ObjectiveWith the ageing population, the prevalence of mild traumatic brain injury (mTBI) among older patients is increasing, and the age criteria of the Canadian CT head rule (CCHR) is challenged by many emergency physicians. We modified the age criteria of the CCHR to evaluate its predictive capacity.MethodsWe conducted a retrospective cohort study at a level 1 trauma centre ED of all mTBI patients 65 years old and over with an mTBI between 2010 and 2014. Main outcome was a clinically important brain injury (CIBI) reported on CT. The clinical and radiological data collection was standardised. Univariate analyses were performed to measure the predictive capacities of different age cut-offs at 70, 75 and 80 years old.Results104 confirmed mTBI were included; CT scan identified 32 (30.8%) CIBI. Sensitivity and specificity (95% CI) of the CCHR were 100% (89.1 to 100) and 4.2% (0.9 to 11.7) for a modified criteria of 70 years old; 100% (89.1 to 100) and 13.9% (6.9 to 24.1) for 75 years old; and 90.6% (75.0 to 98.0) and 23.6% (14.4 to 35.1) for 80 years old. Furthermore, modifying the age criteria to 75 years old showed a reduction of CT up to 25% (n=10/41) among the individuals aged 65–74 without missing CIBI.ConclusionAdjusting the age criteria of the Canadian CT head rule to 75 years old could be safe while reducing radiation and ED resources. A future prospective study is suggested to confirm the proposed modification.
Home care workers (HCWs) are at risk from injury. A case study was undertaken in a local community health center in order (1) to identify the constraints that introduce risk into the work of HCWs, and (2) to study the strategies they apply, depending on their age, to reduce the effects of those constraints. Observation and semistructured interviews were the main sources of data. Analysis shows that HCWs aged 45 or over sometimes adopt different postures from those used by their younger colleagues. During physical care, the HCWs also carry out screening and social support tasks that are not recognized in the organization of their work. Older workers develop strategies that help them save time, refine their screening and support methods, protect themselves against accidents, and react properly in emergencies or dangerous situations. Because the changes that can be made in patients' homes are limited, the expertise of experienced HCWs is essential. The organization of work must maintain a certain flexibility to allow the workers to use their strategies.
Introduction: Clinical decision support (CDS) has been implemented in many clinical settings in order to improve decision-making. Their potential to improve diagnostic accuracy and reduce unnecessary testing is well documented; however, their effectiveness in impacting physician practice in real world implementations has been limited by poor physician adherence. The objective of this systematic review and metaregression was to establish the effectiveness of CDS tools on adherence and identify which characteristics of CDS tools increase physician use of and adherence. Methods: A systematic review and meta-analysis was conducted. MEDLINE, EMBASE, PsychINFO, the Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews were searched from inception to June 2017. Included studies examined CDS in a hospital setting, reported on physician adherence to or use of CDS, utilized a comparative study design, and reported primary data. All tool type was classified based on the Cochrane Effective Practice and Organization of Care (EPOC) classifications. Studies were stratified based on study design (RCT vs. observational). Metaregression was completed to assess the different effect of characteristics of the tool (e.g. whether the tool was mandatory or voluntary, EPOC classifications). Results: A total of 3,359 candidate articles were identified. Seventy-two met inclusion criteria, of which 46 reported outcomes appropriate for meta-regression (5 RCTs and 41 observational studies). Overall, a trend of increased CDS use was found (pooled RCT OR: 1.36 [95% CI: 0.97-1.89]; pooled observational OR: 2.12 [95% CI: 1.75-2.56]).When type of tool is considered, clinical practice guidelines were superior compared to other interventions (p = .150). Reminders (p = .473) and educational interventions (p = .489) were less successful than other interventions. Multi-modal tools were not more successful that single interventions (p = .810). Lastly, voluntary tools may be supperior to than mandatory tools (p = .148). None of these results are statistically significant. Conclusion: CDS tools accompanied by a planned intervention increases physician utilization and adherence to the tool. Meta-regression found that clinical practice guidelines had the biggest impact on physician adherence although not statistically significant. Further research is required to understand the most effective intervention to maximize physician utilization of CDS tools.
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