December 6, 2023
4 minute read
- This rule is designed to simplify by asking a “yes” or “no” question for each item.
- This may help elderly patients avoid the deleterious consequences of prolonged ED stays, such as delirium.
A new clinical decision rule could help doctors determine which older ED patients who have experienced a fall require imaging, according to a study published in . CMAJ.
The development of the fall decision rules comes as emergency medical professionals are “managing an increasing number of older adults who are falling,” the report said. Dr. Kerstin de Wit, Associate Professor and colleagues at Queen’s University, Canada.
Researchers conducted a prospective cohort study to test the effectiveness of a four-point decision rule in identifying patients who can be excluded from CT scans due to intracranial hemorrhage after a fall. The analysis included 4,308 patients (median age 83 years, 64% female) across 11 acute care hospitals in the United States and Canada.
De Wit et al. found that this rule was related to:
- Sensitivity 98.6% (95% CI, 94.9-99.6).
- Specificity 20.3% (95% CI, 19.1-21.5).and
- Negative predictive value 99.8% (95% CI, 99.2-99.9).
De Witt spoke to Helio about what the rules consist of and why researchers developed them.
Helio: What is the Falls decision rule?
De Wit: This decision rule is a clinical decision rule for emergency physicians. This is a rule that can be used primarily when elderly people come to the emergency department after falling at home and being brought to the emergency hospital. This rule helps doctors decide whether a patient should undergo a head CT scan.
At this time, there is no clear guidance for many of these patients. So we decided to come up with a very simple decision-making role with as few items as possible for doctors to apply at the bedside when evaluating patients.
Helio: Why is this rule necessary for ED?
De Wit: There are many reasons. Recently, we have seen severe ED overcrowding, particularly in Canada, but also in the United States and Europe.
Unfortunately, much of the overcrowding disproportionately affects older patients, leaving patients on stretchers and chairs in hallways when emergency departments are full. It is often the elderly who are left behind in the hallways. Many people are suffering from a stroke or heart attack, many are sitting in bed under monitor conditions, and many come to the hospital simply because they are too weak and have fallen at home. There is no need to monitor it, so it will be left alone in the hallway.
There is ample evidence that the more time older adults spend in the ED, the greater the risk of developing delirium. Delirium is obviously a very unpleasant thing to experience, but it also means that you can no longer send the patient away, even if you have examined the patient and have determined that it is safe for him or her to go home. also means If they become confused or delirious, go home. Therefore, they need to be hospitalized. Currently, the hospital is almost full. We don’t have a bed. So when we admit them, it often means they stay in the emergency room for days.
Helio: Under the new rules, which patients should and should not receive CT?
De Wit: The clinical judgment rule we developed has four items. We have a very simple approach where the answer to each question is “yes” or “no,” and if the answer is “yes” to any of these four items, it means you need to scan. I wanted to create rules.
The first item is to make sure the patient did not hit his or her head. So either the patient can tell you that he didn’t hit his head and there are no signs of bruises or lacerations on his head, or he’s probably someone who doesn’t have communication skills or has dementia. means that It’s hard to say, but maybe someone saw them fall and could say, “No, they definitely didn’t hit their head.”
The second item is whether you remember what happened in the fall. So if the patient can’t tell you, or isn’t really sure, or maybe has had long-standing dementia and can’t tell you if they remember the fall, that would be a plus. .
The third item is whether there are any new abnormal neurological signs when examined. So it’s some kind of sign that suggests you’re having a stroke or something different from your normal baseline. It depends on the doctor’s examination.
The fourth item concerns patient frailty and uses one of the simpler frailty scales, which indicates whether the patient needs help performing any of their usual activities. This includes things like housework, heavy shopping, driving, and dealing with finances. More common cases, such as bathing or dressing, will require a head scan.
Helio: What does the data suggest about its effectiveness in identifying patients who do not require CT?
De Wit: We intentionally designed our rules to be very sensitive. We identified the most predictive items and added them to the rules until we had a rule that identified more than 98% of all cases of intracranial hemorrhage diagnosed the next time an emergency was experienced. said. 6 weeks.
When applied to the dataset used to derive this rule, it is highly sensitive and identifies 98.6% of all bleeding cases. But we need to conduct independent validation studies to retest the rules, so to speak, with a different group of patients. That way I can verify those findings and hopefully report that it’s as safe as it seems. Belonging to our derivation cohort.
Helio: What are the next steps to implement this rule in hospitals in Canada and the United States?
De Wit: The first thing to do is to publish the rules and let people know. We have applied to the Canadian Institutes of Health Research for further funding to conduct validation studies. Once a large-scale validation study is completed, the rule is ready to be implemented as long as it is shown to be very safe and work, and it is relevant to national guidelines throughout emergency medicine, internal medicine, and education. It will be. This requires a much higher level of information dissemination.
Disclosure: De Witt does not report any relevant financial disclosures. Please refer to this study for relevant financial disclosures of all other authors.