inception cohort study of whiplash recovery after motor vehicle collision (MVC). The purpose was to investigate the deep and superficial neck extensor muscles with peri-traumatic computed tomography (CT) and longitudinal measures of magnetic resonance imaging (MRI) in participants with varying levels of whiplash-related disability. Thirty-six underwent standard care imaging of the cervical spine with CT at a level-1 trauma designated emergency department. All 36 participants were assessed with MRI of the cervical spine at <1-week, 2-weeks, 3-, and 12-months post-injury and classified into three groups using initial pain severity and percentage scores on the Neck Disability Index (recovered (NDI of 0–8%), mild (NDI of 10–28%), or severe (NDI ≥ 30%)) at 3-months post MVC. CT muscle attenuation values were significantly correlated to muscle fat infiltration (MFI) on MRI at one-week post MVC. There was no significant difference in muscle attenuation across groups at the time of enrollment. A trend of lower muscle attenuation in the deep compared to the superficial extensors was observed in the severe group. MFI values in the deep muscles on MRI were significantly higher in the severe group when compared to the mild group at 1-year post MVC. This study provides further evidence that the magnitude of 1) deep MFI appears unique to those at risk of and eventually transitioning to chronic WAD and that 2) pre- or peri-traumatic muscular health, determined by CT muscle attenuation, may be contribute to our understanding of long-term recovery.
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Affiliation(s)
- James M. Elliott
- Discipline of Physiotherapy, Faculty of Medicine and Health, The University of Sydney, & The Northern Sydney Local Health District, The Kolling Research Institute, St. Leonards, New South Wales, Australia
- Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
- * E-mail:
| | - Andrew C. Smith
- School of Physical Therapy, Regis University, Denver, CO, United States of America
| | - Mark A. Hoggarth
- Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
- Department of Biomedical Engineering, Northwestern University, Evanston, Illinois, United States of America
| | - Stephanie R. Albin
- School of Physical Therapy, Regis University, Denver, CO, United States of America
| | - Ken A. Weber
- Department of Anesthesiology, Perioperative and Pain Medicine, Systems Neuroscience and Pain Lab, Stanford University, Palo Alto, California, United States of America
| | - Mat Haager
- School of Physical Therapy, Regis University, Denver, CO, United States of America
| | - Joel Fundaun
- Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
| | - Marie Wasielewski
- Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
| | - D. Mark Courtney
- Department of Emergency Medicine Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
| | - Todd B. Parrish
- Department of Anesthesiology, Perioperative and Pain Medicine, Systems Neuroscience and Pain Lab, Stanford University, Palo Alto, California, United States of America
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
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17
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Vaillancourt C, Charette M, Taljaard M, Thavorn K, Hall E, McLeod B, Fergusson D, Brehaut J, Graham I, Calder L, Ramsay T, Tugwell P, Kelly P, Cheskes S, Saskin R, Plint A, Osmond M, Macarthur C, Straus S, Rochon P, Prud'homme D, Dahrouge S, Marlin S, Stiell IG. Pragmatic Strategy Empowering Paramedics to Assess Low-Risk Trauma Patients With the Canadian C-Spine Rule and Selectively Transport Them Without Immobilization: Protocol for a Stepped-Wedge Cluster Randomized Trial. JMIR Res Protoc 2020; 9:e16966. [PMID: 32348267 PMCID: PMC7296410 DOI: 10.2196/16966] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 12/23/2019] [Accepted: 12/31/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Each year, half a million patients with a potential neck (c-spine) injury are transported to Ontario emergency departments (EDs). Less than 1.0% (1/100) of these patients have a neck bone fracture. Even less (1/200, 0.5%) have a spinal cord injury or nerve damage. Currently, paramedics transport all trauma victims (with or without an injury) by ambulance using a backboard, cervical collar, and head immobilizers. Importantly, prolonged immobilization is often unnecessary; it causes patient discomfort and pain, decreases community access to paramedics, contributes to ED crowding, and is very costly. We therefore developed the Canadian C-Spine Rule (CCR) for alert and stable trauma patients. This decision rule helps ED physicians and triage nurses to safely and selectively remove immobilization, without x-rays and missed injury. We successfully taught Ottawa paramedics to use the CCR in the field in a single-center study. OBJECTIVE This study aimed to improve patient care and health system efficiency and outcomes by allowing paramedics to assess eligible low-risk trauma patients with the CCR and selectively transport them without immobilization to the ED. METHODS We propose a pragmatic stepped-wedge cluster randomized design with health economic evaluation, designed collaboratively with knowledge users. Our 36-month study will consist of a 12-month setup and training period (year 1), followed by the stepped-wedge trial (year 2) and a 12-month period for study completion, analyses, and knowledge translation. A total of 12 Ontario paramedic services of various sizes distributed across the province will be randomly allocated to one of three sequences. Paramedic services in each sequence will cross from the control condition (usual care) to the intervention condition (CCR implementation) at intervals of 3 months until all communities have crossed to the intervention. Data will be collected on all eligible patients in each paramedic service for a total duration of 12 months. A major strength of our design is that each community will have implemented the CCR by the end of the study. RESULTS Interim results are expected in December 2019 and final results in 2020. If this multicenter trial is successful, we expect the Ontario Ministry of Health will recommend that paramedics evaluate all eligible patients with the CCR in the Province of Ontario. CONCLUSIONS We conservatively estimate that in Ontario, more than 60% of all eligible trauma patients (300,000 annually) could be transported safely and comfortably, without c-spine immobilization devices. This will significantly reduce patient pain and discomfort, paramedic intervention times, and ED length of stay, thereby improving access to paramedics and ED care. This could be achieved rapidly and with lower health care costs compared with current practices (possible cost saving of Can $36 [US $25] per immobilization or Can $10,656,000 [US $7,335,231] per year). TRIAL REGISTRATION ClinicalTrials.gov NCT02786966; https://clinicaltrials.gov/ct2/show/NCT02786966. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/16966.
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Affiliation(s)
- Christian Vaillancourt
- Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | | | | | - Elizabeth Hall
- Patient Representative, Owner-Hall Consulting, Director-Helping Hands for India, Kanata, ON, Canada
| | - Brent McLeod
- Paramedic Representative, Hamilton Paramedic Service, Hamilton, ON, Canada
| | | | - Jamie Brehaut
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Ian Graham
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Lisa Calder
- Medical Care Analytics, Canadian Medical Protective Association, Ottawa, ON, Canada
| | - Tim Ramsay
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Peter Tugwell
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Peter Kelly
- Ottawa Paramedic Service, Ottawa, ON, Canada
| | - Sheldon Cheskes
- Department of Family and Community Medicine, Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada
| | - Refik Saskin
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Amy Plint
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Martin Osmond
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | | | - Sharon Straus
- Knowledge Translation Program, St. Michael's Hospital, Toronto, ON, Canada
| | - Paula Rochon
- Women's College Research Institute, Toronto, ON, Canada
| | | | | | | | - Ian G Stiell
- Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
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18
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Does prehospital spinal immobilization influence in hospital decision to obtain imaging after trauma? Injury 2020; 51:935-941. [PMID: 32113741 DOI: 10.1016/j.injury.2020.02.097] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 02/19/2020] [Indexed: 02/02/2023]
Abstract
IMPORTANCE This study highlights the unnecessarily high suspicion for cervical spine injury among study providers and shows that cervical CT scans were more likely in patients who arrived to the emergency department wearing a cervical collar, even when clinically cleared for suspicion of cervical spine injury by the emergency department provider. OBJECTIVE To determine if patients with a cervical collar were more likely to undergo cervical spine imaging than those who arrived to the emergency department without a collar. DESIGN Adult trauma patients at a level 1 trauma center over 4 months (n = 1,438) were stratified by acuity (1,2, or 3), mechanism, and known injury cephalad to clavicles, defined as pain, wounds, or hematomas. Cervical spine imaging findings were recorded. RESULTS 975 patients (67.8%) had cervical CT scans. Twenty-six (1.81%) sustained a fracture or ligamentous injury, all with known injury cephalad to clavicles. 161 (11.2%) patients without injury cephalad to clavicles all had a negative cervical CT. Category 1 patients with gunshot wounds with injury cephalad to clavicles were more likely to have CT if they arrived with a collar versus without (66.7% vs 14.3%, p = 0.027). Category 2 and 3 patients with injury cephalad to clavicles after motor vehicle collision (MVC) (88.2% vs 69.6%, p = 0.011), low energy falls (88.3% vs 59.4%, p < 0.0001), and assault (86.0% vs 37.1%, p < 0.0001) underwent cervical CT more frequently if they arrived wearing a collar. Category 2 and 3 trauma patients without injury cephalad to clavicles were also more likely to undergo CT when wearing a collar after MVC (66.3% vs 21.4%, p = 0.001), low energy fall (81.8% vs 35.3%, p = 0.016), and pedestrian vs MVC (55.6% vs 12.5%, p = 0.04). CONCLUSION Certain trauma patients were more likely to undergo cervical CT if they arrived wearing a cervical collar. No conscious patients without complaints proximal to the clavicles had cervical injury.
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Ritchie C, Smith A, Sterling M. Medical and allied health service use during acute and chronic post-injury periods in whiplash injured individuals. BMC Health Serv Res 2020; 20:260. [PMID: 32228573 PMCID: PMC7106620 DOI: 10.1186/s12913-020-05146-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 03/24/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Individuals with whiplash associated disorder (WAD) frequently experience neck pain in addition to other physical, psychological and social symptoms. Consequently, treatment is sought from a variety of health professionals. The limited data available about health services use in this population are conflicting. This study aimed to characterise health service use in individuals with WAD from a motor vehicle crash. METHODS Medical (general practitioner (GP), medical specialist, emergency services (ED), radiology - x-ray, computed tomography, magnetic resonance imaging, ultrasound) and allied health service (physiotherapy, chiropractor, psychologist, osteopath, occupational therapy) use during acute (< 12 weeks) and chronic (12 weeks to 2 years) post-injury periods were analysed in adults claiming compensation for WAD in the no-fault jurisdiction of Victoria, Australia (n = 37,315). RESULTS Most WAD claimants had an acute post-injury health service payment (95%, n = 35,348), and approximately one-third (29%, n = 10,871) had a chronic post-injury health service payment. During an acute post-injury period, the most frequently compensated services were for: ED (82% of acute claimants), radiology (56%), and medical specialist (38%). Whereas, physiotherapy (64.4% of chronic claimants), GP (48.1%), and radiology (34.6%) were the most frequently paid services during the chronic period. Females received significantly more payments from physiotherapists (F = 23.4%, M = 18%, z = - 11.3, p < .001, r = 0.13), chiropractors (F = 7.4%, M = 5.6%, z = - 6.3, p < .001, r = 0.13), and psychologists (F = 4.2%, M = 2.8%, z = - 6.7, p < .001, r = 0.18); whereas, males received significantly more medical services payments from medical specialists (F = 41.8%, M = 43.8%, z = - 3.7, p < .001, r = 0.03), ED (F = 74.0%, M = 76.3%, z = - 4.9, p < .001, r = 0.03) and radiology (F = 58.3%, M = 60.1%, z = - 3.4, p < .001, r = 0.02). CONCLUSIONS Individuals with WAD claimed for a range of health services. Radiology imaging use during the acute post-injury period, and physiotherapy and chiropractor service use during the chronic post-injury period appeared concordant with current WAD management guidelines. Conversely, low physiotherapy and chiropractic use during an acute post-injury period, and high radiology and medical specialists use during the chronic post-injury period appeared discordant with current guidelines. Strategies are needed to help inform medical health professionals of the current guidelines to promote early access to health professionals likely to provide an active approach to treatment, and to address unnecessary referral to radiology and medical specialists in individuals with on-going WAD.
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Affiliation(s)
- Carrie Ritchie
- Recover Injury Research Centre, The University of Queensland, Brisbane, Queensland, Australia.
| | - Ashley Smith
- School of Allied Health Sciences, Griffith University, Gold Coast, Australia.,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Michele Sterling
- Recover Injury Research Centre, The University of Queensland, Brisbane, Queensland, Australia.,NHMRC Centre of Research Excellence in Road Traffic Injury Recovery, Brisbane, Australia
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CJEM Debate Series: #ChoosingWisely - The Choosing Wisely campaign will not impact physician behaviour and choices. CAN J EMERG MED 2020. [PMID: 29534784 DOI: 10.1017/cem.2017.402] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Pantoja T, Grimshaw JM, Colomer N, Castañon C, Leniz Martelli J. Manually-generated reminders delivered on paper: effects on professional practice and patient outcomes. Cochrane Database Syst Rev 2019; 12:CD001174. [PMID: 31858588 PMCID: PMC6923326 DOI: 10.1002/14651858.cd001174.pub4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Health professionals sometimes do not use the best evidence to treat their patients, in part due to unconscious acts of omission and information overload. Reminders help clinicians overcome these problems by prompting them to recall information that they already know, or by presenting information in a different and more accessible format. Manually-generated reminders delivered on paper are defined as information given to the health professional with each patient or encounter, provided on paper, in which no computer is involved in the production or delivery of the reminder. Manually-generated reminders delivered on paper are relatively cheap interventions, and are especially relevant in settings where electronic clinical records are not widely available and affordable. This review is one of three Cochrane Reviews focused on the effectiveness of reminders in health care. OBJECTIVES 1. To determine the effectiveness of manually-generated reminders delivered on paper in changing professional practice and improving patient outcomes. 2. To explore whether a number of potential effect modifiers influence the effectiveness of manually-generated reminders delivered on paper. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers on 5 December 2018. We searched grey literature, screened individual journals, conference proceedings and relevant systematic reviews, and reviewed reference lists and cited references of included studies. SELECTION CRITERIA We included randomised and non-randomised trials assessing the impact of manually-generated reminders delivered on paper as a single intervention (compared with usual care) or added to one or more co-interventions as a multicomponent intervention (compared with the co-intervention(s) without the reminder component) on professional practice or patients' outcomes. We also included randomised and non-randomised trials comparing manually-generated reminders with other quality improvement (QI) interventions. DATA COLLECTION AND ANALYSIS Two review authors screened studies for eligibility and abstracted data independently. We extracted the primary outcome as defined by the authors or calculated the median effect size across all reported outcomes in each study. We then calculated the median percentage improvement and interquartile range across the included studies that reported improvement related outcomes, and assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We identified 63 studies (41 cluster-randomised trials, 18 individual randomised trials, and four non-randomised trials) that met all inclusion criteria. Fifty-seven studies reported usable data (64 comparisons). The studies were mainly located in North America (42 studies) and the UK (eight studies). Fifty-four studies took place in outpatient/ambulatory settings. The clinical areas most commonly targeted were cardiovascular disease management (11 studies), cancer screening (10 studies) and preventive care (10 studies), and most studies had physicians as their target population (57 studies). General management of a clinical condition (17 studies), test-ordering (14 studies) and prescription (10 studies) were the behaviours more commonly targeted by the intervention. Forty-eight studies reported changes in professional practice measured as dichotomous process adherence outcomes (e.g. compliance with guidelines recommendations), 16 reported those changes measured as continuous process-of-care outcomes (e.g. number of days with catheters), eight reported dichotomous patient outcomes (e.g. mortality rates) and five reported continuous patient outcomes (e.g. mean systolic blood pressure). Manually-generated reminders delivered on paper probably improve professional practice measured as dichotomous process adherence outcomes) compared with usual care (median improvement 8.45% (IQR 2.54% to 20.58%); 39 comparisons, 40,346 participants; moderate certainty of evidence) and may make little or no difference to continuous process-of-care outcomes (8 comparisons, 3263 participants; low certainty of evidence). Adding manually-generated paper reminders to one or more QI co-interventions may slightly improve professional practice measured as dichotomous process adherence outcomes (median improvement 4.24% (IQR -1.09% to 5.50%); 12 comparisons, 25,359 participants; low certainty of evidence) and probably slightly improve professional practice measured as continuous outcomes (median improvement 0.28 (IQR 0.04 to 0.51); 2 comparisons, 12,372 participants; moderate certainty of evidence). Compared with other QI interventions, manually-generated reminders may slightly decrease professional practice measured as process adherence outcomes (median decrease 7.9% (IQR -0.7% to 11%); 14 comparisons, 21,274 participants; low certainty of evidence). We are uncertain whether manually-generated reminders delivered on paper, compared with usual care or with other QI intervention, lead to better or worse patient outcomes (dichotomous or continuous), as the certainty of the evidence is very low (10 studies, 13 comparisons). Reminders added to other QI interventions may make little or no difference to patient outcomes (dichotomous or continuous) compared with the QI alone (2 studies, 2 comparisons). Regarding resource use, studies reported additional costs per additional point of effectiveness gained, but because of the different currencies and years used the relevance of those figures is uncertain. None of the included studies reported outcomes related to harms or adverse effects. AUTHORS' CONCLUSIONS Manually-generated reminders delivered on paper as a single intervention probably lead to small to moderate increases in outcomes related to adherence to clinical recommendations, and they could be used as a single QI intervention. It is uncertain whether reminders should be added to other QI intervention already in place in the health system, although the effects may be positive. If other QI interventions, such as patient or computerised reminders, are available, they should be preferred over manually-generated reminders, but under close evaluation in order to decrease uncertainty about their potential effect.
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Affiliation(s)
- Tomas Pantoja
- Pontificia Universidad Católica de ChileDepartment of Family Medicine, Faculty of MedicineCentro Medico San Joaquin, Vicuña Mackenna 4686MaculSantiagoChile
| | - Jeremy M Grimshaw
- Ottawa Hospital Research InstituteClinical Epidemiology ProgramThe Ottawa Hospital ‐ General Campus501 Smyth Road, Box 711OttawaONCanadaK1H 8L6
| | - Nathalie Colomer
- Pontificia Universidad Católica de ChileDepartment of Family Medicine, Faculty of MedicineCentro Medico San Joaquin, Vicuña Mackenna 4686MaculSantiagoChile
| | - Carla Castañon
- Pontificia Universidad Católica de ChileDepartment of Family Medicine, Faculty of MedicineCentro Medico San Joaquin, Vicuña Mackenna 4686MaculSantiagoChile
| | - Javiera Leniz Martelli
- Pontificia Universidad Católica de ChileDepartment of Family Medicine, Faculty of MedicineCentro Medico San Joaquin, Vicuña Mackenna 4686MaculSantiagoChile
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Griffin A, Jagnoor J, Arora M, Cameron ID, Kifley A, Sterling M, Kenardy J, Rebbeck T. Evidence-based care in high- and low-risk groups following whiplash injury: a multi-centre inception cohort study. BMC Health Serv Res 2019; 19:806. [PMID: 31694622 PMCID: PMC6836463 DOI: 10.1186/s12913-019-4623-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 10/10/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Studies aimed at improving the provision of evidence-based care (EBC) for the management of acute whiplash injuries have been largely successful. However, whether EBC is broadly provided and whether delivery of EBC varies based on risk of non-recovery, is uncertain. Receiving EBC should improve recovery, though this relationship has yet to be established. Further, mitigating the effect of EBC is the relationship with the practitioner, a phenomenon poorly understood in WAD. This study aimed to determine the proportion of individuals with whiplash, at differing baseline risk levels, receiving EBC. This study also aimed to determine whether receiving EBC and the therapeutic relationship were associated with recovery at 3 months post injury. METHODS Participants with acute whiplash were recruited from public hospital emergency departments, private physiotherapy practices, and State Insurance Regulatory Authority (SIRA) databases. Participants completed questionnaires at baseline (demographics, risk of non-recovery) and 3-months (treatment received, risk identification, therapeutic relationship) post injury. Primary health care providers (HCPs) treating these participants also completed questionnaires at 3-months. Recovery was defined as neck disability index ≤4/50 and global perceived effect of ≥4/5. RESULTS Two-hundred and twenty-eight people with acute whiplash, and 53 primary care practitioners were recruited. The majority of the cohort reported receiving EBC, with correct application of the Canadian C-spine rule (74%), and provision of active treatments (e.g. 89% receiving advice) high. Non-recommended (passive) treatments were also received by a large proportion of the cohort (e.g. 50% receiving massage). The therapeutic relationship was associated with higher odds of recovery, which was potentially clinically significant (OR 1.34, 95% CI 1.18-1.62). EBC was not significantly associated with recovery. CONCLUSIONS Guideline-based knowledge and practice has largely been retained from previous implementation strategies. However, recommendations for routine risk identification and tailored management, and reduction in the provision of passive treatment have not. The therapeutic relationship was identified as one of several important predictors of recovery, suggesting that clinicians must develop rapport and understanding with their patients to improve the likelihood of recovery.
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Affiliation(s)
- Alexandra Griffin
- Faculty of Health Sciences, The University of Sydney, 75 East St, Lidcombe, NSW Australia
- John Walsh Centre for Rehabilitation Research, The University of Sydney, Kolling Institute, St Leonards, NSW Australia
| | - Jagnoor Jagnoor
- John Walsh Centre for Rehabilitation Research, The University of Sydney, Kolling Institute, St Leonards, NSW Australia
- The George Institute for Global Health, The University of Sydney, Level 5, 1 King St, Newtown, NSW Australia
| | - Mohit Arora
- John Walsh Centre for Rehabilitation Research, The University of Sydney, Kolling Institute, St Leonards, NSW Australia
| | - Ian D. Cameron
- John Walsh Centre for Rehabilitation Research, The University of Sydney, Kolling Institute, St Leonards, NSW Australia
| | - Annette Kifley
- John Walsh Centre for Rehabilitation Research, The University of Sydney, Kolling Institute, St Leonards, NSW Australia
| | - Michele Sterling
- NHMRC Centre of Research Excellence in Road Traffic Injury, The University of Queensland, Brisbane, QLD Australia
- Recover Injury Research Centre, The University of Queensland, Level 7, UQ Oral Health Centre, Herston, QLD Australia
| | - Justin Kenardy
- Recover Injury Research Centre, The University of Queensland, Level 7, UQ Oral Health Centre, Herston, QLD Australia
| | - Trudy Rebbeck
- Faculty of Health Sciences, The University of Sydney, 75 East St, Lidcombe, NSW Australia
- John Walsh Centre for Rehabilitation Research, The University of Sydney, Kolling Institute, St Leonards, NSW Australia
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23
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Mulders MAM, Walenkamp MMJ, Sosef NL, Ouwehand F, van Velde R, Goslings CJ, Schep NWL. The Amsterdam Wrist Rules to reduce the need for radiography after a suspected distal radius fracture: an implementation study. Eur J Trauma Emerg Surg 2019; 46:573-582. [PMID: 31541258 PMCID: PMC7280343 DOI: 10.1007/s00068-019-01194-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 07/22/2019] [Indexed: 11/07/2022]
Abstract
Purpose While most patients with wrist trauma are routinely referred for radiography, around 50% of these radiographs show no fracture. To avoid unnecessary radiographs, the Amsterdam Wrist Rules (AWR) have previously been developed and validated. The aim of the current study was to evaluate the effect of the implementation of the AWR at the Emergency Department (ED). Methods In a before-and-after comparative prospective cohort study, all consecutive adult patients with acute wrist trauma presenting at the ED of four hospitals were included. Primary outcome was the number of wrist radiographs before and after implementation of the AWR. Secondary outcomes were the number of clinically relevant missed fractures, the overall length of stay in the ED, physician compliance regarding the AWR, and patient satisfaction and experience with the care received at the ED. Results A total of 402 patients were included. The absolute reduction in wrist radiographs after implementation was 15% (p < 0.001). One clinically irrelevant fracture was missed. Non-fracture patients without wrist radiography due to the AWR spent 34 min less time in the ED compared with non-fracture patients who had a wrist radiograph (p = 0.015). The physicians adhered to the AWR in 36% of patients. Of all patients who did not receive a radiographic examination of the wrist, 87% were satisfied. Conclusion Implementation of the AWR safely reduces the amount of wrist radiographs in selected patients and consequently reducing the length of stay in the ED. Electronic supplementary material The online version of this article (10.1007/s00068-019-01194-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marjolein A M Mulders
- Trauma Unit, Department of Surgery, Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands.
| | - Monique M J Walenkamp
- Trauma Unit, Department of Surgery, Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - Nico L Sosef
- Department of Surgery, Spaarne Gasthuis, P.O. Box 770, 2130 AT, Hoofddorp, The Netherlands
| | - Frank Ouwehand
- Emergency Department, Amsterdam UMC, Location Academic Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - Romuald van Velde
- Department of Surgery, Tergooi Hospitals, P.O. Box 10016, 1201 DA, Hilversum, The Netherlands
| | - Carel J Goslings
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, P.O. Box 95500, 1090 HM, Amsterdam, The Netherlands
| | - Niels W L Schep
- Department of Trauma and Hand Surgery, Maasstad Hospital, P.O. Box 9100, 3007 AC, Rotterdam, The Netherlands
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Leonard JC, Browne LR, Ahmad FA, Schwartz H, Wallendorf M, Leonard JR, Lerner EB, Kuppermann N. Cervical Spine Injury Risk Factors in Children With Blunt Trauma. Pediatrics 2019; 144:peds.2018-3221. [PMID: 31221898 PMCID: PMC6615532 DOI: 10.1542/peds.2018-3221] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/15/2019] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Adult prediction rules for cervical spine injury (CSI) exist; however, pediatric rules do not. Our objectives were to determine test accuracies of retrospectively identified CSI risk factors in a prospective pediatric cohort and compare them to a de novo risk model. METHODS We conducted a 4-center, prospective observational study of children 0 to 17 years old who experienced blunt trauma and underwent emergency medical services scene response, trauma evaluation, and/or cervical imaging. Emergency department providers recorded CSI risk factors. CSIs were classified by reviewing imaging, consultations, and/or telephone follow-up. We calculated bivariable relative risks, multivariable odds ratios, and test characteristics for the retrospective risk model and a de novo model. RESULTS Of 4091 enrolled children, 74 (1.8%) had CSIs. Fourteen factors had bivariable associations with CSIs: diving, axial load, clotheslining, loss of consciousness, neck pain, inability to move neck, altered mental status, signs of basilar skull fracture, torso injury, thoracic injury, intubation, respiratory distress, decreased oxygen saturation, and neurologic deficits. The retrospective model (high-risk motor vehicle crash, diving, predisposing condition, neck pain, decreased neck mobility (report or exam), altered mental status, neurologic deficits, or torso injury) was 90.5% (95% confidence interval: 83.9%-97.2%) sensitive and 45.6% (44.0%-47.1%) specific for CSIs. The de novo model (diving, axial load, neck pain, inability to move neck, altered mental status, intubation, or respiratory distress) was 92.0% (85.7%-98.1%) sensitive and 50.3% (48.7%-51.8%) specific. CONCLUSIONS Our findings support previously identified pediatric CSI risk factors and prospective pediatric CSI prediction rule development.
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Affiliation(s)
| | - Lorin R. Browne
- Department of Pediatrics and Emergency Medicine,
Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Hamilton Schwartz
- Department of Pediatrics, Cincinnati
Children’s Hospital Medical Center and College of Medicine, University of
Cincinnati, Cincinnati, Ohio; and
| | - Michael Wallendorf
- Biostatistics, School of Medicine, Washington
University, St Louis, Missouri
| | - Jeffrey R. Leonard
- Neurosurgery, Nationwide Children’s Hospital
and College of Medicine, The Ohio State University, Columbus, Ohio
| | - E. Brooke Lerner
- Department of Pediatrics and Emergency Medicine,
Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics,
School of Medicine, University of California, Davis, Sacramento,
California
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25
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Kavuri V, Pannu G, Moront M, Pizzutillo P, Herman M. "Next Day" Examination Reduces Radiation Exposure in Cervical Spine Clearance at a Level 1 Pediatric Trauma Center: Preliminary Findings. J Pediatr Orthop 2019; 39:e339-e342. [PMID: 30507861 DOI: 10.1097/bpo.0000000000001309] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Safe and effective clearance of the pediatric cervical spine presents a challenging problem due to a myriad of reasons, which has often led to further imaging studies such as computed tomographic (CT) scans being performed, exposing the pediatric patient to significant radiation with a potential increased cancer risk. The goal of this study is to develop an effective algorithm for cervical spine clearance that minimizes radiation exposure. METHODS A cervical spine clearance protocol had been utilized in our institution from 2002 to 2011. In October 2012, the protocol was revised to provide indications for appropriate imaging by utilizing repeat "next day" physical examination. In 2014, the protocol was again revised with the desired goal of decreasing the use of CT scans through increased involvement of the Spine Service. A retrospective review was commenced using information from the Trauma Database from 2011 to 2014. Three groups were analyzed according to which protocol the patients were evaluated under: 2011, 2012, and 2014 protocols. RESULTS During the study period, 762 patients underwent cervical spine clearance; 259 (2011 protocol), 360 (2012 protocol), and 143 (2014 protocol). The average age of all patients was 8.8 years, with 28% of patients younger than 5 years of age. There were no missed or delayed diagnoses of cervical spine injury. The use of CT scans decreased during the study period from 90% (2011 protocol) to 42% (2012 protocol) to 28.7% (2014 protocol). There was an increase in time to removal of the cervical collar at 13 to 24 hours from 8% (2011 protocol) to 22% (2012 protocol) to 19% (2014 protocol). This was not associated with an increase in hospital length of stay, which averaged 2.51 days (2011 protocol), 2.45 days (2012 protocol), and 2.27 days (2014 protocol). CONCLUSIONS Repeat "next day" clinical examinations and increased involvement of the Spine Service decreased radiation exposure without compromising the diagnosis of cervical spine injury or increasing the length of stay at a Level One Pediatric Trauma Center in this pilot study. LEVEL OF EVIDENCE Level 4-case series.
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Affiliation(s)
- Venkat Kavuri
- Department of Orthopaedic Surgery, Drexel University College of Medicine, Hahnemann University Hospital
| | - Gurpal Pannu
- Department of Orthopaedic Surgery, University of California Davis, Davis, CA
| | - Matthew Moront
- Department of Pediatric Surgery, Cooper University Hospital, Camden, NJ
| | - Peter Pizzutillo
- Department of Pediatric Orthopaedic Surgery, St. Christopher's Hospital for Children, Philadelphia, PA
| | - Martin Herman
- Department of Pediatric Orthopaedic Surgery, St. Christopher's Hospital for Children, Philadelphia, PA
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Atsina KB, Rozenberg A, Selvarajan SK. The utility of whole spine survey MRI in blunt trauma patients sustaining single level or contiguous spinal fractures. Emerg Radiol 2019; 26:493-500. [DOI: 10.1007/s10140-019-01693-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 04/23/2019] [Indexed: 10/26/2022]
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Coggins A, Ebrahimi N, Kemp U, O'Shea K, Fusi M, Murphy M. A prospective evaluation of cervical spine immobilisation in low-risk trauma patients at a tertiary Emergency Department. Australas Emerg Care 2019; 22:69-75. [PMID: 31053486 DOI: 10.1016/j.auec.2019.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/03/2019] [Accepted: 04/03/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND In the Emergency Department cervical spine immobilisation precautions are frequently used. There is controversy in regard to the balance of risks and benefits of routine immobilisation in conscious patients. METHODS A prospective multi-methods evaluation in a tertiary trauma referral centre. The objectives were to investigate current practices and rate of concordance with established international guidelines. A provider survey focused on current knowledge, skills and attitudes and was disseminated to nurses, doctors and paramedics treating trauma patients. Additionally, clinical data were collected on a cohort of immobilised trauma patients. Demographic data were analysed using SPSS and content analysis was completed by manifest coding. RESULTS The response rate to the survey was 85.2%. Interdisciplinary providers included nurses (n=46), doctors (n=68) and paramedics (n=41). Content analysis revealed a range of themes for improving care. Themes identified included improved application of guidelines, tailored use of equipment in low-risk patients, improved access to radiology results, and staff education. The series of five case vignettes provided to participants revealed a high level of variance in intended approaches to immobilisation. In the cohort of trauma patients (n=54), the median age was 54 years and the most common mechanism of injury was falls (40.7%). Median time spent with immobilisation was 325min. Adherence to a recognised decision tool was 35/54 (64.8%). Precautions were initiated by paramedics in 42/54 (77.8%). CONCLUSIONS Despite widespread dissemination of guidelines, observed approaches to patient immobilisation appear to be highly variable in this trauma centre. Reducing variation for low-risk patients is likely to improve the patient journey and minimise the risk of prolonged immobilisation. Further assessment of the causes of variation could define goals for targeted translational change.
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Affiliation(s)
- Andrew Coggins
- Department of Emergency Medicine, Westmead Hospital, Sydney, Australia.
| | - Nargus Ebrahimi
- Department of Emergency Medicine, Westmead Hospital, Sydney, Australia
| | - Ursula Kemp
- Department of Emergency Medicine, Westmead Hospital, Sydney, Australia
| | - Kelly O'Shea
- Department of Emergency Medicine, Westmead Hospital, Sydney, Australia
| | | | - Margaret Murphy
- Department of Emergency Medicine, Westmead Hospital, Sydney, Australia
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Lee HY, Youk H, Kim OH, Kong JS, Kang CY, Sung S, Jang JY, Kim HJ, Kim SC, Lee KH. A predictive model to analyze factors affecting the presence of mild whiplash-associated disorders in minor motor vehicle crashes based on the Korean In-Depth Accidents Study (KIDAS) Database. TRAFFIC INJURY PREVENTION 2019; 19:S48-S54. [PMID: 30633556 DOI: 10.1080/15389588.2018.1519554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 08/28/2018] [Accepted: 08/31/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVES We aimed to analyze factors affecting the severity of mild whiplash-associated disorders (WADs) and to develop a predictive model to evaluate the presence of mild WAD in minor motor vehicle crashes (MVCs). METHODS We used the Korean In-Depth Accident Study (KIDAS) database, which collects data from 4 regional emergency centers, to obtain data from 2011 to 2017. The Collision Deformation Classification code was obtained as vehicle's damage information, and Abbreviated Injury Scale (AIS), Maximum Abbreviated Injury Scale (MAIS), and Injury Severity Score (ISS) were used as occupant's injury information. The degree of WAD was determined using the Quebec Task Force (QTF) classification, comprised of 5 stages (QTF 0-4), depending on the occupant's pain and the physician's findings. QTF 1 was defined as mild WAD, and we used QTF 0 to define those who were uninjured. For KIDAS data between 2011 and 2016, a logistic regression model was used to identify factors affecting the occurrence of mild WAD and a predictive model was constructed. Internal validity was estimated using random bootstrapping, and external validity was evaluated by applying 2017 KIDAS data. Of the 2,629 occupants in the KIDAS database from 2011 to 2016, after applying several exclusion conditions, 459 occupants were used to develop the predictive model. The external validity of the derived predictive model was assessed using the 13 MVC occupants from the 2017 KIDAS database meeting our inclusion criteria. Among the 137 MVC occupants from the 2017 KIDAS database for analysis of the external validity of the derived predictive model, the predictive model was verified for 13 MVC occupants. RESULTS Logistic regression analysis was used to derive a predictive model based on sex, age, body mass index, type of vehicle, belt status, seating row, crush type, and crush extent. This predictive model had an explanatory power of 65.5% to determine an actual QTF of 0 and 1 (c-statistics: 0.655). As a result of the external validity analysis of the predictive model using data from the 2017 KIDAS database (N = 13), sensitivity, specificity, and accuracy were 0.500, 0.857, and 0.692, respectively. CONCLUSIONS Using the predictive model, the results of the external validity analysis showed low sensitivity but high specificity. This predictive model provided meaningful results, with a high success rate for determining no injury to an occupant. Given our study results, future research is needed to create a more accurate predictive model that includes relevant technical and sociological factors.
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Affiliation(s)
- Hee Young Lee
- a Department of Emergency Medicine, Wonju College of Medicine , Yonsei University , Wonju , Korea
| | - Hyun Youk
- a Department of Emergency Medicine, Wonju College of Medicine , Yonsei University , Wonju , Korea
| | - Oh Hyun Kim
- a Department of Emergency Medicine, Wonju College of Medicine , Yonsei University , Wonju , Korea
| | - Joon Seok Kong
- a Department of Emergency Medicine, Wonju College of Medicine , Yonsei University , Wonju , Korea
| | - Chan Young Kang
- a Department of Emergency Medicine, Wonju College of Medicine , Yonsei University , Wonju , Korea
| | - Sil Sung
- a Department of Emergency Medicine, Wonju College of Medicine , Yonsei University , Wonju , Korea
| | - Ji Yun Jang
- b Center of Biomedical Data Science, Wonju College of Medicine , Yonsei University , Wonju , Korea
| | - Ho Jung Kim
- c Department of Emergency Medicine , Soonchunhyang University Bucheon Hospital , Bucheon , Korea
| | - Sang Chul Kim
- d Department of Emergency Medicine , Chungbuk National University Hospital , Cheongju , Korea
| | - Kang Hyun Lee
- a Department of Emergency Medicine, Wonju College of Medicine , Yonsei University , Wonju , Korea
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Hayden JA, Ogilvie R, Stewart SA, French S, Campbell S, Magee K, Slipp P, Wells G, Stiell I. Development of a clinical decision support tool for diagnostic imaging use in patients with low back pain: a study protocol. Diagn Progn Res 2019; 3:1. [PMID: 31093571 PMCID: PMC6460553 DOI: 10.1186/s41512-019-0047-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 01/04/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Low back pain is one of the most common and disabling health problems in Canada and internationally. In most cases, low back pain is a benign, self-limiting condition that can be managed with little diagnostic investigation or treatment. Yet contrary to clinical practice guideline recommendations, diagnostic imaging (here meaning X-ray, MRI, CT) is commonly used in the assessment of low back pain. Diagnostic imaging is of limited value in most cases, exposing patients to unnecessary radiation and leading to increased health services use and worse patient health outcomes. The Choosing Wisely campaign has highlighted the need to reduce diagnostic imaging for low back pain; however, no clinical decision rules are available. METHODS This project will develop a clinical decision support tool for appropriate use of diagnostic imaging for patients with low back pain in the emergency department. We will conduct a prospective cohort study at five Canadian emergency departments. The study will follow recommendations for prediction model development and testing. The study population will be 4000 patients presenting to the emergency department with low back pain. We will assess potential clinical indications of emergent-cause (i.e., "red flag" items), including clinical characteristics and past history. Our outcome, emergent-cause for low back pain such as fracture, cancer, infection, or cauda equina syndrome, will be assessed at discharge and at 1-, 3-, and 12-month follow-up periods using information from self-report and health administrative data. We will construct and assess the performance of a multivariable prediction model that has strong measurement properties, presented as a clinical decision support tool acceptable to knowledge users. DISCUSSION Practice guidelines describe "red flags" for which diagnostic imaging is likely appropriate. However, recommendations across guidelines are discordant, and few studies have evaluated these criteria to determine which characteristics best predict emergent etiology that warrant diagnostic imaging. A clinical decision support tool, that recommends diagnostic imaging where appropriate, has the potential to improve clinical care and patient outcomes and reduce costs associated with managing low back pain patients.
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Affiliation(s)
- Jill A. Hayden
- 0000 0004 1936 8200grid.55602.34Department Community Health and Epidemiology, Dalhousie University, 5790 University Avenue, Halifax, NS B3H 1V7 Canada
| | - Rachel Ogilvie
- 0000 0004 1936 8200grid.55602.34Department Community Health and Epidemiology, Dalhousie University, 5790 University Avenue, Halifax, NS B3H 1V7 Canada
| | - Samuel Alan Stewart
- 0000 0004 1936 8200grid.55602.34Department Community Health and Epidemiology, Dalhousie University, 5790 University Avenue, Halifax, NS B3H 1V7 Canada
| | - Simon French
- 0000 0004 1936 8331grid.410356.5School of Rehabilitation Therapy, Queen’s University, Louise D. Acton Building, 31 George St, Kingston, ON K7L 3N6 Canada
- 0000 0001 2158 5405grid.1004.5Department of Chiropractic, Macquarie University, Sydney, NSW 2109 Australia
| | - Samuel Campbell
- 0000 0004 1936 8200grid.55602.34Department of Emergency Medicine, Dalhousie University, Emergency Medicine, Nova Scotia Health Authority, QEII Health Sciences Centre, Suite 355, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
| | - Kirk Magee
- 0000 0004 1936 8200grid.55602.34Department of Emergency Medicine, Dalhousie University, Emergency Medicine, Nova Scotia Health Authority, QEII Health Sciences Centre, Suite 355, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
| | - Patrick Slipp
- 0000 0004 0407 789Xgrid.413292.fDepartment of Radiology, Nova Scotia Health Authority, QEII Health Sciences Centre, Suite 355, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
| | - George Wells
- 0000 0001 2182 2255grid.28046.38Epidemiology and Community Medicine, University of Ottawa, Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON K1Y 4W7 Canada
| | - Ian Stiell
- 0000 0001 2182 2255grid.28046.38Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, 1053 Carling Avenue, Ottawa, ON K1Y 4E9 Canada
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Vaillancourt C, Charette M, Hall E, McLeod B. Patient and paramedic engagement in prehospital emergency medicine research. CMAJ 2018; 190:S48-S49. [PMID: 30404855 DOI: 10.1503/cmaj.180352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Christian Vaillancourt
- The Ottawa Hospital Research Institute (Vaillancourt), University of Ottawa; The Ottawa Hospital Research Institute (Charette), Ottawa, Ont.; Hall Consulting (Hall); Helping Hands for India (Hall), Kanata, Ont.; Hamilton Paramedic Service (McLeod), Hamilton, Ont.
| | - Manya Charette
- The Ottawa Hospital Research Institute (Vaillancourt), University of Ottawa; The Ottawa Hospital Research Institute (Charette), Ottawa, Ont.; Hall Consulting (Hall); Helping Hands for India (Hall), Kanata, Ont.; Hamilton Paramedic Service (McLeod), Hamilton, Ont
| | - Elizabeth Hall
- The Ottawa Hospital Research Institute (Vaillancourt), University of Ottawa; The Ottawa Hospital Research Institute (Charette), Ottawa, Ont.; Hall Consulting (Hall); Helping Hands for India (Hall), Kanata, Ont.; Hamilton Paramedic Service (McLeod), Hamilton, Ont
| | - Brent McLeod
- The Ottawa Hospital Research Institute (Vaillancourt), University of Ottawa; The Ottawa Hospital Research Institute (Charette), Ottawa, Ont.; Hall Consulting (Hall); Helping Hands for India (Hall), Kanata, Ont.; Hamilton Paramedic Service (McLeod), Hamilton, Ont
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Burkhardt JC, DesJardins SL, Teener CA, Gay SE, Santen SA. Predicting Medical School Enrollment Behavior: Comparing an Enrollment Management Model to Expert Human Judgment. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2018; 93:S68-S73. [PMID: 30365432 DOI: 10.1097/acm.0000000000002374] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
PURPOSE Medical school admissions committees are tasked with fulfilling the values of their institutions through careful recruitment. Making accurate predictions regarding enrollment behavior of admitted students is critical to intentionally formulating class composition and impacts long-term physician representation. The predictive accuracy and potential advantages of employing an enrollment predictive model in medical school admissions compared with expert human judgment have not been tested. METHOD The enrollment management-based predictive model previously generated using historical data was employed to provide a predicted enrollment percentage for each admitted student in the 2016-2017 application pool (N = 352). Concurrently, the human expert created a predicted enrollment percentage for each applicant while blinded to the values generated by the model. An absolute error for each applicant for both approaches was calculated. Statistical significance between approaches (expert vs. enrollment model) was assessed using t tests. RESULTS The enrollment management approach was noninferior to expert prediction in all cases (P < .05) with a superior correct classification rate (77.7% vs. 71.2%). When considering subgroup analyses for specific populations of potential importance in recruiting (underrepresented in medicine, female, and in-state applicants), the enrollment management predictions were statistically more accurate (P < .05). CONCLUSIONS Examining a single admitted class, the enrollment predictions using the enrollment management model were at least as accurate as the expert human estimates, and in specific populations of interest more accurate. This information can be readily exported for a real-time dashboard system to drive recruitment behaviors.
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Affiliation(s)
- John C Burkhardt
- J.C. Burkhardt is assistant professor, Departments of Emergency Medicine and Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Michigan; ORCID: https://orcid.org/0000-0001-6273-8762. S.L. DesJardins is professor, School of Education and School of Public Policy, University of Michigan, Ann Arbor, Michigan. C.A. Teener is admissions director, University of Michigan Medical School, Ann Arbor, Michigan. S.E. Gay is assistant dean for admissions and associate professor, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan. S.A. Santen is senior associate dean for evaluation, assessment, and scholarship of learning, and professor, Department of Emergency Medicine, Virginia Commonwealth School of Medicine, Richmond, Virginia
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Stiell IG, Clement CM, Lowe M, Sheehan C, Miller J, Armstrong S, Bailey B, Posselwhite K, Langlais J, Ruddy K, Thorne S, Armstrong A, Dain C, Perry JJ, Vaillancourt C. A Multicenter Program to Implement the Canadian C-Spine Rule by Emergency Department Triage Nurses. Ann Emerg Med 2018; 72:333-341. [DOI: 10.1016/j.annemergmed.2018.03.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 02/27/2018] [Accepted: 03/23/2018] [Indexed: 11/29/2022]
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Strudwick K, McPhee M, Bell A, Martin-Khan M, Russell T. Review article: Best practice management of neck pain in the emergency department (part 6 of the musculoskeletal injuries rapid review series). Emerg Med Australas 2018; 30:754-772. [PMID: 30168261 DOI: 10.1111/1742-6723.13131] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 03/14/2018] [Accepted: 06/10/2018] [Indexed: 12/13/2022]
Abstract
Neck pain and whiplash injuries are a common presentation to the ED, and a frequent cause of disability globally. This rapid review investigated best practice for the assessment and management of musculoskeletal neck pain in the ED. PubMed, CINAHL, EMBASE, TRIP and the grey literature, including relevant organisational websites, were searched in 2017. Primary studies, systematic reviews and guidelines were considered for inclusion. English-language articles published in the past 12 years addressing acute neck pain assessment, management or prognosis in the ED were included. Data extraction was conducted, followed by quality appraisal to rate levels of evidence where possible. The search revealed 2080 articles, of which 51 were included (n = 22 primary articles, n = 13 systematic reviews and n = 16 guidelines). Consistent evidence was found to support the use of 'red flags' to screen for serious pathologies, judicious use of imaging through clinical decision rule application and promotion of functional exercise coupled with advice and reassurance. Clinicians may also consider applying risk-stratification methods, such as using a clinical prediction rule, to guide patient discharge and referral plans; however, the evidence is still emerging in this population. This rapid review provides clinicians managing neck pain in the ED a summary of the best available evidence to enhance quality of care and optimise patient outcomes.
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Affiliation(s)
- Kirsten Strudwick
- Emergency Department, Queen Elizabeth II Jubilee Hospital, Metro South Hospital and Health Service, Brisbane, Queensland, Australia.,Physiotherapy Department, Queen Elizabeth II Jubilee Hospital, Metro South Hospital and Health Service, Brisbane, Queensland, Australia.,School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Megan McPhee
- Physiotherapy Department, Queen Elizabeth II Jubilee Hospital, Metro South Hospital and Health Service, Brisbane, Queensland, Australia
| | - Anthony Bell
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Brisbane, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Melinda Martin-Khan
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Trevor Russell
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia
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Bandong AN, Leaver A, Mackey M, Ingram R, Shearman S, Chan C, Cameron ID, Moloney N, Mitchell R, Doyle E, Leyten E, Rebbeck T. Adoption and use of guidelines for whiplash: an audit of insurer and health professional practice in New South Wales, Australia. BMC Health Serv Res 2018; 18:622. [PMID: 30089495 PMCID: PMC6083615 DOI: 10.1186/s12913-018-3439-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 08/01/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Australia, the New South Wales (NSW) State Insurance Regulatory Authority has been continuously developing and implementing clinical practice guidelines to address the health and economic burden from whiplash associated disorders (WAD). Despite this, it is uncertain the extent to which the guidelines are followed. This study aimed to determine insurer and health professional compliance with recommendations of the 2014 NSW clinical practice guidelines for the management of acute WAD; and explore factors related to adherence. METHODS This was an observational study involving an audit of 288 randomly-selected claimant files from 4 insurance providers in NSW, Australia between March and October 2016. Data extracted included demographic, claim and injury details, use of health services, and insurer and health professional practices related to the guidelines. Analyses involved descriptive statistics and correlation analysis. RESULTS Median time for general practitioner medical consultation was 4 days post-injury and 25 days for physical treatment (e.g. physiotherapy). Rates of x-ray investigations were low (21.5%) and most patients (90%) were given active treatments in line with the guideline recommendations. The frequency of other practices recommended by the guidelines suggested lower guideline adherence in some areas such as; using the Quebec Task Force classification (19.9%); not using specialised imaging for WAD grades I and II (e.g. MRI, 45.8%); not using routine passive treatments (e.g. manual therapy, 94.0%); and assessing risk of non-recovery using relevant prognostic tools (e.g. Neck Disability Index, 12.8%). Over half of the claimants (59.0%) were referred to other professionals at 9-12 weeks post-injury, among which 31.2% were to psychologists and 68.8% to specialists (surgical specialists, 43.6%; WAD specialists, 20.5%). Legal representation and lodgment of full claim were associated with increased number of medical visits and imaging (ρ 0.23 to 0.3; p < 0.01). CONCLUSION There is evidence of positive uptake of some guideline recommendations by insurers and health professionals; however, there are practices that are not compliant and might lead to poor health outcomes and greater treatment cost. Organisational, regulatory and professional implementation strategies may be considered to change practice, improve scheme performance and ultimately improve outcomes for people with WAD.
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Affiliation(s)
- Aila Nica Bandong
- Faculty of Health Sciences, The University of Sydney, 75 East Street, Sydney, Australia
- College of Allied Medical Professions, University of the Philippines, Manila, Philippines
- Musculoskeletal Lab/Refshauge Lab (S218), Faculty of Health Sciences, The University of Sydney – Cumberland Campus, 75 East Street, Lidcombe, NSW 2141 Australia
| | - Andrew Leaver
- Faculty of Health Sciences, The University of Sydney, 75 East Street, Sydney, Australia
| | - Martin Mackey
- Faculty of Health Sciences, The University of Sydney, 75 East Street, Sydney, Australia
| | - Rodney Ingram
- Faculty of Health Sciences, The University of Sydney, 75 East Street, Sydney, Australia
| | - Samantha Shearman
- Faculty of Health Sciences, The University of Sydney, 75 East Street, Sydney, Australia
| | - Christen Chan
- Faculty of Health Sciences, The University of Sydney, 75 East Street, Sydney, Australia
| | - Ian D Cameron
- John Walsh Centre for Rehabilitation Research, Royal North Shore Hospital, Sydney, Australia
| | - Niamh Moloney
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Rebecca Mitchell
- Macquarie University, Australian Institute of Health Innovation, Sydney, Australia
| | - Eoin Doyle
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Emma Leyten
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Trudy Rebbeck
- Faculty of Health Sciences, The University of Sydney, 75 East Street, Sydney, Australia
- John Walsh Centre for Rehabilitation Research, Royal North Shore Hospital, Sydney, Australia
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Haskell L, Tavender EJ, Wilson C, O’Brien S, Babl FE, Borland ML, Cotterell L, Schuster T, Orsini F, Sheridan N, Johnson D, Oakley E, Dalziel SR. Implementing evidence-based practices in the care of infants with bronchiolitis in Australasian acute care settings: study protocol for a cluster randomised controlled study. BMC Pediatr 2018; 18:218. [PMID: 29980177 PMCID: PMC6035428 DOI: 10.1186/s12887-018-1187-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 06/21/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Bronchiolitis is the most common reason for admission to hospital for infants less than one year of age. Although management is well defined, there is substantial variation in practice, with infants receiving ineffective therapies or management. This study will test the effectiveness of tailored, theory informed knowledge translation (KT) interventions to decrease the use of five clinical therapies or management processes known to be of no benefit, compared to usual dissemination practices in infants with bronchiolitis. The primary objective is to establish whether the KT interventions are effective in increasing compliance to five evidence based recommendations in the first 24 h following presentation to hospital. The five recommendations are that infants do not receive; salbutamol, antibiotics, glucocorticoids, adrenaline, or a chest x-ray. METHODS/DESIGN This study is designed as a cluster randomised controlled trial. We will recruit 24 hospitals in Australia and New Zealand, stratified by country and provision of tertiary or secondary paediatric care. Hospitals will be randomised to either control or intervention groups. Control hospitals will receive a copy of the recent Australasian Bronchiolitis Guideline. Intervention hospitals will receive KT interventions informed by a qualitative analysis of factors influencing clinician care of infants with bronchiolitis. Key interventions include, local stakeholder meetings, identifying medical and nursing clinical leads in both emergency departments and paediatric inpatient areas who will attend a single education train-the-trainer day to then deliver standardised staff education with the training materials provided and coordinate audit and feedback reports locally over the study period. Data will be extracted retrospectively for three years prior to the study intervention year, and for seven months of the study intervention year bronchiolitis season following intervention delivery to determine compliance with the five evidence-based recommendations. Data will be collected to assess fidelity to the implementation strategies and to facilitate an economic evaluation. DISCUSSION This study will contribute to the body of knowledge to determine the effectiveness of tailored, theory informed interventions in acute care paediatric settings, with the aim of reducing the evidence to practice gaps in the care of infants with bronchiolitis. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12616001567415 (retrospectively registered on 14 November 2016).
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Affiliation(s)
- Libby Haskell
- Children’s Emergency Department, Starship Children’s Hospital, Private Bag 92024, Auckland, 1142 New Zealand
- University of Auckland, Auckland, New Zealand
| | - Emma J. Tavender
- Murdoch Childrens Research Institute, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
| | | | - Sharon O’Brien
- Princess Margaret Hospital for Children, Perth, Australia
| | - Franz E. Babl
- Murdoch Childrens Research Institute, Melbourne, Australia
- The Royal Children’s Hospital, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Meredith L. Borland
- Princess Margaret Hospital for Children, Perth, Australia
- Divisions of Paediatrics and Emergency Medicine, School of Medicine, University of Western Australia, Perth, Australia
| | - Liz Cotterell
- Armidale Rural Referral Hospital, Armidale, NSW Australia
- University of New England, Armidale, NSW Australia
| | - Tibor Schuster
- Murdoch Childrens Research Institute, Melbourne, Australia
- Melbourne Children’s Trials Centre, Melbourne, Australia
| | - Francesca Orsini
- Murdoch Childrens Research Institute, Melbourne, Australia
- Melbourne Children’s Trials Centre, Melbourne, Australia
| | | | - David Johnson
- Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Ed Oakley
- Murdoch Childrens Research Institute, Melbourne, Australia
- The Royal Children’s Hospital, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Stuart R. Dalziel
- Children’s Emergency Department, Starship Children’s Hospital, Private Bag 92024, Auckland, 1142 New Zealand
- University of Auckland, Auckland, New Zealand
| | - on behalf of PREDICT
- Paediatric Research in Emergency Departments International Collaborative, Melbourne, Australia
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Desai S, Liu C, Kirkland SW, Krebs LD, Keto‐Lambert D, Rowe BH. Effectiveness of Implementing Evidence-based Interventions to Reduce C-spine Image Ordering in the Emergency Department: A Systematic Review. Acad Emerg Med 2018; 25:672-683. [PMID: 29265532 DOI: 10.1111/acem.13364] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 11/08/2017] [Accepted: 12/12/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Appropriate use of imaging for adult patients with cervical spine (C-spine) injuries in the emergency department (ED) is a longstanding issue. Guidance for C-spine ordering exists; however, the effectiveness of the decision support implementation in the ED is not well studied. This systematic review examines the implementation and effectiveness of evidence-based interventions aimed at reducing C-spine imaging in adults presenting to the ED with neck trauma. METHODS Six electronic databases and the gray literature were searched. Comparative intervention studies were eligible for inclusion. Two independent reviewers screened for study eligibility, study quality, and extracted data. The change in imaging was reported using individual odds ratios (ORs) with 95% confidence intervals (CIs) using random effects. RESULTS A total of 990 unique citations were screened for relevance of which six before-after studies and one randomized controlled trial were included. None of the studies were assessed as high quality. Interventions consisted primarily of locally developed guidelines or established clinical decision rules such as the NEXUS or the Canadian C-spine rule. Overall, implementation of interventions aimed at reducing C-spine image ordering resulted in a statistically significant reduction in imaging (OR = 0.69, 95% CI = 0.51-0.93); however, heterogeneity was high (I2 = 82%). Subgroup analysis revealed no differences between studies that specified enrolling alert and stable patients compared to unspecified trauma (p = 0.81) or between studies employing multifaceted versus nonmultifaceted interventions (p = 0.66). While studies generally provided details on implementation strategies (e.g., teaching sessions, pocket cards, posters, computerized decision support) the effectiveness of these implementation strategies were frequently not reported. CONCLUSION There is moderate evidence regarding the effectiveness of interventions to reduce C-spine image ordering in adult patients seen in the ED with neck trauma. Given the national and international focus on improving appropriateness and reducing unnecessary C-spine imaging through campaigns such as Choosing Wisely, additional interventional research in this field is warranted.
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Affiliation(s)
- Shashwat Desai
- Department of Emergency Medicine University of Alberta Edmonton Alberta Canada
| | - Chaocheng Liu
- Department of Emergency Medicine University of Alberta Edmonton Alberta Canada
| | - Scott W. Kirkland
- Department of Emergency Medicine University of Alberta Edmonton Alberta Canada
| | - Lynette D. Krebs
- Department of Emergency Medicine University of Alberta Edmonton Alberta Canada
| | - Diana Keto‐Lambert
- Department of Emergency Medicine University of Alberta Edmonton Alberta Canada
| | - Brian H. Rowe
- Department of Emergency Medicine University of Alberta Edmonton Alberta Canada
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Heyworth J, Mason SM. Emergency Medicine: great papers from the Summer of Love to 2017. Emerg Med J 2018; 35:152-155. [PMID: 29463634 DOI: 10.1136/emermed-2017-207285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 01/17/2018] [Accepted: 01/18/2018] [Indexed: 11/04/2022]
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Review of implementation strategies to change healthcare provider behaviour in the emergency department. CAN J EMERG MED 2018; 20:453-460. [PMID: 29429430 DOI: 10.1017/cem.2017.432] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Advances in emergency medicine research can be slow to make their way into clinical care, and implementing a new evidence-based intervention can be challenging in the emergency department. The Canadian Association of Emergency Physicians (CAEP) Knowledge Translation Symposium working group set out to produce recommendations for best practice in the implementation of a new science in Canadian emergency departments. METHODS A systematic review of implementation strategies to change health care provider behaviour in the emergency department was conducted simultaneously with a national survey of emergency physician experience. We summarized our findings into a list of draft recommendations that were presented at the national CAEP Conference 2017 and further refined based on feedback through social media strategies. RESULTS We produced 10 recommendations for implementing new evidence-based interventions in the emergency department, which cover identifying a practice gap, evaluating the evidence, planning the intervention strategy, monitoring, providing feedback during implementation, and desired qualities of future implementation research. CONCLUSIONS We present recommendations to guide future emergency department implementation initiatives. There is a need for robust and well-designed implementation research to guide future emergency department implementation initiatives.
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Variation in emergency department use of computed tomography for investigation of acute aortic dissection. Emerg Radiol 2018; 25:293-298. [PMID: 29404804 DOI: 10.1007/s10140-018-1587-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 01/24/2018] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Acute aortic dissection (AAD) is a life-threatening condition making early diagnosis critical. Although 90% present with acute pain, the myriad of associated symptoms can make diagnosis a challenge. Our objective was to assess how we are using computed tomography to rule out acute aortic dissection specifically rate of ordering, diagnostic yield, and variation in practice. METHODS We included consecutive adult patients presenting to two tertiary academic care emergency departments over one calendar year presenting with non-traumatic chest, back, abdominal, or flank pain. Primary outcome was rate of CT thorax/abdomen ordered to rule out AAD. Secondary outcome was variation in CT ordering, measured comparing number of CTs ordered per physician. Sample size of 12 per group was calculated based on an expected delta in mean CT ordered of 5 and a within group SD of 3. RESULTS Thirty-one thousand two hundred one patients presented with truncal pain during the study period, 22,729 were included (mean 47 years, SD 18.5 years, 56.2% female); prevalence of AAD (N = 4) was 0.02%. CT was ordered to rule out AAD in 175 (0.7%) patients (mean 62 years, SD 16.5, 50.6% female). Significant variation between physicians ordering was found, with individual physicians ordering varying from 0.6 to 12%. CONCLUSIONS Current rate of imaging for acute aortic dissection is low and potentially inefficient, with a large variation in practice. These findings suggest potential for more standardized and efficient use of CT for the diagnosis of acute aortic dissection.
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How to conduct implementation trials and multicentre studies in the emergency department. CAN J EMERG MED 2018; 20:448-452. [PMID: 29378671 DOI: 10.1017/cem.2017.433] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The objective of Panel 2b was to present an overview of and recommendations for the conduct of implementation trials and multicentre studies in emergency medicine. METHODS Panel members engaged methodologists to discuss the design and conduct of implementation and multicentre studies. We also conducted semi-structured interviews with 37 Canadian adult and pediatric emergency medicine researchers to elicit barriers and facilitators to conducting these kinds of studies. RESULTS Responses were organized by themes, and, based on these responses, recommendations were developed and refined in an iterative fashion by panel members. CONCLUSIONS We offer eight recommendations to facilitate multicentre clinical and implementation studies, along with guidance for conducting implementation research in the emergency department. Recommendations for multicentre studies reflect the importance of local study investigators and champions, requirements for research infrastructure and staffing, and the cooperation and communication between the coordinating centre and participating sites.
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Moskowitz A, Andersen LW, Cocchi M, Donnino MW. The Misapplication of Severity-of-Illness Scores toward Clinical Decision Making. Am J Respir Crit Care Med 2017; 194:256-8. [PMID: 27299379 DOI: 10.1164/rccm.201605-1005ed] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Ari Moskowitz
- 1 Department of Medicine Massachusetts General Hospital Boston, Massachusetts
| | - Lars W Andersen
- 2 Research Center for Emergency Medicine Aarhus University Hospital Aarhus, Denmark
| | - Michael Cocchi
- 3 Department of Anesthesia Critical Care Beth Israel Deaconess Medical Center Boston, Massachusetts and
| | - Michael W Donnino
- 4 Department of Emergency Medicine Beth Israel Deaconess Medical Center Boston, Massachusetts
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Slaar A, Fockens MM, Wang J, Maas M, Wilson DJ, Goslings JC, Schep NWL, van Rijn RR. Triage tools for detecting cervical spine injury in pediatric trauma patients. Cochrane Database Syst Rev 2017; 12:CD011686. [PMID: 29215711 PMCID: PMC6486014 DOI: 10.1002/14651858.cd011686.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Pediatric cervical spine injury (CSI) after blunt trauma is rare. Nonetheless, missing these injuries can have severe consequences. To prevent the overuse of radiographic imaging, two clinical decision tools have been developed: The National Emergency X-Radiography Utilization Study (NEXUS) criteria and the Canadian C-spine Rule (CCR). Both tools are proven to be accurate in deciding whether or not diagnostic imaging is needed in adults presenting for blunt trauma screening at the emergency department. However, little information is known about the accuracy of these triage tools in a pediatric population. OBJECTIVES To determine the diagnostic accuracy of the NEXUS criteria and the Canadian C-spine Rule in a pediatric population evaluated for CSI following blunt trauma. SEARCH METHODS We searched the following databases to 24 February 2015: CENTRAL, MEDLINE, MEDLINE Non-Indexed and In-Process Citations, PubMed, Embase, Science Citation Index, ProQuest Dissertations & Theses Database, OpenGrey, ClinicalTrials.gov, World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Health Technology Assessment, and the Aggressive Research Intelligence Facility. SELECTION CRITERIA We included all retrospective and prospective studies involving children following blunt trauma that evaluated the accuracy of the NEXUS criteria, the Canadian C-spine Rule, or both. Plain radiography, computed tomography (CT) or magnetic resonance imaging (MRI) of the cervical spine, and follow-up were considered as adequate reference standards. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the quality of included studies using the QUADAS-2 checklists. They extracted data on study design, patient characteristics, inclusion and exclusion criteria, clinical parameters, target condition, reference standard, and the diagnostic two-by-two table. We calculated and plotted sensitivity, specificity and negative predictive value in ROC space, and constructed forest plots for visual examination of variation in test accuracy. MAIN RESULTS Three cohort studies were eligible for analysis, including 3380 patients ; 96 children were diagnosed with CSI. One study evaluated the accuracy of the Canadian C-spine Rule and the NEXUS criteria, and two studies evaluated the accuracy of the NEXUS criteria. The studies were of moderate quality. Due to the small number of included studies and the diverse outcomes of those studies, we could not describe a pooled estimate for the diagnostic test accuracy. The sensitivity of the NEXUS criteria of the individual studies was 0.57 (95% confidence interval (CI) 0.18 to 0.90), 0.98 (95% CI 0.91 to 1.00) and 1.00 (95% CI 0.88 to 1.00). The specificity of the NEXUS criteria was 0.35 (95% CI 0.25 to 0.45), 0.54 (95% CI 0.45 to 0.62) and 0.2 (95% CI 0.18 to 0.21). For the Canadian C-spine Rule the sensitivity was 0.86 (95% CI 0.42 to 1.00) and specificity was 0.15 (95% CI 0.08 to 0.23). Since the quantity of the data was small we were not able to investigate heterogeneity. AUTHORS' CONCLUSIONS There are currently few studies assessing the diagnostic test accuracy of the NEXUS criteria and CCR in children. At the moment, there is not enough evidence to determine the accuracy of the Canadian C-spine Rule to detect CSI in pediatric trauma patients following blunt trauma. The confidence interval of the sensitivity of the NEXUS criteria between the individual studies showed a wide range, with a lower limit varying from 0.18 to 0.91 with a total of four false negative test results, meaning that if physicians use the NEXUS criteria in children, there is a chance of missing CSI. Since missing CSI could have severe consequences with the risk of significant morbidity, we consider that the NEXUS criteria are at best a guide to clinical assessment, with current evidence not supporting strict or protocolized adoption of the tool into pediatric trauma care. Moreover, we have to keep in mind that the sensitivity differs among several studies, and individual confidence intervals of these studies show a wide range. Our main conclusion is therefore that additional well-designed studies with large sample sizes are required to better evaluate the accuracy of the NEXUS criteria or the Canadian C-spine Rule, or both, in order to determine whether they are appropriate triage tools for the clearance of the cervical spine in children following blunt trauma.
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Affiliation(s)
- Annelie Slaar
- WestfriesgasthuisDepartment of RadiologyMaelsonstraat 3HoornNoord HollandNetherlands1624 NP
| | - M M Fockens
- University of AmsterdamAcademic Medical CenterAmsterdamNetherlands
| | - Junfeng Wang
- Academic Medical CenterDepartment of Clinical Epidemiology, Biostatistics and BioinformaticsMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Mario Maas
- Academic Medical CenterDepartment of RadiologyUniversity of AmsterdamMeibergdreefAmsterdamNetherlands
| | - David J Wilson
- St Lukes HospitalDepartment of RadiologyLatimer RoadHeadingtonOxfordUKOX3 7PF
| | - J Carel Goslings
- Academic Medical CenterTrauma Unit, Department of SurgeryMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Niels WL Schep
- Academic Medical CenterDepartment of Surgery/Trauma UnitMeibergdreef 9AmsterdamNetherlands1105AZ
| | - Rick R van Rijn
- Academic Medical Center AmsterdamDepartment of RadiologyMeibergdreef 9AmsterdamNetherlands1105 AZ
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Browne LR, Schwartz H, Ahmad FA, Wallendorf M, Kuppermann N, Lerner EB, Leonard JC. Interobserver Agreement in Pediatric Cervical Spine Injury Assessment Between Prehospital and Emergency Department Providers. Acad Emerg Med 2017; 24:1501-1510. [PMID: 28921731 DOI: 10.1111/acem.13312] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 08/25/2017] [Accepted: 09/11/2017] [Indexed: 01/23/2023]
Abstract
BACKGROUND Investigators have derived cervical spine injury (CSI) decision support tools from physician observations. There is a need to demonstrate that prehospital emergency medical services (EMS) providers can use these tools to appropriately determine the need for spinal motion restrictions and make field disposition decisions. OBJECTIVES The objective was to determine the interobserver agreement between EMS and emergency department (ED) providers for CSI risk assessment variables and overall gestalt for CSI in children after blunt trauma. METHODS This was a planned, substudy of a four-site, prospective cohort of children < 18 years transported by EMS to pediatric EDs for evaluation of CSI after blunt trauma. Inclusion criteria were trauma team activation and/or EMS-initiated spinal motion restriction. Exclusion criteria were penetrating trauma, transfer to another facility for definitive care, state custody, or substantial language barrier. For each eligible child, the transporting EMS provider and treating ED provider independently recorded their clinical assessment for CSI. This included mechanism of injury and patient history and physical examination findings. We assessed each paired variable for interobserver agreement between EMS and ED provider using kappa (κ) analysis. We considered variables with κ lower confidence interval values ≥0.4 to have moderate or better agreement. RESULTS We obtained 1,372 paired observations for 29 variables. After finding prevalence and observer bias were adjusted for, all variables achieved moderate to better agreement including eight variables previously shown to be independently associated with CSI in children: diving mechanism, high-risk motor vehicle collision, altered mental status, focal neurologic findings, neck pain, torticollis, substantial torso injury, and predisposing medical condition. EMS and ED providers, however, showed less than moderate agreement for their overall gestalt for CSI in children. Of note, both EMS and ED providers did not assess for neck pain, inability to move the neck, and/or cervical spine tenderness in more than 10% of study patients. CONCLUSIONS Emergency medical services and ED providers achieved at least moderate agreement in the assessment of CSI risk factors in children after blunt trauma. However, EMS and ED providers did not achieve moderate agreement on gestalt for CSI and some risk factors went unassessed by providers. These findings support the development of a pediatric CSI risk assessment tool for EMS and ED providers to reduce interventions for those children at very low risk for CSIs while still identifying all children with injury.
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Affiliation(s)
- Lorin R. Browne
- Department of Pediatrics and Emergency Medicine; Medical College of Wisconsin (LRB, EBL); Madison WI
| | - Hamilton Schwartz
- Department of Pediatrics; University of Cincinnati College of Medicine (HS); Cincinnati OH
| | - Fahd A. Ahmad
- Department Pediatrics; Washington University School of Medicine in St. Louis; St. Louis MO
| | - Michael Wallendorf
- Department of Biostatistics; Washington University School of Medicine in St. Louis; St. Louis MO
| | - Nathan Kuppermann
- Department of Emergency Medicine and Pediatrics; University of California Davis School of Medicine; Sacramento CA
| | - E. Brooke Lerner
- Department of Pediatrics and Emergency Medicine; Medical College of Wisconsin (LRB, EBL); Madison WI
| | - Julie C. Leonard
- Nationwide Children's Hospital and The Ohio State University College of Medicine; Columbus OH
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Reiley AS, Vickory FM, Funderburg SE, Cesario RA, Clendaniel RA. How to diagnose cervicogenic dizziness. Arch Physiother 2017; 7:12. [PMID: 29340206 PMCID: PMC5759906 DOI: 10.1186/s40945-017-0040-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 09/04/2017] [Indexed: 12/21/2022] Open
Abstract
Cervicogenic dizziness (CGD) is a clinical syndrome characterized by the presence of dizziness and associated neck pain. There are no definitive clinical or laboratory tests for CGD and therefore CGD is a diagnosis of exclusion. It can be difficult for healthcare professionals to differentiate CGD from other vestibular, medical and vascular disorders that cause dizziness, requiring a high level of skill and a thorough understanding of the proper tests and measures to accurately rule in or rule out competing diagnoses. Consequently, the purpose of this paper is to provide a systematic diagnostic approach to enable healthcare providers to accurately diagnose CGD. This narrative will outline a stepwise process for evaluating patients who may have CGD and provide steps to exclude diagnoses that can present with symptoms similar to those seen in CGD, including central and peripheral vestibular disorders, vestibular migraine, labyrinthine concussion, cervical arterial dysfunction, and whiplash associated disorder.
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Affiliation(s)
- Alexander S. Reiley
- Doctor of Physical Therapy Division, Duke University, 2200 W Main St., Durham, NC 27705 USA
| | - Frank M. Vickory
- Doctor of Physical Therapy Division, Duke University, 2200 W Main St., Durham, NC 27705 USA
| | - Sarah E. Funderburg
- Doctor of Physical Therapy Division, Duke University, 2200 W Main St., Durham, NC 27705 USA
| | - Rachel A. Cesario
- Doctor of Physical Therapy Division, Duke University, 2200 W Main St., Durham, NC 27705 USA
| | - Richard A. Clendaniel
- Doctor of Physical Therapy Division, Duke University, 2200 W Main St., Durham, NC 27705 USA
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Caspers CG. Care of Traumatic Conditions in an Observation Unit. Emerg Med Clin North Am 2017; 35:673-683. [PMID: 28711130 DOI: 10.1016/j.emc.2017.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Patients presenting to the emergency department with certain traumatic conditions can be managed in observation units. The evidence base supporting the use of observation units to manage injured patients is smaller than the evidence base supporting the management of medical conditions in observation units. The conditions that are eligible for management in an observation unit are not limited to those described in this article, and investigators should continue to identify types of conditions that may benefit from this type of health care delivery.
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Affiliation(s)
- Christopher G Caspers
- Ronald O. Perelman Department of Emergency Medicine, New York University Langone Medical Center, 560 First Avenue, New York, NY 10016, USA.
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Abstract
The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to neck pain. J Orthop Sports Phys Ther. 2017;47(7):A1-A83. doi:10.2519/jospt.2017.0302.
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Cervical Spine Clearance in Pediatric Trauma Centers: The Need for Standardization and an Evidence-based Protocol. J Pediatr Orthop 2017; 37:e145-e149. [PMID: 27328122 DOI: 10.1097/bpo.0000000000000806] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cervical spine clearance in the pediatric trauma patient represents a particularly challenging task. Unfortunately, standardized clearance protocols for pediatric cervical clearance are poorly reported in the literature and imaging recommendations demonstrate considerable variability. With the use of a web-based survey, this study aims to define the methods utilized by pediatric trauma centers throughout North America. Specific attention was given to the identification of personnel responsible for cervical spine care, diagnostic imaging modalities used, and the presence or absence of a written pediatric cervical spine clearance protocol. METHODS A 10-question electronic survey was given to members of the newly formed Pediatric Cervical Spine Study Group, all of whom are active POSNA members. The survey was submitted via the online service SurveyMonkey (https://www.surveymonkey.com/r/7NVVQZR). The survey assessed the respondent's institution demographics, such as trauma level and services primarily responsible for consultation and operative management of cervical spine injuries. In addition, respondents were asked to identify the protocols and primary imaging modality used for cervical spine clearance. Finally, respondents were asked if their institution had a documented cervical spine clearance protocol. RESULTS Of the 25 separate institutions evaluated, 21 were designated as level 1 trauma centers. Considerable variation was reported with regards to the primary service responsible for cervical spine clearance. General Surgery/Trauma (44%) is most commonly the primary service, followed by a rotating schedule (33%), Neurosugery (11%), and Orthopaedic Surgery (8%). Spine consults tend to be seen most commonly by a rotating schedule of Orthopaedic Surgery and Neurosurgery. The majority of responding institutions utilize computed tomographic imaging (46%) as the primary imaging modality, whereas 42% of hospitals used x-ray primarily. The remaining institutions reported using a combination of x-ray and computed tomographic imaging. Only 46% of institutions utilize a written, standardized pediatric cervical spine clearance protocol. CONCLUSIONS This study demonstrates a striking variability in the use of personnel, imaging modalities and, most importantly, standardized protocol in the evaluation of the pediatric trauma patient with a potential cervical spine injury. Cervical spine clearance protocols have been shown to decrease the incidence of missed injuries, minimize excessive radiation exposure, decrease the time to collar removal, and lower overall associated costs. It is our opinion that development of a task force or multicenter research protocol that incorporates existing evidence-based literature is the next best step in improving the care of children with cervical spine injuries. LEVEL OF EVIDENCE Level 4-economic and decision analyses.
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Choosing Wisely Canada®: Five tests, procedures and treatments to question in Emergency Medicine. CAN J EMERG MED 2017; 19:S9-S17. [PMID: 28251880 DOI: 10.1017/cem.2017.1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVES Choosing Wisely Canada (CWC) is an initiative to encourage patient-physician discussions about the appropriate, evidence based use of medical tests, procedures and treatments. We present the Canadian Association of Emergency Physicians' (CAEP) top five list of recommendations, and the process undertaken to generate them. METHODS The CAEP Expert Working Group (EWG) generated a candidate list of 52 tests, procedures, and treatments in emergency medicine whose value to care was questioned. This list was distributed to CAEP committee chairs, revised, and then divided and randomly allocated to 107 Canadian emergency physicians (EWG nominated) who voted on each item based on: action-ability, effectiveness, safety, economic burden, and frequency of use. The EWG discussed the items with the highest votes, and generated the recommendations by consensus. RESULTS The top five CAEP CWC recommendations are: 1) Don't order CT head scans in adults and children who have suffered minor head injuries (unless positive for a validated head injury clinical decision rule); 2) Don't prescribe antibiotics in adults with bronchitis/asthma and children with bronchiolitis; 3) Don't order lumbosacral spinal imaging in patients with non-traumatic low back pain who have no red flags/pathologic indicators; 4) Don't order neck radiographs in patients who have a negative examination using the Canadian C-spine rules; and 5) Don't prescribe antibiotics after incision and drainage of uncomplicated skin abscesses unless extensive cellulitis exists. CONCLUSIONS The CWC recommendations for emergency medicine were selected using a mixed methods approach. This top 5 list was released at the CAEP Conference in June 2015 and should form the basis for future implementation efforts.
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Stiell IG, Perry JJ, Clement CM, Brison RJ, Rowe BH, Aaron SD, McRae AD, Borgundvaag B, Calder LA, Forster AJ, Wells GA. Prospective and Explicit Clinical Validation of the Ottawa Heart Failure Risk Scale, With and Without Use of Quantitative NT-proBNP. Acad Emerg Med 2017; 24:316-327. [PMID: 27976497 DOI: 10.1111/acem.13141] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 11/29/2016] [Accepted: 12/03/2016] [Indexed: 12/23/2022]
Abstract
OBJECTIVES We previously developed the Ottawa Heart Failure Risk Scale (OHFRS) to assist with disposition decisions for acute heart failure patients in the emergency department (ED). We sought to prospectively evaluate the accuracy, acceptability, and potential impact of OHFRS. METHODS This prospective observational cohort study was conducted at six tertiary hospital EDs. Patients with acute heart failure were evaluated by ED physicians for the 10 OHFRS criteria and then followed for 30 days. Quantitative NT-proBNP was measured where feasible. Serious adverse event (SAE) was defined as death within 30 days, admission to monitored unit, intubation, noninvasive ventilation, myocardial infarction, or relapse resulting in hospital admission within 14 days. RESULTS We enrolled 1,100 patients with mean (±SD) age 77.7 (±10.7) years. SAEs occurred in 170 (15.5%) cases (19.4% if admitted and 10.2% if discharged). Compared to actual practice, using an admission threshold of OHFRS score > 1 would have increased sensitivity (71.8% vs. 91.8%) but increased admissions (57.2% vs. 77.6%). For 684 cases with NT-proBNP values, using a threshold score > 1 would have significantly increased sensitivity (69.8% vs. 95.8%) while increasing admissions (60.8% vs. 88.0%). In only 11.9% of cases did physicians indicate discomfort with use of OHFRS. CONCLUSION Prospective clinical validation found the OHFRS tool to be highly sensitive for SAEs in acute heart failure patients, albeit with an increase in admission rates. When available, NT-proBNP values further improve sensitivity. With adequate physician training, OHFRS should help improve and standardize admission practices, diminishing both unnecessary admissions for low-risk patients and unsafe discharge decisions for high-risk patients.
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Affiliation(s)
- Ian G. Stiell
- Department of Emergency Medicine University of Ottawa Ottawa Ontario
| | - Jeffrey J. Perry
- Department of Emergency Medicine University of Ottawa Ottawa Ontario
| | - Catherine M. Clement
- Clinical Epidemiology Program Ottawa Hospital Research Institute University of Ottawa Ottawa Ontario
| | - Robert J. Brison
- Department of Emergency Medicine Queen's University Kingston Ontario
| | - Brian H. Rowe
- Department of Emergency Medicine and School for Public Health University of Alberta and Alberta Health Services Edmonton Alberta Canada
| | - Shawn D. Aaron
- Department of Medicine University of Ottawa Ottawa Ontario
| | - Andrew D. McRae
- Department of Emergency Medicine Cumming School of Medicine University of Calgary Calgary Alberta
| | - Bjug Borgundvaag
- Division of Emergency Medicine University of Toronto Toronto Ontario
| | - Lisa A. Calder
- Department of Emergency Medicine University of Ottawa Ottawa Ontario
| | | | - George A. Wells
- University of Ottawa Heart Institute University of Ottawa Ottawa Ontario
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Sanders SL, Rathbone J, Bell KJL, Glasziou PP, Doust JA. Systematic review of the effects of care provided with and without diagnostic clinical prediction rules. Diagn Progn Res 2017; 1:13. [PMID: 31093542 PMCID: PMC6460683 DOI: 10.1186/s41512-017-0013-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 04/06/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Diagnostic clinical prediction rules (CPRs) are worthwhile if they improve patient outcomes or provide benefits such as reduced resource use, without harming patients. We conducted a systematic review to assess the effects of diagnostic CPRs on patient and process of care outcomes. METHODS We searched electronic databases and a trial registry and performed citation and reference checks, for randomised trials comparing a diagnostic strategy with and without a CPR. Included studies were assessed for risk of bias and similar studies meta-analysed. RESULTS Twenty-seven studies evaluating diagnostic CPRs for 14 conditions were included. A clinical management decision was the primary outcome in the majority of studies. Most studies were judged to be at high or uncertain risk of bias on ≥3 of 6 domains. Details of study interventions and implementation were infrequently reported.For suspected Group A Streptococcus throat infection, diagnostic CPRs reduced symptoms (1 study) and antibiotic prescriptions (5 studies, RR 0.86, 95% CI 0.75 to 0.99). For suspected cardiac chest pain, diagnostic strategies incorporating a CPR improved early discharge rates (1 study), decreased objective cardiac testing (1 study) and decreased hospitalisations (1 study). For ankle injuries, Ottawa Ankle Rules reduced radiography when used with clinical examination (1 study) but had no effect on length of stay as a triage test (1 study). For suspected acute appendicitis, CPRs had no effect on rates of perforated appendix (1 study) or the number of non-therapeutic operations (5 studies, RR 0.68, 95% CI 0.43 to 1.08). For suspected pneumonia, CPRs reduced antibiotic prescribing without unfavourable outcomes (3 studies). For children with possible serious bacterial infection, diagnostic CPRs did not improve process of care outcomes (3 studies). CONCLUSION There are few randomised trials of diagnostic CPRs, and patient outcomes are infrequently reported. Diagnostic CPRs had a positive effect on process outcomes in some clinical conditions; however, many studies were at unclear or high risk of bias and the results may be context specific. Future studies should seek to detail how the CPR might alter the diagnostic pathway, report effects on both patient and process outcomes, and improve reporting of the study interventions and implementation. TRIAL REGISTRATION The protocol for this review was not registered with PROSPERO, the international prospective register of systematic review protocols. The review was conceived and protocol prepared prior to the launch of PROSPERO in February 2011.
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Affiliation(s)
- Sharon L Sanders
- 1Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, Queensland Australia
| | - John Rathbone
- 1Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, Queensland Australia
| | - Katy J L Bell
- 1Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, Queensland Australia
- 2Sydney School of Public Health, Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Paul P Glasziou
- 1Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, Queensland Australia
| | - Jenny A Doust
- 1Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, Queensland Australia
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