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Perry JJ, Sivilotti MLA, Emond M, et al. Prospective Implementation of the Ottawa Subarachnoid Hemorrhage Rule and 6-Hour Computed Tomography Rule. Stroke. 2020 Feb;51(2):424-430. doi: 10.1161/STROKEAHA.119.026969. Epub 2019 Dec 6. (Original study)
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.

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Comments from MORE raters

Physician rater

This is a very interesting article. I did not know about the Ottawa headache rule, nor the CT rule.

Physician rater

Helpful.

Physician rater

Essential decision-aid research exploring the actual clinical impact associated with implementing a new instrument into practice. Unfortunately, most decision-aid researchers never bothered to conduct such impact analyses. Although the Ottawa SAH decision-aid impact analysis is important, 3 issues are worth discussion: 1) Is the 13% LP reduction (or 9% LP/CTA reduction) important?; 2) What factors limit the capacity of the decision aid to further reduce LP/CTA rates closer to 0% since the aid is 100% sensitive?; and 3) For which patients ought clinicians pursue LP or CTA despite low-risk Ottawa SAH score? The last question was addressed by both https://onlinelibrary.wiley.com/doi/full/10.1111/acem.12984 and https://onlinelibrary.wiley.com/doi/full/10.1111/acem.13042.

Physician rater

I don't follow this literature.
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