Prospective Implementation of the Ottawa Subarachnoid Hemorrhage Rule and 6-Hour Computed Tomography Rule.
Stroke
; 51(2): 424-430, 2020 02.
Article
en En
| MEDLINE
| ID: mdl-31805846
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 >1×106/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.
Palabras clave
Texto completo:
1
Colección:
01-internacional
Banco de datos:
MEDLINE
Asunto principal:
Punción Espinal
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Hemorragia Subaracnoidea
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Tomografía Computarizada por Rayos X
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Angiografía por Tomografía Computarizada
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Cefalea
Tipo de estudio:
Clinical_trials
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Diagnostic_studies
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Etiology_studies
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Observational_studies
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Prognostic_studies
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Risk_factors_studies
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Sysrev_observational_studies
Límite:
Adolescent
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Adult
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Aged
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Aged80
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Female
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Humans
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Male
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Middle aged
País/Región como asunto:
America do norte
Idioma:
En
Revista:
Stroke
Año:
2020
Tipo del documento:
Article
País de afiliación:
Canadá