Improving Outcomes, Neurology, Pediatrics

CDRs- good for you, patients, and lawyers!

One of my favorite tweets ever is the following from Jeff Kline:

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This paper from Academic Emergency Medicine continues to drive home Kline’s point – evidence based medicine is protective – both for the provider medicolegally, and for the patient to be saved from harm’s way of overtesting.

The author’s reviewed WestlawNext (from what I can tell, the closest thing law has to PubMed), for all cases, jury verdicts, settlements, and arbitrations from 1973 (when CT first was used clinically) until January 2014 for all instances of head injuries in which head CT was NOT performed. After trudging through about 1,000 cases in their initial search, the authors eventually found (only) 60 cases in which a head CT was not performed and a provider was sued because of it. Two abstractors independently determined which clinical decision rules applied to that specific case (PECARN, NEXUS, Canadian CT head rule, etc), and if imaging was warranted. Inter-rater agreement was 99.2% for determining tge presence or absence of decision rule indications for CT in a given case, and 98.3% for which specific decision rule applied to a particular case.

The Results: Only 8 out of the 60 cases involved patients under age 18. Among all patients, isolated subdurals were most common (58% of cases), 32/60 died from their injury, while the rest sustained permanent neurologic deficits. Time from when a CT should have been ordered to deterioration or death was <6 hours in 39% of cases, 6-24 hrs in 36% of cases, and >24 hrs in 25% of cases.

The juicy stuff: in all ten cases in which the provider was found negligent, a CT was indicated. Providers settled in 10/11 cases in which a CT was indicated. In the ONE case in which a CT was not clearly indicated involved an MVC with multiple facial fractures and experienced left sided numbness and was scheduled for CT the following day. For all 8 pediatric patients, CT was indicated.

So, if a CT was indicated, and you didn’t do it, good luck.

What about the other cases? Well, The authors do not go into much detail about the necessity of CT for these remaining cases except saying that there were 27 cases which found the provider not liable. This also leaves a few cases outcomes unaccounted for.

All in all, since 1973, there has been a grand total of 60 cases in which a head CT was not done that evolved into a lawsuit.  Many of these cases occurred before the publication of recommended guidelines. In some ways, that is not quite fair – I’d hate to be brought to court for not doing ECMO on a patient because ECMO found its way into standard practice in 10 years.  Regardless, I take this study as a step in the trend of discussing with decision rules with the patient and their family family & documenting clinical decision rule recommendations to minimize the swinging pendulum of both the over and underwork up of patients.


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