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de Wit K, Mercuri M, Clayton N, Mercier É, Morris J, Jeanmonod R, Eagles D, Varner C, Barbic D, Buchanan IM, Ali M, Kagoma YK, Shoamanesh A, Engels P, Sharma S, Worster A, McLeod S, Émond M, Stiell I, Papaioannou A, Parpia S. Derivation of the Falls Decision Rule to exclude intracranial bleeding without head CT in older adults who have fallen. CMAJ 2023; 195:E1614-E1621. [PMID: 38049159 PMCID: PMC10699318 DOI: 10.1503/cmaj.230634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND Ground-level falls are common among older adults and are the most frequent cause of traumatic intracranial bleeding. The aim of this study was to derive a clinical decision rule that safely excludes clinically important intracranial bleeding in older adults who present to the emergency department after a fall, without the need for a computed tomography (CT) scan of the head. METHODS This prospective cohort study in 11 emergency departments in Canada and the United States enrolled patients aged 65 years or older who presented after falling from standing on level ground, off a chair or toilet seat, or out of bed. We collected data on 17 potential predictor variables. The primary outcome was the diagnosis of clinically important intracranial bleeding within 42 days of the index emergency department visit. An independent adjudication committee, blinded to baseline data, determined the primary outcome. We derived a clinical decision rule using logistic regression. RESULTS The cohort included 4308 participants, with a median age of 83 years; 2770 (64%) were female, 1119 (26%) took anticoagulant medication and 1567 (36%) took antiplatelet medication. Of the participants, 139 (3.2%) received a diagnosis of clinically important intracranial bleeding. We developed a decision rule indicating that no head CT is required if there is no history of head injury on falling; no amnesia of the fall; no new abnormality on neurologic examination; and the Clinical Frailty Scale score is less than 5. Rule sensitivity was 98.6% (95% confidence interval [CI] 94.9%-99.6%), specificity was 20.3% (95% CI 19.1%-21.5%) and negative predictive value was 99.8% (95% CI 99.2%-99.9%). INTERPRETATION We derived a Falls Decision Rule, which requires external validation, followed by clinical impact assessment. Trial registration: ClinicalTrials. gov, no. NCT03745755.
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Affiliation(s)
- Kerstin de Wit
- Department of Emergency Medicine (de Wit), Queen's University, Kingston, Ont.; Division of Emergency Medicine, Department of Medicine (de Wit, Mercuri, Buchanan, Worster), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (de Wit, Parpia), McMaster University, Hamilton, Ont.; Dalla Lana School of Public Health (Mercuri), University of Toronto, Ont.; Emergency Department (Clayton), Hamilton Health Sciences; Department of Medicine (Clayton, Ali, Shoamanesh, Papaioannou, Parpia), McMaster University, Hamilton, Ont.; Centre de recherche du Centre hospitalier universitaire de Québec (Mercier) - Université Laval, Laval, Que.; VITAM - Centre de recherche en santé durable (Mercier, Émond), Québec, Que.; Department of Family Medicine and Emergency Medicine (Morris, Émond), Université de Montréal, Montréal, Que.; St. Luke's University Health Network (Jeanmonod), Bethlehem, Penn.; Department of Emergency Medicine (Eagles, Stiell), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Eagles, Stiell), University of Ottawa, Ottawa, Ont.; Schwartz/Reisman Emergency Medicine Institute (Eagles), Sinai Health, Toronto, Ont.; Clinical Epidemiology Program (Varner, McLeod), Ottawa Hospital Research Institute, Ottawa, Ont.; Division of Emergency Medicine (Varner, McLeod), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Barbic), University of British Columbia; Centre for Health Evaluation Outcome Sciences (Barbic), St. Paul's Hospital, Vancouver, BC; Department of Medical Imaging (Kagoma) and of Surgery (Engels, Sharma), McMaster University, Hamilton, Ont.
| | - Mathew Mercuri
- Department of Emergency Medicine (de Wit), Queen's University, Kingston, Ont.; Division of Emergency Medicine, Department of Medicine (de Wit, Mercuri, Buchanan, Worster), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (de Wit, Parpia), McMaster University, Hamilton, Ont.; Dalla Lana School of Public Health (Mercuri), University of Toronto, Ont.; Emergency Department (Clayton), Hamilton Health Sciences; Department of Medicine (Clayton, Ali, Shoamanesh, Papaioannou, Parpia), McMaster University, Hamilton, Ont.; Centre de recherche du Centre hospitalier universitaire de Québec (Mercier) - Université Laval, Laval, Que.; VITAM - Centre de recherche en santé durable (Mercier, Émond), Québec, Que.; Department of Family Medicine and Emergency Medicine (Morris, Émond), Université de Montréal, Montréal, Que.; St. Luke's University Health Network (Jeanmonod), Bethlehem, Penn.; Department of Emergency Medicine (Eagles, Stiell), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Eagles, Stiell), University of Ottawa, Ottawa, Ont.; Schwartz/Reisman Emergency Medicine Institute (Eagles), Sinai Health, Toronto, Ont.; Clinical Epidemiology Program (Varner, McLeod), Ottawa Hospital Research Institute, Ottawa, Ont.; Division of Emergency Medicine (Varner, McLeod), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Barbic), University of British Columbia; Centre for Health Evaluation Outcome Sciences (Barbic), St. Paul's Hospital, Vancouver, BC; Department of Medical Imaging (Kagoma) and of Surgery (Engels, Sharma), McMaster University, Hamilton, Ont
| | - Natasha Clayton
- Department of Emergency Medicine (de Wit), Queen's University, Kingston, Ont.; Division of Emergency Medicine, Department of Medicine (de Wit, Mercuri, Buchanan, Worster), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (de Wit, Parpia), McMaster University, Hamilton, Ont.; Dalla Lana School of Public Health (Mercuri), University of Toronto, Ont.; Emergency Department (Clayton), Hamilton Health Sciences; Department of Medicine (Clayton, Ali, Shoamanesh, Papaioannou, Parpia), McMaster University, Hamilton, Ont.; Centre de recherche du Centre hospitalier universitaire de Québec (Mercier) - Université Laval, Laval, Que.; VITAM - Centre de recherche en santé durable (Mercier, Émond), Québec, Que.; Department of Family Medicine and Emergency Medicine (Morris, Émond), Université de Montréal, Montréal, Que.; St. Luke's University Health Network (Jeanmonod), Bethlehem, Penn.; Department of Emergency Medicine (Eagles, Stiell), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Eagles, Stiell), University of Ottawa, Ottawa, Ont.; Schwartz/Reisman Emergency Medicine Institute (Eagles), Sinai Health, Toronto, Ont.; Clinical Epidemiology Program (Varner, McLeod), Ottawa Hospital Research Institute, Ottawa, Ont.; Division of Emergency Medicine (Varner, McLeod), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Barbic), University of British Columbia; Centre for Health Evaluation Outcome Sciences (Barbic), St. Paul's Hospital, Vancouver, BC; Department of Medical Imaging (Kagoma) and of Surgery (Engels, Sharma), McMaster University, Hamilton, Ont
| | - Éric Mercier
- Department of Emergency Medicine (de Wit), Queen's University, Kingston, Ont.; Division of Emergency Medicine, Department of Medicine (de Wit, Mercuri, Buchanan, Worster), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (de Wit, Parpia), McMaster University, Hamilton, Ont.; Dalla Lana School of Public Health (Mercuri), University of Toronto, Ont.; Emergency Department (Clayton), Hamilton Health Sciences; Department of Medicine (Clayton, Ali, Shoamanesh, Papaioannou, Parpia), McMaster University, Hamilton, Ont.; Centre de recherche du Centre hospitalier universitaire de Québec (Mercier) - Université Laval, Laval, Que.; VITAM - Centre de recherche en santé durable (Mercier, Émond), Québec, Que.; Department of Family Medicine and Emergency Medicine (Morris, Émond), Université de Montréal, Montréal, Que.; St. Luke's University Health Network (Jeanmonod), Bethlehem, Penn.; Department of Emergency Medicine (Eagles, Stiell), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Eagles, Stiell), University of Ottawa, Ottawa, Ont.; Schwartz/Reisman Emergency Medicine Institute (Eagles), Sinai Health, Toronto, Ont.; Clinical Epidemiology Program (Varner, McLeod), Ottawa Hospital Research Institute, Ottawa, Ont.; Division of Emergency Medicine (Varner, McLeod), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Barbic), University of British Columbia; Centre for Health Evaluation Outcome Sciences (Barbic), St. Paul's Hospital, Vancouver, BC; Department of Medical Imaging (Kagoma) and of Surgery (Engels, Sharma), McMaster University, Hamilton, Ont
| | - Judy Morris
- Department of Emergency Medicine (de Wit), Queen's University, Kingston, Ont.; Division of Emergency Medicine, Department of Medicine (de Wit, Mercuri, Buchanan, Worster), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (de Wit, Parpia), McMaster University, Hamilton, Ont.; Dalla Lana School of Public Health (Mercuri), University of Toronto, Ont.; Emergency Department (Clayton), Hamilton Health Sciences; Department of Medicine (Clayton, Ali, Shoamanesh, Papaioannou, Parpia), McMaster University, Hamilton, Ont.; Centre de recherche du Centre hospitalier universitaire de Québec (Mercier) - Université Laval, Laval, Que.; VITAM - Centre de recherche en santé durable (Mercier, Émond), Québec, Que.; Department of Family Medicine and Emergency Medicine (Morris, Émond), Université de Montréal, Montréal, Que.; St. Luke's University Health Network (Jeanmonod), Bethlehem, Penn.; Department of Emergency Medicine (Eagles, Stiell), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Eagles, Stiell), University of Ottawa, Ottawa, Ont.; Schwartz/Reisman Emergency Medicine Institute (Eagles), Sinai Health, Toronto, Ont.; Clinical Epidemiology Program (Varner, McLeod), Ottawa Hospital Research Institute, Ottawa, Ont.; Division of Emergency Medicine (Varner, McLeod), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Barbic), University of British Columbia; Centre for Health Evaluation Outcome Sciences (Barbic), St. Paul's Hospital, Vancouver, BC; Department of Medical Imaging (Kagoma) and of Surgery (Engels, Sharma), McMaster University, Hamilton, Ont
| | - Rebecca Jeanmonod
- Department of Emergency Medicine (de Wit), Queen's University, Kingston, Ont.; Division of Emergency Medicine, Department of Medicine (de Wit, Mercuri, Buchanan, Worster), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (de Wit, Parpia), McMaster University, Hamilton, Ont.; Dalla Lana School of Public Health (Mercuri), University of Toronto, Ont.; Emergency Department (Clayton), Hamilton Health Sciences; Department of Medicine (Clayton, Ali, Shoamanesh, Papaioannou, Parpia), McMaster University, Hamilton, Ont.; Centre de recherche du Centre hospitalier universitaire de Québec (Mercier) - Université Laval, Laval, Que.; VITAM - Centre de recherche en santé durable (Mercier, Émond), Québec, Que.; Department of Family Medicine and Emergency Medicine (Morris, Émond), Université de Montréal, Montréal, Que.; St. Luke's University Health Network (Jeanmonod), Bethlehem, Penn.; Department of Emergency Medicine (Eagles, Stiell), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Eagles, Stiell), University of Ottawa, Ottawa, Ont.; Schwartz/Reisman Emergency Medicine Institute (Eagles), Sinai Health, Toronto, Ont.; Clinical Epidemiology Program (Varner, McLeod), Ottawa Hospital Research Institute, Ottawa, Ont.; Division of Emergency Medicine (Varner, McLeod), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Barbic), University of British Columbia; Centre for Health Evaluation Outcome Sciences (Barbic), St. Paul's Hospital, Vancouver, BC; Department of Medical Imaging (Kagoma) and of Surgery (Engels, Sharma), McMaster University, Hamilton, Ont
| | - Debra Eagles
- Department of Emergency Medicine (de Wit), Queen's University, Kingston, Ont.; Division of Emergency Medicine, Department of Medicine (de Wit, Mercuri, Buchanan, Worster), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (de Wit, Parpia), McMaster University, Hamilton, Ont.; Dalla Lana School of Public Health (Mercuri), University of Toronto, Ont.; Emergency Department (Clayton), Hamilton Health Sciences; Department of Medicine (Clayton, Ali, Shoamanesh, Papaioannou, Parpia), McMaster University, Hamilton, Ont.; Centre de recherche du Centre hospitalier universitaire de Québec (Mercier) - Université Laval, Laval, Que.; VITAM - Centre de recherche en santé durable (Mercier, Émond), Québec, Que.; Department of Family Medicine and Emergency Medicine (Morris, Émond), Université de Montréal, Montréal, Que.; St. Luke's University Health Network (Jeanmonod), Bethlehem, Penn.; Department of Emergency Medicine (Eagles, Stiell), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Eagles, Stiell), University of Ottawa, Ottawa, Ont.; Schwartz/Reisman Emergency Medicine Institute (Eagles), Sinai Health, Toronto, Ont.; Clinical Epidemiology Program (Varner, McLeod), Ottawa Hospital Research Institute, Ottawa, Ont.; Division of Emergency Medicine (Varner, McLeod), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Barbic), University of British Columbia; Centre for Health Evaluation Outcome Sciences (Barbic), St. Paul's Hospital, Vancouver, BC; Department of Medical Imaging (Kagoma) and of Surgery (Engels, Sharma), McMaster University, Hamilton, Ont
| | - Catherine Varner
- Department of Emergency Medicine (de Wit), Queen's University, Kingston, Ont.; Division of Emergency Medicine, Department of Medicine (de Wit, Mercuri, Buchanan, Worster), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (de Wit, Parpia), McMaster University, Hamilton, Ont.; Dalla Lana School of Public Health (Mercuri), University of Toronto, Ont.; Emergency Department (Clayton), Hamilton Health Sciences; Department of Medicine (Clayton, Ali, Shoamanesh, Papaioannou, Parpia), McMaster University, Hamilton, Ont.; Centre de recherche du Centre hospitalier universitaire de Québec (Mercier) - Université Laval, Laval, Que.; VITAM - Centre de recherche en santé durable (Mercier, Émond), Québec, Que.; Department of Family Medicine and Emergency Medicine (Morris, Émond), Université de Montréal, Montréal, Que.; St. Luke's University Health Network (Jeanmonod), Bethlehem, Penn.; Department of Emergency Medicine (Eagles, Stiell), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Eagles, Stiell), University of Ottawa, Ottawa, Ont.; Schwartz/Reisman Emergency Medicine Institute (Eagles), Sinai Health, Toronto, Ont.; Clinical Epidemiology Program (Varner, McLeod), Ottawa Hospital Research Institute, Ottawa, Ont.; Division of Emergency Medicine (Varner, McLeod), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Barbic), University of British Columbia; Centre for Health Evaluation Outcome Sciences (Barbic), St. Paul's Hospital, Vancouver, BC; Department of Medical Imaging (Kagoma) and of Surgery (Engels, Sharma), McMaster University, Hamilton, Ont
| | - David Barbic
- Department of Emergency Medicine (de Wit), Queen's University, Kingston, Ont.; Division of Emergency Medicine, Department of Medicine (de Wit, Mercuri, Buchanan, Worster), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (de Wit, Parpia), McMaster University, Hamilton, Ont.; Dalla Lana School of Public Health (Mercuri), University of Toronto, Ont.; Emergency Department (Clayton), Hamilton Health Sciences; Department of Medicine (Clayton, Ali, Shoamanesh, Papaioannou, Parpia), McMaster University, Hamilton, Ont.; Centre de recherche du Centre hospitalier universitaire de Québec (Mercier) - Université Laval, Laval, Que.; VITAM - Centre de recherche en santé durable (Mercier, Émond), Québec, Que.; Department of Family Medicine and Emergency Medicine (Morris, Émond), Université de Montréal, Montréal, Que.; St. Luke's University Health Network (Jeanmonod), Bethlehem, Penn.; Department of Emergency Medicine (Eagles, Stiell), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Eagles, Stiell), University of Ottawa, Ottawa, Ont.; Schwartz/Reisman Emergency Medicine Institute (Eagles), Sinai Health, Toronto, Ont.; Clinical Epidemiology Program (Varner, McLeod), Ottawa Hospital Research Institute, Ottawa, Ont.; Division of Emergency Medicine (Varner, McLeod), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Barbic), University of British Columbia; Centre for Health Evaluation Outcome Sciences (Barbic), St. Paul's Hospital, Vancouver, BC; Department of Medical Imaging (Kagoma) and of Surgery (Engels, Sharma), McMaster University, Hamilton, Ont
| | - Ian M Buchanan
- Department of Emergency Medicine (de Wit), Queen's University, Kingston, Ont.; Division of Emergency Medicine, Department of Medicine (de Wit, Mercuri, Buchanan, Worster), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (de Wit, Parpia), McMaster University, Hamilton, Ont.; Dalla Lana School of Public Health (Mercuri), University of Toronto, Ont.; Emergency Department (Clayton), Hamilton Health Sciences; Department of Medicine (Clayton, Ali, Shoamanesh, Papaioannou, Parpia), McMaster University, Hamilton, Ont.; Centre de recherche du Centre hospitalier universitaire de Québec (Mercier) - Université Laval, Laval, Que.; VITAM - Centre de recherche en santé durable (Mercier, Émond), Québec, Que.; Department of Family Medicine and Emergency Medicine (Morris, Émond), Université de Montréal, Montréal, Que.; St. Luke's University Health Network (Jeanmonod), Bethlehem, Penn.; Department of Emergency Medicine (Eagles, Stiell), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Eagles, Stiell), University of Ottawa, Ottawa, Ont.; Schwartz/Reisman Emergency Medicine Institute (Eagles), Sinai Health, Toronto, Ont.; Clinical Epidemiology Program (Varner, McLeod), Ottawa Hospital Research Institute, Ottawa, Ont.; Division of Emergency Medicine (Varner, McLeod), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Barbic), University of British Columbia; Centre for Health Evaluation Outcome Sciences (Barbic), St. Paul's Hospital, Vancouver, BC; Department of Medical Imaging (Kagoma) and of Surgery (Engels, Sharma), McMaster University, Hamilton, Ont
| | - Mariyam Ali
- Department of Emergency Medicine (de Wit), Queen's University, Kingston, Ont.; Division of Emergency Medicine, Department of Medicine (de Wit, Mercuri, Buchanan, Worster), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (de Wit, Parpia), McMaster University, Hamilton, Ont.; Dalla Lana School of Public Health (Mercuri), University of Toronto, Ont.; Emergency Department (Clayton), Hamilton Health Sciences; Department of Medicine (Clayton, Ali, Shoamanesh, Papaioannou, Parpia), McMaster University, Hamilton, Ont.; Centre de recherche du Centre hospitalier universitaire de Québec (Mercier) - Université Laval, Laval, Que.; VITAM - Centre de recherche en santé durable (Mercier, Émond), Québec, Que.; Department of Family Medicine and Emergency Medicine (Morris, Émond), Université de Montréal, Montréal, Que.; St. Luke's University Health Network (Jeanmonod), Bethlehem, Penn.; Department of Emergency Medicine (Eagles, Stiell), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Eagles, Stiell), University of Ottawa, Ottawa, Ont.; Schwartz/Reisman Emergency Medicine Institute (Eagles), Sinai Health, Toronto, Ont.; Clinical Epidemiology Program (Varner, McLeod), Ottawa Hospital Research Institute, Ottawa, Ont.; Division of Emergency Medicine (Varner, McLeod), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Barbic), University of British Columbia; Centre for Health Evaluation Outcome Sciences (Barbic), St. Paul's Hospital, Vancouver, BC; Department of Medical Imaging (Kagoma) and of Surgery (Engels, Sharma), McMaster University, Hamilton, Ont
| | - Yoan K Kagoma
- Department of Emergency Medicine (de Wit), Queen's University, Kingston, Ont.; Division of Emergency Medicine, Department of Medicine (de Wit, Mercuri, Buchanan, Worster), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (de Wit, Parpia), McMaster University, Hamilton, Ont.; Dalla Lana School of Public Health (Mercuri), University of Toronto, Ont.; Emergency Department (Clayton), Hamilton Health Sciences; Department of Medicine (Clayton, Ali, Shoamanesh, Papaioannou, Parpia), McMaster University, Hamilton, Ont.; Centre de recherche du Centre hospitalier universitaire de Québec (Mercier) - Université Laval, Laval, Que.; VITAM - Centre de recherche en santé durable (Mercier, Émond), Québec, Que.; Department of Family Medicine and Emergency Medicine (Morris, Émond), Université de Montréal, Montréal, Que.; St. Luke's University Health Network (Jeanmonod), Bethlehem, Penn.; Department of Emergency Medicine (Eagles, Stiell), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Eagles, Stiell), University of Ottawa, Ottawa, Ont.; Schwartz/Reisman Emergency Medicine Institute (Eagles), Sinai Health, Toronto, Ont.; Clinical Epidemiology Program (Varner, McLeod), Ottawa Hospital Research Institute, Ottawa, Ont.; Division of Emergency Medicine (Varner, McLeod), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Barbic), University of British Columbia; Centre for Health Evaluation Outcome Sciences (Barbic), St. Paul's Hospital, Vancouver, BC; Department of Medical Imaging (Kagoma) and of Surgery (Engels, Sharma), McMaster University, Hamilton, Ont
| | - Ashkan Shoamanesh
- Department of Emergency Medicine (de Wit), Queen's University, Kingston, Ont.; Division of Emergency Medicine, Department of Medicine (de Wit, Mercuri, Buchanan, Worster), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (de Wit, Parpia), McMaster University, Hamilton, Ont.; Dalla Lana School of Public Health (Mercuri), University of Toronto, Ont.; Emergency Department (Clayton), Hamilton Health Sciences; Department of Medicine (Clayton, Ali, Shoamanesh, Papaioannou, Parpia), McMaster University, Hamilton, Ont.; Centre de recherche du Centre hospitalier universitaire de Québec (Mercier) - Université Laval, Laval, Que.; VITAM - Centre de recherche en santé durable (Mercier, Émond), Québec, Que.; Department of Family Medicine and Emergency Medicine (Morris, Émond), Université de Montréal, Montréal, Que.; St. Luke's University Health Network (Jeanmonod), Bethlehem, Penn.; Department of Emergency Medicine (Eagles, Stiell), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Eagles, Stiell), University of Ottawa, Ottawa, Ont.; Schwartz/Reisman Emergency Medicine Institute (Eagles), Sinai Health, Toronto, Ont.; Clinical Epidemiology Program (Varner, McLeod), Ottawa Hospital Research Institute, Ottawa, Ont.; Division of Emergency Medicine (Varner, McLeod), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Barbic), University of British Columbia; Centre for Health Evaluation Outcome Sciences (Barbic), St. Paul's Hospital, Vancouver, BC; Department of Medical Imaging (Kagoma) and of Surgery (Engels, Sharma), McMaster University, Hamilton, Ont
| | - Paul Engels
- Department of Emergency Medicine (de Wit), Queen's University, Kingston, Ont.; Division of Emergency Medicine, Department of Medicine (de Wit, Mercuri, Buchanan, Worster), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (de Wit, Parpia), McMaster University, Hamilton, Ont.; Dalla Lana School of Public Health (Mercuri), University of Toronto, Ont.; Emergency Department (Clayton), Hamilton Health Sciences; Department of Medicine (Clayton, Ali, Shoamanesh, Papaioannou, Parpia), McMaster University, Hamilton, Ont.; Centre de recherche du Centre hospitalier universitaire de Québec (Mercier) - Université Laval, Laval, Que.; VITAM - Centre de recherche en santé durable (Mercier, Émond), Québec, Que.; Department of Family Medicine and Emergency Medicine (Morris, Émond), Université de Montréal, Montréal, Que.; St. Luke's University Health Network (Jeanmonod), Bethlehem, Penn.; Department of Emergency Medicine (Eagles, Stiell), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Eagles, Stiell), University of Ottawa, Ottawa, Ont.; Schwartz/Reisman Emergency Medicine Institute (Eagles), Sinai Health, Toronto, Ont.; Clinical Epidemiology Program (Varner, McLeod), Ottawa Hospital Research Institute, Ottawa, Ont.; Division of Emergency Medicine (Varner, McLeod), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Barbic), University of British Columbia; Centre for Health Evaluation Outcome Sciences (Barbic), St. Paul's Hospital, Vancouver, BC; Department of Medical Imaging (Kagoma) and of Surgery (Engels, Sharma), McMaster University, Hamilton, Ont
| | - Sunjay Sharma
- Department of Emergency Medicine (de Wit), Queen's University, Kingston, Ont.; Division of Emergency Medicine, Department of Medicine (de Wit, Mercuri, Buchanan, Worster), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (de Wit, Parpia), McMaster University, Hamilton, Ont.; Dalla Lana School of Public Health (Mercuri), University of Toronto, Ont.; Emergency Department (Clayton), Hamilton Health Sciences; Department of Medicine (Clayton, Ali, Shoamanesh, Papaioannou, Parpia), McMaster University, Hamilton, Ont.; Centre de recherche du Centre hospitalier universitaire de Québec (Mercier) - Université Laval, Laval, Que.; VITAM - Centre de recherche en santé durable (Mercier, Émond), Québec, Que.; Department of Family Medicine and Emergency Medicine (Morris, Émond), Université de Montréal, Montréal, Que.; St. Luke's University Health Network (Jeanmonod), Bethlehem, Penn.; Department of Emergency Medicine (Eagles, Stiell), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Eagles, Stiell), University of Ottawa, Ottawa, Ont.; Schwartz/Reisman Emergency Medicine Institute (Eagles), Sinai Health, Toronto, Ont.; Clinical Epidemiology Program (Varner, McLeod), Ottawa Hospital Research Institute, Ottawa, Ont.; Division of Emergency Medicine (Varner, McLeod), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Barbic), University of British Columbia; Centre for Health Evaluation Outcome Sciences (Barbic), St. Paul's Hospital, Vancouver, BC; Department of Medical Imaging (Kagoma) and of Surgery (Engels, Sharma), McMaster University, Hamilton, Ont
| | - Andrew Worster
- Department of Emergency Medicine (de Wit), Queen's University, Kingston, Ont.; Division of Emergency Medicine, Department of Medicine (de Wit, Mercuri, Buchanan, Worster), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (de Wit, Parpia), McMaster University, Hamilton, Ont.; Dalla Lana School of Public Health (Mercuri), University of Toronto, Ont.; Emergency Department (Clayton), Hamilton Health Sciences; Department of Medicine (Clayton, Ali, Shoamanesh, Papaioannou, Parpia), McMaster University, Hamilton, Ont.; Centre de recherche du Centre hospitalier universitaire de Québec (Mercier) - Université Laval, Laval, Que.; VITAM - Centre de recherche en santé durable (Mercier, Émond), Québec, Que.; Department of Family Medicine and Emergency Medicine (Morris, Émond), Université de Montréal, Montréal, Que.; St. Luke's University Health Network (Jeanmonod), Bethlehem, Penn.; Department of Emergency Medicine (Eagles, Stiell), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Eagles, Stiell), University of Ottawa, Ottawa, Ont.; Schwartz/Reisman Emergency Medicine Institute (Eagles), Sinai Health, Toronto, Ont.; Clinical Epidemiology Program (Varner, McLeod), Ottawa Hospital Research Institute, Ottawa, Ont.; Division of Emergency Medicine (Varner, McLeod), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Barbic), University of British Columbia; Centre for Health Evaluation Outcome Sciences (Barbic), St. Paul's Hospital, Vancouver, BC; Department of Medical Imaging (Kagoma) and of Surgery (Engels, Sharma), McMaster University, Hamilton, Ont
| | - Shelley McLeod
- Department of Emergency Medicine (de Wit), Queen's University, Kingston, Ont.; Division of Emergency Medicine, Department of Medicine (de Wit, Mercuri, Buchanan, Worster), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (de Wit, Parpia), McMaster University, Hamilton, Ont.; Dalla Lana School of Public Health (Mercuri), University of Toronto, Ont.; Emergency Department (Clayton), Hamilton Health Sciences; Department of Medicine (Clayton, Ali, Shoamanesh, Papaioannou, Parpia), McMaster University, Hamilton, Ont.; Centre de recherche du Centre hospitalier universitaire de Québec (Mercier) - Université Laval, Laval, Que.; VITAM - Centre de recherche en santé durable (Mercier, Émond), Québec, Que.; Department of Family Medicine and Emergency Medicine (Morris, Émond), Université de Montréal, Montréal, Que.; St. Luke's University Health Network (Jeanmonod), Bethlehem, Penn.; Department of Emergency Medicine (Eagles, Stiell), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Eagles, Stiell), University of Ottawa, Ottawa, Ont.; Schwartz/Reisman Emergency Medicine Institute (Eagles), Sinai Health, Toronto, Ont.; Clinical Epidemiology Program (Varner, McLeod), Ottawa Hospital Research Institute, Ottawa, Ont.; Division of Emergency Medicine (Varner, McLeod), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Barbic), University of British Columbia; Centre for Health Evaluation Outcome Sciences (Barbic), St. Paul's Hospital, Vancouver, BC; Department of Medical Imaging (Kagoma) and of Surgery (Engels, Sharma), McMaster University, Hamilton, Ont
| | - Marcel Émond
- Department of Emergency Medicine (de Wit), Queen's University, Kingston, Ont.; Division of Emergency Medicine, Department of Medicine (de Wit, Mercuri, Buchanan, Worster), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (de Wit, Parpia), McMaster University, Hamilton, Ont.; Dalla Lana School of Public Health (Mercuri), University of Toronto, Ont.; Emergency Department (Clayton), Hamilton Health Sciences; Department of Medicine (Clayton, Ali, Shoamanesh, Papaioannou, Parpia), McMaster University, Hamilton, Ont.; Centre de recherche du Centre hospitalier universitaire de Québec (Mercier) - Université Laval, Laval, Que.; VITAM - Centre de recherche en santé durable (Mercier, Émond), Québec, Que.; Department of Family Medicine and Emergency Medicine (Morris, Émond), Université de Montréal, Montréal, Que.; St. Luke's University Health Network (Jeanmonod), Bethlehem, Penn.; Department of Emergency Medicine (Eagles, Stiell), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Eagles, Stiell), University of Ottawa, Ottawa, Ont.; Schwartz/Reisman Emergency Medicine Institute (Eagles), Sinai Health, Toronto, Ont.; Clinical Epidemiology Program (Varner, McLeod), Ottawa Hospital Research Institute, Ottawa, Ont.; Division of Emergency Medicine (Varner, McLeod), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Barbic), University of British Columbia; Centre for Health Evaluation Outcome Sciences (Barbic), St. Paul's Hospital, Vancouver, BC; Department of Medical Imaging (Kagoma) and of Surgery (Engels, Sharma), McMaster University, Hamilton, Ont
| | - Ian Stiell
- Department of Emergency Medicine (de Wit), Queen's University, Kingston, Ont.; Division of Emergency Medicine, Department of Medicine (de Wit, Mercuri, Buchanan, Worster), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (de Wit, Parpia), McMaster University, Hamilton, Ont.; Dalla Lana School of Public Health (Mercuri), University of Toronto, Ont.; Emergency Department (Clayton), Hamilton Health Sciences; Department of Medicine (Clayton, Ali, Shoamanesh, Papaioannou, Parpia), McMaster University, Hamilton, Ont.; Centre de recherche du Centre hospitalier universitaire de Québec (Mercier) - Université Laval, Laval, Que.; VITAM - Centre de recherche en santé durable (Mercier, Émond), Québec, Que.; Department of Family Medicine and Emergency Medicine (Morris, Émond), Université de Montréal, Montréal, Que.; St. Luke's University Health Network (Jeanmonod), Bethlehem, Penn.; Department of Emergency Medicine (Eagles, Stiell), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Eagles, Stiell), University of Ottawa, Ottawa, Ont.; Schwartz/Reisman Emergency Medicine Institute (Eagles), Sinai Health, Toronto, Ont.; Clinical Epidemiology Program (Varner, McLeod), Ottawa Hospital Research Institute, Ottawa, Ont.; Division of Emergency Medicine (Varner, McLeod), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Barbic), University of British Columbia; Centre for Health Evaluation Outcome Sciences (Barbic), St. Paul's Hospital, Vancouver, BC; Department of Medical Imaging (Kagoma) and of Surgery (Engels, Sharma), McMaster University, Hamilton, Ont
| | - Alexandra Papaioannou
- Department of Emergency Medicine (de Wit), Queen's University, Kingston, Ont.; Division of Emergency Medicine, Department of Medicine (de Wit, Mercuri, Buchanan, Worster), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (de Wit, Parpia), McMaster University, Hamilton, Ont.; Dalla Lana School of Public Health (Mercuri), University of Toronto, Ont.; Emergency Department (Clayton), Hamilton Health Sciences; Department of Medicine (Clayton, Ali, Shoamanesh, Papaioannou, Parpia), McMaster University, Hamilton, Ont.; Centre de recherche du Centre hospitalier universitaire de Québec (Mercier) - Université Laval, Laval, Que.; VITAM - Centre de recherche en santé durable (Mercier, Émond), Québec, Que.; Department of Family Medicine and Emergency Medicine (Morris, Émond), Université de Montréal, Montréal, Que.; St. Luke's University Health Network (Jeanmonod), Bethlehem, Penn.; Department of Emergency Medicine (Eagles, Stiell), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Eagles, Stiell), University of Ottawa, Ottawa, Ont.; Schwartz/Reisman Emergency Medicine Institute (Eagles), Sinai Health, Toronto, Ont.; Clinical Epidemiology Program (Varner, McLeod), Ottawa Hospital Research Institute, Ottawa, Ont.; Division of Emergency Medicine (Varner, McLeod), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Barbic), University of British Columbia; Centre for Health Evaluation Outcome Sciences (Barbic), St. Paul's Hospital, Vancouver, BC; Department of Medical Imaging (Kagoma) and of Surgery (Engels, Sharma), McMaster University, Hamilton, Ont
| | - Sameer Parpia
- Department of Emergency Medicine (de Wit), Queen's University, Kingston, Ont.; Division of Emergency Medicine, Department of Medicine (de Wit, Mercuri, Buchanan, Worster), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (de Wit, Parpia), McMaster University, Hamilton, Ont.; Dalla Lana School of Public Health (Mercuri), University of Toronto, Ont.; Emergency Department (Clayton), Hamilton Health Sciences; Department of Medicine (Clayton, Ali, Shoamanesh, Papaioannou, Parpia), McMaster University, Hamilton, Ont.; Centre de recherche du Centre hospitalier universitaire de Québec (Mercier) - Université Laval, Laval, Que.; VITAM - Centre de recherche en santé durable (Mercier, Émond), Québec, Que.; Department of Family Medicine and Emergency Medicine (Morris, Émond), Université de Montréal, Montréal, Que.; St. Luke's University Health Network (Jeanmonod), Bethlehem, Penn.; Department of Emergency Medicine (Eagles, Stiell), Ottawa Hospital Research Institute; School of Epidemiology and Public Health (Eagles, Stiell), University of Ottawa, Ottawa, Ont.; Schwartz/Reisman Emergency Medicine Institute (Eagles), Sinai Health, Toronto, Ont.; Clinical Epidemiology Program (Varner, McLeod), Ottawa Hospital Research Institute, Ottawa, Ont.; Division of Emergency Medicine (Varner, McLeod), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Department of Emergency Medicine (Barbic), University of British Columbia; Centre for Health Evaluation Outcome Sciences (Barbic), St. Paul's Hospital, Vancouver, BC; Department of Medical Imaging (Kagoma) and of Surgery (Engels, Sharma), McMaster University, Hamilton, Ont
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