Change in Guardians' Favor in Computed Tomography after Explained by Emergency Physicians in Pediatric Head Injury

PURPOSE: Head injury in children is a common problem presenting to emergency departments, and cranial computed tomography scan is the diagnostic standard for these patients. Several decision rules are used to determine whether computed tomography scans should be used; however, the use of computed tomography scans is often influenced by guardian favor toward the scans. The objective of this study was to identify changes in guardian favor for explanation of minor head injuries based on the institutional clinical practice guidelines. METHODS: A survey was conducted between July 2010 and June 2012. Patients younger than 16 years with a Glasgow Coma Scale score of 15 after a head injury and guardians of these patients were included. Pre- and post-explanation questionnaires were administered to guardians to evaluate their favor for computed tomography scans and factors related to the degree of favor. Treating physicians explained the risks and benefits of cranial computed tomography scans using the institutional clinical practice guidelines. Guardian favor for a computed tomography (CT) scan was examined using a 100-mm visual analog scale. RESULTS: A total of 208 patients and their guardians were included in this survey. Guardian favor for computed tomography scans was significantly reduced after explanation (46.7 vs. 17.4, p<0.01). Pre-explanation favor and the degree of physician recommending computed tomography were the most important factors affecting pre- and postexplanation changes in favor. CONCLUSION: Explanation of the risks and benefits of cranial computed tomography scans using the institutional clinical practice guidelines may significantly reduce guardian favor for computed tomography scans.

Clinical Predictors of Subarachnoid Hemorrhage in Patients with Acute Non-traumatic Headache in Emergency Department

PURPOSE: Missing subarachnoid hemorrhage (SAH) can cause catastrophic results. We aimed to find clinical factors for predicting SAH in neurologically intact patients with acute non-traumatic headache visiting the emergency department (ED). METHODS: This was a retrospective chart review study. Data were collected from September 2006 until October 2011. We included patients aged over 16 with acute non-traumatic headache who had brain imaging work up results during ED visits. Information on candidate clinical predictor variables was obtained from previous reports, and the outcome was confirmed SAH in brain imaging work up or cerebrospinal fluid study. We found the predictors for SAH through multivariable analysis with variables chosen in univariable analysis considering clinical application. Then we simulated possible SAH prediction scoring models using receiver operating characteristic (ROC) analysis and assessed model fit through the Hosmer-Lemeshow test. RESULTS: A total of 3294 patients were enrolled. Seven clinical characteristics were proven for relation of SAH; age, visiting emergency department within six hours from symptom onset time, visiting mode, vomiting, neck pain or neck stiffness, blood pressure, and respiratory rate. We constructed six available SAH prediction scoring models. The area under the ROC curves of each model ranged from 0.810 to 0.834 and all simulated models were good-fit. With these models, we can expect to reduce unnecessary computed tomography use. CONCLUSION: Seven clinical predictors could be helpful in selection of high risk patients of SAH. The proposed SAH prediction models using these characteristics will have to be tested prospectively for external validation.

Association between Case Volume of Cardiopulmonary Resuscitation and Implementation of Therapeutic Hypothermia

PURPOSE: Therapeutic hypothermia (TH) is recommended as a strategic post-resuscitation care for favorable neurologic outcomes. However, information concerning the implementation of TH and associated number of cardiopulmonary resuscitation (CPR) volumes is lacking. METHODS: We conducted a telephone survey using a designed questionnaire from March to December, 2009. Information of target hospitals was collected from a national registry of out of hospital cardiac arrest (2006-2007). Hospital name, service levels of emergency department (ED; level 1-4), case volume of cardiopulmonary resuscitation given at each ED (high versus low volume by 34 cases per year derived from a previous sensitivity analysis study), population (metropolis exceeding one million residents), and year when TH was adopted were recorded. Demographics and factors associated with adaptation of TH were analyzed and odds ratios were calculated using a multivariate logistic regression model. RESULTS: A total of 39,833 OHCA cases for 2 years were transported to 840 hospitals. Of these hospitals, 461 (55.8%) were included for final analysis. Thirty four of the hospitals (7.4%) had adopted TH. Of these, 16 hospitals housed a high-volume ED (odds ratio=2.93). Twenty four hospitals were located in a metropolis (odds ratio=3.05) and 25 hospitals were ED level 1 or 2. CONCLUSION: Only 7.4% of surveyed Korean hospitals had adopted TH in Korea by the end of 2009. Hospitals with high-volume EDs adopted TH early, when adjusting for population and ED level.