MedicalResearch.com Interview with:
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Dr. Perry[/caption]
Jeff Perry, MD, MSc, CCFP-EM
Professor, Department of Emergency Medicine
Senior Scientist, Ottawa Hospital Research Institute
Research Chair in Emergency Neurological Research, University of Ottawa
Emergency Physician and Epidemiology Program
The Ottawa Hospital
Ottawa, Ontario
MedicalResearch.com: What is the background for this study? What are the main findings?
Response: Headache accounts for about 1-2% of all emergency department visits. One of the most feared diagnosis within these patients is subarachnoid hemorrhage. While investigations are clearly warranted for patients with a diminished level of consciousness or new focal neurological deficits, approximately 50% of patients with subarachnoid hemorrhage (SAH) have no focal or global neurological findings. Deciding whether to image headache patients with no deficits is difficult, especially since timely diagnosis and treatment results in substantially better outcomes.
The desire to never miss a subarachnoid hemorrhage, however, contributes to escalating neuroimaging rates and a dogmatic adherence to lumbar puncture, even if the scan is negative, despite the very high sensitivity of computed tomography. However, a recent population-based study suggested that over 5% of confirmed subarachnoid hemorrhages were missed at initial presentation, especially in smaller hospitals. Therefore, identifying which headache patients require investigations to rule-out SAH is of great importance.
We have previously derived (N=1,999) and refined (N=2,131) the Ottawa SAH Rule. In this study, we conducted an multicenter prospective cohort study at six tertiary care hospitals, and found that the Ottawa SAH Rule performed well, with an 100% sensitivity, and specificity of 13.6%.
Dr. Schnapp[/caption]
Benjamin H. Schnapp, MD
BerBee Walsh Department of Emergency Medicine
Assistant Professor (CHS)
Assistant Emergency Medicine Residency Program Director
University of Wisconsin
MedicalResearch.com: What is the background for this study? What are the main findings?
Response: Medical errors harm thousands of patients per year. There’s already a lot we know about systems errors - the ways that care delivery can go wrong. We know less about cognitive errors, or the ways in which doctors think that can lead to bad outcomes. An Emergency Department can feel particularly vulnerable to this type of errors - it’s a chaotic environment with patients in various states of illness, many unaccompanied, without records, or too ill to communicate well.
An Emergency Department with trainee physicians can feel even more chaotic - even though they are supervised by staff physicians, resident physicians in their first few months to years of training have not yet accumulated the same level of knowledge and experience as longer-tenured doctors. Errors that get made on the hospital floor are errors of information processing - physicians have the right information, they just don’t always do the right thing with it. We wanted to know what kinds of errors get made in an Emergency Department with trainees. Are the errors related to the chaos and an inability to obtain reliable information from patients? Are they related to the trainees not having enough knowledge and experience? Or are they like the errors that get made on an inpatient floor?
Our study found that the most frequent type of errors were errors of information processing - just like on the hospital floors. The most common types of errors we saw were physicians settling on a diagnosis prematurely and weighing the importance of findings incorrectly. Patients with abdominal problems had the highest number of errors in our study. Patients with certain risk factors, such as psychiatric disease or substance abuse, seemed to be particularly prone to errors.
