Prospective Implementation of the Ottawa Subarachnoid Hemorrhage Rule and 6-Hour Computed Tomography Rule.

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  • Additional Information
    • Source:
      Publisher: Lippincott Williams & Wilkins Country of Publication: United States NLM ID: 0235266 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1524-4628 (Electronic) Linking ISSN: 00392499 NLM ISO Abbreviation: Stroke Subsets: MEDLINE
    • Publication Information:
      Publication: 1998- : Baltimore, Md. : Lippincott Williams & Wilkins
      Original Publication: Dallas : American Heart Association
    • Subject Terms:
      Computed Tomography Angiography/*statistics & numerical data ; Headache/*diagnosis ; Spinal Puncture/*statistics & numerical data ; Subarachnoid Hemorrhage/*diagnosis ; Tomography, X-Ray Computed/*statistics & numerical data; 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
    • 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 6 /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.
    • Grant Information:
      67107 Canada CIHR; 153742 Canada CIHR
    • Contributed Indexing:
      Keywords: adult; aneurysm; headache; implementation; subarachnoid hemorrhage
    • Publication Date:
      Date Created: 20191207 Date Completed: 20200701 Latest Revision: 20200701
    • Publication Date:
      20221213
    • Accession Number:
      10.1161/STROKEAHA.119.026969
    • Accession Number:
      31805846