Jane Sutherland

Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study

Objective To measure the sensitivity of modern third generation computed tomography in emergency patients being evaluated for possible subarachnoid haemorrhage, especially when carried out within six hours of headache onset. Design Prospective cohort study. Setting 11 tertiary care emergency departments across Canada, 2000-9. Participants Neurologically intact adults with a new acute headache peaking in intensity within one hour of onset in whom a computed tomography was ordered by the treating physician to rule out subarachnoid haemorrhage. Main outcome measures Subarachnoid haemorrhage was defined by any of subarachnoid blood on computed tomography, xanthochromia in cerebrospinal fluid, or any red blood cells in final tube of cerebrospinal fluid collected with positive results on cerebral angiography. Results Of the 3132 patients enrolled (mean age 45.1, 2571 (82.1%) with worst headache ever), 240 had subarachnoid haemorrhage (7.7%). The sensitivity of computed tomography overall for subarachnoid haemorrhage was 92.9% (95% confidence interval 89.0% to 95.5%), the specificity was 100% (99.9% to 100%), the negative predictive value was 99.4% (99.1% to 99.6%), and the positive predictive value was 100% (98.3% to 100%). For the 953 patients scanned within six hours of headache onset, all 121 patients with subarachnoid haemorrhage were identified by computed tomography, yielding a sensitivity of 100% (97.0% to 100.0%), specificity of 100% (99.5% to 100%), negative predictive value of 100% (99.5% to 100%), and positive predictive value of 100% (96.9% to 100%). Conclusion Modern third generation computed tomography is extremely sensitive in identifying subarachnoid haemorrhage when it is carried out within six hours of headache onset and interpreted by a qualified radiologist.

High risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: prospective cohort study

Objective To identify high risk clinical characteristics for subarachnoid haemorrhage in neurologically intact patients with headache. Design Multicentre prospective cohort study over five years. Setting Six university affiliated tertiary care teaching hospitals in Canada. Data collected from November 2000 until November 2005. Participants Neurologically intact adults with a non-traumatic headache peaking within an hour. Main outcome measures Subarachnoid haemorrhage, as defined by any of subarachnoid haemorrhage on computed tomography of the head, xanthochromia in the cerebrospinal fluid, or red blood cells in the final sample of cerebrospinal fluid with positive results on angiography. Physicians completed data collection forms before investigations. Results In the 1999 patients enrolled there were 130 cases of subarachnoid haemorrhage. Mean (range) age was 43.4 (16-93), 1207 (60.4%) were women, and 1546 (78.5%) reported that it was the worst headache of their life. Thirteen of the variables collected on history and three on examination were reliable and associated with subarachnoid haemorrhage. We used recursive partitioning with different combinations of these variables to create three clinical decisions rules. All had 100% (95% confidence interval 97.1% to 100.0%) sensitivity with specificities from 28.4% to 38.8%. Use of any one of these rules would have lowered rates of investigation (computed tomography, lumbar puncture, or both) from the current 82.9% to between 63.7% and 73.5%. Conclusion Clinical characteristics can be predictive for subarachnoid haemorrhage. Practical and sensitive clinical decision rules can be used in patients with a headache peaking within an hour. Further study of these proposed decision rules, including prospective validation, could allow clinicians to be more selective and accurate when investigating patients with headache.

Differentiation between traumatic tap and aneurysmal subarachnoid hemorrhage: prospective cohort study

Objectives To describe the findings in cerebrospinal fluid from patients with acute headache that could distinguish subarachnoid hemorrhage from the effects of a traumatic lumbar puncture. Design A substudy of a prospective multicenter cohort study. Setting 12 Canadian academic emergency departments, from November 2000 to December 2009. Participants Alert patients aged over 15 with an acute non-traumatic headache who underwent lumbar puncture to rule out subarachnoid hemorrhage. Main outcome measure Aneurysmal subarachnoid hemorrhage requiring intervention or resulting in death. Results Of the 1739 patients enrolled, 641 (36.9%) had abnormal results on cerebrospinal fluid analysis with >1×106/L red blood cells in the final tube of cerebrospinal fluid and/or xanthochromia in one or more tubes. There were 15 (0.9%) patients with aneurysmal subarachnoid hemorrhage based on abnormal results of a lumbar puncture. The presence of fewer than 2000×106/L red blood cells in addition to no xanthochromia excluded the diagnosis of aneurysmal subarachnoid hemorrhage, with a sensitivity of 100% (95% confidence interval 74.7% to 100%) and specificity of 91.2% (88.6% to 93.3%). Conclusion No xanthochromia and red blood cell count <2000×106/L reasonably excludes the diagnosis of aneurysmal subarachnoid hemorrhage. Most patients with acute headache who meet this cut off will need no further investigations and aneurysmal subarachnoid hemorrhage can be excluded as a cause of their headache.

Assessment of the impact on time to complete medical record using an electronic medical record versus a paper record on emergency department patients: a study.

Background Electronic medical records are becoming an integral part of healthcare delivery. Objective The goal of this study was to compare paper documentation versus electronic medical record for non-traumatic chest pain to determine differences in time for physicians to complete medical records using paper versus electronic mediums. We also assessed physician satisfaction with the electronic format. Methods We conducted this before-after study in a single large tertiary care academic emergency department. In the ‘Before Period’, stopwatches determined the time for paper medical recording. In the ‘After Period’, a template-based electronic medical record was introduced and the time for electronic recording was measured. The time to record in the before and after periods were compared using a two-sided t test. We surveyed physicians to assess satisfaction. Results We enrolled 100 non-traumatic patients with chest pain in the before period and 73 in the after period. The documentation time was longer using electronic charting, (9.6±5.9 min vs 6.1±2.5 min; p<0.001). 18 of 20 physicians participating in the after period completed surveys. Physicians were not satisfied with the electronic patient recording for non-traumatic chest pain. Conclusions This is the first study that we are aware of which compared paper versus electronic medical records in the emergency department. Electronic recording took longer than paper records. Physicians were not satisfied using this electronic record. Given the time pressures on emergency physicians, a solution to minimise the charting time using electronic medical records must be found before widespread uptake of electronic charting will be possible.

How do we manage emergency department patients diagnosed with transient ischemic attack

INTRODUCTION Multiple studies have demonstrated low rates of antithrombotic use, low neuroimaging rates, and high subsequent risk of stroke at 90 days following an emergency department (ED) diagnosis of transient ischemic attack (TIA). This study assessed the use of antithrombotic medications, neuroimaging, and subsequent 90-day stroke rate for patients in a more recent cohort of ED patients discharged home with TIA. METHODS We conducted a 1-year historical cohort study of all patients discharged with a TIA at a tertiary care ED (census 60,000 visits/year), which was one of the four sites participating in one of the aforementioned studies. Data were extracted from paper and electronic records onto standardized data extraction forms. Clinical findings, medications, and tests were recorded. RESULTS A total of 211 patients were enrolled in the study. The patients had the following characteristics: the mean age was 71.2 years (SD 13.8 years), 56.9% were female, 53.1% had a history of hypertension, 26.5% had a history of ischemic heart disease, and 17.1% had a previous stroke. The most frequent neurologic deficit was unilateral weakness (53.6%), and most deficits lasted for more than 60 minutes (71.6%). Antithrombotic medications were used for 96.7% of patients at ED discharge. Neuroimaging was conducted in 94.3% of patients while in the ED. Our cohort had a 90-day stroke rate of 1.9%. CONCLUSION This study established that most TIA patients receive neuroimaging in the ED and are started on or maintained on antithrombotic agents. Clinicians are encouraged to ensure that electrocardiography is done routinely and to involve Neurology in follow-up care.

Factors influencing time to computed tomography in emergency department patients with suspected subarachnoid haemorrhage

Background CT has excellent sensitivity for subarachnoid haemorrhage (SAH) when performed within 6 hours of headache onset, but it is unknown to what extent patients with more severe disease are likely to undergo earlier CT, potentially inflating estimates of sensitivity. Our objective was to evaluate which patient and hospital factors were associated with earlier neuroimaging in alert, neurologically intact ED patients with suspected SAH. Methods We analysed data from two large sequential prospective cohorts of ED patients with acute headache undergoing CT for suspected SAH. We examined the time interval from headache onset to CT, both overall and subdivided from headache onset to hospital registration and from registration to CT. Results Among 2412 patients with headache, 194 had SAH, with 178 identified on unenhanced CT. Of these, 91 (51.1%) were identified by CT within 6 hours of headache onset and 87 after 6 hours. Patients with SAH had a shorter time from headache onset to hospital presentation (median 4.5 hours, IQR 1.7–22.7 vs 9.6 hours, IQR 2.8–46.0, p<0.001) and were imaged sooner after headache onset (6.4 hours, IQR 3.5–27.1 vs 12.6 hours, IQR 5.5–48.0, p<0.001) compared with those without SAH. The median time from in-hospital registration to CT scan was significantly shorter in those patients with SAH although this difference was less than 1 hour (1.9 hours, IQR 1.2–2.8 vs 2.5 hours, IQR 1.5–3.9, p<0.001). Arrival by ambulance (OR 3.1, 95% CI 1.94 to 4.98, p<0.001) and higher acuity at triage (OR 1.39, 95% CI 1.02 to 1.88, p=0.032) were among the factors associated with having CT imaging within 6 hours of headache onset. Conclusions Time from headache onset to imaging is moderately associated with positive imaging for SAH. Delay to hospital presentation accounts for the largest fraction of time to imaging, especially those without SAH. These findings suggest limited opportunity to reduce lumbar puncture rates simply by accelerating in-hospital processes when imaging delays are under 2 hours, as diagnostic yield of imaging decreases beyond the 6-hour imaging window from headache onset.

'A foot in the door' – an introductory programme for patients with early stage motor neuron disease

Introduction Patients with MND are usually referred to palliative care services late in their disease progression. Reasons for this appear to centre on patients being so distressed at the prospect of palliative care services involvement, that they delay referral for as long as possible. Having identified this as a problem, the hospice embarked on a joint venture with the Motor Neurone Disease Association. The premise of such joint working was to develop an outreach project for local patients with early stage MND. A grant was successfully secured from the DH (project 64 grant). Aims The aims of the project were to introduce this cohort of patients/carers to palliative care services at a much earlier stage in their illness and to decrease levels of distress/anxiety associated with a referral. It was also to give the opportunity for patients/carers to meet others in a similar situation and to provide them with information about common problems. Methods Two programmes were devised, each of 10 sessions, with a different theme per session. Each programme was devised to support 10 new patients/carers, with sessions taking place in the day hospice (hence the title ‘a foot in the door’). Results During the first and final sessions of each programme, patients/carers were asked to anonymously score a series of statements concerning their confidence in (and experience in accessing) care, their concerns for the future and feelings about hospice services. Results show that a positive change in all domains occurred. Conclusion This outreach project had a positive impact on MND patients/carers. The project format can be replicated by other palliative care providers. A DVD further detailing the project is being made in order to help other palliative care providers develop similar work.

Clinical and marketing teams working in partnership to improve access to services

Improving access to palliative care has been high on the agenda for hospices for a number of years. Barriers to access are many and varied. Much work has been done to identify and reduce them but still evidence suggests that barriers remain. In 2008 our marketing team carried out a consultation exercise to gain a better understanding of the challenges the hospice faced in improving access for our locality. Over 400 local people, service users and providers were asked their views. A range of methods were used including key stakeholder focus groups and one-to-one interviews with the general public. Results demonstrated significant barriers to accessing our services. Many were not aware of services on offer nor who could use them; and there was a real need for literature that clearly communicates the work of the hospice and the range of services it provides. The consultation exercise resulted in a rebranding in 2009. Since then our marketing and clinical teams have worked in partnership to raise the profile of the hospice and reduce barriers to access through a range of promotional and marketing initiatives. We have produced a range of service information leaflets and clinical literature and have successfully developed networks and collaborative working relationships with colleagues in non-cancer specialities. Some 3 years on we are beginning to see the results of our partnership working. We have achieved more by combining our marketing and clinical expertise than we could have achieved singularly. Statistics suggest that we are beginning to improve access to people not previously accessing our services well. While there is still a long way to go we can see that our joint working and enhanced information giving is raising the profile of our hospice and the services it provides, paving the way for more patients to access them.