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Acad Emerg Med. 2011 Mar;18(3):313-6. doi: 10.1111/j.1553-2712.2011.01017.x. Epub 2011 Feb 25.

Orbital fracture clinical decision rule development: burden of disease and use of a mandatory electronic survey instrument.

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Department of Emergency Medicine, The George Washington University, Washington, DC, USA.



In preparation for development of a clinical decision rule (CDR) to promote more efficient use of computed tomography (CT) for diagnosing orbital fractures, the authors sought to estimate the annual incidence of orbital fractures in emergency departments (EDs) and the usage of CT to make these diagnoses. The authors also sought to evaluate a mandatory electronic data collection instrument (EDCI) administered to providers to facilitate CDR data collection.


National estimates were made by analyzing the 2007 National Hospital Ambulatory Medical Care Survey (NHAMCS) database, while hospital billing system and coding data were used to make local estimates. An EDCI was integrated into the CT ordering system such that providers had to complete the form to perform a CT. Because the EDCI had to be filled out for every CT ordered, data collection efficiency was measured by compliance (counting the number of unrealistic data collection instrument answers) and by timing a convenience sample of providers completing the EDCI.


Out of 116.8 million ED visits in the United States in 2007, 4.1 million patients were treated for injuries of the eye and face. Of those, 820,252 patients underwent CT imaging, with 102,999 patients (12.5%) diagnosed with an orbital fracture. In our local hospital system with 122,500 annual ED visits, 752 CTs of orbits were performed, with 172 (23%) orbital fractures. The EDCI compliance rate was 94.9% and took less than 5 minutes to complete.


National and local data demonstrate a low yield for CT imaging in identifying orbital fractures. Data collection using a mandatory EDCI linked to computerized provider order entry can provide prospective, consecutive patient data that are needed to develop a CDR for the selective use of CT imaging in orbital trauma. Such a decision rule could increase the efficiency in diagnosing orbital fractures, thereby improving patient care, reducing radiation exposure, and decreasing costs.

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