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PubMedDate not supplied

Clinical management protocols: the bedside answer to clinical practice guidelines.

TOPIC: Clinical Management Protocols for trauma patients. PURPOSE: The goals and process for developing and implementing Clinical Management Protocols are presented. Protocol development and the differences between clinical practice guidelines, critical pathways, and clinical management protocols are discussed. SOURCES: Published literature, experience, and clinical expertise. CONCLUSIONS: Utilizing annotated algorithms, the protocols are designed for and driven by patient care based on patient need and require the collaboration of experts and trauma team members.

Algorithms↗

PubMed2003

Evaluation of two devices for self-measurement of blood pressure according to the international protocol: the Omron M5-I and the Omron 705IT.

BACKGROUND: Two devices for self-measurement of blood pressure at the brachial artery-the Omron M5-I and the Omron 705IT-were evaluated according to the international protocol of the European Society of Hypertension. DESIGN: The international validation protocol is divided into two phases: the first phase is performed on 15 selected subjects and if the device passes this phase, 18 supplementary subjects are included making a total number of 33 subjects on which the final validation is performed. METHODS: For each subject, four blood pressure (BP) measurements were performed simultaneously by two trained observers using mercury sphygmomanometers alternately with three measurements by the tested device. The difference between the BP value given by the device and that obtained by the two observers (mean of the two observers) was calculated for each measure. The 99 differences were classified into categories (<or=5, <or=10, <or=15 mmHg). The number of differences in each category was compared to the number required by the international protocol. An individual analysis was then done to determine for each subject the number of comparisons <or=5 mmHg. At least 22 of the 33 subjects should have two of their three comparisons <or=5 mmHg. RESULTS: The two tested devices passed the first phase of the validation process. For the second phase, the average differences between the device and mercury sphygmomanometer readings were -0.9+/-5.8 and -0.8+/-4.8 mmHg for systolic blood pressure (SBP) and diastolic blood pressure (DBP) respectively for the Omron M5-I device and -0.2+/-4.5 and -2.0+/-4.8 mmHg for the Omron 705IT device. Readings for the two devices differing by less than 5, 10 and 15 mmHg for systolic and diastolic values fulfil the recommendation criteria of the international protocol as well as the individual analysis. CONCLUSIONS: The Omron M-5I and the Omron 705IT devices pass the validation recommendations of the international protocol.

Adult↗

PubMed2006

Reduction of postoperative spinal infections based on an etiologic protocol.

UNLABELLED: Acute postoperative spinal infections are serious complications. We saw a sudden increase in the infection rate in our unit during a 6-month period. This led us to construct an assessment protocol combining risk factors into a mnemonic we named the "Nine Ps Protocol" (patient-related factors, personnel, place, preoperative length of stay, procedure, prosthetics, prophylaxis, packed red blood cells, and pus cultures). We reviewed 102 consecutive patients having spine surgery in three sequential 6 month periods: Group A included 34 patients before the outbreak of infection and Group B included 26 patients during the outbreak of infection. We prospectively applied the protocol in 26 patients (Group C) after the outbreak. After the implementation of the protocol the infection rate dropped from 16.7% (Group B) to 3.6% (Group C). Increased risk factors for postoperative infection included advanced age, posterior instrumented fusion, high allogenic blood transfusion rates, and suboptimal sheet and dressing changing conditions. We propose the Nine Ps Protocol as a useful clinical tool for the etiologic assessment and prevention of spinal infections. LEVEL OF EVIDENCE: Prognostic study, Level II (Lesser quality prospective study [eg, patients enrolled at different points in their disease or < 80% followup]). Please see Guidelines for Authors for a complete description of levels of evidence.

Adult↗

PubMed2007

Mandatory protocol for treating adult patients with diabetic ketoacidosis decreases intensive care unit and hospital lengths of stay: results of a nonrandomized trial.

OBJECTIVE: To determine the effect of a mandatory protocol for treating diabetic ketoacidosis. DESIGN: Chart review of patients treated before and after protocol implementation. SETTING: University-affiliated U.S. public teaching hospital. PATIENTS: A total of 241 consecutive nonpregnant patients >18 yrs old admitted to a medical intensive care unit for diabetic ketoacidosis between January 2000 and January 2005. INTERVENTION: Implementation of a mandatory treatment protocol in May 2003. MEASUREMENTS: Intensive care unit and hospital lengths of stay, time to correction of anion gap and ketone clearance, and hypoglycemic episodes. RESULTS: Before protocol implementation, the mean +/- sd intensive care unit and hospital lengths of stay were 44 +/- 28 hrs and 91 +/- 73 hrs, respectively. After implementation, intensive care unit and hospital lengths of stay decreased 23% and 30%, to 34 +/- 18 hrs and 64 +/- 41 hrs, respectively (both p < .007). Time to anion gap closure and ketone clearance also decreased (both p < .05). No difference in the number of hypoglycemic episodes was observed. CONCLUSION: Implementing a mandatory protocol for treating adult patients with diabetic ketoacidosis decreases intensive care and hospital lengths of stay and time to anion gap closure and ketone clearance, without increasing the rate of hypoglycemia.

Acid-Base Equilibrium↗

PubMed2005

Sexually transmitted disease testing protocols, sexually transmitted disease testing, and discussion of sexual behaviors in HIV clinics in Los Angeles County.

OBJECTIVE/GOAL: The objective of this study was to evaluate the use of written protocols for sexually transmitted disease (STD) screening, the frequency and types of STD tests performed, and the occurrence and frequency of obtaining sexual risk assessments among HIV clinics. STUDY: A survey was administered to 36 medical directors, clinic directors, and HIV providers representing 48 HIV healthcare clinics in Los Angeles. RESULTS: The use of a written or electronic protocol for STD testing was reported by 50% of clinics. Clinics with written or electronic STD protocols were significantly more likely to report questioning patients at each visit regarding their sexual practices (prevalence ratio, 2.2; 95% confidence interval, 1.4-3.4). Clinics with written or electronic protocols were not more likely to report more frequent STD testing. CONCLUSIONS: Written or electronic protocols for STD testing may promote sexual risk assessment questioning among HIV healthcare providers and may help to ensure STD testing per Centers for Disease Control and Prevention/IDSA guidelines for HIV-positive persons at sexual risk.

Ambulatory Care Facilities↗

PubMedDate not supplied

Implementing a protocol for weaning patients off mechanical ventilation.

Weaning patients from ventilation can be a costly and time-consuming intervention. This article describes how a protocol was designed and introduced into the critical care unit of a district general hospital in 2003. A step-by-step approach was used based on that outlined by the Modernisation Agency and The National Institute for Clinical Excellence. The purpose of the project was to improve the weaning process in the unit by devising a protocol, which would give structure to weaning and help maintain continuity. It was hoped that the changes in practice would also reduce ventilator time and improve patient outcomes. A multi-professional group interested in weaning worked together to formulate a protocol, which was duly implemented into the unit. After implementation, the protocol was audited and subsequently adopted by the unit. Although it was agreed that the structure and the continuity of weaning had improved, reducing weaning times and patient outcomes was difficult to measure. This article explains how the protocol came to be written and how it was implemented into the unit.

Algorithms↗

PubMed2004

Secondary prevention of fractures in older people: evaluation of a protocol for the investigation and treatment of osteoporosis.

It has been found previously that the investigation and treatment of osteoporosis following a fracture is poor, with only 9% of older people after a fracture being on effective osteoporosis treatment. To improve this aspect of post-fracture care in older people, a protocol has been instituted on an orthogeriatric rehabilitation ward in Christchurch, New Zealand. An audit was performed to assess the efficacy of this protocol in improving the investigation and treatment of osteoporosis (n = 193). Compliance with the investigation protocol was assessed and the pharmacological therapy initiated was requested from the general practitioner. All recommended blood-test investigations were requested in 62.8% of cases. Compared to a pre-protocol population, there was a marked increase in the measurement of bone mineral density (BMD; 93 vs 11%, P < 0.01) and vitamin D (95 vs 12%, P < 0.01). Vitamin D levels were low/-borderline in 95.6% of cases. BMD was performed in 77.7% of cases and showed osteoporosis and osteopenia to be present in 78.6 and 14.0%, respectively. For the 60 patients with BMD-confirmed osteoporosis whose therapy was obtained, 13.3% had no pharmacological therapy prescribed. Calcium, vitamin D or both were prescribed in 85.0%, bisphosphonates in 50.0% and hormone replacement therapy in 1.7% of patients. Vitamin D deficiency and osteoporosis on the basis of the BMD result are very common. The institution of a protocol has shown a significant improvement in the management of osteoporosis following a fracture. Some of the multifactorial barriers to full implementation of the guidelines are described.

Aged↗

PubMed2005

Evaluation of a pre-operative staging protocol in the management of colorectal carcinoma.

OBJECTIVE: The optimum strategy for pre-operative staging of colorectal carcinoma (CRC) has yet to be defined. A protocol for staging CRC patients was set up in this hospital in 1998. The protocol included complete colonic visualization together with assessment of the liver and lung for potential metastatic disease. Pelvic imaging was required to assess the local spread of rectal tumours. Our aim was to evaluate prospectively this protocol. PATIENTS AND METHODS: Data from all patients diagnosed with primary CRC between January 1999 and December 2002 were prospectively collected and analysed. RESULTS: There were 295 patients; 56 (19%) patients presented as an emergency and were excluded. The study group consisted of 239 patients (206 had elective surgery and 33 had no resectional surgery). In the patients who presented electively; 88% had complete colonic imaging; 87% chest imaging; 90% had liver imaging; 91% of rectal tumours had pelvic imaging. Overall 75% of the elective patients completed the staging protocol. Reasons for incomplete staging were numerous and most were justifiable. Findings which influenced clinical management included alteration in surgical approach (14), lung metastases (7), primary lung cancers (2), definite liver metastases (25), possible liver metastases (8), neo-adjuvant radiotherapy required (27), advanced local disease (9) and other incidental findings (12). CONCLUSION: Our protocol influenced further management decisions in 39% of patients. Better stratification of patient care is possible, with the ultimate aim to avoid unnecessary surgery. However, complete staging is not always possible to perform.

Adult↗

PubMed2006

Importance of peripheral biopsies in maximising the detection of early prostate cancer in repeat 12-core biopsy protocols.

OBJECTIVE: To assess cancer-detection rates in repeat 12-core biopsy protocols, as extended multicore prostate biopsy protocols have become standard when investigating men with a raised prostate-specific antigen (PSA) level, but repeat prostate biopsy protocols are still developing. PATIENTS AND METHODS: During a 4.5-year period, 241 of 590 patients with persistently high age-specific PSA levels of 2.6-10 ng/mL and an initial benign biopsy were invited for repeat transrectal ultrasonography-guided 12-core prostatic biopsy. The protocol for repeat biopsy was identical to the first biopsy, and included a periprostatic nerve block. The first six biopsies were obtained from the periphery of the gland directed more laterally at the base, mid-zone and apices. The remainder were parasagittal sextant biopsies. Pathological findings were analysed on an individual core basis. RESULTS: The mean age of the 241 men was 63.4 years; cancer was diagnosed in 40 (16.6%) on repeat biopsy. Men with cancer were older and had a higher median PSA level. The median Gleason score was 6, with a median of two cores positive for cancer. Maximum cancer detection rates were from peripheral apices (37.5%), basal biopsies had the lowest detection rates (23.8% and 16.3%), and parasagittal biopsies missed 35% of detected cancers. Patients with cancer also had significantly lower prostate volumes and higher PSA densities (both P < 0.001). CONCLUSION: A low cancer yield from both peripheral basal and parasagittal basal specimens on repeat biopsy indicates adequate sampling at initial biopsy. The maximum cancer yield in the peripheral mid-zones and apical zones suggests the necessity for concentrated sampling of these zones in repeat biopsy protocols.

Adult↗

PubMed2001

A protocol of selective antibiotic prophylaxis for caesarean section based on risk factors.

The aim of the study was to identify risk factors associated with increased risks of post Caesarean febrile morbidity from a retrospective epidemiological analysis, and to prospectively evaluate a protocol of selective antibiotic prophylaxis based on these risk factors. Caesarean section births over a three-year period--during which no antibiotic prophylaxis protocol was practised--were reviewed. Risk factors for febrile morbidity were identified using both univariate and multivariate analysis. A protocol of selective antibiotic prophylaxis, incorporating the significant risk factors identified, was then evaluated prospectively over a nine-month period. The incidence of febrile morbidity from the retrospective study was 16.9%. A logistic regression model, with febrile morbidity as the dependent variable, identified only the duration of labour over 10 hours as a significant factor. A protocol of antibiotic prophylaxis using intravenous ampicillin was then practised in the presence of these two factors. Evaluation of this protocol after nine months showed that the incidence of febrile morbidity was reduced significantly from 20% in those not given antibiotics to around 9.6% in those eligible for and given antibiotics. However, the overall incidence of febrile morbidity remained at around 16-18%.

Adult↗

PubMed2005

A comparison of two FMRI protocols for eliciting hippocampal activation.

PURPOSE: Previous research suggests that the hippocampus is modulated both by stimulus novelty and by the extent to which relational processing (formation of associations) occurs during episodic encoding. The aim of this study was to compare hippocampal activation patterns measured by functional magnetic resonance imaging (fMRI) during encoding protocols emphasizing either novelty or relational processing. METHODS: fMRI was performed on 32 healthy volunteers while they encoded complex visual scenes or unrecognizable scrambled versions of the same scenes. In the Novelty contrast, encoding of novel scenes was compared with encoding of a repeated pair of scenes. In the Relational Processing contrast, semantic encoding of novel scenes was compared with structural encoding of scrambled scenes. RESULTS: Both protocols elicited bilateral hippocampal activation. Overall mean activation values were similar for the two protocols, but the Relational Processing protocol resulted in a larger volume of hippocampal activation. The pattern of activation along the longitudinal hippocampal axis differed for the two protocols. The Novelty contrast produced stronger activation in the posterior hippocampus, whereas the Relational Processing contrast produced stronger activation in the anterior hippocampus. CONCLUSIONS: Hippocampal activation is determined by both stimulus novelty and degree of relational processing during encoding. Given the importance of anterior hippocampal pathology in temporal lobe epilepsy, an approach emphasizing modulation of relational processing may be preferable for clinical fMRI of the medial temporal lobes.

Adolescent↗

PubMed2000

Evaluation of protocols allowing emergency medical technicians to determine need for treatment and transport.

OBJECTIVE: To determine whether emergency medical technicians (EMTs) can safely apply protocols to assign transport options and to assess agreement between groups of providers on application of the protocols. METHODS: Developed protocols categorized patients as: 1) needs ambulance; 2) go to the emergency department (ED) by alternative means; 3) contact primary care provider (PCP); or 4) treat and release. After education on the application of the protocols, first responders and ambulance EMTs categorized patients at the scene prior to transport but did not change current practice. Ambulance reports were reviewed using a predetermined list of critical events that signified the need for an ambulance. RESULTS: The EMTs categorized 1,300 study patients as follows: 1,023 (79%) needed ambulance transport, 200 (15%) could go to the ED by alternative means, 63 (5%) could contact a PCP, 14 (1%) could be treated and released. Categorizations by a first responder and the transporting EMT were compared for 209 patients. Collapsing categories to "need ambulance/do not need ambulance" showed fair concordance (kappa = 0.51). Initially, 30 of 277 (11%) patients determined not to need an ambulance appeared to experience a critical event. After review, 23 patients had events that may not warrant advanced life support transport. Seven (3%) had critical events in the ambulance warranting ambulance transport. Most were miscategorized by the EMT. Overall sensitivity and specificity for identifying patients needing ambulance transport were 94.5% and 32.8%, respectively. CONCLUSIONS: From 3% to 11% of patients determined on scene not to need an ambulance had a critical event. Emergency medical services systems need to determine an acceptable rate of undertriage. Further study is needed to determine whether better adherence to the protocols might increase safety.

Adult↗

PubMed2001

Variation in institutional review board responses to a standard protocol for a multicenter clinical trial.

UNLABELLED: Multicenter clinical trials require approval by multiple local institutional review boards (IRBs). The Multicenter Airway Research Collaboration mailed a clinical trial protocol to its U.S. investigators and 44 IRBs ultimately reviewed it. OBJECTIVE: To describe IRB responses to one standard protocol and thereby gain insight into the advantages and disadvantages of local IRB review. METHODS: Two surveys were mailed to participants, with telephone follow-up of nonrespondents. Survey 1 was mailed to 82 investigators across North AMERICA: Survey 2 was mailed to investigators from 44 medical centers in 17 U.S. states. Survey 1 asked about each investigator's local IRB (e.g., frequency of meetings, membership), whereas survey 2 asked about IRB queries and concerns related to the submitted clinical trial. RESULTS: Both surveys had 100% response rate. Investigators submitted applications a median of 58 days (interquartile range [IQR], 40--83) after receipt of the protocol, and IRB approval took an additional 38 days (IQR, 26--62). Although eight applications were approved with little or no changes, IRBs requested an average of 3.5 changes per site. Changes involved study logistics and supervision for 45%, the research process for 43%, and the consent form for 91%. Despite these numerous requests, all eventually approved the basic protocol, including inclusion criteria, intervention, and data collection. CONCLUSIONS: The IRBs showed extreme variability in their initial responses to a standard protocol, but ultimately all gave approval. Almost all IRBs changed the consent form. A national, multicenter IRB process might streamline ethical review and warrants further consideration.

Androstadienes↗

PubMed2002

Impact of emergency medicine faculty and an airway protocol on airway management.

OBJECTIVE: To determine the impact of emergency medicine (EM) faculty presence and an airway management protocol on success rates of tracheal intubation in the emergency department (ED). METHODS: A retrospective observational study of prospectively collected data on rates of successful intubations between June 1997 and December 2001 in the ED of a large urban teaching hospital. The authors compared success rates of the first attempt at intubation and times to intubation prior to and after EM faculty presence and the institution of an airway management protocol. RESULTS: Prior to EM faculty presence and the airway management protocol, tracheal intubation was achieved on the first attempt 46% of the time; more than six attempts were required 2.9% of the time. The mean time to intubation was 9.2 minutes (+/-13.2 SD). Following EM faculty presence and the airway protocol, the success rate on the first attempt was 62%, more than six attempts were required 1.1% of the time, and the mean time to intubation was 4.6 minutes (+/-6.2 SD). CONCLUSIONS: First-attempt intubation success rates and decreased mean time to successful intubation improved following EM faculty presence and the introduction of an airway management protocol.

Clinical Protocols↗

PubMed2001

Reference dosimetry in clinical high-energy electron beams: comparison of the AAPM TG-51 and AAPM TG-21 dosimetry protocols.

A comparison of the determination of absorbed dose to water in reference conditions with high-energy electron beams (Enominal of 6, 8, 10, 12, 15, and 18 MeV) following the recommendations given in the AAPM TG-51 and in the original TG-21 dosimetry protocols has been made. Six different ionization chamber types have been used, two Farmer-type cylindrical (PTW 30001, PMMA wall; NE 2571, graphite wall) and four plane parallel (PTW Markus, and Scanditronix-Wellhöfer NACP, PPC-05 and Roos PPC-40). Depending upon the cylindrical chamber type used and the beam energy, the doses at dmax determined with TG-51 were higher than with TG-21 by about 1%-3%. Approximately 1% of this difference is due to the differences in the data given in the two protocols; another 1.1%-1.2% difference is due to the change of standards, from air-kerma to absorbed dose to water. For plane-parallel chambers, absorbed doses were determined by using two chamber calibration methods: (i) direct use of the ADCL calibration factors N(60Co)D,w and Nx for each chamber type in the appropriate equations for dose determination recommended by each protocol, and (ii) cross-calibration techniques in a high-energy electron beam, as recommended by TG-21, TG-39, and TG-51. Depending upon the plane-parallel chamber type used and the beam energy, the doses at dmax determined with TG-51 were higher than with TG-21 by about 0.7%-2.9% for the direct calibration procedures and by 0.8%-3.2% for the cross-calibration techniques. Measured values of photon-electron conversion kecal, for the NACP and Markus chambers were found to be 0.3% higher and 1.7% lower than the corresponding values given in TG-51. For the PPC-05 and PPC-40 (Roos) chamber types, the values of kecal were measured to be 0.889 and 0.893, respectively. The uncertainty for the entire calibration chain, starting from the calibration of the ionization chamber in the standards laboratory to the determination of absorbed dose to water in the user beam, has been analyzed for the two formalisms. For cylindrical chambers, the observed differences between the two protocols are within the estimated combined uncertainty of the ratios of absorbed doses for 6 and 8 MeV; however, at higher energies (10< or =E< or =18 MeV), the differences are larger than the estimated combined uncertainties by about 1%. For plane-parallel chambers, the observed differences are within the estimated combined uncertainties for the direct calibration technique; for the cross-calibration technique the differences are within the uncertainty estimates at low energies whereas they are comparable to the uncertainty estimates at higher energies. A detailed analysis of the reasons for the discrepancies is made which includes comparing the formalisms, correction factors, and quantities in the two protocols, as well as the influence of the implementation of the different standards for chamber calibration.

Biophysical Phenomena↗

PubMed1999

AAPM's TG-51 protocol for clinical reference dosimetry of high-energy photon and electron beams.

A protocol is prescribed for clinical reference dosimetry of external beam radiation therapy using photon beams with nominal energies between 60Co and 50 MV and electron beams with nominal energies between 4 and 50 MeV. The protocol was written by Task Group 51 (TG-51) of the Radiation Therapy Committee of the American Association of Physicists in Medicine (AAPM) and has been formally approved by the AAPM for clinical use. The protocol uses ion chambers with absorbed-dose-to-water calibration factors, N(60Co)D,w which are traceable to national primary standards, and the equation D(Q)w = MkQN(60Co)D,w where Q is the beam quality of the clinical beam, D(Q)w is the absorbed dose to water at the point of measurement of the ion chamber placed under reference conditions, M is the fully corrected ion chamber reading, and kQ is the quality conversion factor which converts the calibration factor for a 60Co beam to that for a beam of quality Q. Values of kQ are presented as a function of Q for many ion chambers. The value of M is given by M = PionP(TP)PelecPpolMraw, where Mraw is the raw, uncorrected ion chamber reading and Pion corrects for ion recombination, P(TP) for temperature and pressure variations, Pelec for inaccuracy of the electrometer if calibrated separately, and Ppol for chamber polarity effects. Beam quality, Q, is specified (i) for photon beams, by %dd(10)x, the photon component of the percentage depth dose at 10 cm depth for a field size of 10x10 cm2 on the surface of a phantom at an SSD of 100 cm and (ii) for electron beams, by R50, the depth at which the absorbed-dose falls to 50% of the maximum dose in a beam with field size > or =10x10 cm2 on the surface of the phantom (> or =20x20 cm2 for R50>8.5 cm) at an SSD of 100 cm. R50 is determined directly from the measured value of I50, the depth at which the ionization falls to 50% of its maximum value. All clinical reference dosimetry is performed in a water phantom. The reference depth for calibration purposes is 10 cm for photon beams and 0.6R50-0.1 cm for electron beams. For photon beams clinical reference dosimetry is performed in either an SSD or SAD setup with a 10x10 cm2 field size defined on the phantom surface for an SSD setup or at the depth of the detector for an SAD setup. For electron beams clinical reference dosimetry is performed with a field size of > or =10x10 cm2 (> or =20x20 cm2 for R50>8.5 cm) at an SSD between 90 and 110 cm. This protocol represents a major simplification compared to the AAPM's TG-21 protocol in the sense that large tables of stopping-power ratios and mass-energy absorption coefficients are not needed and the user does not need to calculate any theoretical dosimetry factors. Worksheets for various situations are presented along with a list of equipment required.

Biophysical Phenomena↗

PubMed2000

Clinical reference dosimetry: comparison between AAPM TG-21 and TG-51 protocols.

We compare the results of absorbed dose determined at reference conditions according to the AAPM TG-21 dose calibration protocol and the new AAPM TG-51 protocol. The AAPM TG-21 protocol for absorbed dose calibration is based on ionization chambers having exposure calibration factors for 60Co gamma rays, N(x). The new AAPM TG-51 dosimetry protocol for absorbed dose calibration is based on ionization chambers having 60Co absorbed dose-to-water calibration factor, N60Co(D,w). This study shows that the dose changes are within 1% for a cobalt beam, 0.5% for photon energies of 6 and 18 MV, and 2%-3% for electron beams with energies of 6 to 20 MeV. The chamber primary calibration factors, Nx and N60Co(D,w), are traceable to the Canadian primary standards laboratory (NRCC). We also present estimated dose changes between the two protocols when calibration factors are traceable to NIST in the United States.

Biophysical Phenomena↗

PubMed1991

Clinical and financial audit of diagnostic protocols for lesions of the cerebellopontine angle.

OBJECTIVE: To assess the diagnostic efficiency and costs of protocols used for investigating patients with suspected lesions of the cerebellopontine angle. DESIGN: Prospective evaluation of tests of auditory brain stem responses and acoustic reflex thresholds, electronystagmography, and calorics. Positive test results were confirmed or refuted by high resolution computed tomography with intravenous enhancement. SETTING: Single general otolaryngology clinic in a teaching hospital. PATIENTS: 270 consecutive patients with sensorineural hearing loss requiring investigation to exclude a lesion of the cerebellopontine angle. MAIN OUTCOME MEASURES: Estimated costs of various diagnostic protocols and performance in detecting tumours of the cerebellopontine angle. RESULTS: Protocols including tests of auditory brain stem responses and acoustic reflex thresholds as sifting tests before computed tomography were clinically acceptable and presented considerable savings over the use of computed tomography in all patients (74,000 pounds or 84,000 pounds v 122,000 pounds). The use of electronystagmography and calorics could not be justified on clinical or financial grounds. CONCLUSIONS: Audiological tests of auditory brain stem responses and acoustic reflex thresholds followed by computed tomography constitute the most cost effective protocol for determining suspected lesions of the cerebellopontine angle. IMPLICATIONS: The cost effectiveness of diagnostic protocols should be evaluated throughout the health service.

Caloric Tests↗