Implementation of Clinical Decision Rules in the Emergency Department

Abstract

Clinical decision rules (CDRs) are tools designed to help clinicians make bedside diagnostic and therapeutic decisions. The development of a CDR involves three stages: derivation, validation, and implementation. Several criteria need to be considered when designing and evaluating the results of an implementation trial. In this article, the authors review the results of implementation studies evaluating the effect of four CDRs: the Ottawa Ankle Rules, the Ottawa Knee Rule, the Canadian C-Spine Rule, and the Canadian CT Head Rule. Four implementation studies demonstrated that the implementation of CDRs in the emergency department (ED) safely reduced the use of radiography for ankle, knee, and cervical spine injuries. However, a recent trial failed to demonstrate an impact on computed tomography imaging rates. Well-developed and validated CDRs can be successfully implemented into practice, efficiently standardizing ED care. However, further research is needed to identify barriers to implementation in order to achieve improved uptake in the ED.

External validation and optimisation of a model for predicting foot ulcers in patients with diabetes

“…And so, we chose to adopt a conservative approach and retain them in the model. Ideally, 10 to 15 patients should be enrolled for each variable analysed [20] and therefore sample size should be between 300 and 450 participants. We included 360 patients, a figure comprising all patients available over the study period.…”

Implementation of the Ottawa ankle rules by general practitioners in an emergency department of a Turkish district hospital

“…The OAR have been widely applied in many countries, [6][7][8][9][10][11] and are regarded as a highly sensitive and modestly specific method of detecting fracture in clinical setting. [12] However, the introduction of any new diagnostic method in a specific clinical setting and culture requires considerable caution, as sensitivity and specificity may be significantly affected.…”

Paramedics assessing Elders at Risk for Independence Loss (PERIL): Derivation, Reliability and Comparative Effectiveness of a Clinical Prediction Rule

“…This study adds to the evidence supporting the feasibility of community paramedicine, a model of care whereby paramedics apply their training and skills in "nontraditional," preventative, community-based roles. [19][20][21][22][23][24] Gerson et al first studied screening by paramedics for clues of unmet needs in the home environment of older adults. 18 In 121/124 cases where paramedics identified older adults as having unmet needs, this was confirmed during a home-visit by a "gold-standard" geriatric assessor from a community agency.…”

“…21 A pool of 43 candidate predictor variables was selected based on three published systematic reviews. 11,22,23 Our aim was to ensure that the rule was "clinically sensible," i.e., all required data elements would be available to paramedics and feasible to collect during the EMS encounter.…”