Clinical Decision Rule

Aka: Clinical Decision Rule, Decision Support Techniques, Clinical Prediction Rule, Decision Aids

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II. Indications

  1. Risk stratification for the evaluation and management of presentations with risk of poor outcome
  2. Limit testing that would otherwise risk adverse effects (e.g. radiation exposure)
  3. Standardize the approach to common conditions (esp. for those with less experience)
  4. Checklist documentation to prevent errors

III. Precautions: Pitfalls

  1. Clinical Decision Rules may be misapplied
  2. Use decision rules that have been prospectively validated, refined and used in clinical practice
  3. Decision rules should have high Test Sensitivity
    1. However, this is at the expense of Test Specificity with a high rate of False Positive tests
    2. Use clinical gestalt when interpreting the results of Clinical Decision Rules
  4. Many decision rules have a subjective component (e.g. Wells Score "PE more likely than alternatives")
  5. Avoid applying the decision tool to patients outside the population studied
    1. Be aware of the study inclusion and exclusion criteria
  6. Avoid mashing multiple decision tools together
    1. Use each decision tool individually, in the way it was validated
    2. Be cautious when applying 2 decision rules, each directing a different approach

IV. Examples

  1. Head and Neck
    1. Canadian CT Head Rule
    2. New Orleans Head CT Rule
    3. Canadian Cervical Spine Rule
    4. NEXUS Cervical Spine Decision Rule
    5. Sinusitis Prediction Rule
    6. Strep Score
  2. Thoracic
    1. See Chest Pain Decision Rules
    2. Bosner Chest Pain Decision Rule
    3. Diamond and Forrester Chest Pain Prediction Rule
    4. Vancouver Chest Pain Rule
    5. Dual-Antiplatelet Therapy Decision Rule
    6. Chest Wall Pain Prediction Rule
    7. CHF Decision Rule for Predicting Mortality
    8. Diehr Rule to Diagnose Pneumonia
    9. Nexus Chest CT Decision Rule in Blunt Trauma
    10. San Francisco Syncope Rule
  3. Abdomen
    1. Blunt Abdominal Trauma Decision Rule for Children
  4. Hematology and Oncology
    1. Neutropenic Fever Clinical Decision Rule
    2. Wells Clinical Prediction Rule for DVT
    3. Wells Clinical Prediction Rule for PE
    4. PERC Rule (Pulmonary Embolism Rule-Out Criteria)
  5. Neurologic
    1. Oostenbrink Clinical Decision Rule for Meningitis
    2. Nigrovic Clinical Decision Rule (Meningitis)
  6. Musculoskeletal
    1. Ottawa Ankle Rule
    2. Ottawa Knee Rule
    3. Pittsburgh Knee Rules
    4. Rheumatoid Arthritis Prediction Rule for Undifferentiated Arthritis
  7. Miscellaneous
    1. TEN-4 Rule (Child Abuse)

V. References

  1. Mason, Grock, Carmelli in Herbert (2018) 18(6): EM:Rap 12-3

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