PP297 Management Of Sudden Onset Severe Headache Presenting To The Emergency Department: A Systematic Review

2021 ◽  
Vol 37 (S1) ◽  
pp. 33-34
Author(s):  
Ros Wade ◽  
Matthew Walton ◽  
Melissa Harden ◽  
Robert Hodgson ◽  
Alison Eastwood ◽  
...  
Keyword(s):  
Systematic Review ◽  
Emergency Department ◽  
Adverse Events ◽  
Diagnostic Accuracy ◽  
False Positive ◽  
Clinical Decision ◽  
Sudden Onset ◽  
Severe Headache ◽  
Sufficient Information ◽  
Headache Onset

IntroductionSudden onset severe headache is usually caused by a primary headache disorder but occasionally is secondary to a more serious problem, such as subarachnoid hemorrhage (SAH). Guidelines recommend non-contrast brain computed tomography (CT) followed by lumbar puncture (LP) to exclude SAH. However, guidelines pre-date the introduction of more sensitive modern CT scanners. A systematic review was undertaken to assess the clinical effectiveness of different care pathways for the management of headache in the Emergency Department.MethodsEighteen databases (including MEDLINE and Embase) were searched to February 2020. Studies were quality assessed using criteria relevant to the study design; most studies were assessed using the QUADAS-2 tool for diagnostic accuracy studies. Where sufficient information was reported, diagnostic accuracy data were extracted into 2 × 2 tables to calculate sensitivity, specificity, false-positive and false-negative rates. Where possible, hierarchical bivariate meta-analysis was used to synthesize results, otherwise studies were synthesized narratively.ResultsFifty-one studies were included in the review. Eight studies assessing the accuracy of the Ottawa SAH clinical decision rule were pooled; sensitivity was 99.5 percent, specificity was 23.7 percent. The high false positive rate suggests that 76.3 percent SAH-negative patients would undergo further investigation unnecessarily. Four studies assessing the accuracy of CT within six hours of headache onset were pooled; sensitivity was 98.7 percent, specificity was 100 percent. CT sensitivity beyond six hours was considerably lower (≤90%; 2 studies). Three studies assessing LP following negative CT were pooled; sensitivity was 100 percent, specificity was 95.2 percent. LP-related adverse events were reported in 5.3–9.5 percent of patients.ConclusionsThe evidence suggests that the Ottawa SAH Rule is not sufficiently accurate for ruling out SAH and does little to aid clinical decision making. Modern CT within six hours of headache onset (with images assessed by a neuroradiologist) is highly accurate, but sensitivity reduces considerably over time. The CT-LP pathway is highly sensitive for detecting SAH, although LP resulted in some false-positives and adverse events.

PP296 Patient Involvement In An Assessment Of The Management Of Sudden Onset Severe Headache Presenting To The Emergency Department

2021 ◽  
Vol 37 (S1) ◽  
pp. 33-33
Author(s):  
Ros Wade ◽  
Matthew Walton ◽  
Melissa Harden ◽  
Robert Hodgson ◽  
Alison Eastwood ◽  
...  
Keyword(s):  
Systematic Review ◽  
Emergency Department ◽  
Lumbar Puncture ◽  
Patient Involvement ◽  
Primary Headache ◽  
Development Stage ◽  
Sudden Onset ◽  
Severe Headache ◽  
Advisory Group ◽  
Protocol Development

IntroductionSudden onset severe headache is usually caused by a primary headache disorder but may be secondary to a more serious problem, such as subarachnoid hemorrhage (SAH). Very few patients who present to hospital with headache have suffered a SAH, but early identification is important to improve patient outcomes. A systematic review was undertaken to assess the clinical effectiveness of different care pathways for the management of headache, suspicious for SAH, in the Emergency Department. Capturing the perspective of patients was an important part of the research.MethodsThe project team included a patient collaborator with experience of presenting to the Emergency Department with sudden onset severe headache. Three additional patients were recruited to our advisory group. The patient's perspective was collected at various points through the project including at team meetings, during protocol development and when interpreting the results of the systematic review and drawing conclusions.ResultsPatients were reassured by the very high diagnostic accuracy of computed tomography (CT) for detecting SAH. Patients and clinicians emphasized the importance of shared decision making about whether to undergo additional tests to rule out SAH, after a negative CT result. When lumbar puncture was necessary, patients expressed a preference to have it on an ambulatory basis; further research on the safety and acceptability of ambulatory lumbar puncture was recommended.ConclusionsPatient input at the protocol development stage helped researchers understand the patient experience and highlighted important outcomes for assessment. Patient involvement added context to the review findings and highlighted the preferences of patients regarding the management of headache.

scholarly journals Diagnostic utility of the Active Compression Test for the superior labrum anterior posterior tear: A systematic review

2018 ◽  
Vol 11 (5) ◽  
pp. 321-331
Author(s):  
Cody Davis ◽  
Jenna Immormino ◽  
Brendan M Higgins ◽  
Kyle Clark ◽  
Samuel Engebose ◽  
...  
Keyword(s):  
Systematic Review ◽  
Diagnostic Accuracy ◽  
Compression Test ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Risk Of Bias ◽  
Pretest Probability ◽  
Positive Finding ◽  
Negative Finding ◽  
Superior Labrum

Background The Active Compression Test has been proposed to have high diagnostic accuracy for superior labrum anterior to posterior tears. The aim of this systematic review was to compile the available evidence for this test and evaluate its diagnostic accuracy. Methods The databases PubMed, Embase, Cochrane, CINAHL, and SCOPUS were searched for case control, diagnostic studies that evaluated the Active Compression Test between 1999 (date of test introduction) and February 2018. Two independent review authors screened the search results, assessed the risk of bias using QUADAS-2, and extracted the data. Results Eighteen studies (pooled sample = 3091) were included in this review. Twelve out of 18 studies either had high or unclear risk of bias (66.6%). Results from the pooled analysis of all 18 studies provided that the Active Compression Test is more sensitive (71.5: 95% CI = 68.8, 74.0) than specific (51.9: 95% CI = 50.7, 53.1) and only marginally influenced posttest probability from a pretest probability of 31.7–40.72% with a positive finding and a pretest probability of 31.7–20.33% with a negative finding. Discussion The Active Compression Test has both limited screening and confirmation ability; therefore, we do not advocate for its use in clinical decision making.

scholarly journals P121: Derivation of a clinical decision tool for predicting adverse outcomes among emergency department patients with lower gastrointestinal bleeding

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S99-S100
Author(s):  
R. Ramaekers ◽  
C. Leafloor ◽  
J. J. Perry ◽  
V. Thiruganasambandamoorthy
Keyword(s):  
Emergency Department ◽  
Adverse Events ◽  
Gastrointestinal Bleeding ◽  
Likelihood Ratio ◽  
Negative Likelihood Ratio ◽  
Clinical Decision ◽  
Lower Gastrointestinal Bleeding ◽  
Bloody Stool ◽  
Decision Tool ◽  
Serious Adverse Events

Introduction: Lower gastrointestinal bleeding (LGIB) can result in serious adverse events, including recurrent bleeding, need for intervention and death. Endoscopy is important in the management of LGIB, however gastroenterologists have limited resources to safe endoscopy. Risk stratification of LGIB patients can aid physicians in disposition decisions. Objective: to develop a clinical decision tool to accurately identify LGIB patients presenting to the emergency department (ED) who are at risk for 30-day serious adverse events. Methods: We conducted a health records review and included 372 adult ED patients who presented with an acute LGIB. The outcome was a 30-day composite outcome consisting of all-cause death, recurrent LGIB, need for intervention to control the bleed and ICU admission. A second researcher confirmed data-collection of 10% of the data and we calculated a -value for inter-rater reliability. We analyzed the data using stepwise backwards selection and SELECTION=SCORE option and calculated the diagnostic accuracy of the final model. Results: Age 75 years, hemoglobin 100 g/L, INR 2.0, a bloody stool in the ED and a past medical history of colorectal polyps were significant predictors in the multivariable regression analysis. The AUC was 0.83 (95% CI 0.77-0.89), sensitivity 0.96 (0.90-1.00), specificity 0.53 (0.48-0.59), and negative likelihood ratio 0.08 (0.02-0.30) for a cut-off score of 1. Conclusion: This model showed good ability to identify LGIB patients at low risk for adverse events as evidenced by the high AUC, sensitivity and negative likelihood ratio. Future, large prospective studies should be done to confirm the data, after which it should be validated and implemented.

scholarly journals Adverse Events Related to Emergency Department Care: A Systematic Review

PLoS ONE ◽  
2013 ◽  
Vol 8 (9) ◽  
pp. e74214 ◽  
Author(s):  
Antonia S. Stang ◽  
Aireen S. Wingert ◽  
Lisa Hartling ◽  
Amy C. Plint
Keyword(s):  
Systematic Review ◽  
Emergency Department ◽  
Adverse Events ◽  
Emergency Department Care

Prediction of Early Adverse Events in Emergency Department Patients With Acute Heart Failure: A Systematic Review

2018 ◽  
Vol 34 (2) ◽  
pp. 168-179 ◽  
Author(s):  
Allison M. Michaud ◽  
Shannon I.A. Parker ◽  
Heather Ganshorn ◽  
Justin A. Ezekowitz ◽  
Andrew D. McRae
Keyword(s):  
Heart Failure ◽  
Systematic Review ◽  
Emergency Department ◽  
Adverse Events ◽  
Acute Heart Failure ◽  
Emergency Department Patients

scholarly journals The HEART score for early rule out of acute coronary syndromes in the emergency department: a systematic review and meta-analysis

2017 ◽  
Vol 7 (2) ◽  
pp. 111-119 ◽  
Author(s):  
Patricia Van Den Berg ◽  
Richard Body
Keyword(s):  
Systematic Review ◽  
Emergency Department ◽  
Diagnostic Accuracy ◽  
Meta Analysis ◽  
Low Risk ◽  
Major Adverse Cardiac Events ◽  
Current Evidence ◽  
Cardiac Events ◽  
Heart Score ◽  
Adverse Cardiac Events

Aims: The objective of this systematic review was to summarise the current evidence on the diagnostic accuracy of the HEART score for predicting major adverse cardiac events in patients presenting with undifferentiated chest pain to the emergency department. Methods and results: Two investigators independently searched Medline, Embase and Cochrane databases between 2008 and May 2016 identifying eligible studies providing diagnostic accuracy data on the HEART score for predicting major adverse cardiac events as the primary outcome. For the 12 studies meeting inclusion criteria, study characteristics and diagnostic accuracy measures were systematically extracted and study quality assessed using the QUADAS-2 tool. After quality assessment, nine studies including data from 11,217 patients were combined in the meta-analysis applying a generalised linear mixed model approach with random effects assumption (Stata 13.1). In total, 15.4% of patients (range 7.3–29.1%) developed major adverse cardiac events after a mean of 6 weeks’ follow-up. Among patients categorised as ‘low risk’ and suitable for early discharge (HEART score 0–3), the pooled incidence of ‘missed’ major adverse cardiac events was 1.6%. The pooled sensitivity and specificity of the HEART score for predicting major adverse cardiac events were 96.7% (95% confidence interval (CI) 94.0–98.2%) and 47.0% (95% CI 41.0–53.5%), respectively. Conclusions: Patients with a HEART score of 0–3 are at low risk of incident major adverse cardiac events. As 3.3% of patients with major adverse cardiac events are ‘missed’ by the HEART score, clinicians must ask whether this risk is acceptably low for clinical implementation.

scholarly journals Causes of misdiagnoses by thyroid fine-needle aspiration cytology (FNAC): our experience and a systematic review

2020 ◽  
Vol 15 (1) ◽  
Author(s):  
Yanli Zhu ◽  
Yuntao Song ◽  
Guohui Xu ◽  
Zhihui Fan ◽  
Wenhao Ren
Keyword(s):  
Systematic Review ◽  
Diagnostic Accuracy ◽  
Predictive Value ◽  
False Positive ◽  
False Negative ◽  
Diagnostic Errors ◽  
Published Data ◽  
Cystic Lesions ◽  
Adenomatous Hyperplasia ◽  
Sensitivity Specificity

Abstract Objective FNA is a simple, safe, cost-effective and accurate diagnostic tool for the initial screening of patients with thyroid nodules. The aims of this study were to determine the diagnostic utility of FNAC performed in our institution, assess the cytomorphologic features that contribute to diagnostic errors and propose improvement measures. Methods A total of 2781 FNACs were included in the study, and 1122 cases were compared with their histological diagnoses. We retrospectively reexamined our discordant (both false-negative and false-positive) cases and performed a systematic review of previous studies on causes of misdiagnoses. Results When DC V and DC VI were both considered cytologic-positive, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy were 98.3, 30.9, 94.9, 58.3 and 93.5%, respectively. If DC VI was considered cytologic-positive, the sensitivity, specificity, PPV, NPV and diagnostic accuracy of FNAC were 98.0, 84.0, 99.4, 58.3, and 97.5% respectively. The main cause of false-negative diagnoses was sampling error (13/15, 86.7%), while interpretation error led to the majority of the false-positive diagnoses (38/47, 80.9%). Overlapping cytological features in adenomatous hyperplasia, thyroiditis and cystic lesions were the major factors contributing to interpretation errors, while the size and number of nodules may have led to false-negative diagnoses because of heterogeneity and unsampled areas. Conclusions The sensitivity and PPV of thyroid FNAC in our institution were higher than those in the published data, while the specificity and NPV were lower. Regarding the FNA category DC V, a frozen section analysis during diagnostic lobectomy is necessary. Multiple passes should be performed in various parts of a large nodule or from different nodules to reduce the risk of false-negative findings. Cytopathologists should strengthen their criteria for the identification of adenomatous hyperplasia, thyroiditis and cystic lesions to avoid false-positive diagnoses. NIFTP has little effect on diagnostic accuracy and the distribution of diagnostic errors.

scholarly journals P122: Ready for the story? A mixed methods systematic review of factors that influence handovers between prehospital personnel and emergency department nurses receiving patients arriving by ambulance

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S100-S100
Author(s):  
G. Reay ◽  
J. Norris ◽  
L. Nowell ◽  
J. Abraham ◽  
A. Hayden ◽  
...  
Keyword(s):  
Systematic Review ◽  
Emergency Department ◽  
Mixed Methods ◽  
Adverse Events ◽  
Assessment Tool ◽  
Public Health Practice ◽  
Grey Literature ◽  
Learning Program ◽  
Emergency Nurses ◽  
Emergency Department Nurses

Introduction: Safe and efficient handovers between emergency medical services (EMS) practitioners and emergency nurses are vital as poor transitions may lead to loss of information and place patients at risk for adverse events. We conducted a mixed methods systematic review to a) examine factors that disrupt or improve handovers from EMS practitioners to emergency department nurses, and b) investigate the effectiveness of interventional strategies that lead to improvements in communication and fewer adverse events. Methods: We searched electronic databases (DARE, MEDLINE, EMBASE, Cochrane, CINAHL, Joanna Briggs Institute EBP; Communication Abstracts); grey literature (grey literature databases, organization websites, querying experts in emergency medicine); and reference lists of the included studies. Citation tracking was conducted for the included studies. Two reviewers independently screened titles/abstracts and full-texts for inclusion and methodological quality using the Effective Public Health Practice Project Quality Assessment Tool for quantitative studies and the Joanna Briggs Institute Critic Appraisal Checklist for Qualitative Research. Narrative and thematic synthesis were conducted to integrate and explore relationships within the data. Results: Twenty-two studies were included in this review from the 6150 records initially retrieved. Our analysis suggests that qualitative, quantitative, and mixed methods research approaches have been utilized to explore handovers. Studies (n=11) have predominantly explored existing patterns of handovers focusing on barriers and facilitators. Interventions (e.g. multimedia transmission of pre-hospital information, tailored e-learning program) were investigated in five studies. Results suggest that lack of formal handover training, workflow interruptions, workload, and strained working relationships between EMS and nursing are perceived threats to optimal handovers. Conclusion: The findings from this review can inform the development of handover interventions and contribute to a more rigorous approach to researching handovers between EMS practitioners and emergency nurses. Furthermore, there is a need for studies in which specific interventions to optimize handovers are examined.

scholarly journals LO15: Paramedic and allied health professional interventions at long-term care facilities to reduce emergency department visits: systematic review

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S12-S12
Author(s):  
S. Leduc ◽  
Z. Cantor ◽  
P. Kelly ◽  
V. Thiruganasambandamoorthy ◽  
G. Wells ◽  
...  
Keyword(s):  
Systematic Review ◽  
Emergency Department ◽  
Adverse Events ◽  
Health Professionals ◽  
Allied Health ◽  
Long Term Care ◽  
Allied Health Professionals ◽  
Term Care ◽  
Ed Visits

Introduction: Emergency department (ED) crowding, long waits for care, and paramedic offload delay are of increasing concern. Older adults living in long-term care (LTC) are more likely to utilize the ED and are vulnerable to adverse events. We sought to identify existing programs that seek to avoid ED visits from LTC facilities where allied health professionals are the primary providers of the intervention and, to evaluate their efficacy and safety. Methods: We completed this systematic review based on a protocol we published apriori and following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. We systematically searched Medline, CINAHL and EMBASE with terms relating to long-term care, emergency services, hospitalization and allied health personnel. Two investigators independently selected studies and extracted data using a piloted standardized form and evaluated the risk of bias of included studies. We report a narrative synthesis grouped by intervention categories. Results: We reviewed 11,176 abstracts and included 22 studies. Most studies were observational and few assessed patient safety. We found five categories of interventions including: 1) use of advanced practice nursing; 2) a program called Interventions to Reduce Acute Care Transfers (INTERACT); 3) end-of-life care; 4) condition specific interventions; and 5) use of extended care paramedics. Of the 13 studies that reported ED visits, all (100%) reported a decrease, and of the 16/17 that reported hospitalization, 94.1% reported a decrease. Patient adverse events such as functional status and relapse were seldom reported (6/22) as were measures of emergency system function such as crowding/inability of paramedics to transfer care to the ED (1/22). Only 4/22 studies evaluated patient mortality and 3/4 found a non-statistically significant worsening. When measured, studies reported decreased hospital length of stay, more time spent with patients by allied health professionals and cost savings. Conclusion: We found five types of programs/interventions which all demonstrated a decrease in ED visits or hospitalization. Many identified programs focused on improved primary care for patients. Interventions addressing acute care issues such as those provided by community paramedics, patient preferences, and quality of life indicators all deserve more study.

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