Correspondence In response to your other points, patients in the nonopioid group were treated with acetaminophen (APAP), nonsteroidal anti-inflammatory drugs, and dental blocks. In fact, as part of the initial performance improvement project, we had a local dentist come to our staff meeting to re-educate our group on dental block techniques. This was particularly helpful for physicians whose initial training did not include such procedures.2 The majority of the opioid prescriptions written by our group in both pre- and postguideline periods were for hydrocodone/ APAP, oxycodone, or oxycodone/APAP, in quantities of up to 20 tablets and no refills. No prescriptions in either period included fentanyl patches. Finally, on the issue of safe prescribing, our guidelines also encourage the use of the Maine Office of Substance Abuse Webbased Prescription Monitoring Program. As of this writing, similar programs are operational and available to physicians in 43 other states.3 We believe that identifying patients with multiple prescriptions or prescribers is a useful step in reducing prescription opioid abuse.4 Our opioid prescription guideline is available for viewing online at http://rx.lchcare.org. James Li, MD Timothy Fox, MD Sandra Stevens, MD Tracy Tippie, MD Miles Memorial Hospital Department of Emergency Medicine Damariscotta, ME http://dx.doi.org/10.1016/j.annemergmed.2013.10.009
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. 1. Katz K. Tramadol is an opioid. J Med Toxicol. 2008;4:145. 2. Saint Louis C. ER doctors face quandary on painkillers. New York Times. April 30, 2012. Available at: http://www.nytimes.com/2012/05/01/ health/emergency-room-doctors-dental-patients-and-drugs.html. Accessed October 18, 2013. 3. Federation of State Medical Boards. Prescription Drug Monitoring Programs: State-by-State Overview. Washington, DC: FSMB; 2013. Available at: http://www.fsmb.org/pdf/GRPOL_pmp_overview_by_state. pdf. Accessed October 18, 2013. 4. Baehren DF, Marco CA, Droz DE, et al. A statewide prescription monitoring program affects emergency department prescribing behaviors. Ann Emerg Med. 2010;56:19-23.
When Do Clinical Decision Rules Improve Patient Care? To the Editor: We read with interest “When Do Clinical Decision Rules Improve Patient Care?,”1 which referenced an article we 372 Annals of Emergency Medicine
published in Annals.2 In this editorial, Green questions the utility of clinical “decision” rules. In response, we suggest these tools be referred to as “prediction” rules, rather than decision rules.2 Prediction implies that the tool predicts the patient’s outcome as opposed to mandating a clinical decision and risk-stratifies patients to aid physicians with data-driven evidence packaged in an easily interpreted form. Green suggests that application of the prediction rule would decrease abdominal computed tomography (CT) use by only 11%.1 That calculation, however, is misleading; 5,380 children in the study underwent abdominal CT in the emergency department, and 1,254 (23.3%) were very low risk by the prediction rule.2 The prediction rule suggests that low-risk children do not require abdominal CT while not mandating CT in children at more than low risk. Therefore, appropriate application of the rule may result in up to a 23.3% reduction in abdominal CT scanning. Substantial variability in trauma care exists and results in clinical inefficiency. To limit variability and improve care, rigorous, well-designed research studies must be performed and then appropriately implemented.3 During the last 15 years, CT use in trauma has increased at a greater rate than the research to support use. Evidence-based tools are necessary to decrease inappropriate CT use. As with any research, care must be used in the interpretation and application of our prediction rule. Applying the prediction rule as intended could improve clinical efficiency and decrease radiation exposure to a vulnerable population. It would seem intuitive that practicing medicine based on the best evidence, in addition to clinical judgment, would be superior to use of clinical gestalt alone. Green also suggests that “[t]his decision rule newly derived by Holmes et al is thus already obsolete in trauma centers using FAST [focused abdominal sonography for trauma].” This view seems inappropriately strong. First, the FAST examination is not available for all pediatric trauma patients either because of a lack of equipment or a lack of ultrasonographic skills by the treating physician. Over time, this can be addressed, but this prediction rule can be applied to all children evaluated after blunt torso trauma regardless of ultrasonographic availability. A patient who has a negative prediction rule result but whom the clinician still considers at non-negligible risk of abdominal injury may undergo the FAST examination for further risk stratification. A normal FAST examination result in a patient with a negative prediction rule result places the patient at such low risk that abdominal CT is likely not warranted. Finally, the prediction rule identifies the particular patient’s risk of important intra-abdominal injury and may guide further evaluation (FAST examination, laboratory screening, observation, or abdominal CT scanning). Unfortunately, no published randomized trials of FAST examination in pediatric trauma patients exist, to our knowledge. Such studies need to be performed before the utility of the FAST can be determined. Finally, Green is critical of the complexity of prediction rules. We anticipate that the integration of clinician decision support Volume 63, no. 3 : March 2014
Correspondence tools into the electronic health record to assist clinicians will greatly mitigate such concerns.4 James F. Holmes, MD, MPH Department of Emergency Medicine UC Davis School of Medicine Sacramento, CA Nathan Kuppermann, MD, MPH Department of Emergency Medicine and Pediatrics UC Davis School of Medicine Sacramento, CA http://dx.doi.org/10.1016/j.annemergmed.2013.10.023
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. The primary study was supported by a grant from the Centers for Disease Control (1 R49CE00100201). 1. Green SM. When do clinical decision rules improve patient care? Ann Emerg Med. 2013;62:132-135. 2. Holmes JF, Lillis K, Monroe D, et al. Identifying children at very low risk of clinically important blunt abdominal injuries. Ann Emerg Med. 2013;62:107-116.e102. 3. McGinn TG, Guyatt GH, Wyer PC, et al. Users’ guides to the medical literature, XXII: how to use articles about clinical decision rules. Evidence-Based Medicine Working Group. JAMA. 2000;284:79-84. 4. Sheehan B, Nigrovic LE, Dayan PS, et al. Informing the design of clinical decision support services for evaluation of children with minor blunt head trauma in the emergency department: a sociotechnical analysis. J Biomed Inform. 2013;46:905-913.
In reply: Holmes and Kuppermann alter the perception of potential computed tomography (CT) reduction from their clinical decision rule by substituting CT scans for their denominator rather than the population involved. As discussed,1 their recommended 1-way application of their rule would most optimistically decrease CT ordering in 11% of children compared with baseline clinical judgment. This 11% estimate likely overstates actual performance because decision rules rarely perform as well when retested in new samples. Furthermore, should clinicians instead apply the rule in 2-way fashion, as is standard for most decision rules, this would instead increase CT ordering in 13% of children compared with baseline physician judgment. Whether this new clinical decision rule might ultimately decrease or increase abdominal CT scanning will not be known until an attempt is made to validate it. It is hoped that any such
Volume 63, no. 3 : March 2014
validation study will also address concerns about rule sensitivity because the rule missed 6 children with intra-abdominal injury requiring intervention, whereas baseline physician judgment missed only 1. Holmes and Kuppermann dispute the value of the focused assessment with sonography for trauma (FAST) examination for blunt abdominal trauma in children, a position at odds with both the overwhelming adult evidence and the viewpoints of emergency medicine leaders in ultrasonography.2-5 Because the FAST examination is typically performed before the decision to obtain CT scanning, their clinical decision rule omits what likely represents the single most important piece of information available to guide such decisionmaking, indeed one that would appear to have quickly identified all 6 children with hemoperitoneum missed by their decision rule. Holmes and Kuppermann suggest ways in which their rule might be used in conjunction with FAST; however, caution is warranted because they did not actually study their rule together with FAST. The modern clinical question unanswered by their decision rule is, when do children with blunt torso trauma and a negative FAST result need abdominal CT? Holmes and Kuppermann note that electronic medical records can readily calculate complex clinical decision rules such as theirs. Someone, however, must type in the data points. Are clinicians willing to do such data entry, particularly while they are preoccupied with caring for an acutely traumatized child? Steven M. Green, MD Loma Linda University Medical Center & Children’s Hospital Loma Linda, CA http://dx.doi.org/10.1016/j.annemergmed.2013.10.022
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The author has stated that no such relationships exist. 1. Green SM. When do clinical decision rules improve patient care? Ann Emerg Med. 2013;62:132-135. 2. Noble VE, Blaivas M, Blankenship R, et al. Decision rule for imaging utilization in blunt abdominal trauma—where is ultrasound [letter]? Ann Emerg Med. 2010;55:487-489. 3. Fox JC, Boysen M, Gharahbaghian L, et al. Test characteristics of focused assessment of sonography for trauma for clinically significant abdominal free fluid in pediatric blunt abdominal trauma. Acad Emerg Med. 2011;18:477-482. 4. American College of Emergency Physicians. Policy statement: emergency ultrasound guidelines. Approved 2008. Available at: http:// www.acep.org/workarea/downloadasset.aspx?id¼32878. Accessed October 20, 2013. 5. Vieira RL, Hsu D, Nagler J, et al. Pediatric emergency medicine fellow training in ultrasound: consensus educational guidelines. Acad Emerg Med. 2013;20:300-306.
Annals of Emergency Medicine 373
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. 1. Katz K. Tramadol is an opioid. J Med Toxicol. 2008;4:145. 2. Saint Louis C. ER doctors face quandary on painkillers. New York Times. April 30, 2012. Available at: http://www.nytimes.com/2012/05/01/ health/emergency-room-doctors-dental-patients-and-drugs.html. Accessed October 18, 2013. 3. Federation of State Medical Boards. Prescription Drug Monitoring Programs: State-by-State Overview. Washington, DC: FSMB; 2013. Available at: http://www.fsmb.org/pdf/GRPOL_pmp_overview_by_state. pdf. Accessed October 18, 2013. 4. Baehren DF, Marco CA, Droz DE, et al. A statewide prescription monitoring program affects emergency department prescribing behaviors. Ann Emerg Med. 2010;56:19-23.
When Do Clinical Decision Rules Improve Patient Care? To the Editor: We read with interest “When Do Clinical Decision Rules Improve Patient Care?,”1 which referenced an article we 372 Annals of Emergency Medicine
published in Annals.2 In this editorial, Green questions the utility of clinical “decision” rules. In response, we suggest these tools be referred to as “prediction” rules, rather than decision rules.2 Prediction implies that the tool predicts the patient’s outcome as opposed to mandating a clinical decision and risk-stratifies patients to aid physicians with data-driven evidence packaged in an easily interpreted form. Green suggests that application of the prediction rule would decrease abdominal computed tomography (CT) use by only 11%.1 That calculation, however, is misleading; 5,380 children in the study underwent abdominal CT in the emergency department, and 1,254 (23.3%) were very low risk by the prediction rule.2 The prediction rule suggests that low-risk children do not require abdominal CT while not mandating CT in children at more than low risk. Therefore, appropriate application of the rule may result in up to a 23.3% reduction in abdominal CT scanning. Substantial variability in trauma care exists and results in clinical inefficiency. To limit variability and improve care, rigorous, well-designed research studies must be performed and then appropriately implemented.3 During the last 15 years, CT use in trauma has increased at a greater rate than the research to support use. Evidence-based tools are necessary to decrease inappropriate CT use. As with any research, care must be used in the interpretation and application of our prediction rule. Applying the prediction rule as intended could improve clinical efficiency and decrease radiation exposure to a vulnerable population. It would seem intuitive that practicing medicine based on the best evidence, in addition to clinical judgment, would be superior to use of clinical gestalt alone. Green also suggests that “[t]his decision rule newly derived by Holmes et al is thus already obsolete in trauma centers using FAST [focused abdominal sonography for trauma].” This view seems inappropriately strong. First, the FAST examination is not available for all pediatric trauma patients either because of a lack of equipment or a lack of ultrasonographic skills by the treating physician. Over time, this can be addressed, but this prediction rule can be applied to all children evaluated after blunt torso trauma regardless of ultrasonographic availability. A patient who has a negative prediction rule result but whom the clinician still considers at non-negligible risk of abdominal injury may undergo the FAST examination for further risk stratification. A normal FAST examination result in a patient with a negative prediction rule result places the patient at such low risk that abdominal CT is likely not warranted. Finally, the prediction rule identifies the particular patient’s risk of important intra-abdominal injury and may guide further evaluation (FAST examination, laboratory screening, observation, or abdominal CT scanning). Unfortunately, no published randomized trials of FAST examination in pediatric trauma patients exist, to our knowledge. Such studies need to be performed before the utility of the FAST can be determined. Finally, Green is critical of the complexity of prediction rules. We anticipate that the integration of clinician decision support Volume 63, no. 3 : March 2014
Correspondence tools into the electronic health record to assist clinicians will greatly mitigate such concerns.4 James F. Holmes, MD, MPH Department of Emergency Medicine UC Davis School of Medicine Sacramento, CA Nathan Kuppermann, MD, MPH Department of Emergency Medicine and Pediatrics UC Davis School of Medicine Sacramento, CA http://dx.doi.org/10.1016/j.annemergmed.2013.10.023
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. The primary study was supported by a grant from the Centers for Disease Control (1 R49CE00100201). 1. Green SM. When do clinical decision rules improve patient care? Ann Emerg Med. 2013;62:132-135. 2. Holmes JF, Lillis K, Monroe D, et al. Identifying children at very low risk of clinically important blunt abdominal injuries. Ann Emerg Med. 2013;62:107-116.e102. 3. McGinn TG, Guyatt GH, Wyer PC, et al. Users’ guides to the medical literature, XXII: how to use articles about clinical decision rules. Evidence-Based Medicine Working Group. JAMA. 2000;284:79-84. 4. Sheehan B, Nigrovic LE, Dayan PS, et al. Informing the design of clinical decision support services for evaluation of children with minor blunt head trauma in the emergency department: a sociotechnical analysis. J Biomed Inform. 2013;46:905-913.
In reply: Holmes and Kuppermann alter the perception of potential computed tomography (CT) reduction from their clinical decision rule by substituting CT scans for their denominator rather than the population involved. As discussed,1 their recommended 1-way application of their rule would most optimistically decrease CT ordering in 11% of children compared with baseline clinical judgment. This 11% estimate likely overstates actual performance because decision rules rarely perform as well when retested in new samples. Furthermore, should clinicians instead apply the rule in 2-way fashion, as is standard for most decision rules, this would instead increase CT ordering in 13% of children compared with baseline physician judgment. Whether this new clinical decision rule might ultimately decrease or increase abdominal CT scanning will not be known until an attempt is made to validate it. It is hoped that any such
Volume 63, no. 3 : March 2014
validation study will also address concerns about rule sensitivity because the rule missed 6 children with intra-abdominal injury requiring intervention, whereas baseline physician judgment missed only 1. Holmes and Kuppermann dispute the value of the focused assessment with sonography for trauma (FAST) examination for blunt abdominal trauma in children, a position at odds with both the overwhelming adult evidence and the viewpoints of emergency medicine leaders in ultrasonography.2-5 Because the FAST examination is typically performed before the decision to obtain CT scanning, their clinical decision rule omits what likely represents the single most important piece of information available to guide such decisionmaking, indeed one that would appear to have quickly identified all 6 children with hemoperitoneum missed by their decision rule. Holmes and Kuppermann suggest ways in which their rule might be used in conjunction with FAST; however, caution is warranted because they did not actually study their rule together with FAST. The modern clinical question unanswered by their decision rule is, when do children with blunt torso trauma and a negative FAST result need abdominal CT? Holmes and Kuppermann note that electronic medical records can readily calculate complex clinical decision rules such as theirs. Someone, however, must type in the data points. Are clinicians willing to do such data entry, particularly while they are preoccupied with caring for an acutely traumatized child? Steven M. Green, MD Loma Linda University Medical Center & Children’s Hospital Loma Linda, CA http://dx.doi.org/10.1016/j.annemergmed.2013.10.022
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The author has stated that no such relationships exist. 1. Green SM. When do clinical decision rules improve patient care? Ann Emerg Med. 2013;62:132-135. 2. Noble VE, Blaivas M, Blankenship R, et al. Decision rule for imaging utilization in blunt abdominal trauma—where is ultrasound [letter]? Ann Emerg Med. 2010;55:487-489. 3. Fox JC, Boysen M, Gharahbaghian L, et al. Test characteristics of focused assessment of sonography for trauma for clinically significant abdominal free fluid in pediatric blunt abdominal trauma. Acad Emerg Med. 2011;18:477-482. 4. American College of Emergency Physicians. Policy statement: emergency ultrasound guidelines. Approved 2008. Available at: http:// www.acep.org/workarea/downloadasset.aspx?id¼32878. Accessed October 20, 2013. 5. Vieira RL, Hsu D, Nagler J, et al. Pediatric emergency medicine fellow training in ultrasound: consensus educational guidelines. Acad Emerg Med. 2013;20:300-306.
Annals of Emergency Medicine 373
