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Prospective Implementation of the Ottawa Subarachnoid Hemorrhage Rule and 6-Hour Computed Tomography Rule.
- Source :
-
Stroke [Stroke] 2020 Feb; Vol. 51 (2), pp. 424-430. Date of Electronic Publication: 2019 Dec 06. - Publication Year :
- 2020
-
Abstract
- Background and Purpose- The Ottawa subarachnoid hemorrhage (SAH) rule identifies patients with headache requiring no testing for SAH, while the 6-hour computed tomography (CT) rule guides when to forgo a lumbar puncture. Our objectives were to: (1) estimate the clinical impact of the Ottawa SAH rule and the 6-hour-CT rule on testing rates (ie, CT, lumbar puncture, CT angiography); (2) validate the 6-hour-CT rule for SAH when applied prospectively in a new cohort of patients. Methods- We conducted a multicenter prospective before/after implementation study from 2011 to 2016 with 6 months follow-up at 6 tertiary-care Canadian Academic Emergency Departments. Consecutive alert, neurologically intact adults with headache were included. For intervention period, physicians were given a 1-hour lecture, pocket cards, posters were installed, and physicians indicated Ottawa SAH rule criteria when ordering CTs. SAH was defined by blood on CT, xanthochromia in cerebrospinal fluid, or >1×10 <superscript>6</superscript> /L red blood cells in cerebrospinal fluid with aneurysm. Results- We enrolled 3672 patients, 1743 before and 1929 after implementation, including 188 with SAH. Proportions undergoing CT was unchanged (88.0% versus 87.5%; P =0.643). Lumbar puncture use decreased (38.9% versus 25.9%; P <0.0001). Additional testing following CT (ie, lumbar puncture or CT angiography) decreased (51.3% versus 42.2%; P <0.0001). Admissions declined (9.8% versus 7.4%; P =0.011). Mean emergency department stay was unchanged (6.3±4.0 versus 6.4±4.2 hours; P =0.685). The Ottawa SAH rule was 100% (95% CI, 98.1%-100%) sensitive, and the 6-hour-CT rule was 95.5% (95% CI, 89.8-98.5) sensitive for SAH. The 6-hour-CT rule missed 5 SAHs: 1 radiology misread, 2 incidental aneurysms, 1 nonaneurysmal cause, and 1 profoundly anemic patient. Conclusions- The Ottawa SAH rule and the 6-hour-CT rule are highly sensitive and can be used routinely when SAH is considered in patients with headache. Implementing both rules was associated with a meaningful decrease in testing and admissions to hospital.
- Subjects :
- Adolescent
Adult
Aged
Aged, 80 and over
Canada
Clinical Decision-Making
Emergency Service, Hospital
Female
Headache etiology
Humans
Implementation Science
Male
Middle Aged
Prospective Studies
Sensitivity and Specificity
Subarachnoid Hemorrhage complications
Subarachnoid Hemorrhage diagnostic imaging
Young Adult
Computed Tomography Angiography statistics & numerical data
Headache diagnosis
Spinal Puncture statistics & numerical data
Subarachnoid Hemorrhage diagnosis
Tomography, X-Ray Computed statistics & numerical data
Subjects
Details
- Language :
- English
- ISSN :
- 1524-4628
- Volume :
- 51
- Issue :
- 2
- Database :
- MEDLINE
- Journal :
- Stroke
- Publication Type :
- Academic Journal
- Accession number :
- 31805846
- Full Text :
- https://doi.org/10.1161/STROKEAHA.119.026969