Physician Management and CT Ordering in the Emergency Department for Primary Headaches.

OBJECTIVE: Management of primary headache (PHA) varies across emergency departments (ED), yet there is widespread agreement that computed tomography (CT) scans are overused. This study assessed emergency physicians' (EPs) PHA management and their attitudes towards head CT ordering. METHODS: A cross-sectional study was undertaken with EPs from one Canadian center. Drivers of physicians' perceptions regarding the appropriateness of CT ordering for patients with PHA were explored. RESULTS: A total of 73 EPs (70% males; 48% with <10 years of practice) participated in the study. Most EPs (88%) did not order investigations for moderate-severe primary headaches; however, CT was the common investigation (47%) for headaches that did not improve. Computed tomography ordering was frequently motivated by the need for specialist consultation (64%) or admission (64%). A small proportion (27%) believed patients usually/frequently expected a scan. Nearly half of EPs (48%) identified patient imaging expectations/requests as a barrier to reducing CT ordering. Emergency physicians with CCFP (EM) certification were less likely to perceive CT ordering for patients with PHA as appropriate. Conversely, those who identified the possibility of missing a condition as a major barrier to limiting their CT use were more likely to perceive CT ordering for patients with PHA as appropriate. CONCLUSIONS: Emergency physicians reported consistency and evidence-based medical management. They highlighted the complexities of limiting CT ordering and both their level of training and their perceived barriers for limiting CT ordering seem to be influencing their attitudes. Further studies could elucidate these and other factors influencing their practice.

How to diagnose and treat benign headaches.

A 19-year-old female, university student with a long-standing history of migraine headaches presented to the emergency department (ED) with a 36-hour history of gradual onset of left-sided headache, preceded by visual aura. She stated that her headache was worse than usual and now associated with nausea, vomiting, and photophobia, despite use of oral ibuprofen. On examination, she was afebrile, her SaO2 = 98% on room air, her pulse was 110 beats/minute, and she was breathing 20 breaths/minute. She received a Canadian Triage and Acuity Scale score of 2 due to her pain score of 8/10 on a Visual Analogue Scale (VAS). Her neurological examination was normal and her neck was supple with full range of motion. She was a non-smoker, infrequent cannabis user, and her last menstrual period was normal.

Effectiveness of Interventions to Decrease Image Ordering for Low Back Pain Presentations in the Emergency Department: A Systematic Review.

BACKGROUND: Low back pain (LBP) is an extremely frequent reason for patients to present to an emergency department (ED). Despite evidence against the utility of imaging, simple and advanced imaging (i.e., computed tomography [CT], magnetic resonance imaging) for patients with LBP has become increasingly frequent in the ED. The objective of this review was to identify and examine the effectiveness of interventions aimed at reducing image ordering in the ED for LBP patients. METHODS: A protocol was developed a priori, following the PRISMA guidelines, and registered with PROSPERO. Six bibliographic databases (including MEDLINE, EMBASE, EBM Reviews, SCOPUS, CINAHL, and Dissertation Abstracts) and the gray literature were searched. Comparative studies assessing interventions that targeted image ordering in the ED for adult patients with LBP were eligible for inclusion. Two reviewers independently screened study eligibility and completed data extraction. Study quality was completed independently by two reviewers using the before-after quality assessment checklist, with a third-party mediator resolving any differences. Due to a limited number of studies and significant heterogeneity, only a descriptive analysis was performed. RESULTS: The search yielded 603 unique citations of which a total of five before-after studies were included. Quality assessment identified potential biases relating to comparability between the pre- and postintervention groups, reliable assessment of outcomes, and an overall lack of information on the intervention (i.e., time point, description, intervention data collection). The type of interventions utilized included clinical decision support tools, clinical practice guidelines, a knowledge translation initiative, and multidisciplinary protocols. Overall, four studies reported a decrease in the relative percentage change in imaging in a specific image modality (22.7%-47.4%) following implementation of the interventions; however, one study reported a 35% increase in patient referrals to radiography, while another study reported a subsequent 15.4% increase in referrals to CT and myelography after implementing an intervention which reduced referrals for simple radiography. DISCUSSION: While imaging of LBP has been identified as a key area of imaging overuse (e.g., Choosing Wisely recommendation), evidence on interventions to reduce image ordering for ED patients with LBP is sparse. There is some evidence to suggest that interventions can reduce the use of simple imaging in LBP in the ED; however, a shift in imaging modality has also been demonstrated. Additional studies employing higher-quality methods and measuring intervention fidelity are strongly recommended to further explore the potential of ED-based interventions to reduce image ordering for this patient population.

Effectiveness of Implementing Evidence-based Interventions to Reduce C-spine Image Ordering in the Emergency Department: A Systematic Review.

OBJECTIVES: Appropriate use of imaging for adult patients with cervical spine (C-spine) injuries in the emergency department (ED) is a longstanding issue. Guidance for C-spine ordering exists; however, the effectiveness of the decision support implementation in the ED is not well studied. This systematic review examines the implementation and effectiveness of evidence-based interventions aimed at reducing C-spine imaging in adults presenting to the ED with neck trauma. METHODS: Six electronic databases and the gray literature were searched. Comparative intervention studies were eligible for inclusion. Two independent reviewers screened for study eligibility, study quality, and extracted data. The change in imaging was reported using individual odds ratios (ORs) with 95% confidence intervals (CIs) using random effects. RESULTS: A total of 990 unique citations were screened for relevance of which six before-after studies and one randomized controlled trial were included. None of the studies were assessed as high quality. Interventions consisted primarily of locally developed guidelines or established clinical decision rules such as the NEXUS or the Canadian C-spine rule. Overall, implementation of interventions aimed at reducing C-spine image ordering resulted in a statistically significant reduction in imaging (OR = 0.69, 95% CI = 0.51-0.93); however, heterogeneity was high (I2  = 82%). Subgroup analysis revealed no differences between studies that specified enrolling alert and stable patients compared to unspecified trauma (p = 0.81) or between studies employing multifaceted versus nonmultifaceted interventions (p = 0.66). While studies generally provided details on implementation strategies (e.g., teaching sessions, pocket cards, posters, computerized decision support) the effectiveness of these implementation strategies were frequently not reported. CONCLUSION: There is moderate evidence regarding the effectiveness of interventions to reduce C-spine image ordering in adult patients seen in the ED with neck trauma. Given the national and international focus on improving appropriateness and reducing unnecessary C-spine imaging through campaigns such as Choosing Wisely, additional interventional research in this field is warranted.

Emergency Department Use: Influence of Connection to a Family Physician on ED Use and Attempts to Avoid Presentation.

Some low-acuity emergency department (ED) presentations are potentially avoidable with improved primary care access. The majority of ED patients (74.4%) in this study had a family physician, but the frequency of visits varied substantially. The variable frequency of patients' visits to these providers calls into question the validity of linkage assumptions. Several sociodemographic factors were associated with having a family physician, including female sex, being married/common law, race (Caucasian), being employed over the previous 12 months and having received a flu shot in the past year. These factors need to be explored further.

Low-acuity presentations to the emergency department in Canada: exploring the alternative attempts to avoid presentation.

OBJECTIVE: ED visits have been rising year on year worldwide. It has been suggested that some of these visits could be avoided if low-acuity patients had better primary care access. This study explored patients' efforts to avoid ED presentation and alternative care sought prior to presentation. METHODS: Consecutive adult patients presenting to three urban EDs in Edmonton, Canada, completed a questionnaire collecting demographics, actions attempted to avoid presentation and reasons for presentation. Survey data were cross-referenced to a minimal patient dataset containing ED and demographic information. RESULTS: A total of 1402 patients (66.5%) completed the survey. Although 89.3% of the patients felt that the ED was their best care option, the majority of patients (60.1%) sought alternative care or advice prior to presentation. Men, individuals who presented with injury only, and individuals with less than a high school education were all less likely to seek alternative care. Alternative care actions included visiting a physician (54.1%) or an alternative healthcare professional (eg, chiropractor, physiotherapist, etc; 21.2%), calling physician offices (47%) or the regional health information line (13%). Of those who called their physicians, the majority received advice to present to the ED (67.5%). CONCLUSIONS: Most low-acuity patients attempt to avoid ED presentation by seeking alternative care. This analysis identifies groups of individuals in the study region who are less likely to seek alternative care first and may benefit from targeted interventions/education. Other regions may wish to complete a similar profile to determine which patients are less likely to seek alternative care first.

Emergency Physician Training on Mild Traumatic Brain Injury: A Systematic Review.

OBJECTIVES: Mild traumatic brain injury (mTBI) is the most common emergency department (ED) brain injury presentation worldwide. Despite its frequency, practice variation and care gaps exist among emergency physicians (EPs) in diagnosing and appropriately managing mTBI in the ED. The objective of this review was to identify mTBI-specific training undertaken to improve the detection and management of mTBIs by EPs and its impact on practice. METHODS: A comprehensive search strategy utilized four bibliographic databases, the gray literature and the keywords concussion, mild traumatic brain injury, medical education, and continuing medical education (CME). To be included, studies were required to report on mTBI training received by practicing EPs at any point during their medical education or career. Studies examining clinical practice guidelines or use of diagnostic tools without active implementation or formal training were not included. Two reviewers screened unique citations for relevance and reviewed the full texts of relevant articles. Two independent researchers extracted data and assessed methodologic quality. At all stages, a third independent reviewer adjudicated discrepancies. RESULTS: Overall, five studies were included from 409 unique results. None of the included studies were of high quality. Identified training on mTBI consisted of three training toolkits, conference presentations and academic journal articles, and pediatric fellowship training. Training primarily occurred as CME and focused on awareness of and management of mTBI; three studies reported physician practice changes, including increases in the use of evidence-based return-to-school and return-to-activity recommendations. CONCLUSIONS: The few studies identified addressing mTBI training targeting EPs demonstrate the limited attention given to this issue. The current evidence-to-practice gap in mTBI management places patients at risk for suboptimal care in the ED, and existing mTBI knowledge translation, including education, requires optimization to effectively address the current gap in evidence-based practice for mTBI diagnosis and management in the ED.

Are women who quit smoking at high risk of excess weight gain throughout pregnancy?

BACKGROUND: Smoking cessation has been reported to be associated with high total gestational weight gain (GWG), which itself is a risk factor for adverse maternal-infant outcomes. Recent studies have criticized conventional single measures of GWG, since they may lead to biased results. Therefore, we aimed to compare patterns of GWG based on serial antenatal weight measurements between women who: never smoked, quit during pregnancy, continued to smoke. METHODS: Participants (N = 509) of our longitudinal study were recruited from seven antenatal clinics in Southwestern Ontario. Serial GWG measurements were abstracted from medical charts, while information on smoking status was obtained from a self-administered questionnaire at a median gestational age of 32 (27-37) weeks. GWG patterns were assessed by fitting piecewise mixed-effects models. First trimester weight gains and weekly rates for the last two trimesters were compared by smoking status. RESULTS: During the first trimester, women who never smoked and those who quit during pregnancy gained on average 1.7 kg (95 % CI: 1.4-2.1) and 1.2 kg (0.3-2.1), respectively, whereas women who continued smoking gained more than twice as much (3.5 kg, 2.4-4.6). Weekly rate of gain in the second and third trimesters was highest in women who quit smoking (0.60 kg/week, 0.54-0.65), approximately 20 and 50 % higher than in women who never smoked and those who smoked during pregnancy, respectively. CONCLUSIONS: In this longitudinal study to examine GWG by smoking status based on serial GWG measurements, we found that women who quit smoking experienced a rapid rate of gain during the last two trimesters, suggesting that this high-risk group may benefit from targeted interventions.

Binge Eating Predicts Excess Gestational Weight Gain: A Pilot Prospective Cohort Study.

OBJECTIVE: One half of women's gestational weight gain (GWG) exceeds the recommended amount. In attempting to prevent this, randomized trials targeting diet and/or exercise have been generally unsuccessful. In response, study of psychological factors has been called for. We aimed to determine the feasibility of a full-scale prospective cohort study examining psychological and other factors affecting GWG and to obtain prospective pilot data. METHODS: We conducted a prospective cohort feasibility study in seven clinics in southwestern Ontario. Women with a singleton pregnancy were recruited between May and September 2013 and subsequently completed a questionnaire. GWG was abstracted from medical records and was categorized as below, within, or above guideline-recommended limits. RESULTS: All clinics and 89.7% of women approached (n = 525) agreed to participate, and 514 were eligible for analysis. For the prospective analysis, we included participants enrolled during their first or second trimester (27%), because only 11% were less than 21 weeks' gestation. Planning GWG predicted excess GWG (adjusted RR [aRR] 9.44; 95% CI 2.64 to 33.80), as did binge eating (aRR 6.51; 95% CI 1.03 to 41.18). Dietary restraint was not significantly associated with excess GWG (aRR 2.74; 95% CI 0.67 to 11.22) or inadequate GWG (aRR 3.86; 95% CI 0.82 to 18.11). CONCLUSION: This prospective pilot study demonstrated the feasibility of a full-scale study and identified a need for additional strategies to permit recruitment before 21 weeks, such as a longer recruitment period and involvement of more clinics. Previously identified knowledge factors, particularly planned weight gain, were predictive of excess GWG. However, psychological factors identified in this study, especially binge eating (which was found to be independently predictive for the first time) and dietary restraint, are areas requiring further study.

Objectif : Dans la moitié des cas, le gain pondéral gestationnel (GPG) dépasse les recommandations. Des essais randomisés ont constaté que les efforts qui ont cherché à prévenir cette situation en ciblant le régime alimentaire et/ou l'exercice se sont, d'ordre général, soldés en échec. En guise de réponse, l'attention s'est tournée vers des facteurs psychologiques. Nous avons donc cherché à déterminer la faisabilité d'une étude de cohorte prospective exhaustive examinant les facteurs psychologiques et autres qui affectent le GPG, ainsi qu'à obtenir des données préliminaires en menant un essai pilote prospectif. Méthodes : Nous avons mené une étude de cohorte prospective de faisabilité auprès de sept cliniques du sud-ouest de l'Ontario. La participation de femmes connaissant une grossesse monofœtale a été sollicitée entre mai et septembre 2013; nous avons par la suite demandé à ces femmes de remplir un questionnaire. Le GPG a été tiré des dossiers médicaux et a été réparti en trois catégories : en deçà, à l'intérieur ou au-delà des limites recommandées par les lignes directrices. Résultats : Toutes les cliniques et 89,7 % des femmes sollicitées (n = 525) ont consenti à participer, et 514 d'entre elles se sont avérées admissibles à l'analyse. Aux fins de l'analyse prospective, nous avons inclus les participantes admises au cours de leur premier ou de leur deuxième trimestre (27 %), car seulement 11 % des participantes en étaient à moins de 21 semaines de gestation. Le fait d'avoir procédé à la planification du GPG constituait un facteur permettant de prédire l'obtention d'un GPG excessif (RR corrigé [RRc], 9,44; IC à 95 %, 2,64 - 33,80), tout comme l'hyperphagie (RRc, 6,51; IC à 95 %, 1,03 - 41,18). Les restrictions alimentaires n'ont pas été associées de façon significative à l'obtention d'un GPG excessif (RRc, 2,74; IC à 95 %, 0,67 - 11,22) ou d'un GPG inadéquat (RRc, 3,86; IC à 95 %, 0,82 - 18,11). Conclusion : Cette étude pilote prospective a démontré la faisabilité d'une étude exhaustive et a identifié un besoin quant à l'obtention de stratégies additionnelles qui permettraient de solliciter la participation de femmes dont la grossesse n'a pas encore atteint 21 semaines de gestation (comme l'utilisation d'une période de sollicitation prolongée et la participation d'un plus grand nombre de cliniques). Des facteurs ayant déjà été identifiés (plus particulièrement, le gain pondéral planifié) ont permis de prédire l'obtention d'un GPG excessif. Toutefois, certains des facteurs psychologiques identifiés dans le cadre de cette étude, particulièrement l'hyperphagie (identifiée comme étant un facteur prédictif indépendant pour la première fois) et les restrictions alimentaires, constituent des domaines qui nécessitent la tenue d'études plus approfondies.