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Study Objective Patients on warfarin or clopidogrel are considered at increased risk for traumatic intracranial hemorrhage (tICH) following blunt head trauma. The prevalence of immediate tICH and the cumulative incidence of delayed tICH in these patients, however, are unknown. Methods A prospective, observational study at two trauma centers and four community hospitals enrolled emergency department (ED) patients with blunt head trauma and pre-injury warfarin or clopidogrel use from April 2009 through January 2011. Patients were followed for two weeks. The prevalence of immediate tICH and the cumulative incidence of delayed tICH were calculated from patients who received an initial cranial computed tomography (CT) in the ED. Delayed tICH was defined as tICH within two weeks following an initially normal CT scan and in the absence of repeat head trauma. Results A total of 1,064 patients were enrolled (768 warfarin patients [72.2%] and 296 clopidogrel patients [27.8%]). There were 364 patients [34.2%] from Level 1 or 2 trauma centers and 700 patients [65.8%] from community hospitals. One thousand patients received a cranial CT scan in the ED. Both warfarin and clopidogrel groups had similar demographic and clinical characteristics although concomitant aspirin use was more prevalent among patients on clopidogrel. The prevalence of immediate tICH was higher in patients on clopidogrel (33/276, 12.0%; 95% confidence interval [CI] 8.4-16.4%) than patients on warfarin (37/724, 5.1%; 95%CI 3.6-7.0%), relative risk 2.31 (95%CI 1.48-3.63). Delayed tICH was identified in 4/687 (0.6%; 95%CI 0.2-1.5%) patients on warfarin and 0/243 (0%; 95%CI 0-1.5%) patients on clopidogrel. Conclusion While there may be unmeasured confounders that limit intergroup comparison, patients on clopidogrel have a significantly higher prevalence of immediate tICH compared to patients on warfarin. Delayed tICH is rare and occurred only in patients on warfarin. Discharging patients on anticoagulant or antiplatelet medications from the ED after a normal cranial CT scan is reasonable but appropriate instructions are required as delayed tICH may occur.

In spite of recommendations to the contrary, opioids are still used in more than half of all emergency department visits for migraine. Though use of meperidine has decreased markedly between 1998 and 2010, it has largely been replaced by hydromorphone. Opioid use in migraine visits is independently associated with prior visits to the same emergency department in the previous 12 months.

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Public relative performance feedback (RPF) on an individual worker’s productivity metrics is used in various organizations with the hopes of improving worker productivity, but its effects are not well understood. We examine whether public RPF could be leveraged to facilitate adoption of best practices in an organization by enabling the validation of best practices shared by identifiable top performers. We use data from two emergency departments, both of which shared best practices for improving productivity and one of which changed from privately to publicly disclosing RPF to physicians. The public disclosure of RPF allowed workers to identify their top-performing coworkers, which in turn enabled the identification and validation of best practices within the work group. We find that the intervention is associated with a 10.9% improvement in physician productivity. We also find evidence for a significant reduction in variation in productivity across providers, which stems from bottom-ranked workers exhibiting differentially large improvements in productivity. These effects hold without sacrificing system-level performance, service quality, or worker attrition. Our results suggest that public disclosure of RPF, along with the validation of the best practices being shared, can improve worker productivity. The online supplement is available at https://doi.org/10.1287/mnsc.2017.2745 . This paper was accepted by Serguei Netessine, operations management.

The implementation of TBI prediction rules and provision of risks of ciTBIs by using CDS was associated with modest, safe, but variable decreases in CT use. However, some secular trends were also noted.

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