1. Which Headache needs to be imaged in the ED?
Eric REVUE
Head of Emergency Medicine Department
and Prehospital Emergency Medicine EMS (SMUR)
Louis Pasteur Hospital, Chartres, France
Secretary of the International Council of the
French Society of Emergency Medicine (SFMU)
Chair of the Website of the
European Society for Emergency Medicine (EuSEM)
AbstractObjective:  To describe in some detail the methods used and outcome of an application of concepts from Lean Thinking in establishing streams for patient flows in a teaching general hospital ED.Methods:  Detailed understanding was gained through process mapping with staff followed by the identification of value streams (those patients likely to be discharged from the ED, those who were likely to be admitted) and the implementation of a process of seeing those patients that minimized complex queuing in the ED.Results:  Streaming had a significant impact on waiting times and total durations of stay in the ED. There was a general flattening of the waiting time across all groups. A slight increase in wait for Triage categories 2 and 3 patients was offset by reductions in wait for Triage category 4 patients. All groups of patients spent significantly less overall time in the department and the average number of patients in the ED at any time decreased. There was a significant reduction in number of patients who do not wait and a slight decrease in access block.Conclusions:  The streaming of patients into groups of patients cared for by a specific team of doctors and nurses, and the minimizing of complex queues in this ED by altering the practices in relation to the function of the Australasian Triage Scale improved patient flow, thereby decreasing potential for overcrowding.
Emergency departments (EDs) face problems with crowding, delays, cost containment, and patient safety. To address these and other problems, EDs increasingly implement an approach called Lean thinking. This study critically reviewed 18 articles describing the implementation of Lean in 15 EDs in the United States, Australia, and Canada. An analytic framework based on human factors engineering and occupational research generated 6 core questions about the effects of Lean on ED work structures and processes, patient care, and employees, as well as the factors on which Lean's success is contingent. The review revealed numerous ED process changes, often involving separate patient streams, accompanied by structural changes such as new technologies, communication systems, staffing changes, and the reorganization of physical space. Patient care usually improved after implementation of Lean, with many EDs reporting decreases in length of stay, waiting times, and proportion of patients leaving the ED without being seen. Few null or negative patient care effects were reported, and studies typically did not report patient quality or safety outcomes beyond patient satisfaction. The effects of Lean on employees were rarely discussed or measured systematically, but there were some indications of positive effects on employees and organizational culture. Success factors included employee involvement, management support, and preparedness for change. Despite some methodological, practical, and theoretic concerns, Lean appears to offer significant improvement opportunities. Many questions remain about Lean's effects on patient health and employees and how Lean can be best implemented in health care.

2. Acute Headache: Who should we CT? Steven A. Godwin, MD, FACEP
Case Presentation
35 year old female presents to the emergency department with sudden onset of severe headache after stating she had been outside reading all day in the sun. She admits to taking 2 of a friend’s hydroxycodone and now is feeling better. Her physical exam is normal.
Acute Headache: Who should we CT? Steven A. Godwin, MD, FACEP

3. Does she need a CT scan?

4. Headaches
Headache accounts for 1% of all ED visits in the US (1 million patients/year)1
An estimated 1-4% of all patients presenting to the ED with headache complaint have emergent or urgent diagnosis1,2
The vast majority of primary headaches do not require neuroimaging.
a good history is the key to diagnosis.
1 Dhopesh V, Anwar R, Herring C. A retrospective assessment of emergency department patients with complaint of headache. Headache. 1979;19: (Retrospective review; 872 patients)
2 Ramirez-Lassepas M, Espinosa C, Cicero J, et al. Predictors of intracranial pathologic findings in patients who seek emergency care because of headache. Arch Neurol 1997;54: (Retrospective review; 329 patients)

5. How do we narrow down which patients need further studies?
History
Presentation of ominous headaches vary but important factors that provide a clue for the clinician include:
Severity
Onset
Quality of pain
Associated symptoms

6. Headache history
How many different headache types does the patient experience?
Time questions
a) Why consulting now? b) How recent in onset?
c) How frequent ? d) How long lasting?
Character questions : Intensity ? Nature /quality of pain ? Site ? Associated symptoms ?
Trigger factors ? Aggravating factors ? History of headache ?
What medication ?
State of health between attacks ? Persisting symptoms ?
How many different headache types does the patient experience?
Separate histories are necessary for each. It is reasonable to concentrate on the most bother someto the patient but others should always attract some enquiry in case they are clinicallyimportant.
2. Time questions
a) Why consulting now?
b) How recent in onset?
c) How frequent, and what temporal pattern (especially distinguishing between episodic anddaily or unremitting)?
d) How long lasting?
3. Character questions
a) Intensity of painb) Nature and quality of painc) Site and spread of pain d) Associated symptoms
4. Cause questions
a) Predisposing and/or trigger factors
b) Aggravating and/or relieving factors
c) Family history of similar headache
5. Response questions
a) What does the patient do during the headache?
b) How much is activity (function) limited or prevented?
c) What medication has been and is used, and in what manner?
6. State of health between attacksa) Completely well, or residual or persisting symptoms?b) Concerns, anxieties, fears about recurrent attacks, and/or their cause

7. What Is the Goal of Neuroimaging in the ED?
To identify a treatable lesion.
Emergent- essential for a timely decision regarding potentially life-threatening or severely disabling entities
Urgent- arranged prior to discharge from the ED or, performed prior to disposition when follow-up cannot be assured
Routine- indicated when the studies results are not considered to make a change in the patients disposition from the ED
ACEP and AAN have categorized neuroimaging
Acute Headache: Who should we CT? Steven A. Godwin, MD, FACEP

8. Practice Guidelines:What is the evidence?
In 1994, AAN published “Practice Parameter: The utility of neuroimaging in the evaluation of headache patients with normal neurologic examination”
3 American College of Neurology. Practice parameter: The utility of neuroimaging in the evaluation of headache patients with normal neurologic examination. Neurology. 1994;44:

9. Acute Headache: Who should we CT? Steven A. Godwin, MD, FACEP
AAN 1994 Guidelines
Evidence based recommendations
1. Neuroimaging is not warranted in patients with migraine presenting with a typical event
2. Neuroimaging should be considered in patients with atypical headaches, history of seizures, or focal neurologic findings
3. Insufficient evidence to define role of MRI vs CT in headache patients without a migraine
Acute Headache: Who should we CT? Steven A. Godwin, MD, FACEP

10. The 2000 US Headache Consortium
Reviewed articles dealing with chronic headache
Key findings:
Abnormality on neurologic exam increased the likelihood of positive results with neuroimaging by 3 fold (95% CI 2.3 to 4.0)
Normal findings with a neurologic exam reduced the odds of positive findings in a neuroimaging study by 30%
4 US Headache Consortium. Evidence-based guidelines in the primary care setting: neuroimaging in patients with nonacute headache. American Academy of Neurology, 2000

11. The US Headache Consortium Conclusions
Neuroimaging should be considered in patients with nonacute headache and an unexplained abnormality on neurologic examination
Insufficient evidence to make neuroimaging recommendations based on the presence or absence of neuro finding (in patients with chronic headache)
Neuroimaging is not warranted in typical migraine and no neuro findings
unexplained abnormal finding on the neurologic examination (Grade B)
atypical headache features
headaches that do not fulfill the strict definition of migraine or other primary headache disorder when a lower thresholdfor neuroimaging may be applied (Grade C)·
4 US Headache Consortium. Evidence-based guidelines in the primary care setting: neuroimaging in patients with nonacute headache. American Academy of Neurology, 2000

12. The US Headache Consortium Conclusions
Insufficient evidence to make neuroimaging recommendations in patients with tension-type headaches
Insufficient data for evidence-based recommendations regarding CT versus MRI in the evaluation of nonacute headache
Neuroimaging recommendations for nonacute headache
4 US Headache Consortium. Evidence-based guidelines in the primary care setting: neuroimaging in patients with nonacute headache. American Academy of Neurology, 2000

14. first presentation of thunderclap headache = CT Brain scan
exclusion of subarachnoid hemorrhage
lumbar puncture if CT scan is normal (D).
or alternative secondary cause (intracranial hemorrhage, meningitis, cerebral venous sinus thrombosis)
For patients with headache and features suggestive of infection of the central nervous system (such as fever, rash), refer immediately to hospital (D). Pathognomonic of aneurysm
3 % of all strokes in ED
5 % of stroke deaths
Pathognomonic of aneurysm
3 % of all strokes in ED
5 % of stroke deaths

15. Neuroimaging is not indicated
clear history of migraine
no “red flag” features
and a normal neurological examination (D)
BMJ 2008;337:a2329

16. “Sudden Worst Headache”
Is this predictive?
One retrospective study found a 29% yield for positive head CT in patients complaining of “worst headache” but no correlation with diagnosis of subarachnoid hemorrhage4
Harling et al. in a prospective study of patients presenting with thunderclap headache found 35/49 to have SAH on CT or LP5
5 Mills ML, Russo LS, Vines FS, et al. High yield criteria for urgent cranial computed tomography scans. Ann Emerg Med. 1986;15: (III)
6 Harling DW, Peatfield RC, Van Hille PT, et al Thunderclap headache: is it a migraine? Cephalagia. 1989;9:87-90 (II)

17. “Sudden Worst Headache”
Prospective study of 27 patients
All patients had acute sudden-onset HA with normal neurologic findings
All patients had CT, if negative an LP was performed and were then followed for 3 months
9 patients had SAH, 1 intraventricular hemorrhage, 1 bacterial meningitis, 1 with viral meningitis
7 Lledo A, calandre L, Marinez-Menendez B, et al. Acute headache of recent onset and subarachnoid hemorrhage: a prospective study. Headache. 1994;34: (I)

18. “Sudden Worst Headache”
Some studies have failed to demonstrate a significant correlation
One retrospective review of 333 ED patients complaining of acute or acutely worsening HA
17 patients had “worst headache of life”; only one had positive CT results7
Another study found only 1/27 patients with “worst headache complaint to have intracranial pathology8
8 Reinus WR, Wippold FJ, Erickson KK. Practical Selection Criteria for Unenhanced Cranial CT in Patients With Acute Headache. Emerg Radiol. 1994;94:67-70(II)
9 Mitchell CS, Osborn RE, Grosskreutz SR. Computed tomography in the headache patient: is routine evaluation really necessary? Headache.1993;33:82-86 (III)

19. Headache in HIV Related Disorders
Prospective study
49 consecutive HIV patients with headache
82% had a serious identifiable cause.
HIV positive patients with headache should be considered for CT and LP
10 Lipton RB, Feraru ER, Weiss G, et al. Headache in HIV Related Disorders. Headache. 1991;31: (II)

20. ED Utilization of Noncontrast Head CT in HIV Infected Patients
Prospective convenience sample of 110 HIV patients with neurologic complaints
New seizure, depressed or altered mental status, and headache that was different in character or lasted longer than 3 days
New or different HA was reported in 25% of the cases
All cases of focal lesions identified
11 Rothman RE, Keyl PM, McArthur JC, et al . A decision guideline for the utilization of noncontrast head CT in HIV infected patients. Acad Emerg Med. 1999;6: (II)

21. Patient Management Recommendations
Level A
None
Level B
Patients presenting to the ED with headache and abnormal findings on neurologic examination should undergo emergent non contrast head CT.
Patients presenting with acute sudden-onset headache should be considered for emergent head CT scan.
HIV positive patients with a new type of headache should be considered for urgent neuroimaging study.

22. Patient Management Recommendations
Level C Recommendations
Patients who are older than 50 years old with a new type of headache without abnormal finding on neurologic exam should be considered for urgent neuroimaging.
Acute Headache: Who should we CT? Steven A. Godwin, MD, FACEP

23. Summary warning signs or “red flags”
new headache in a patient aged over 50 thunderclap onset (abrupt and severe)
focal and non-focal symptoms
abnormal signs
headache changing with posture
valsalva headache (coughing, sneezing, bending, heavy lifting, straining)
fever; history of HIV; cancer
for potential secondary headache (D)

24. Thank you Clinical evaluation Decision rules
The data evaluating decision rules are strongest for adults, particularly the CCHR, which has been validated in a number of new cohorts and in different settings. Studies by Stein et al.,71Ibanez et al.60 and Smits et al.68 have compared multiple decision rules in large cohorts to provide powerful evidence of comparative diagnostic performance. Validation of decision rules for children, by contrast, is much more limited. Where validation has been undertaken it has shownthat specificity may be much lower than estimated in the derivation cohort. This could haveimportant implications if implementation of decision rules leads to increases in unnecessaryCT scanning.
Studies of clinical decision rules have inevitable limitations. Most patients with MHI do not routinely receive CT scanning. Indeed the aim of developing a decision rule is to formalise the selection process for scanning. So, although a CT scan might be considered the ideal reference standard, it is unlikely to be performed on all patients if an appropriate patient spectrum isrecruited. Studies may increase the proportion receiving CT scanning by limiting patient selection, but this may lead to spectrum bias. An associated limitation is that there seems to bein consistency in what is considered a clinically significant intracranial abnormality on CT. If liberal criteria for clinical significance are used then sensitivity will be apparently reduced, but the addition FNs may not be clinically significant. The best way of determining clinical significance isto undertake follow-up studies and identify whether or not particular lesions are associated withan adverse outcome.