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Benchmarking patient delays in Ontario's emergency departments: what are we waiting for?

https://arctichealth.org/en/permalink/ahliterature173513
Source
Healthc Q. 2005;8(3):21-2
Publication Type
Article
Date
2005
Author
Michael Schull
Author Affiliation
Department of Medicine, University of Toronto.
Source
Healthc Q. 2005;8(3):21-2
Date
2005
Language
English
Publication Type
Article
Keywords
Benchmarking
Efficiency, Organizational
Emergency Service, Hospital - standards - utilization
Humans
National Health Programs
Ontario
Time and Motion Studies
Waiting Lists
PubMed ID
16078394 View in PubMed
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The Canadian C-spine rule performs better than unstructured physician judgment.

https://arctichealth.org/en/permalink/ahliterature183855
Source
Ann Emerg Med. 2003 Sep;42(3):395-402
Publication Type
Article
Date
Sep-2003
Author
Glen Bandiera
Ian G Stiell
George A Wells
Catherine Clement
Valerie De Maio
Katherine L Vandemheen
Gary H Greenberg
Howard Lesiuk
Robert Brison
Daniel Cass
Jonathan Dreyer
Mary A Eisenhauer
Iain Macphail
R Douglas McKnight
Laurie Morrison
Mark Reardon
Michael Schull
James Worthington
Author Affiliation
Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada.
Source
Ann Emerg Med. 2003 Sep;42(3):395-402
Date
Sep-2003
Language
English
Publication Type
Article
Keywords
Adolescent
Adult
Aged
Aged, 80 and over
Canada
Cervical Vertebrae - injuries - radiography
Clinical Competence
Emergency Service, Hospital
Female
Humans
Male
Middle Aged
Predictive value of tests
Prospective Studies
ROC Curve
Sensitivity and specificity
Spinal Injuries - diagnosis - radiography
Abstract
We compare the predictive accuracy of emergency physicians' unstructured clinical judgment to the Canadian C-Spine rule.
This prospective multicenter cohort study was conducted at 10 Canadian urban academic emergency departments. Included in the study were alert, stable, adult patients with a Glasgow Coma Scale score of 15 and trauma to the head or neck. This was a substudy of the Canadian C-Spine and CT Head Study. Eligible patients were prospectively evaluated before radiography. Physicians estimated the probability of unstable cervical spine injury from 0% to 100% according to clinical judgment alone and filled out a data form. Interobserver assessments were done when feasible. Patients underwent cervical spine radiography or follow-up to determine clinically important cervical spine injuries. Analyses included comparison of areas under the receiver operating characteristic (ROC) curve with 95% confidence intervals (CIs) and the kappa coefficient.
During 18 months, 6265 patients were enrolled. The mean age was 36.6 years (range 16 to 97 years), and 50.1% were men. Sixty-four (1%) patients had a clinically important injury. The physicians' kappa for a 0% predicted probability of injury was 0.46 (95% CI 0.28 to 0.65). The respective areas under the ROC curve for predicting cervical spine injury were 0.85 (95% CI 0.80 to 0.89) for physician judgment and 0.91 (95% CI 0.89 to 0.92) for the Canadian C-Spine rule (P
Notes
Comment In: Ann Emerg Med. 2004 Jun;43(6):789-90; author reply 790-115259167
Comment In: Ann Emerg Med. 2003 Sep;42(3):403-412944894
Comment In: Ann Emerg Med. 2004 Jun;43(6):78815259165
Comment In: Ann Emerg Med. 2004 Jun;43(6):788-915259166
PubMed ID
12944893 View in PubMed
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Data collection on patients in emergency departments in Canada.

https://arctichealth.org/en/permalink/ahliterature165762
Source
CJEM. 2006 Nov;8(6):417-24
Publication Type
Article
Date
Nov-2006
Author
Brian H Rowe
Kenneth Bond
Maria B Ospina
Sandra Blitz
Michael Schull
Douglas Sinclair
Michael Bullard
Author Affiliation
Department of Emergency Medicine, University of Alberta, 8440 112th Street, Edmonton, AB.
Source
CJEM. 2006 Nov;8(6):417-24
Date
Nov-2006
Language
English
Publication Type
Article
Keywords
Canada
Health Care Surveys
Hospitals - manpower
Humans
Medical Records Systems, Computerized - utilization
Abstract
Relatively little is known about the ability of Canadian emergency departments (EDs) and the federal, provincial and territorial governments to quantify ED activity. The objectives of this study were to determine the use of electronic patient data in Canadian EDs, the accessibility of provincial data on ED visits, and to identify the data elements and current methods of ED information system (EDIS) data collection nationally.
Surveys were conducted of the following 3 groups: 1) all ED directors of Canadian hospitals located in communities of >10,000 people, 2) all electronic EDIS vendors, and 3) representatives from the ministries of health from 13 provincial and territorial jurisdictions who had knowledge of ED data collection.
Of the 243 ED directors contacted, 158 completed the survey (65% response rate) and 39% of those reported using an electronic EDIS. All 11 EDIS vendor representatives responded. Most of the vendors provide a similar package of basic EDIS options, with add-on features. All 13 provincial or territorial government representatives completed the survey. Nine (69%) provinces and territories collect ED data, however the source of this information varies. Five provinces and territories collect triage data, and 3 have a comprehensive, jurisdiction-wide, population-based ED database. Thirty-nine percent of EDs in larger Canadian communities track patients using electronic methods. A variety of EDIS vendor options are available and used in Canada.
The wide variation in methods and in data collected presents serious barriers to meaningful comparison of ED services across the country. It is little wonder that the majority of information regarding ED overcrowding in Canada is anecdotal, when the collection of this critical health information is so variable. There is an urgent need to place the collection of ED information on the provincial and national agenda and to ensure that the collection of this information consistent, comprehensive and mandatory.
PubMed ID
17209491 View in PubMed
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Development of the Canadian Emergency Department Diagnosis Shortlist.

https://arctichealth.org/en/permalink/ahliterature142008
Source
CJEM. 2010 Jul;12(4):311-9
Publication Type
Article
Date
Jul-2010
Author
Bernard Unger
Marc Afilalo
Jean François Boivin
Michael Bullard
Eric Grafstein
Michael Schull
Eddy Lang
Antoinette Colacone
Nathalie Soucy
Xiaoqing Xue
Eli Segal
Author Affiliation
Emergency Multidisciplinary Research Unit, Jewish General Hospital, McGill University, 3755 Cote Ste. Catherine Rd., Montréal QC, Canada. bernard.unger@mcgill.ca
Source
CJEM. 2010 Jul;12(4):311-9
Date
Jul-2010
Language
English
Publication Type
Article
Keywords
Canada
Delphi Technique
Emergency Service, Hospital - organization & administration - standards
Humans
International Classification of Diseases - organization & administration - standards
Abstract
Managers of emergency departments (EDs), governments and researchers would benefit from reliable data sets that characterize use of EDs. Although Canadian ED lists for chief complaints and triage acuity exist, no such list exists for diagnosis classification. This study was aimed at developing a standardized Canadian Emergency Department Diagnosis Shortlist (CED-DxS), as a subset of the full International Classification of Diseases, 10th revision, with Canadian Enhancement (ICD-10-CA).
Emergency physicians from across Canada participated in the revision of the ICD-10-CA through 2 rounds of the modified Delphi method. We randomly assigned chapters from the ICD-10-CA (approximately 3000 diagnoses) to reviewers, who rated the importance of including each diagnosis in the ED-specific diagnosis list. If 80% or more of the reviewers agreed on the importance of a diagnosis, it was retained for the final revision. The retained diagnoses were further aggregated and adjusted, thus creating the CED-DxS.
Of the 83 reviewers, 76% were emergency medicine (EM)-trained physicians with an average of 12 years of experience in EM, and 92% were affiliated with a university teaching hospital. The modified Delphi process and further adjustments resulted in the creation of the CED-DxS, containing 837 items. The chapter with the largest number of retained diagnoses was injury and poisoning (n = 292), followed by gastrointestinal (n = 59), musculoskeletal (n = 55) and infectious disease (n = 42). Chapters with the lowest number retained were neoplasm (n = 18) and pregnancy (n = 12).
We report the creation of the uniform CED-DxS, tailored for Canadian EDs. The addition of ED diagnoses to existing standardized parameters for the ED will contribute to homogeneity of data across the country.
PubMed ID
20650023 View in PubMed
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Effect of socioeconomic status on out-of-hospital transport delays of patients with chest pain.

https://arctichealth.org/en/permalink/ahliterature186130
Source
Ann Emerg Med. 2003 Apr;41(4):481-90
Publication Type
Article
Date
Apr-2003
Author
Anand Govindarajan
Michael Schull
Author Affiliation
Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
Source
Ann Emerg Med. 2003 Apr;41(4):481-90
Date
Apr-2003
Language
English
Publication Type
Article
Keywords
Age Factors
Aged
Allied Health Personnel - supply & distribution
Analysis of Variance
Chest Pain - therapy
Emergency Medical Service Communication Systems - statistics & numerical data
Emergency Medical Services - economics - statistics & numerical data
Female
Health Services Research
Humans
Income - statistics & numerical data
Male
Middle Aged
Ontario
Poverty Areas
Predictive value of tests
Regression Analysis
Residence Characteristics - statistics & numerical data
Retrospective Studies
Severity of Illness Index
Sex Factors
Social Class
Time Factors
Transportation of Patients - economics - statistics & numerical data
Abstract
The effect of socioeconomic status on out-of-hospital care has not been widely examined. We determine whether socioeconomic status was associated with out-of-hospital transport delays for patients with chest pain.
A retrospective study of patients with chest pain transported by means of ambulance in Toronto, Ontario, Canada, in 1999 was conducted. The primary outcome measure was the 90th percentile system response interval, with secondary outcomes being the 90th percentile on-scene interval, transport interval, and total out-of-hospital interval. Socioeconomic status was the primary independent variable. Covariates were age, sex, case severity, dispatch and return priority, time and day of transport, paramedic training, and percentage of high-rise apartments in the region.
Four thousand three hundred fifty-six patients met the inclusion criteria. The 90th percentile system response interval and total out-of-hospital interval were 11 minutes and 49 minutes, respectively. In multivariate analyses, the highest socioeconomic status neighborhoods were significantly associated with decreased system response interval (34.0 seconds; 95% confidence interval [CI] 6.2 to 70.9 seconds) and transport interval (132.3 seconds; 95% CI 24.1 to 229.6 seconds). In addition, age (+45.3 seconds per 10 years; 95% CI 13.3 to 75.1 seconds), female sex (+205.0 seconds; 95% CI 78.1 to 287.7 seconds), and advanced care paramedic crews (+371.6 seconds; 95% CI 263.3 to 490.1 seconds) were associated with delays in total out-of-hospital interval. Lastly, calls originating from the highest socioeconomic status neighborhoods were dispatched the highest proportion of advanced care paramedic crews, despite similar dispatch priorities and case severities.
High socioeconomic status neighborhoods were associated with shorter out-of-hospital transport intervals for patients with chest pain. In addition, out-of-hospital delays were associated with age, sex, and advanced care paramedic crew type, with calls from the highest socioeconomic status neighborhoods being most likely to receive advanced care paramedic crews.
Notes
Comment In: Ann Emerg Med. 2003 Apr;41(4):491-312658248
PubMed ID
12658247 View in PubMed
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Frequency and pattern of emergency department visits by long-term care residents--a population-based study.

https://arctichealth.org/en/permalink/ahliterature144174
Source
J Am Geriatr Soc. 2010 Mar;58(3):510-7
Publication Type
Article
Date
Mar-2010
Author
Andrea Gruneir
Chaim M Bell
Susan E Bronskill
Michael Schull
Geoffrey M Anderson
Paula A Rochon
Author Affiliation
Women's College Research Institute, Women's College Hospital, Toronto, Canada. andrea.gruneir@wchospital.ca
Source
J Am Geriatr Soc. 2010 Mar;58(3):510-7
Date
Mar-2010
Language
English
Publication Type
Article
Keywords
Aged
Aged, 80 and over
Emergency Service, Hospital - utilization
Female
Health Services Accessibility
Health services needs and demand
Humans
Long-Term Care
Male
Nursing Homes
Ontario
Preventive Health Services
Primary Health Care
Retrospective Studies
Abstract
To obtain population-based estimates of emergency department (ED) visits by long-term care (LTC) residents.
Retrospective cohort study using administrative data.
All LTC facilities in Ontario, Canada.
All LTC residents who visited an ED at least once during a 6-month period.
All ED visits were described using the National Ambulatory Care Reporting System. Two distinct visit types were defined. Potentially preventable visits were defined as those for any ambulatory care sensitive condition; these are conditions for which exacerbations that result in hospital use suggest lack of access to adequate primary care. Low-acuity visits were defined as those triaged as non-urgent at ED registration and ended with return to the LTC facility without hospital admission.
Nearly one-quarter of LTC residents visited the ED at least once in 6 months. Of all visits, 24.6% were for a potentially preventable reason, most commonly pneumonia, urinary tract infection, and congestive heart failure. These visits had a high frequency of ambulance transport (90.4%), emergent triage (35.3%), hospital admission (62.4%), and death within 30 days (23.6%). Of all visits, 11.0% were low acuity. Fall-related injury was the most common cause. Low-acuity visits were the shortest (mean length 4.5 +/- 4.0 hours) and had the lowest frequency of death within 30 days (4.3%).
LTC residents made frequent visits to the ED. The visit types showed distinct patterns that suggest a need for better access to medical care for common conditions and a greater emphasis on fall prevention in LTC.
PubMed ID
20398120 View in PubMed
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Frequency, determinants and impact of overcrowding in emergency departments in Canada: a national survey.

https://arctichealth.org/en/permalink/ahliterature160289
Source
Healthc Q. 2007;10(4):32-40
Publication Type
Article
Date
2007
Author
Kenneth Bond
Maria B Ospina
Sandra Blitz
Marc Afilalo
Sam G Campbell
Michael Bullard
Grant Innes
Brian Holroyd
Gil Curry
Michael Schull
Brian H Rowe
Author Affiliation
Capital Health/University of Alberta Evidence-Based Practice Center, Edmonton.
Source
Healthc Q. 2007;10(4):32-40
Date
2007
Language
English
Publication Type
Article
Keywords
Canada
Crowding
Emergency Service, Hospital - organization & administration
Health Care Surveys
Humans
National Health Programs
Abstract
Several reports have documented the prevalence and severity of emergency department (ED) overcrowding at specific hospitals or cities in Canada; however, no study has examined the issue at a national level. A 54-item, self-administered, postal and web-based questionnaire was distributed to 243 ED directors in Canada to collect data on the frequency, impact and factors associated with ED overcrowding. The survey was completed by 158 (65% response rate) ED directors, 62% of whom reported overcrowding as a major or severe problem during the past year. Directors attributed overcrowding to a variety of issues including a lack of admitting beds (85%), lack of acute care beds (74%) and the increased length of stay of admitted patients in the ED (63%). They perceived ED overcrowding to have a major impact on increasing stress among nurses (82%), ED wait times (79%) and the boarding of admitted patients in the ED while waiting for beds (67%). Overcrowding is not limited to large urban centres; nor is it limited to academic and teaching hospitals. The perspective of ED directors reinforces the need for further examination of effective policies and interventions to reduce ED overcrowding.
PubMed ID
18019897 View in PubMed
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Implementing wait-time reductions under Ontario government benchmarks (Pay-for-Results): a Cluster Randomized Trial of the Effect of a Physician-Nurse Supplementary Triage Assistance team (MDRNSTAT) on emergency department patient wait times.

https://arctichealth.org/en/permalink/ahliterature106258
Source
BMC Emerg Med. 2013;13:17
Publication Type
Article
Date
2013
Author
Ivy Cheng
Jacques Lee
Nicole Mittmann
Jeffrey Tyberg
Sharon Ramagnano
Alex Kiss
Michael Schull
Fergus Kerr
Merrick Zwarenstein
Author Affiliation
Emergency Services, Sunnybrook Health Sciences Center, Toronto, Canada. ivy.cheng@sunnybrook.ca.
Source
BMC Emerg Med. 2013;13:17
Date
2013
Language
English
Publication Type
Article
Keywords
Benchmarking
Cluster analysis
Efficiency, Organizational
Emergency Service, Hospital - standards - statistics & numerical data
Female
Humans
Length of Stay
Male
Middle Aged
National Health Programs
Nurse's Practice Patterns - standards - statistics & numerical data
Ontario
Outcome Assessment (Health Care)
Patient Admission - statistics & numerical data
Patient Care Team - organization & administration
Patient Discharge - statistics & numerical data
Physician-Nurse Relations
Reimbursement, Incentive
Time Factors
Triage
Waiting Lists
Abstract
Internationally, emergency departments are struggling with crowding and its associated morbidity, mortality, and decreased patient and health-care worker satisfaction. The objective was to evaluate the addition of a MDRNSTAT (Physician (MD)-Nurse (RN) Supplementary Team At Triage) on emergency department patient flow and quality of care.
Pragmatic cluster randomized trial. From 131 weekday shifts (8:00-14:30) during a 26-week period, we randomized 65 days (3173 visits) to the intervention cluster with a MDRNSTAT presence, and 66 days (3163 visits) to the nurse-only triage control cluster. The primary outcome was emergency department length-of-stay (EDLOS) for patients managed and discharged only by the emergency department. Secondary outcomes included EDLOS for patients initially seen by the emergency department, and subsequently consulted and admitted, patients reaching government-mandated thresholds, time to initial physician assessment, left-without being seen rate, time to investigation, and measurement of harm.
The intervention's median EDLOS for discharged, non-consulted, high acuity patients was 4:05 [95th% CI: 3:58 to 4:15] versus 4:29 [95th% CI: 4:19-4:38] during comparator shifts. The intervention's median EDLOS for discharged, non-consulted, low acuity patients was 1:55 [95th% CI: 1:48 to 2:05] versus 2:08 [95th% CI: 2:02-2:14]. The intervention's median physician initial assessment time was 0:55 [95th% CI: 0:53 to 0:58] versus 1:21 [95th% CI: 1:18 to 1:25]. The intervention's left-without-being-seen rate was 1.5% versus 2.2% for the control (p = 0.06). The MDRNSTAT subgroup analysis resulted in significant decreases in median EDLOS for discharged, non-consulted high (4:01 [95th% CI: 3:43-4:16]) and low acuity patients (1:10 95th% CI: 0:58-1:19]), as well as physician initial assessment time (0:25 [95th% CI: 0:23-0:26]). No patients returned to the emergency department after being discharged by the MDRNSTAT at triage.
The intervention reduced delays and left-without-being-seen rate without increased return visits or jeopardizing urgent care of severely ill patients.
NCT00991471 ClinicalTrials.gov.
PubMed ID
24207160 View in PubMed
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Recent health care transitions and emergency department use by chronic long term care residents: a population-based cohort study.

https://arctichealth.org/en/permalink/ahliterature129869
Source
J Am Med Dir Assoc. 2012 Mar;13(3):202-6
Publication Type
Article
Date
Mar-2012
Author
Andrea Gruneir
Susan Bronskill
Chaim Bell
Sudeep Gill
Michael Schull
Xiaomu Ma
Geoffrey Anderson
Paula A Rochon
Author Affiliation
Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada. andrea.gruneir@wchospital.ca
Source
J Am Med Dir Assoc. 2012 Mar;13(3):202-6
Date
Mar-2012
Language
English
Publication Type
Article
Keywords
Aged
Aged, 80 and over
Cohort Studies
Emergency Service, Hospital - utilization
Female
Humans
Male
Nursing Homes - utilization
Ontario
Patient Transfer - trends
Abstract
Long term care (LTC) residents commonly experience transitions between health care settings that can have important health consequences. The objective of this study was to quantify the effect of recent transitions on the risk of emergency department (ED) transfer among chronic LTC residents. Two types of transitions were considered: admission into LTC and discharge from hospital.
Retrospective cohort study using linked administrative data from Ontario, Canada.
All chronic LTC residents in Ontario older than 66 years on the date of the 2005 provincial LTC facility census.
Using facility census date as baseline, admission to LTC was defined as the number of days between LTC admission and baseline. Residents were categorized as one of: newly admitted (=30 days), shorter-stay (31-90 days), or longer-stay (=91 days). Within each group, residents were further subdivided based on having had a recent discharge from hospital. The first ED visit for each resident during the 6-month follow-up was counted, as were death and other competing risks. The cumulative incidence of ED transfer for each group was estimated and logistic regression was used to test whether differences between groups persisted after controlling for resident characteristics.
Of the 64,589 residents, 3.0% were newly admitted, 4.9% were shorter-stay, and 92.1% were longer-stay. The 6-month cumulative incidences of ED transfers were 35.0% for newly admitted, 30.7% for shorter-stay, and 22.0% for longer-stay. The odds of an ED transfer were higher for newly admitted and shorter-stay residents relative to longer-stay residents, even after adjustment for resident characteristics (adjusted odds ratio, 95% confidence interval 1.9, 1.7-2.1; and 1.5, 1.4-1.7, respectively). Regardless of time since LTC admission, residents with a recent discharge from hospital had a cumulative incidence of nearly 40% and an increase in the odds of ED transfer of at least 50% compared with those who had not been in hospital.
Health care transitions, especially those from hospital, are associated with an increase in ED transfers among older chronic LTC residents. These findings highlight the need for a stronger focus on transitional care, especially posthospital care, for LTC residents.
PubMed ID
22056922 View in PubMed
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Retrospective application of the NEXUS low-risk criteria for cervical spine radiography in Canadian emergency departments.

https://arctichealth.org/en/permalink/ahliterature180978
Source
Ann Emerg Med. 2004 Apr;43(4):507-14
Publication Type
Article
Date
Apr-2004
Author
Garth Dickinson
Ian G Stiell
Michael Schull
Robert Brison
Catherine M Clement
Katherine L Vandemheen
Daniel Cass
Douglas McKnight
Gary Greenberg
James R Worthington
Mark Reardon
Laurie Morrison
Mary A Eisenhauer
Jonathan Dreyer
George A Wells
Author Affiliation
Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada.
Source
Ann Emerg Med. 2004 Apr;43(4):507-14
Date
Apr-2004
Language
English
Publication Type
Article
Keywords
Adolescent
Adult
Aged
Aged, 80 and over
Canada
Cervical Vertebrae - injuries - radiography
Emergency Service, Hospital
Female
Humans
Male
Middle Aged
Retrospective Studies
Sensitivity and specificity
Spinal Cord Injuries - radiography
Spinal Injuries - radiography
Wounds, Nonpenetrating - radiography
Abstract
We evaluate the accuracy, reliability, and potential impact of the National Emergency X-Radiography Utilization Study (NEXUS) low-risk criteria for cervical spine radiography, when applied in Canadian emergency departments (EDs).
The Canadian C-Spine Rule derivation study was a prospective cohort study conducted in 10 Canadian EDs that recruited alert and stable adult trauma patients. Physicians completed a 20-item data form for each patient and performed interobserver assessments when feasible. The prospective assessments included the 5 individual NEXUS criteria but not an explicit interpretation of the overall need for radiography according to the criteria. Patients underwent plain radiography, flexion-extension views, and computed tomography at the discretion of the treating physician. Patients who did not have radiography were followed up with a structured outcome assessment by telephone to determine clinically important cervical spine injury, a previously validated outcome measurement. Analyses included sensitivity and specificity with 95% confidence interval (CI), kappa coefficient, and potential radiography rates.
Among 8,924 patients, 151 (1.7%) patients had an important cervical spine injury. The combined NEXUS criteria identified important cervical spine injury with a sensitivity of 92.7% (95% CI 87% to 96%) and a specificity of 37.8% (95% CI 37% to 39%). Application of the NEXUS criteria would have potentially reduced cervical spine radiography rates by 6.1% from the actual rate of 68.9% to 62.8%. Of 11 patients with important injuries not identified, 2 were treated with internal fixation and 3 with a halo.
This retrospective validation found the NEXUS low-risk criteria to be less sensitive than previously reported. The NEXUS low-risk criteria should be further explicitly and prospectively evaluated for accuracy and reliability before widespread clinical use outside of the United States.
Notes
Comment In: Ann Emerg Med. 2004 Apr;43(4):515-715039696
Comment In: Ann Emerg Med. 2004 Apr;43(4):518-2015039697
PubMed ID
15039695 View in PubMed
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12 records – page 1 of 2.