CJEM Articles: clinical decision rules

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  • Emergency physicians' management of transient ischemic attack and desired sensitivity of a clinical decision rule for stroke in three countries
    January 2011 13 1
    Ian G. Stiell, Jamie Brehaut, Jeffrey J. Perry, Monica Taljaard, Reena Goindi, Sandra Schneider

    Objective: Four to 10% of patients with transient ischemic attack (TIA) suffer a stroke or die within 7 days. Our objectives were to determine (1) current practice for investigating and treating emergency department (ED) patients with TIA, (2) willingness to use a clinical decision rule to identify patients at high risk of impending stroke or death, and (3) the required sensitivity of this rule.
    Methods: We administered a mail survey to a random sample of members of three national emergency physician associations in Australia, Canada, and the United States using a modified Dillman technique. A prenotification letter and up to three surveys were sent.
    Results: A total of 801 responses (53.7%) from 1,493 surveys were received; 53.6% (95% CI 47.5–59.7) of emergency physicians reported routinely admitting TIA patients, ranging from 6.6% in Canada to 56.7% in the United States, and 9.9% of emergency physicians have a stroke prevention clinic, with 4.7% estimating that patients are seen within 7 days. A sensitive clinical decision rule for TIA patients would be used by 96.3% (95% CI 93.9–98.7) of emergency physicians. The median required sensitivity of this rule for stroke or death within 7 days was 97%.
    Conclusions: Almost half of all TIA patients are managed as outpatients, which is neither expedited nor in a dedicated stroke clinic. Emergency physicians indicate a willingness to use a highly sensitive clinical decision rule to triage TIA patients.

  • An international study of emergency physicians’ practice for acute headache management and the need for a clinical decision rule
    November 2009 11 6
    Anne-Maree Kelly, Catherine M. Clement, Debra Eagles, Ian G. Stiell, Jamie Brehaut, Jeffrey J. Perry, Suzanne Mason

    Objective: Patients with acute headache often undergo com puted tomography (CT) followed by a lumbar puncture to rule out subarachnoid hemorrhage. Our international study exam ined current practice, the perceived need for a clinical deci sion rule for acute headache and the required sensitivity for such a rule.

    Methods: We approached 2100 emergency physicians from 4 countries (Australia, Canada, the United Kingdom and the United States) to participate in our survey by sampling the membership of their emergency associations. We used a modified Dillman technique with 3-5 notifications and a prenotification letter employing a combination of electronic mail and postal mail. Physicians were questioned about neu rologically intact patients who presented with headache. Analysis included both descriptive statistics for the entire sample and stratification by country.

    Results: The total response rate was 54.7% (1149/2100). Respondents were primarily male (75.5%), with a mean age of 42.5 years and a mean 12.3 years of emergency depart ment (ED) experience. Of the physicians who responded, 49.5% thought all acute headache patients should be investi gated with CT and 57.4% felt CT should always be followed by lumbar puncture. Of the respondents, 95.7% reported they would consider using a clinical decision rule for patients with acute headache to rule out subarachnoid hemorrhage. Respondents deemed the median sensitivity required by such a rule to be 99% (interquartile range 98%-99%). Approxi mately 1 in 5 physicians suggested that 100% sensitivity was required.

    Conclusion: Emergency physicians report that they would welcome a clinical decision rule for headache that would determine which patients require costly or invasive tests to rule out subarachnoid hemorrhage. The required sensitivity of such a rule was realistic. These results will inform and inspire the development of clinical decision rules for acute headache in the ED.

  • Refinement of the Quebec decision rule for radiography in shoulder dislocation
    January 2009 11 1
    André Lavoie, Lynne Moore, Marcel Émond, Natalie Le Sage

    Objective: We prospectively derived a clinical decision rule to guide pre- and postreduction radiography for emergency department (ED) patients with anterior glenohumeral dislocation.

    Methods: This prospective cohort derivation study took place at 4 university-affiliated EDs over a 3-year period and enrolled consenting patients with anterior glenohumeral dislocation who were 18 years of age or older. We compared patients with a clinically important fracture-dislocation with those who had an uncomplicated dislocation to provide the clinical decision rule components using recursive partitioning. The final rule involved age, mechanism, prior dislocation and humeral ecchymosis.

    Results: A total of 222 patients were included in the study. Forty (18.0%) had clinically important fracture-dislocation. A clinical decision rule using 4 factors reached a sensitivity of 100% (95% confidence interval [CI] 89.4%-100%), a specificity of 34.2% (95% CI 27.7%-41.2%), a negative predictive value of 99.2% (95% CI 92.8%-99.9%) and a negative likelihood ratio of 0.04 (95% CI 0.002-0.27). Patients younger than 40 years are at high risk for clinically important fracture- dislocation only if the mechanism of injury involves substantial force (i.e., a fall greater than their own height, a sport injury, an assault or a motor vehicle collision). Patients 40 years of age or older are at high risk only in the presence of humeral ecchymosis or after their first dislocation. Projected use of the rule would reduce the absolute number of prereduction radiographs by 27.9% and of postreduction by 81.9%.

    Conclusion: The Quebec shoulder dislocation rule for patients with acute anterior glenohumeral dislocation holds promise to reduce unnecessary imaging, pending validation.