Objectives: Emergency department (ED) computed tomography (CT) use has increased significantly during the past decade. It has been suggested that adherence to clinical decision support (CDS) may result in a safe decrease in CT ordering. In this study, the authors quantified the percentage agreement between routine and CDS-recommended care and the anticipated consequence of strict adherence to CDS on CT use in mild traumatic brain injury (mTBI).Methods: This was a prospective observational study of patients with mTBI who presented to an urban academic ED of a tertiary care hospital. Patients 18 years or older, presenting within 24 hours of nonpenetrating trauma to the head, from August 2010 to July 2011, were eligible for enrollment. Structured data forms were completed by trained research assistants (RAs). The primary outcome was the percentage agreement between routine head CT use and CDS-recommended head CT use. CDS examined were: the 2008 American College of Emergency Physicians [ACEP] neuroimaging, the New Orleans rule, and the Canadian head CT rule. Differences between outcome groups were assessed using the chi-square test for categorical variables and the Kruskal-Wallis rank test for continuous variables. The percentage agreement between routine practice and CDS-recommended practice was calculated.Results: Of the 169 patients enrolled, 130 (76.9%) received head CT scans, and five of the 130 (3.8%) had acute traumatic intracranial findings. For all subjects, agreement between routine practice and CDSrecommended practice was 77.5, 65.7, and 78.1%, for the ACEP, Canadian, and New Orleans CDS, respectively. Strict adherence to the 2008 ACEP neuroimaging CDS would result in no statistically significant difference in head CT use (routine care, 76.9%; CDS-recommended, 82.8%; p = 0.17). Strict adherence to the New Orleans CDS would result in an increase in head CT use (routine care, 76.9%; CDS-recommended, 94.1%; p < 0.01). Strict adherence to the Canadian CDS would result in a decrease in head CT use (routine care, 76.9%; CDS-recommended, 56.8%; p < 0.01).Conclusions: There is a 60% to 80% agreement between routine and CDS-recommended head CT use. Of the three CDS systems examined, the only one that may result in a reduction in head CT use if strictly followed was the Canadian head CT CDS. Further studies are needed to examine reasons for the less than optimal agreement between routine care and care recommended by the Canadian head CT CDS.ACADEMIC EMERGENCY MEDICINE 2013; 20:463-469

Background: The preoperative period has gained recognition as a crucial time to identify and manage preoperative medical conditions for preventing perioperative complications. Consequently, preoperative clinics have now become an essential component of perioperative care at many large hospitals. As the prevalence of preoperative clinics continues to grow, and the field of perioperative medicine progresses, respiratory therapists (RTs) will inevitably find a growing role to participate in preoperative patient optimization to mitigate pulmonary complications. Methods: Keyword searches on perioperative pulmonary complications were conducted on the Medline database via PubMed and identified over 2000 candidate articles for review. Articles were included if they were English only and resulted with one or more of the following search terms; pulmonary complications, postoperative complications, postoperative pulmonary complications (PPCs), prehabilitation, incentive spirometry, smoking cessation, noninvasive ventilation. Preference was given for meta-analyses, randomized controlled trials, and systematic reviews. Publications within the past two decades were given additional preference toward final inclusion. The authors discussed eligible articles in group meetings over the span of multiple years to assess relevance and quality of data for narrowing eligible articles to the final selection of publications for the review. Findings: The following narrative review examines preoperative optimization strategies to prevent PPCs and highlight areas where RTs may play a key role. After examining challenges in defining PPCs, the review examines key risk models available to predict PPCs and their implications for subsequent discussion on preventive measures that RTs may assist with in a multidisciplinary team. Conclusion: RTs can reduce the health care burden of PPCs by assisting fellow perioperative clinicians in providing respiratory care for patients with premorbid conditions. While much of our review focused on pre-existing pulmonary pathologies and both the pharmacological and nonpharmacological optimization of these pathologies, there are other factors contributing to PPCs deserving future exploration.

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