Physicians' Risk Tolerance and Head Computed Tomography Use for Pediatric Patients With Minor Head Injury.

OBJECTIVES: Traumatic brain injury is the leading cause of death and disability in children worldwide. The objective of this study was to determine the association between physician risk tolerance and head computed tomography (CT) use in patients with minor head injury (MHI) in the emergency department (ED). METHODS: We retrospectively analyzed pediatric patients (<17 years old) with MHI in the ED and then administered 2 questionnaires (a risk-taking subscale [RTS] of the Jackson Personality Inventory and a malpractice fear scale [MFS]) to attending physicians who had evaluated these patients and made decisions regarding head CT use. The primary outcome was head CT use during ED evaluation; the secondary outcome was ED length of stay and final diagnosis of intracranial injury (ICI). RESULTS: Of 523 patients with MHI, 233 (44.6%) underwent brain CT, and 16 (3.1%) received a final diagnosis of ICI. Among the 16 emergency physicians (EPs), the median scores of the MFS and RTS were 22 (interquartile range, 17-26) and 23 (interquartile range, 19-25), respectively. Emergency physicians who were most risk averse tended to order more head CT scans compared with the more risk-tolerant EPs (56.96% vs 37.37%; odds ratio, 8.463; confidence interval, 2.783-25.736). The ED length of stay (P = 0.442 and P = 0.889) and final diagnosis (P = 0.155 and P = 0.835) of ICI were not significantly associated with the RTS and MFS scores. CONCLUSIONS: Individual EP risk tolerance, as measured by RTS, was predictive of CT use in pediatric patients with MHI.

The Ottawa subarachnoid hemorrhage clinical decision rule for classifying emergency department headache patients.

BACKGROUND: Subarachnoid hemorrhage (SAH) is a serious cause of headaches. The Ottawa subarachnoid hemorrhage (OSAH) rule helps identify SAH in patients with acute nontraumatic headache with high sensitivity, but provides limited information for identifying other intracranial pathology (ICP). OBJECTIVES: To assess the performance of the OSAH rule in emergency department (ED) headache patients and evaluate its impact on the diagnosis of intracranial hemorrhage (ICH) and other ICP. METHOD: We conducted a retrospective cohort study from January 2016 to March 2017. Patients with acute headache with onset within 14 days of the ED visit, were included. We excluded patients with head trauma that occurred in the previous 7 days, new onset of abnormal neurologic findings, or consciousness disturbance. According to the OSAH rule, patients with any included predictors required further investigation. RESULTS: Of 913 patients were included, 15 of them were diagnosed with SAH. The OSAH rule had 100% (95% CI, 78.2%-100%) sensitivity and 37.0% (95% CI, 33.8-40.2%) specificity for identifying SAH. Twenty-two cases were identified as SAH or ICH with 100% sensitivity (95% CI, 84.6%-100%) and 37.3% (95% CI, 34.1%-40.5%) specificity. As for non-hemorrhagic ICP, both the sensitivity and negative predictive values (NPV) decreased to 75.0% (95% CI, 53.3%-90.2%) and 98.2% (95% CI, 96.1%-99.3%), respectively. CONCLUSIONS: The OSAH rule had 100% sensitivity and NPV for diagnosing SAH and ICH with acute headache. The sensitivity and specificity were lower for non-hemorrhagic ICP. The OSAH rule may be an effective tool to exclude acute ICH and SAH in our setting.

The effect of peer influence on the use of CT by emergency physicians for patients with headaches.

BACKGROUND: It is challenging for emergency physicians (EPs) to distinguish between patients with life-threatening and benign headaches. We examined the effect of peer influence on computed tomography use by EPs for patients with headache and evaluated the peer influence effect in EPs with different levels of risk tolerance. METHODS: We conducted a before- and after-retrospective case review, and administered the Risk-Taking subscale of the Jackson Personality Index to attending physicians. Each EP computed tomography (CT) use rate, patient number, and CT use, were e-mailed every two months to enhance EP team norm and establish a trend in behavior. RESULTS: Of the 665 (before intervention) and 669 (after intervention) patients with headache, 206 (31%) and 171 (25.6%) underwent brain CT scans, respectively. Decreased use of CT examination was found in the post-intervention group (OR = 0.758, 95% CI: 0.593-0.967), especially for most risk-tolerant physicians (OR = 0.530, 95% CI: 0.311-0.889). There was prolonged ED length of stay (LOS) in the pre-intervention group (OR = 51.52, 95% CI: 26.998-76.050). CONCLUSIONS: We observed that peer influence is an effective way to improve CT use rate and emergency department LOS for patients with isolated headache, especially for most risk-tolerant physicians. These findings could enhance the development of appropriate guidelines to assist ED physicians' CT use.

ICU admission following an unscheduled return visit to the pediatric emergency department within 72 hours.

INTRODUCTION: The purpose of this study was to describe the demographic characteristics and prognosis of children admitted to the intensive care unit (ICU) after a pediatric emergency department (PED) return visit within 72 h. METHOD: We conducted this retrospective study from 2010 to 2016 in the PED of a tertiary medical center in Taiwan and included patients under the age of 18 years old admitted to the ICU after a PED return visit within 72 h. Clinical characteristics were collected to perform demographic analysis. Pediatric patients who were admitted to the ICU on an initial visit were also enrolled as a comparison group for outcome analysis, including mortality, ventilator use, and length of hospital stay. RESULTS: We included a total of 136 patients in this study. Their mean age was 3.3 years old, 65.4% were male, and 36.0% had Chronic Health Condition (CHC). Disease-related return (73.5%) was by far the most common reason for return. Compared to those admitted on an initial PED visit, clinical characteristics, including vital signs at triage and laboratory tests on return visit with ICU admission, demonstrated no significant differences. Regarding prognosis, ICU admission on return visit has a higher likelihood of ventilator use (aOR:2.117, 95%CI 1.021~4.387), but was not associated with increased mortality (aOR:0.658, 95%CI 0.150~2.882) or LOHS (OR:-1.853, 95%CI -4.045~0.339). CONCLUSION: Patients who were admitted to the ICU on return PED visits were associated with an increased risk of ventilator use but not mortality or LOHS compared to those admitted on an initial visit.

Physician Risk Tolerance and Head Computed Tomography Use for Patients with Isolated Headaches.

BACKGROUND: Headaches are one of the most common afflictions in adults and reasons for emergency department (ED) visits. OBJECTIVE: We sought to determine the association between physician risk tolerance and head computed tomography (CT) use in patients with headaches in the ED. METHODS: We performed a retrospective study of patients with nontraumatic isolated headaches in the ED and then administered two instruments (Risk-Taking subscale [RTS] of the Jackson Personality Index and a Malpractice Fear Scale [MFS]) to attending physicians who had evaluated these patients and made decisions regarding head CT scans. Outcomes were head CT use during ED evaluation and hospital admission. A hierarchical logistic regression was used to determine the effect of risk scales on head CT use. RESULTS: Of the 1328 patients with headaches, 521 (39.2%) received brain CTs and 83 (6.9%) were admitted; 33 (2.5%) patients received a final diagnosis that the central nervous system was the origin of the disease. Among the 17 emergency physicians (EPs), the median of the MFS and RTS was 23 (interquartile range [IQR] 19-25) and 21 (IQR 20-23), respectively. EPs who were relatively risk-averse and those who possessed a higher level of malpractice fear were not more likely to order brain CTs for patients with isolated headaches. CONCLUSIONS: Individual EP risk tolerance, as measured by RTS, and malpractice concerns, measured by MFS, were not predictive of CT use in patients with isolated headaches.

Delta Shock Index During Emergency Department Stay Is Associated With in Hospital Mortality in Critically Ill Patients.

Background: Delta shock index (SI; i.e., change in SI over time) has been shown to predict mortality and need for surgical intervention among trauma patients at the emergency department (ED). However, the usefulness of delta SI for prognosis assessment in non-traumatic critically ill patients at the ED remains unknown. The aim of this study was to analyze the association between delta SI during ED management and in-hospital outcomes in patients admitted to the intensive care unit (ICU). Method: This was a retrospective study conducted in two tertiary medical centers in Taiwan from January 1, 2016, to December 31, 2017. All adult non-traumatic patients who visited the ED and who were subsequently admitted to the ICU were included. We calculated delta SI by subtracting SI at ICU admission from SI at ED triage, and we analyzed its association with in-hospital outcomes. SI was defined as the ratio of heart rate to systolic blood pressure (SBP). The primary outcome was in-hospital mortality, and the secondary outcomes were hospital length of stay (HLOS) and early mortality. Early mortality was defined as mortality within 48 h of ICU admission. Result: During the study period, 11,268 patients met the criteria and were included. Their mean age was 64.5 ± 15.9 years old. Overall, 5,830 (51.6%) patients had positive delta SI. Factors associated with a positive delta SI were multiple comorbidities (51.2% vs. 46.3%, p < 0.001) and high Simplified Acute Physiology Score [39 (29-51) vs. 37 (28-47), p < 0.001). Patients with positive delta SI were more likely to have tachycardia, hypotension, and higher SI at ICU admission. In the regression analysis, high delta SI was associated with in-hospital mortality [aOR (95% CI): 1.21 (1.03-1.42)] and early mortality [aOR (95% CI): 1.26 (1.07-1.48)], but not for HLOS [difference (95% CI): 0.34 (-0.48 to 1.17)]. In the subgroup analysis, high delta SI had higher odds ratios for both mortality and early mortality in elderly [aOR (95% CI): 1.59 (1.11-2.29)] and septic patients [aOR (95% CI): 1.54 (1.13-2.11)]. It also showed a higher odds ratio for early mortality in patients with triage SBP <100 mmHg [aOR (95% CI): 2.14 (1.21-3.77)] and patients with triage SI ≥ 0.9 [aOR (95% CI): 1.62 (1.01-2.60)]. Conclusion: High delta SI during ED stay is correlated with in-hospital mortality and early mortality in patients admitted to the ICU via ED. Prompt resuscitation should be performed, especially for those with old age, sepsis, triage SBP <100 mmHg, or triage SI ≥ 0.9.

In-Hospital Outcomes in Patients Admitted to the Intensive Care Unit after a Return Visit to the Emergency Department.

BACKGROUND: Intensive care unit (ICU) admission following a short-term emergency department (ED) revisit has been considered a particularly undesirable outcome among return-visit patients, although their in-hospital prognosis has not been discussed. We aimed to compare clinical outcomes between adult patients admitted to the ICU after unscheduled ED revisits and those admitted during index ED visits. METHOD: This retrospective study was conducted at two tertiary medical centers in Taiwan from 1 January 2016 to 31 December 2017. All adult non-trauma patients admitted to the ICU directly via the ED during the study period were included and divided into two comparison groups: patients admitted to the ICU during index ED visits and those admitted to the ICU during return ED visits. The outcomes of interest included in-hospital mortality, mechanical ventilation (MV) support, profound shock, hospital length of stay (HLOS), and total medical cost. RESULTS: Altogether, 12,075 patients with a mean (standard deviation) age of 64.6 (15.7) years were included. Among these, 5.3% were admitted to the ICU following a return ED visit within 14 days and 3.1% were admitted following a return ED visit within 7 days. After adjusting for confounding factors for multivariate regression analysis, ICU admission following an ED revisit within 14 days was not associated with an increased mortality rate (adjusted odds ratio (aOR): 1.08, 95% confidence interval (CI): 0.89 to 1.32), MV support (aOR: 1.06, 95% CI: 0.89 to 1.26), profound shock (aOR: 0.99, 95% CI: 0.84 to 1.18), prolonged HLOS (difference: 0.04 days, 95% CI: -1.02 to 1.09), and increased total medical cost (difference: USD 361, 95% CI: -303 to 1025). Similar results were observed after the regression analysis in patients that had a 7-day return visit. CONCLUSION: ICU admission following a return ED visit was not associated with major in-hospital outcomes including mortality, MV support, shock, increased HLOS, or medical cost. Although ICU admissions following ED revisits are considered serious adverse events, they may not indicate poor prognosis in ED practice.

Effectiveness of peer pressure on computed tomography use for dizziness/vertigo patients.

Dizziness/vertigo is a common complaint in the emergency department (ED). We aimed to evaluate the effect of peer pressure on decision making in emergency physicians (EPs) to use computed tomography (CT) for patients with dizziness/vertigo.We conducted a before-and-after retrospective case review of patients who visited the ED with dizziness/vertigo. EPs were categorized into 3 groups according to seniority (in years of experience: >12, 7-12, and <7). The rate of CT use for EPs, patient number, and CT use were e-mailed monthly to update the EP team on the benchmark rate and shape of the behavior.Among the 1657 (preintervention) and 1508 (postintervention) patients with dizziness/vertigo, 320 (19.3%) and 230 (15.3%), respectively, underwent brain CT. A decrease in the rate of CT use was observed in the postintervention group (odds ratio [OR] = 0.743, 95% confidence interval [CI] = 0.615-0.897), especially in junior EPs (years of experience, <7; OR = 0.667, 95% CI: 0.474-0.933) and younger patients (age, <60) (OR = 0.625, 95% CI: 0.453-0.857).The intervention strategy created peer pressure through e-mail reminders and decreased the rate of CT use for patients with isolated dizziness/vertigo, especially in junior EPs and younger patients.

Incidence of Stevens-Johnson syndrome following combination drug use of allopurinol, carbamazepine and phenytoin in Taiwan: A case-control study.

The goal of our study was to investigate the incidence of Stevens-Johnson syndrome (SJS), the frequency of SJS diagnosis, and the association between SJS and prior use of allopurinol, carbamazepine or phenytoin. This case-control study utilized data from the National Health Insurance Research Database (NHIRD) of Taiwan. Controls visited the emergency department of the same hospital for trauma or fractures (excluding burns) and used allopurinol, carbamazepine or phenytoin during the past 3 months. We determined whether patients were prescribed a combination of drugs in addition to allopurinol, carbamazepine or phenytoin within the last 3 months. We identified 1 853 985 controls and 7327 SJS-diagnosed patients using the Taiwan NHIRD records for 2000-2008. Higher use of allopurinol (49.8%), carbamazepine (39.1%) or phenytoin (21.3%) was observed among patients (n = 3131) than among controls (n = 2858). The overall SJS incidence rate was 3.6/1 000 000. Drug combinations were uncommon (<10%) in patients or controls taking allopurinol. However, combination drug use exceeded 10% in patients taking carbamazepine or phenytoin. Logistic regression analysis of recent combination drug use revealed that phenobarbital, valproate, non-steroidal anti-inflammatory drugs (NSAIDs) including piroxicam and tenoxicam, and antibiotics including amoxicillin and cephalexin were strongly associated with SJS. Patients with gout or epilepsy taking allopurinol, carbamazepine or phenytoin should be evaluated carefully by physicians. Concurrent use of piroxicam, tenoxicam, phenobarbital, valproate, amoxicillin or cephalexin, in addition to carbamazepine or phenytoin, may increase the incidence of SJS.