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.ACADEMIC EMERGENCY MEDICINE 2007; 14:955-959 ª

Emergency Department Management of Heart Failure and COPD: A National Survey of Attitudes and Practice

“…Although each of these factors is arguably important when deciding upon definitive management, it is impossible for each of a patient's personal factors to be included into a succinct bedside decision tool. To date, most successful bedside decision tools, including the Ottawa Ankle Rules and the Canadian C-Spine Rule, [8][9][10] have aimed to provide concrete answers to straightforward clinical presentations with dichotomous problems. With the new OHFRS and OCRS, however, we are attempting to address much more complex clinical issues where the answers are not binary.…”

Impact of clinical decision support on head computed tomography use in patients with mild traumatic brain injury in the ED

“…These rules allow for risk stratification of patients with suspected intracranial injuries, based on clinical findings [3][4][5]. When used appropriately, they can help avoid unnecessary head CTs, without jeopardizing patient safety [6]. Despite their potential utility [7][8][9][10] and acceptance by professional societies [11], their clinical adoption remains scarce.…”

Concussive Symptoms in Emergency Department Patients Diagnosed with Minor Head Injury

“…This evidence comes from the concussion literature and has been observed in patients in other clinical settings (e.g., sports medicine, neurology) (14,15). In Canada, the annual incidence of patients who are treated in a hospital or clinic for minor head injury each year is 150 per 100,000 population (16). Similar annual rates have been reported for the United States (130 per 100,000), the United Kingdom (200 -300 per 100,000), and for multiple countries by the World Health Organization (100 -300 per 100,000, with higher rates among teenagers and adults) (16 -20).…”