Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Acad Emerg Med. 2013 May;20(5):463-9. doi: 10.1111/acem.12136.
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).
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.
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 CDS-recommended 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).
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.
在过去的十年中，急诊科（ED）计算机断层扫描（CT）的使用显著增加。有人认为，坚持临床决策支持（CDS）可能会安全地减少 CT 订购量。在这项研究中，作者量化了常规和 CDS 推荐护理之间的百分比一致性，以及严格遵守 CDS 对轻度创伤性脑损伤（mTBI）中 CT 使用的预期影响。
这是一项前瞻性观察研究，纳入了 2010 年 8 月至 2011 年 7 月期间在一家三级护理医院的城市学术 ED 就诊的 mTBI 患者。18 岁或以上，在头部非穿透性创伤后 24 小时内就诊，有资格入组。受过培训的研究助理（RA）填写了结构化数据表格。主要结局是常规头部 CT 使用与 CDS 推荐的头部 CT 使用之间的百分比一致性。所检查的 CDS 为：2008 年美国急诊医师学院[ACEP]神经影像学、新奥尔良规则和加拿大头部 CT 规则。使用卡方检验比较分类变量，使用 Kruskal-Wallis 秩检验比较连续变量。计算常规实践和 CDS 推荐实践之间的百分比一致性。
在纳入的 169 名患者中，130 名（76.9%）接受了头部 CT 扫描，130 名中有 5 名（3.8%）有急性创伤性颅内发现。对于所有受试者，常规实践与 CDS 推荐实践之间的一致性分别为 ACEP、加拿大和新奥尔良 CDS 的 77.5%、65.7%和 78.1%。严格遵守 2008 年 ACEP 神经影像学 CDS，头部 CT 使用量无统计学显著差异（常规治疗，76.9%；CDS 推荐，82.8%；p=0.17）。严格遵守新奥尔良 CDS，头部 CT 使用量增加（常规治疗，76.9%；CDS 推荐，94.1%；p<0.01）。严格遵守加拿大 CDS，头部 CT 使用量减少（常规治疗，76.9%；CDS 推荐，56.8%；p<0.01）。
常规和 CDS 推荐的头部 CT 使用之间有 60%至 80%的一致性。在所检查的三个 CDS 系统中，只有加拿大头部 CT CDS 如果严格遵循，可能会导致头部 CT 使用减少。需要进一步研究以探讨常规护理与加拿大头部 CT CDS 推荐护理之间一致性不佳的原因。
Zotero 插件