Multifaceted education initiative minimizes pethidine prescribing in the emergency department

Background: Pain management experts have recommended a diminished role for pethidine because of lack of superiority for any indication and greater potential for adverse effects compared with morphine. Objectives: To evaluate the impact of a multifaceted education initiative on prescribing patterns and to minimize pethidine use in the ED. Methods: This was a pre‐ and post‐intervention study. The intervention was an education initiative, introduced between December 2003 and January 2004. It comprised ED pharmacist in‐services for medical and nursing staff, championing by senior medical staff (ED consultants, surgical units, Drug and Therapeutics Committee) and concurrent prescriber feedback by ED pharmacists. The pre‐intervention prescribing practices guided the development of in‐services and the educational programme. The intervention was evaluated by a medical record review of analgesic prescribing in March–April of both 2003 (pre‐intervention period) and 2004 (post‐intervention period). Outcome measures were the proportions of patients who were prescribed pethidine and the proportions of pethidine ampoules supplied to the ED. Results were analysed as differences in proportions. Results: In the pre‐intervention period, 60 ampoules of pethidine (7.2% of opiate doses) and 777 ampoules of morphine (92.8% of opiate doses) were administered compared with 15 ampoules of pethidine (1.7%) and 869 ampoules of morphine (98.3%) in the post‐intervention period (P < 0.001). Of patients who received an opiate dose, 50 of 798 (6.3%) and 11 of 747 (1.5%) received pethidine in the pre‐ and post‐intervention periods, respectively (P < 0.001). Conclusion: Our education initiative resulted in a sustained and significant reduction in pethidine prescribing in the ED. Sustainability requires ongoing in‐services for ED staff, usually as part of the orientation programme.     

An intervention to encourage ambulance paramedics to bring patients' own medications to the ED: Impact on medications brought in and prescribing errors

Objective: To undertake and evaluate a multifaceted intervention to encourage paramedics to bring patients' own medications (POM) to the ED. Method: Adult patients were enrolled in each of the pre‐intervention (March 2006) and post‐intervention (December 2006) periods if they were brought to ED by ambulance, taking four or more medications, admitted to hospital and were not referred to a pharmacist prior to the admission medication chart being written. ED pharmacists determined patients' regular medication and details of medications brought in by ambulance. Medication charts were assessed for discrepancies related to medications taken prior to presentation. These were recorded as errors if a change was made to the medication chart after discussion with the prescriber. The intervention, conducted in October and November 2006, involved meetings with Metropolitan Ambulance Service * team managers and dissemination of promotional material. Paramedics of the Metropolitan Ambulance Service were participants for the intervention. Main outcome measures were: percentage of regular medications incorrectly prescribed; and percentage of POM brought to ED by paramedics. Results: One hundred patients were enrolled in each of the pre‐ and post‐intervention periods. The percentage of regular medications incorrectly prescribed significantly decreased from 18.9% (151/800, 95% CI 16–22%) to 8.8% (73/834, 95% CI 7–11%) in the pre‐ and post‐intervention periods, respectively (P < 0.001). Pre‐intervention, paramedics brought some or all POM to ED in 67.0% (67/100, 95% CI 57–76%) of cases compared with 87.0% (87/100, 95% CI 78–93%) of cases, post‐intervention. Conclusion: The multifaceted intervention encouraging paramedics to bring POM to ED was effective. POM were brought into ED more frequently and prescribing errors reduced.     

Intermediate dose metoclopramide is not more effective than standard dose metoclopramide for patients who present to the emergency department with nausea and vomiting: a pilot study

Objective: To determine whether intermediate dose metoclopramide is more effective than standard dose metoclopramide for patients who present to the ED with nausea and vomiting. Methods: This prospective, single‐blind, randomized trial was conducted in the ED of two community teaching hospitals in a convenience sample of adult patients who presented to ED with nausea and vomiting. Patients were randomized to receive either 10 mg metoclopramide IV or 0.4 mg/kg IV (up to a maximum dose of 32 mg). The outcomes measured were: change in nausea score (measured on a 11‐point verbal rating scale), requirement for other anti‐emetic drug administration, and presence of side‐effects. Results: Fifty‐eight patients were eligible for analysis (34 in 10 mg group and 24 in 0.4 mg/kg group). Median reduction in nausea score in 10 mg group was four (range 0–10, 95% CI 3–5) compared with five for 0.4 mg/kg group (range ?1–10, 95% CI 4–6). This difference was not statistically significant (P = 0.629). Five patients in the 10 mg group required rescue anti‐emetic, compared with three in the 0.4 mg/kg group (P = 1.00). There were no side‐effects in the 10 mg group and two in the 0.4 mg/kg group. Conclusion: This study suggests that there is no difference in effectiveness between 10 mg and 0.4 mg/kg of metoclopramide in the ED population with nausea and vomiting.     

The influences of prompted voiding for urinary incontinence among older people in nursing homes

Research question: What are the influences of prompted voiding (PV) for urinary incontinence (UI) among older people in nursing homes? Research problem: This study aims to evaluate the effects of PV for UI of older people's subjects in nursing homes. Management of UI among older people is needed to overcome the possibility of new problem for older people. A randomized controlled study was performed of pre‐test post‐test design for 12 subjects (6 of control and 6 of intervention group). An intervention group followed PV instructions for 24 hours during 28 days, while the control group was instructed to urinate in toilet or to use diapers. Outcome variables were measured using incontinence severity index (ISI). There was statistically significant main effect across ISI among intervention group pre‐ (8.67 ± 1.97) and post‐ (6.67 ± 2.73) intervention of PV (P = .007). While there was statistically significant differenced ISI between control and intervention group (9.67 ± 1.86 vs 6.67 ± 2.73) post‐intervention of PV (P = .005). There was higher reduced ISI in the intervention group (?M ?2.00 ± 1.09) after 28 days of PV (P = .001). PV could be used to increase the older people's initiative to go to toilet and decrease incontinence episodes during a short time by their self in the nursing home.     

Tropisetron versus metoclopramide for the treatment of nausea and vomiting in the emergency department: A randomized,double‐blinded,clinical trial

Aim: We aimed to compare the relative efficacy of tropisetron and metoclopramide in treating nausea/vomiting in undifferentiated ED patients. Methods: We undertook a randomized, double‐blinded, clinical trial. Adult patients requiring treatment for nausea/vomiting were randomly assigned to either tropisetron (5 mg) or metoclopramide (10 mg), by i.v. bolus. The primary end‐point was incidence of vomiting. Secondary end‐points were decrease in nausea score from baseline (0–100 VAS), the requirement of ‘rescue’ anti‐emetics, ongoing nausea over 48 h and side‐effects. Results: Fifty patients were enrolled in each group. The demographic variables, presenting complaints and nausea scores at baseline did not differ (P > 0.05). By 180 min, two (4.0%) and nine (18.0%) patients had vomited in the tropisetron and metoclopramide groups respectively (difference 14.0%, 95% CI 0.1–28.0, P= 0.05). Also, there were two and 20 episodes of vomiting respectively. Vomiting rates were 0.02 and 0.16 episodes/person‐hour (difference 0.14 episodes/person‐hour, 95% CI 0.07–0.21, P < 0.001) respectively. By 60 min and thereafter, the decrease in nausea score from baseline was greater (although not significantly so) in the tropisetron group. At 180 min, the decreases were 47.9 mm and 37.0 mm respectively (difference 10.9 mm, 95% CI ?0.7–22.6). Five (10.0%) and 13 (26.0%) patients required a rescue anti‐emetic respectively (difference 16.0%, 95% CI ?0.7–32.7, P= 0.07). Of patients followed up, 13/47 (27.7%) and 20/49 (40.8%) had ongoing nausea respectively (difference 13.2%, 95% CI ?7.7–34.0, P= 0.25). The tropisetron group had less akathisia. Conclusions: Tropisetron was associated with a significantly lower vomiting rate and shows promise as an alternative anti‐emetic in the ED.     

Senior Streaming Assessment Further Evaluation after Triage zone: A novel model of care encompassing various emergency department throughput measures

Objective: Access block (AB) and hospital overcrowding adversely affect ED functionality. ED throughput measures have been described in the literature with positive impacts on key performance indicators (KPIs) – time to first seen, did‐not‐wait rates, off‐stretcher times for ambulances and ED length of stay figures. In this study, we aimed to assess the impact of a new model of care, the Senior Streaming Assessment Further Evaluation after Triage (SAFE‐T) zone concept on ED performance indicators and statistical outcomes. Methods: We implemented a model of care at our tertiary hospital ED amalgamating multiple ED throughput interventions. These interventions included dynamic transition waiting room concept, early senior ED physician assessment and decision‐making, early streaming, acute‐care bed quarantining and ED short stay and observation units. The principal intervention was the SAFE‐T zone. End‐point data were compared for similar periods (77 days) of 2010 and 2011 with and without the new model of care. Results: In total, 11 408 and 11 845 patients were included in the study periods pre‐ and post‐intervention, respectively. Time to physician KPI improved from 72.5% to 84.1%. Did‐not‐wait rates dropped from 10.7% to 9.6% (P= 0.02) and off‐stretcher times for ambulances KPI improved from 74.5% to 79.5% (P < 0.001). ED length of stay dropped most significantly for Australasian Triage Scale categories 3 and 4 (14.3% and 11.8%, P‐values <0.001). These results were achieved despite worsened AB and hospital bed‐occupancy rates during the intervention period (+3.9% and +6.7%). Conclusions: The SAFE‐T zone model of care involving multiple ED throughput measures achieved improvements in ED performance despite AB and hospital overcrowding.     

Evidence-based implementation of adult asthma guidelines in the emergency department: a controlled trial

Objective: To determine if an evidence‐based implementation (EBI) strategy could lead to the successful implementation of guidelines for the management of adult asthma in a large rural ED. Methods: This was a pre‐ and post‐intervention trial, comparing data for seven clinical indicators from a study hospital and a control hospital. Retrospective pre‐intervention audits were conducted at the study hospital for 3 months (1 April?30 June 2004) and the control hospital for 4 months (1 March?30 June 2004). The effect of an EBI to implement established guidelines for the management of asthma at the study hospital was compared with the effect of a mail‐out of guideline booklets and wall charts to the control hospital. Post‐intervention audits were then performed at both hospitals. Sustainability of the EBI was gauged by 12 month follow‐up data at the study hospital. Results: There were 55 presentations of adult asthma at the study hospital in the pre‐intervention phase and 67 post‐intervention. The corresponding numbers for the control hospital were 51 and 42, respectively. Following the EBI there were significant improvements at the study hospital for the documentation of severity (27–99%, P < 0.01), use of spirometry (38–84%, P < 0.01), medication delivery via spacer device (0–26%, P < 0.01), use of systemic steroids (66–84%P < 0.05), use of written short‐term asthma plans (14–82%, P < 0.01), reduction of ipratropium use in mild asthma (43–16%, P < 0.05) and reduction in antibiotic use in afebrile asthmatics (37–6%, P < 0.01). For the control hospital there was a significant increase in spirometry use from 2% to 40% (P < 0.01). For seven clinical indicators combined, compliance with the guideline increased from 38% to 79.1% (P < 0.01) at the study hospital, whereas there was no change at the control hospital, 44.3% to 43% (P = 0.75) There were 68 presentations at 12 month follow up at the study hospital and compliance with the seven clinical indicators was 78.2%. Conclusion: An EBI significantly improved compliance at the study hospital with no improvement noted in the control hospital. These improvements were maintained at 12 month follow up. An EBI can lead to significant improvements in the management of asthma at a large rural referral hospital ED and might have implications for hospitals with similar roles and profiles.     

Impact of a modified nursing handover model for improving nursing care and documentation in the emergency department: A pre‐ and post‐implementation study

The aim of this study was to evaluate whether implementation of a new nursing handover model led to improved completion of nursing care activities and documentation. A pre‐ and post‐implementation study, using a survey and document audit, was conducted in a hospital ED in Melbourne. A convenience sample of nurses completed the survey at baseline (n = 67) and post‐intervention (n = 59), and the audit was completed at both time points. Results showed significant improvements in several processes: handover in front of the patient (P < 0.001), patients contributed and/or listened to handover discussions (P < 0.001), and provision of adequate information about all patients in the department (P < 0.001). Nurses also reported a reduction in omission of vital signs (P = 0.022) during handover. Three hundred sixty‐eight medical records were audited in the two study periods: 173 (pre‐intervention) and 195 (post‐intervention). Statistically significant improvements in the completion of two nursing care tasks and three documentation items were identified. The findings suggest that implementation of a new handover model improved completion of nursing care activities and documentation, and transfer of important information to nurses on oncoming shifts.     

Prophylactic metoclopramide is unnecessary with intravenous analgesia in the ED

Antiemetics are commonly prescribed as prophylaxis for nausea and vomiting when opiate analgesics are prescribed in the emergency department. This prospective, randomized, double-blind, placebo-controlled trial assessed the incidence of nausea and vomiting after morphine and pethidine (meperidine) analgesia, and the effect of metoclopramide on this incidence. Intravenous morphine or pethidine analgesia was administered with metoclopramide or placebo to 122 opiate-na?ve patients with acute severe pain. Seven patients (5.7%) experienced nausea, three in the metoclopramide group and four in the placebo group. One patient (0.8%) had vomiting. The frequency of other side effects was higher in the metoclopramide group (7.9% versus 3.4%). None of these differences reached statistical significance. The low incidence of nausea and vomiting after opiate analgesia, and higher incidence of side effects with metoclopramide, are consistent with controlled data in the literature. Prophylactic metoclopramide should not be used routinely in ED patients receiving parenteral morphine or pethidine analgesia.     

Feasibility and benefits of a school-based academic and counseling program for older school-age students with asthma

An asthma education program for older school‐age students with asthma was developed in collaboration with school personnel, healthcare professionals, and community partners. Feasibility and benefits were evaluated using a single‐group, prospective, quasi‐experimental design. The convenience sample, consisting of 28 grade 6 and 7 students with asthma, had 50% males, a diverse racial background, and a wide range of incomes. Feasibility and benefits were demonstrated by comparing pre‐intervention to 1‐ and 12‐month post‐intervention evaluation of students who completed more than 70% of the 10 sessions. Statistically significant improvements in cognitive, behavioral, psychosocial, and quality of life outcomes were seen from pre‐intervention to 1‐month post‐intervention (all p < .03). Severity of asthma significantly improved from 1‐ to 12‐month post‐intervention (p = .04). © 2012 Wiley Periodicals, Inc. Res Nurs Health 35:507–517, 2012     

Peripheral Intravenous Cannula Insertion and Use in the Emergency Department: An Intervention Study

Objectives

The objective was to examine cannulation practice and effectiveness of a multimodal intervention to reduce peripheral intravenous cannula (PIVC) insertion in emergency department (ED) patients.

Methods

A prospective before and after study and cost analysis was conducted at a single tertiary ED in Australia. Data were collected 24 hours a day for 2 weeks pre‐ and post implementation of a multimodal intervention. PIVC placement and utilization within 24 hours were evaluated in all eligible patients.

Results

A total of 4,173 participants were included in the analysis. PIVCs were placed in 42.1% of patients' pre intervention and 32.4% post intervention, a reduction of 9.8% (95% confidence interval [CI] = 6.8 to –12.72%). PIVC usage within 24 hours of admission was 70.5% pre intervention and 83.4% post intervention, an increase of 12.9% (95% CI = 8.8% to 17.0%). Sixty‐six patients were observed in the ED for cost analysis. The mean time per PIVC insertion was 15.3 (95% CI = 12.6 to 17.9) minutes. PIVC insertion cost, including staff time and consumables per participant, was A$22.79 (95% CI = A$19.35 to A$26.23).

Conclusions

The intervention reduced PIVC placement in the ED and increased the percentage of PIVCs placed that were used. This program benefits patients and health services alike, with potential for large cost savings.

     

Video of a disaster drill is effective in educating registrars on the hospital disaster plan

Objective: To test whether an instructional video of edited footage from a disaster drill is effective in educating registrars on the hospital disaster plan. Methods: This was a prospective pre‐ and post‐intervention study. Forty hospital registrars were shown a 15 min video based on footage obtained at a simulated mass casualty incident. The video provided information on the ED disaster response plan and principles of hospital disaster management. A survey was developed to assess disaster plan knowledge before and after viewing the video. The survey had a predetermined ‘pass mark’ of 14/20 (70%). Results: Thirty‐nine registrars completed the surveys. Three of 39 (7.7% 95% confidence interval [CI] 7.0–8.3%) registrars achieved the pass mark in the pre‐video survey and 35/39 (89.7% 95% CI 81.2–98.3%) registrars achieved the pass mark in the post‐video survey (χ²‐test P < 0.001) with an absolute increase in the pass rate of 82% (95% CI 75.8–88.2%). Conclusion: This finding justifies compulsory viewing of the video in the registrar orientation package locally and might encourage more widespread use of educational video in hospital disaster preparedness.     

Comparison of lignocaine and water-based lubricating gels for female urethral catheterization: a randomized controlled trial

Objectives: It is standard practice to use lignocaine gel during male urethral catheterization. However, it is commonly believed that topical anaesthetic confers no benefit during female catheterization hence lubricating gel alone is more commonly used. The present study aimed to determine whether lignocaine gel decreased pain compared with water‐based lubricating gel for female urethral catheterization in the ED. Methods: This randomized double‐blinded study was carried out at two Sydney hospitals – an urban district inner western hospital and a south‐western major trauma centre. A convenience sample of 62 alert, cooperative adult female ED patients provided written informed consent. The indications for, and technique of catheterization, were at the discretion of the clinical staff. Pre‐ and immediate post‐procedure pain was scored by the patient on a 100 mm Visual Analogue Scale (VAS). The primary outcome was the difference in VAS scores (post‐ minus pre‐procedure) in millimetres. Values for each group were expressed as medians and interquartile ranges, statistical significance determined using the Mann–Whitney U‐test. Results: The groups were well matched for age, indication for catheterization, pre‐procedural pain score, catheter size and the number of catheterization attempts. Patients receiving lignocaine gel had a significantly lower median procedural pain score than patients receiving lubricating gel (6 mm vs 33 mm, P = 0.007). Conclusions: Lignocaine gel substantially reduces the procedural pain of female urethral catheterization by comparison with use of a water‐based lubricating gel.     

Impact of a government triple zero awareness campaign on emergency department patient characteristics

Objective: To evaluate the impact of a government triple zero community awareness campaign on the characteristics of patients attending an ED. Methods: A study using Emergency Department Information System data was conducted in an adult metropolitan tertiary‐referral teaching hospital in Brisbane. The three outcomes measured in the 3 month post‐campaign period were arrival mode, Australasian Triage Scale and departure status. These measures reflect ambulance usage, clinical urgency and illness severity, respectively. They were compared with those in the 3 month pre‐campaign period. Multivariate logistic regression models were used to investigate the impacts of the campaign on each of the three outcome measures after controlling for age, sex, day and time of arrival, and daily minimum temperature. Results: There were 17 920 visits in the pre‐ and 17 793 visits in the post‐campaign period. After the campaign, fewer patients arrived at the ED by road ambulance (odds ratio [OR] 0.90, 95% confidence interval [CI] 0.80–1.00), although the impact of the campaign on the arrival mode was only close to statistical significance (Wald χ²‐test, P= 0.055); and patients were significantly less likely to have higher clinical urgency (OR 0.86, 95% CI 0.79–0.94), while more likely to be admitted (OR 1.68, 95% CI 1.38–2.05) or complete treatment in the ED (OR 1.46, 95% CI 1.23–1.73) instead of leaving without waiting to be seen. Conclusions: The campaign had no significant impact on the arrival mode of the patients. After the campaign, the illness acuity of the patients decreased, whereas the illness severity of the patients increased.     

T HE E FFECTS OF P REHOSPITAL A DVANCED L IFE S UPPORT D RUG T REATMENT ON P ATIENT I MPROVEMENT AND I N-HOSPITAL U TILIZATION

Objective. There is little published evidence to support the benefits of prehospital drug administration by ambulance personnel in reducing subsequent hospital utilization by the medical patients receiving such drugs. The authors studied the outcome of patients treated by Ontario's Emergency Health Services “Symptom Relief Drug Program,” which was developed to relieve patient symptoms in the field for specific medical emergencies. Methods. A retrospective study spanning a three-year period from January 1996 to December 1998 was undertaken in a mid-sized southern Ontario community. From a review of ambulance call reports (ACRs), eligible patients were recruited by mail and divided into two groups: those treated before the introduction of the program (pre) and those treated after (post). Out-of-hospital data were retrieved from ACRs and in-hospital data were gathered from medical chart reviews. Outcomes included emergency department (ED) length of stay (LOS), frequency of admissions, and departmental use. Secondary endpoints included differences in prehospital improvement, ED interventions, and ambulance scene times. Results. For the unpaired analysis, 406 patients provided consent (pre: 215 vs post: 191). Ambulance time on scene was longer in the post group, 14.2 minutes (95% CI 13.7–14.8), versus the pre group, 12.3 minutes (95% CI 11.7–12.9), p < 0.001. A larger proportion of patients receiving prehospital drug treatment were judged to have improved on ED arrival (pre: 19.5% vs post: 48.2%, χ² p < 0.0001). The ED LOSs did not differ between groups (pre: 206.9?min, 95% CI 185.9–230.4, vs post: 220.9?min, 95% CI 196.9–247.7, p = 0.42) but were shorter within the post group for hypoglycemic patients receiving glucagon. The overall proportion of admissions was significantly lower in the post group (pre: 145 [67.4%] vs post: 102 [54.3%], χ² p < 0.01), and this was driven by chest pain patients. Conclusions. The lower rate of admissions for chest pain patients is the first published evidence of prehospital drug treatment's reducing hospital utilization in a subgroup of such medical patients. The “Symptom Relief Drug Program” is effective in improving patients' field conditions and can decrease ED LOS in hypoglycemic persons receiving glucagon injections. More outcome research pertaining to ambulance-administered prehospital drug treatment is warranted.     

Improving adherence to asthma clinical guidelines and discharge documentation from emergency departments: Implementation of a dynamic and integrated electronic decision support system†

Objective: The authors previously developed a dynamic and integrated electronic decision support system called ACAFE (Asthma Clinical Assessment Form and Electronic decision support). The objective of this present study was to evaluate the effectiveness of this system on asthma management and documentation in an ED. Method: Observational study using a pre‐ and post‐intervention design, comparing patients managed using ACAFE after its implementation with historical controls. A systematic data abstraction process was used to compare patient records. Results: A total of 50 patients were enrolled in the study group. These were compared with 50 historical controls. Use of ACAFE was associated with significantly higher rates of documentation of asthma severity (98% vs 18%, P < 0.01), as well as other clinically important variables, such as asthma precipitants, intensive care admission history and smoking history. ACAFE was also associated with significantly higher rate of asthma discharge plan documentation (76% vs 16%, P < 0.01), and this remained significant after adjustment for triage category and seniority of treating doctor in a regression model. Conclusion: The use of this decision support system in patients presenting to emergency with asthma was associated with improvements in clinical documentation and discharge management plans. Electronic decision support systems developed collaboratively with clinicians should play an important part of system‐wide efforts to improve guideline adherence and compliance in ED.     

Nontraumatic Headaches in the Emergency Department: Evaluation of a Clinical Pathway

Objective.— To determine the impact and efficacy of a clinical pathway in the management of patients with nontraumatic and afebrile headache (NTAH) in the emergency department (ED). Background.— Nontraumatic and afebrile headache is one of the most common neurological symptoms in the ED. However, data about the application of an evidence‐based operative protocol are lacking. Methods.— A before–after intervention study comparing adult patients presenting to the ED with atraumatic headache was conducted during a 6‐month period from April to September 2005 and with the same type of patients in the same period in 2006 after a clinical pathway had been implemented. According to their clinical presentations, patients of the 2006 group were divided into 3 subgroups and managed following the established protocol. Study results were based on analysis of 6 months of clinical outcome, the number of CT head scans in the ED, number of neurological consultations in the ED, number of admissions, and length of stay in the ED. Results.— A total of 686 patients were enrolled in the study, of which 374 were those presenting to our ED with NTAH in 2006 and managed with the aid of the study protocol; the other 312 patients were those who presented in 2005, before the intervention. The study protocol was strictly applied to 247 patients (66%) of the 2006 group. There were fewer neurological consultations after the intervention (41.2% vs 52.5%, difference: ?11.3%, 95% confidence intervals [CI]: ?18.7% to ?3.9%; P = .003); likewise, admissions were significantly reduced after the intervention (9.0% vs 14.7%, difference: ?5.7%, 95% CI: ?10.6% to ?0.8%; P = .02). No significant differences were found between the 2 groups for number of CT head scans (42.2% vs 38.4%, difference: 3.7%, 95% CI: ?3.5% to 11%; P = .3). Mean length of stay in the ED was lower after the intervention, though not significantly (170.6 ± 102 minutes vs 180.5 ± 105 minutes, difference: ?9.8 minutes, 95% CI: ?20.3 to 5.7; P = .09). A 6‐month follow‐up was completed involving 302 (96.7%) patients in the first group and 370 (98.9%) in the second group. There was only one misdiagnosis after the intervention while 2 incorrect diagnoses were made before the intervention (0.27% vs 0.6%, difference: ?0.33%, 95% CI: ?2.1% to 0.9%; P = .5). Conclusions.— Our diagnostic protocol for NTAH appears to be safe and sensitive in diagnosing malignant headaches. In addition, it may improve use of resources by reducing the need for neurological consultations and admissions without increasing the number of CT scans or prolonging length of stay in the ED. Furthermore, when using the protocol ED physicians seem more confident in their evaluations of headache resulting in fewer requests for specialist input.