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QUESTION: In patients with minor head injury, can a clinical decision rule using 7 clinical criteria identify those patients who do not need computed tomography (CT)?
2 cohort studies, one for derivation and one for validation of the clinical criteria.
A large, inner city, level 1 trauma centre in New Orleans, Louisiana, USA.
Consecutive patients with minor head injury (loss of consciousness with normal findings on a brief neurological examination and a score of 15 on the Glasgow Coma Scale) in 2 phases (520 in the derivation set, 909 in the validation set, each with mean age 36 y, 65% men). Inclusion criteria were age ≥3 years and presentation <24 hours after injury.
Description of prediction guide
Prognostic clinical criteria recorded before CT in the derivation set were age and presence of headache, vomiting, drug or alcohol intoxication, short term antegrade memory deficits, seizure, history of coagulopathy, and physical evidence of trauma above the clavicles. For the validation set, the same criteria, excluding history of coagulopathy, were recorded before CT. Patients were separated into 2 groups: those who had 0 findings and those who had ≥1 of the 7 findings. All patients had CT.
Main outcome measure
36 (6.9%) patients from the derivation set and 57 patients (6.3%) from the validation set had an abnormal CT. All of these patients had ≥1 of the clinical findingsbefore CT scanning (sensitivity 100%, specificity 25%) (table). The absence of all of the 7 findings ruled out an abnormal CT for the derivation sample (negative predictive value 100%).
In patients with minor head injury, the absence of 7 clinical criteria identified patients who did not need computed tomography.
Although the studies by Haydel and Hoffman et al use somewhat different methods, they reach remarkably similar conclusions about the initial management of 2 important clinical problems in the ED: minor head injury and suspected (blunt) injury to the neck. In traditional practice, almost all patients with minor head injuries have CT, and those with suspected neck injuries have radiography of the cervical spine. The 2 studies show that for both conditions a small but important, clinically identifiable subset of patients can have imaging studies safely omitted.
The decision rules in both studies are based on a sufficiently large number of signs, symptoms, and other clinical attributes to guarantee essentially perfect sensitivity at the cost of very low specificity. Thus, the decision rules are typical screening instruments: they are most valuable in the context of high occurrence rates in busy EDs. In such settings, the systematic implementation of the decision rules in these 2 groups of patients may reduce imaging costs by approximately 20%.
Defensive physicians might argue that no decision rule is perfect. To guard against even the smallest risk for missing an occult intracranial haemorrhage or an unstable cervical fracture, they routinely order imaging procedures on all patients on the basis of the unspoken assertion that the risks and costs of the procedures are less than those of not ordering the tests. The 2 studies allow us to bracket the risks of omission. Taking a somewhat broader view, the quest for total certainty can actually negatively affect the health of a population. Healthcare budgets, however large, are limited; every additional procedure done implies that some other healthcare activity must be curtailed.1 The studies allow us to identify patients in whom imaging would provide marginal cost benefits. Not ordering radiological procedures for patients identified by the decision rules as low risk, can improve, therefore the overall quality of health care.
3 potential applications of these studies immediately come to mind. Firstly, as clinical decision aids, they provide peace of mind for physicians torn between concern for patients and administrative demands for cost saving. Secondly, as auditing tools, they can identify potential areas in which to economise without sacrificing quality of care. Thirdly, they can serve as a safeguard against unjustified accusations of substandard care.
The rules are only as valid as the individual clinical items on which the decisions are based. Identification may be trivial for such items as age, headache, or vomiting. Some skill, however, may be required to elicit a history of antegrade amnesia, and a fair degree of clinical competence is needed to rule out the presence of minor focal neurological deficits. Institutions that plan to impose the use of decision rules to reduce the number of unnecessary investigations should ensure that clinical assessments are done at the required level of competence.
Neither of the studies explicitly addresses the role of patients' preferences to have imaging studies. Current concepts of clinical decision making and patient autonomy assert that patient preferences need to be respected.2 Thus, the real challenge for ED physicians will be to convince patients that less is more.
Source of funding: not stated.
For correspondence: Dr M J Haydel, Emergency Medicine Offices, Charity Hospital, 13th Floor, 1532 Tulane Avenue, New Orleans, LA 70112, USA. Fax +1 504 568 3449.
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