Publications (10)159.96 Total impact
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Article: Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study.
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ABSTRACT: To measure the sensitivity of modern third generation computed tomography in emergency patients being evaluated for possible subarachnoid haemorrhage, especially when carried out within six hours of headache onset. Prospective cohort study. 11 tertiary care emergency departments across Canada, 2000-9. Neurologically intact adults with a new acute headache peaking in intensity within one hour of onset in whom a computed tomography was ordered by the treating physician to rule out subarachnoid haemorrhage. Subarachnoid haemorrhage was defined by any of subarachnoid blood on computed tomography, xanthochromia in cerebrospinal fluid, or any red blood cells in final tube of cerebrospinal fluid collected with positive results on cerebral angiography. Of the 3132 patients enrolled (mean age 45.1, 2571 (82.1%) with worst headache ever), 240 had subarachnoid haemorrhage (7.7%). The sensitivity of computed tomography overall for subarachnoid haemorrhage was 92.9% (95% confidence interval 89.0% to 95.5%), the specificity was 100% (99.9% to 100%), the negative predictive value was 99.4% (99.1% to 99.6%), and the positive predictive value was 100% (98.3% to 100%). For the 953 patients scanned within six hours of headache onset, all 121 patients with subarachnoid haemorrhage were identified by computed tomography, yielding a sensitivity of 100% (97.0% to 100.0%), specificity of 100% (99.5% to 100%), negative predictive value of 100% (99.5% to 100%), and positive predictive value of 100% (96.9% to 100%). Modern third generation computed tomography is extremely sensitive in identifying subarachnoid haemorrhage when it is carried out within six hours of headache onset and interpreted by a qualified radiologist.BMJ (Clinical research ed.). 01/2011; 343:d4277. -
Article: A prospective cluster-randomized trial to implement the Canadian CT Head Rule in emergency departments.
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ABSTRACT: The Canadian CT Head Rule was developed to allow physicians to be more selective when ordering computed tomography (CT) imaging for patients with minor head injury. We sought to evaluate the effectiveness of implementing this validated decision rule at multiple emergency departments. We conducted a matched-pair cluster-randomized trial that compared the outcomes of 4531 patients with minor head injury during two 12-month periods (before and after) at hospital emergency departments in Canada, six of which were randomly allocated as intervention sites and six as control sites. At the intervention sites, active strategies, including education, changes to policy and real-time reminders on radiologic requisitions were used to implement the Canadian CT Head Rule. The main outcome measure was referral for CT scan of the head. Baseline characteristics of patients were similar when comparing control to intervention sites. At the intervention sites, the proportion of patients referred for CT imaging increased from the "before" period (62.8%) to the "after" period (76.2%) (difference +13.3%, 95% CI 9.7%-17.0%). At the control sites, the proportion of CT imaging usage also increased, from 67.5% to 74.1% (difference +6.7%, 95% CI 2.6%-10.8%). The change in mean imaging rates from the "before" period to the "after" period for intervention versus control hospitals was not significant (p = 0.16). There were no missed brain injuries or adverse outcomes. Our knowledge-translation-based trial of the Canadian CT Head Rule did not reduce rates of CT imaging in Canadian emergency departments. Future studies should identify strategies to deal with barriers to implementation of this decision rule and explore more effective approaches to knowledge translation. (ClinicalTrials.gov trial register no. NCT00993252).Canadian Medical Association Journal 10/2010; 182(14):1527-32. · 8.22 Impact Factor -
Article: Implementation of the Canadian C-Spine Rule: prospective 12 centre cluster randomised trial.
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ABSTRACT: To evaluate the effectiveness of an active strategy to implement the validated Canadian C-Spine Rule into multiple emergency departments. Matched pair cluster randomised trial. University and community emergency departments in Canada. Participants 11 824 alert and stable adults presenting with blunt trauma to the head or neck at one of 12 hospitals. Six hospitals were randomly allocated to the intervention and six to the control. At the intervention sites, active strategies were used to implement the Canadian C-Spine Rule, including education, policy, and real time reminders on radiology requisitions. No specific intervention was introduced to alter the behaviour of doctors requesting cervical spine imaging at the control sites. Diagnostic imaging rate of the cervical spine during two 12 month before and after periods. Patients were balanced between control and intervention sites. From the before to the after periods, the intervention group showed a relative reduction in cervical spine imaging of 12.8% (95% confidence interval 9% to 16%; 61.7% v 53.3%; P=0.01) and the control group a relative increase of 12.5% (7% to 18%; 52.8% v 58.9%; P=0.03). These changes were significant when both groups were compared (P<0.001). No fractures were missed and no adverse outcomes occurred. Implementation of the Canadian C-Spine Rule led to a significant decrease in imaging without injuries being missed or patient morbidity. Final imaging rates were much lower at intervention sites than at most US hospitals. Widespread implementation of this rule could lead to reduced healthcare costs and more efficient patient flow in busy emergency departments worldwide. Clinical trials NCT00290875.BMJ (Clinical research ed.). 01/2009; 339:b4146. -
Article: Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury.
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ABSTRACT: Current use of cranial computed tomography (CT) for minor head injury is increasing rapidly, highly variable, and inefficient. The Canadian CT Head Rule (CCHR) and New Orleans Criteria (NOC) are previously developed clinical decision rules to guide CT use for patients with minor head injury and with Glasgow Coma Scale (GCS) scores of 13 to 15 for the CCHR and a score of 15 for the NOC. However, uncertainty about the clinical performance of these rules exists. To compare the clinical performance of these 2 decision rules for detecting the need for neurosurgical intervention and clinically important brain injury. In a prospective cohort study (June 2000-December 2002) that included 9 emergency departments in large Canadian community and university hospitals, the CCHR was evaluated in a convenience sample of 2707 adults who presented to the emergency department with blunt head trauma resulting in witnessed loss of consciousness, disorientation, or definite amnesia and a GCS score of 13 to 15. The CCHR and NOC were compared in a subgroup of 1822 adults with minor head injury and GCS score of 15. Neurosurgical intervention and clinically important brain injury evaluated by CT and a structured follow-up telephone interview. Among 1822 patients with GCS score of 15, 8 (0.4%) required neurosurgical intervention and 97 (5.3%) had clinically important brain injury. The NOC and the CCHR both had 100% sensitivity but the CCHR was more specific (76.3% vs 12.1%, P<.001) for predicting need for neurosurgical intervention. For clinically important brain injury, the CCHR and the NOC had similar sensitivity (100% vs 100%; 95% confidence interval [CI], 96%-100%) but the CCHR was more specific (50.6% vs 12.7%, P<.001), and would result in lower CT rates (52.1% vs 88.0%, P<.001). The kappa values for physician interpretation of the rules, CCHR vs NOC, were 0.85 vs 0.47. Physicians misinterpreted the rules as not requiring imaging for 4.0% of patients according to CCHR and 5.5% according to NOC (P = .04). Among all 2707 patients with a GCS score of 13 to 15, the CCHR had sensitivities of 100% (95% CI, 91%-100%) for 41 patients requiring neurosurgical intervention and 100% (95% CI, 98%-100%) for 231 patients with clinically important brain injury. For patients with minor head injury and GCS score of 15, the CCHR and the NOC have equivalent high sensitivities for need for neurosurgical intervention and clinically important brain injury, but the CCHR has higher specificity for important clinical outcomes than does the NOC, and its use may result in reduced imaging rates.JAMA The Journal of the American Medical Association 09/2005; 294(12):1511-8. · 30.03 Impact Factor -
Article: Retrospective application of the NEXUS low-risk criteria for cervical spine radiography in Canadian emergency departments.
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ABSTRACT: We evaluate the accuracy, reliability, and potential impact of the National Emergency X-Radiography Utilization Study (NEXUS) low-risk criteria for cervical spine radiography, when applied in Canadian emergency departments (EDs). The Canadian C-Spine Rule derivation study was a prospective cohort study conducted in 10 Canadian EDs that recruited alert and stable adult trauma patients. Physicians completed a 20-item data form for each patient and performed interobserver assessments when feasible. The prospective assessments included the 5 individual NEXUS criteria but not an explicit interpretation of the overall need for radiography according to the criteria. Patients underwent plain radiography, flexion-extension views, and computed tomography at the discretion of the treating physician. Patients who did not have radiography were followed up with a structured outcome assessment by telephone to determine clinically important cervical spine injury, a previously validated outcome measurement. Analyses included sensitivity and specificity with 95% confidence interval (CI), kappa coefficient, and potential radiography rates. Among 8,924 patients, 151 (1.7%) patients had an important cervical spine injury. The combined NEXUS criteria identified important cervical spine injury with a sensitivity of 92.7% (95% CI 87% to 96%) and a specificity of 37.8% (95% CI 37% to 39%). Application of the NEXUS criteria would have potentially reduced cervical spine radiography rates by 6.1% from the actual rate of 68.9% to 62.8%. Of 11 patients with important injuries not identified, 2 were treated with internal fixation and 3 with a halo. This retrospective validation found the NEXUS low-risk criteria to be less sensitive than previously reported. The NEXUS low-risk criteria should be further explicitly and prospectively evaluated for accuracy and reliability before widespread clinical use outside of the United States.Annals of emergency medicine 05/2004; 43(4):507-14. · 4.23 Impact Factor -
Article: The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma.
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ABSTRACT: The Canadian C-Spine (cervical-spine) Rule (CCR) and the National Emergency X-Radiography Utilization Study (NEXUS) Low-Risk Criteria (NLC) are decision rules to guide the use of cervical-spine radiography in patients with trauma. It is unclear how the two decision rules compare in terms of clinical performance. We conducted a prospective cohort study in nine Canadian emergency departments comparing the CCR and NLC as applied to alert patients with trauma who were in stable condition. The CCR and NLC were interpreted by 394 physicians for patients before radiography. Among the 8283 patients, 169 (2.0 percent) had clinically important cervical-spine injuries. In 845 (10.2 percent) of the patients, physicians did not evaluate range of motion as required by the CCR algorithm. In analyses that excluded these indeterminate cases, the CCR was more sensitive than the NLC (99.4 percent vs. 90.7 percent, P<0.001) and more specific (45.1 percent vs. 36.8 percent, P<0.001) for injury, and its use would have resulted in lower radiography rates (55.9 percent vs. 66.6 percent, P<0.001). In secondary analyses that included all patients, the sensitivity and specificity of CCR, assuming that the indeterminate cases were all positive, were 99.4 percent and 40.4 percent, respectively (P<0.001 for both comparisons with the NLC). Assuming that the CCR was negative for all indeterminate cases, these rates were 95.3 percent (P=0.09 for the comparison with the NLC) and 50.7 percent (P=0.001). The CCR would have missed 1 patient and the NLC would have missed 16 patients with important injuries. For alert patients with trauma who are in stable condition, the CCR is superior to the NLC with respect to sensitivity and specificity for cervical-spine injury, and its use would result in reduced rates of radiography.New England Journal of Medicine 01/2004; 349(26):2510-8. · 53.30 Impact Factor -
Article: The Canadian C-spine rule performs better than unstructured physician judgment.
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ABSTRACT: We compare the predictive accuracy of emergency physicians' unstructured clinical judgment to the Canadian C-Spine rule. This prospective multicenter cohort study was conducted at 10 Canadian urban academic emergency departments. Included in the study were alert, stable, adult patients with a Glasgow Coma Scale score of 15 and trauma to the head or neck. This was a substudy of the Canadian C-Spine and CT Head Study. Eligible patients were prospectively evaluated before radiography. Physicians estimated the probability of unstable cervical spine injury from 0% to 100% according to clinical judgment alone and filled out a data form. Interobserver assessments were done when feasible. Patients underwent cervical spine radiography or follow-up to determine clinically important cervical spine injuries. Analyses included comparison of areas under the receiver operating characteristic (ROC) curve with 95% confidence intervals (CIs) and the kappa coefficient. During 18 months, 6265 patients were enrolled. The mean age was 36.6 years (range 16 to 97 years), and 50.1% were men. Sixty-four (1%) patients had a clinically important injury. The physicians' kappa for a 0% predicted probability of injury was 0.46 (95% CI 0.28 to 0.65). The respective areas under the ROC curve for predicting cervical spine injury were 0.85 (95% CI 0.80 to 0.89) for physician judgment and 0.91 (95% CI 0.89 to 0.92) for the Canadian C-Spine rule (P <.05). With a threshold of 0% predicted probability of injury, the respective indices of accuracy for physicians and the Canadian C-Spine rule were sensitivity 92.2% versus 100% (P <.001) and specificity 53.9% versus 44.0% (P <.001). Interobserver agreement of unstructured clinical judgment for predicting clinically important cervical spine injury is only fair, and the sensitivity is unacceptably low. The Canadian C-Spine rule was better at detecting clinically important injuries with a sensitivity of 100%. Prospective validation has recently been completed and should permit widespread use of the Canadian C-Spine rule.Annals of Emergency Medicine 10/2003; 42(3):395-402. · 4.13 Impact Factor -
Article: The Canadian C-Spine Rule for Radiography in Alert and Stable Trauma Patients
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ABSTRACT: Context High levels of variation and inefficiency exist in current clinical practice regarding use of cervical spine (C-spine) radiography in alert and stable trauma patients.Objective To derive a clinical decision rule that is highly sensitive for detecting acute C-spine injury and will allow emergency department (ED) physicians to be more selective in use of radiography in alert and stable trauma patients.Design Prospective cohort study conducted from October 1996 to April 1999, in which physicians evaluated patients for 20 standardized clinical findings prior to radiography. In some cases, a second physician performed independent interobserver assessments.Setting Ten EDs in large Canadian community and university hospitals.Patients Convenience sample of 8924 adults (mean age, 37 years) who presented to the ED with blunt trauma to the head/neck, stable vital signs, and a Glasgow Coma Scale score of 15.Main Outcome Measure Clinically important C-spine injury, evaluated by plain radiography, computed tomography, and a structured follow-up telephone interview. The clinical decision rule was derived using the κ coefficient, logistic regression analysis, and χ2 recursive partitioning techniques.Results Among the study sample, 151 (1.7%) had important C-spine injury. The resultant model and final Canadian C-Spine Rule comprises 3 main questions: (1) is there any high-risk factor present that mandates radiography (ie, age ≥65 years, dangerous mechanism, or paresthesias in extremities)? (2) is there any low-risk factor present that allows safe assessment of range of motion (ie, simple rear-end motor vehicle collision, sitting position in ED, ambulatory at any time since injury, delayed onset of neck pain, or absence of midline C-spine tenderness)? and (3) is the patient able to actively rotate neck 45° to the left and right? By cross-validation, this rule had 100% sensitivity (95% confidence interval [CI], 98%-100%) and 42.5% specificity (95% CI, 40%-44%) for identifying 151 clinically important C-spine injuries. The potential radiography ordering rate would be 58.2%.Conclusion We have derived the Canadian C-Spine Rule, a highly sensitive decision rule for use of C-spine radiography in alert and stable trauma patients. If prospectively validated in other cohorts, this rule has the potential to significantly reduce practice variation and inefficiency in ED use of C-spine radiography. Figures in this Article More than 1 million patients with blunt trauma and potential cervical spine (C-spine) injury are treated each year in US emergency departments (EDs).1- 2 Among those patients presenting with intact neurological status (arriving either walking or by ambulance), the incidence of acute fracture or spinal injury is less than 1%.3- 5 Due to concerns about potentially disabling spinal injuries, most clinicians make liberal use of C-spine radiography.6- 9 Nevertheless, such practice is inefficient—more than 98% of C-spine radiographs are negative for fracture.10- 16 Furthermore, there is considerable practice variation among well-trained emergency physicians, with radiography rates ranging as much as 6-fold.17 Cervical spine radiography is an example of a "little ticket" item, a low-cost procedure that significantly adds to health care costs due to its high volumes of use.18- 19 There are no widely accepted guidelines that have been shown to be both safe and efficient in guiding the use of C-spine radiography. Recently, clinical decision rules have been developed to guide physicians in making diagnostic or therapeutic decisions—for example, the use of radiography for patients with ankle or knee injuries.20- 23 A clinical decision rule may be defined as a decision-making tool that is derived from original research and that incorporates 3 or more variables from the history, physical examination, or simple tests.24- 25 The National Emergency X-Radiography Utilization Study (NEXUS) low-risk criteria for C-spine radiography were recently evaluated in a large study of EDs that found the criteria to be 99.6% sensitive for clinically important injuries.26 However, the specificity was only 12.9%, leading to concerns that use of the NEXUS criteria would actually increase the use of radiography in some US jurisdictions and in most countries outside of the United States. We believe that the current inefficiency and variability of clinical practice can be remedied with the development of an accurate, reliable, and clinically sensible decision rule. Hence, the objective of this study was to derive a clinical decision rule that would be highly sensitive for detecting acute C-spine injury among patients sustaining blunt trauma who are alert and stable but at risk for neck injury. This will ultimately allow physicians to be more selective in their use of radiography without jeopardizing patient care.JAMA The Journal of the American Medical Association 286(15):1841-1848. · 30.03 Impact Factor -
Article: Comparison of the Canadian CT Head Rule and the New Orleans Criteria in Patients With Minor Head Injury
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ABSTRACT: Context Current use of cranial computed tomography (CT) for minor head injury is increasing rapidly, highly variable, and inefficient. The Canadian CT Head Rule (CCHR) and New Orleans Criteria (NOC) are previously developed clinical decision rules to guide CT use for patients with minor head injury and with Glasgow Coma Scale (GCS) scores of 13 to 15 for the CCHR and a score of 15 for the NOC. However, uncertainty about the clinical performance of these rules exists.Objective To compare the clinical performance of these 2 decision rules for detecting the need for neurosurgical intervention and clinically important brain injury.Design, Setting, and Patients In a prospective cohort study (June 2000-December 2002) that included 9 emergency departments in large Canadian community and university hospitals, the CCHR was evaluated in a convenience sample of 2707 adults who presented to the emergency department with blunt head trauma resulting in witnessed loss of consciousness, disorientation, or definite amnesia and a GCS score of 13 to 15. The CCHR and NOC were compared in a subgroup of 1822 adults with minor head injury and GCS score of 15.Main Outcome Measures Neurosurgical intervention and clinically important brain injury evaluated by CT and a structured follow-up telephone interview.Results Among 1822 patients with GCS score of 15, 8 (0.4%) required neurosurgical intervention and 97 (5.3%) had clinically important brain injury. The NOC and the CCHR both had 100% sensitivity but the CCHR was more specific (76.3% vs 12.1%, P<.001) for predicting need for neurosurgical intervention. For clinically important brain injury, the CCHR and the NOC had similar sensitivity (100% vs 100%; 95% confidence interval [CI], 96%-100%) but the CCHR was more specific (50.6% vs 12.7%, P<.001), and would result in lower CT rates (52.1% vs 88.0%, P<.001). The κ values for physician interpretation of the rules, CCHR vs NOC, were 0.85 vs 0.47. Physicians misinterpreted the rules as not requiring imaging for 4.0% of patients according to CCHR and 5.5% according to NOC (P = .04). Among all 2707 patients with a GCS score of 13 to 15, the CCHR had sensitivities of 100% (95% CI, 91%-100%) for 41 patients requiring neurosurgical intervention and 100% (95% CI, 98%-100%) for 231 patients with clinically important brain injury.Conclusion For patients with minor head injury and GCS score of 15, the CCHR and the NOC have equivalent high sensitivities for need for neurosurgical intervention and clinically important brain injury, but the CCHR has higher specificity for important clinical outcomes than does the NOC, and its use may result in reduced imaging rates. Each year, physicians in Canadian and US emergency departments (EDs) treat more than 8 million patients with head injury, representing approximately 6.7% of the 120 million total ED visits.1 Although some of these patients have sustained moderate or severe head injury leading to death or serious morbidity, the vast majority of patients are classified as having minimal or minor head injury.2- 3 Patients with minimal head injury have not experienced loss of consciousness or other neurological alteration. Minor head injury or concussion is defined by a history of loss of consciousness, amnesia, or disorientation in a patient who is conscious and talking, ie, has a Glasgow Coma Scale (GCS) score of 13 to 15.2- 6 Although after a period of observation most patients with minor head injury can be discharged without sequelae, a small portion deteriorate and require neurosurgical intervention for intracranial hematoma.7- 8 The key to managing these patients is early diagnosis of intracranial injuries using computed tomography (CT) followed by early craniotomy.2,9- 10 Current use of CT for minor head injury is increasing rapidly, is highly variable, and is inefficient. Between 1992 and 2000, use of CT imaging for all conditions in US EDs has increased from 2.4% to 5.3% of all visits, a 120% increase.1 In 10 large Canadian hospitals, the use of CT has increased 165%, from 30% to 80%, specifically for patients with minor head injury.11 We previously demonstrated large variation among similar Canadian teaching hospitals in ordering of CT for minor head injury.11 Our data show that 90% of CTs are negative for clinically important brain injury.12 Inefficient use of CT adds significantly to health care costs and adds to the burden of overcrowding in EDs.13- 15 Rural centers without CT scanners must arrange for costly and time-consuming transfers of patients to larger urban centers for a CT scan. Substantial potential for improving the efficiency of minor head injury management appears possible through the application of clinical decision rules. A clinical decision rule is derived from original research and is defined as a decision-making tool that incorporates 3 or more variables from the history, examination, or simple tests.16- 21 Two decision rules have been independently developed to allow more selective ordering of CT scans, more rapid discharge of patients with minor head injury, and significant health care savings. The New Orleans Criteria (NOC) include 7 items (Box 1) that were developed for a study of 1429 patients with minor head injury and a GCS score of 15,22 and have been widely disseminated in the United States.23 Our group derived the Canadian CT Head Rule (CCHR) in a study of 3121 patients with minor head injury and a GCS score of 13 to 15.12,24- 25 This rule is based on 5 high-risk and 2 medium-risk criteria (Box 2). BOX 1. NEW ORLEANS CRITERIA ABSTRACT | BOX 1. NEW ORLEANS CRITERIA | BOX 2. CANADIAN CT HEAD RULE* | METHODS | RESULTS | COMMENT | AUTHOR INFORMATION | REFERENCES Computed tomography is required for patients with minor head injury with any 1 of the following findings. The criteria apply only to patients who also have a Glasgow Coma Scale score of 15. HeadacheVomitingOlder than 60 yearsDrug or alcohol intoxicationPersistent anterograde amnesia (deficits in short-term memory)Visible trauma above the clavicleSeizure BOX 2. CANADIAN CT HEAD RULE* ABSTRACT | BOX 1. NEW ORLEANS CRITERIA | BOX 2. CANADIAN CT HEAD RULE* | METHODS | RESULTS | COMMENT | AUTHOR INFORMATION | REFERENCES Computed tomography is only required for patients with minor head injury with any 1 of the following findings: Patients with minor head injury who present with a Glasgow Coma Scale score of 13 to 15 after witnessed loss of consciousness, amnesia, or confusion. High Risk for Neurosurgical Intervention1. Glasgow Coma Scale score lower than 15 at 2 hours after injury2. Suspected open or depressed skull fracture3. Any sign of basal skull fracture†4. Two or more episodes of vomiting5. 65 years or olderMedium Risk for Brain Injury Detection by Computed Tomographic Imaging6. Amnesia before impact of 30 or more minutes7. Dangerous mechanism‡ *The rule is not applicable if the patient did not experience a trauma, has a Glasgow Coma Scale score lower than 13, is younger than 16 years, is taking warfarin or has a bleeding disorder, or has an obvious open skull fracture. †Signs of of basal skull fracture include hemotympanum, racoon eyes, cerebrospinal fluid, otorrhea or rhinorrhea, Battle’s sign. ‡Dangerous mechanism is a pedestrian struck by a motor vehicle, an occupant ejected from a motor vehicle, or a fall from an elevation of 3 or more feet or 5 stairs. Decision tools may not perform as well in a validation setting as they did in the initial derivation phase.26 Therefore, the goal of this study was to prospectively compare the accuracy, reliability, and potential impact of the CCHR and the NOC in minor head injury patients. Such a validation study is an essential step prior to the implementation of a decision rule for patient care.JAMA The Journal of the American Medical Association 294(12):1511-1518. · 30.03 Impact Factor -
Article: The Canadian C-Spine rule performs better than unstructured physician judgment
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ABSTRACT: Study objectiveWe compare the predictive accuracy of emergency physicians' unstructured clinical judgment to the Canadian C-Spine rule.MethodsThis prospective multicenter cohort study was conducted at 10 Canadian urban academic emergency departments. Included in the study were alert, stable, adult patients with a Glasgow Coma Scale score of 15 and trauma to the head or neck. This was a substudy of the Canadian C-Spine and CT Head Study. Eligible patients were prospectively evaluated before radiography. Physicians estimated the probability of unstable cervical spine injury from 0% to 100% according to clinical judgment alone and filled out a data form. Interobserver assessments were done when feasible. Patients underwent cervical spine radiography or follow-up to determine clinically important cervical spine injuries. Analyses included comparison of areas under the receiver operating characteristic (ROC) curve with 95% confidence intervals (CIs) and the κ coefficient.ResultsDuring 18 months, 6,265 patients were enrolled. The mean age was 36.6 years (range 16 to 97 years), and 50.1% were men. Sixty-four (1%) patients had a clinically important injury. The physicians' κ for a 0% predicted probability of injury was 0.46 (95% CI 0.28 to 0.65). The respective areas under the ROC curve for predicting cervical spine injury were 0.85 (95% CI 0.80 to 0.89) for physician judgment and 0.91 (95% CI 0.89 to 0.92) for the Canadian C-Spine rule (P<.05). With a threshold of 0% predicted probability of injury, the respective indices of accuracy for physicians and the Canadian C-Spine rule were sensitivity 92.2% versus 100% (P<.001) and specificity 53.9% versus 44.0% (P<.001).ConclusionInterobserver agreement of unstructured clinical judgment for predicting clinically important cervical spine injury is only fair, and the sensitivity is unacceptably low. The Canadian C-Spine rule was better at detecting clinically important injuries with a sensitivity of 100%. Prospective validation has recently been completed and should permit widespread use of the Canadian C-Spine rule.Annals of Emergency Medicine.
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2004–2011
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University of Ottawa
- Department of Emergency Medicine
Ottawa, Ontario, Canada
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2003
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University of Toronto
Toronto, Ontario, Canada
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