Calculating Emergency Risk Scores

1. What is the clinical question to be answered? (Default: identify primary complaint driving score selection)
2. What are the patient's demographics (age, sex)? (Default: required for most scoring systems)
3. What are the current vital signs? (Default: full set required before scoring)
4. What laboratory values are available (troponin, D-dimer, lactate, BNP, creatinine)? (Default: collect before calculating dependent scores)
5. What is the patient's medical history relevant to the scoring system? (Default: query PMH, DVT/PE history, cancer history, prior cardiac history)
6. Is the patient pregnant? (Default: pregnancy modifies applicability of several scores)
7. What imaging results are available? (Default: collect CXR, ECG results before scoring)

Documents to Request

• Complete vital signs with time stamps
• Laboratory results (troponin, D-dimer, BMP, CBC, coagulation studies, lactate)
• 12-lead ECG
• Chest X-ray report
• Prior cardiac testing results (stress test, catheterization)
• Problem list and medication list

Step 1: HEART Score (Chest Pain / ACS Risk)

Use for: Adult chest pain patients being evaluated for acute coronary syndrome.

Risk stratification:

Documentation requirement: Record each component value and total score. Example: "HEART score: H=1, E=0, A=2, R=1, T=0 = 4 (moderate risk)."

Step 2: PERC Rule and Wells Score (Pulmonary Embolism)

Pre-Test Probability: Wells Score for PE

PERC Rule (applies only if Wells ≤4)

All 8 criteria must be negative to rule out PE without D-dimer:

1. Age <50
2. Heart rate <100
3. SpO2 ≥95% on room air
4. No unilateral leg swelling
5. No hemoptysis
6. No surgery or trauma within 4 weeks
7. No prior DVT/PE
8. No estrogen use (OCP, HRT)

If all 8 negative: PE effectively excluded (miss rate <2%, below test threshold). No D-dimer or CTA needed. If any positive: Obtain D-dimer. If D-dimer negative (age-adjusted: <age × 10 for patients >50) → PE excluded. If positive → CTA.

Step 3: Ottawa Ankle and Knee Rules

Ottawa Ankle Rules

Obtain ankle X-ray only if:

• Bone tenderness at posterior edge or tip of lateral malleolus (distal 6 cm), OR
• Bone tenderness at posterior edge or tip of medial malleolus (distal 6 cm), OR
• Inability to bear weight (4 steps) immediately and in ED

Obtain foot X-ray only if:

• Bone tenderness at base of 5th metatarsal, OR
• Bone tenderness at navicular bone, OR
• Inability to bear weight (4 steps) immediately and in ED

Sensitivity: 98-100% for clinically significant fractures. Specificity: 40-50%. Exclusions: Age <18, intoxication, distracting injuries, diminished sensation, pregnant, isolated skin injury.

Ottawa Knee Rule

Obtain knee X-ray only if any of the following present:

1. Age ≥55
2. Isolated tenderness of the patella (no other bony tenderness)
3. Tenderness at the fibular head
4. Inability to flex knee to 90°
5. Inability to bear weight (4 steps) immediately and in ED

Sensitivity: 98.5% for knee fractures.

Step 4: CURB-65 (Pneumonia Severity)

CRB-65 variant: When BUN is unavailable (e.g., clinic setting), drop the U criterion. Score ≥2 suggests hospitalization.

Step 5: Additional Commonly Used ED Risk Scores

Canadian CT Head Rule (Minor Head Injury, GCS 13-15)

High risk for neurosurgical intervention (any one = CT):

1. GCS <15 at 2 hours post-injury
2. Suspected open or depressed skull fracture
3. Any sign of basal skull fracture (Battle's sign, raccoon eyes, CSF otorrhea/rhinorrhea, hemotympanum)
4. ≥2 episodes of vomiting
5. Age ≥65

Medium risk for brain injury on CT (any one = CT): 6. Amnesia before impact >30 minutes 7. Dangerous mechanism (pedestrian struck, ejection from vehicle, fall >3 feet or >5 stairs)

NEXUS Criteria (C-Spine Clearance)

C-spine imaging NOT required if ALL five criteria met:

1. No posterior midline cervical tenderness
2. No focal neurologic deficit
3. Normal alertness (GCS 15)
4. No intoxication
5. No painful distracting injury

San Francisco Syncope Rule (CHESS)

Admit or pursue workup if any present:

• CHF history
• Hematocrit <30%
• ECG abnormal (non-sinus rhythm or new changes)
• Shortness of breath
• Systolic BP <90 mmHg

Checkpoint B: Post-Draft Alignment (Mandatory)

1. Was the appropriate scoring tool selected for the clinical question being addressed?
2. Were all individual score components documented with their respective values?
3. Is the total score correctly calculated and the risk category accurately assigned?
4. Does the documented clinical plan align with the score's recommended disposition?
5. Were exclusion criteria checked (scores have populations where they are not validated)?

Quality Audit

• Correct scoring tool selected for the clinical question
• All individual component values documented (not just the total score)
• Total score calculated correctly with arithmetic verified
• Risk category assigned matches the score range
• Exclusion criteria for the scoring tool checked and documented
• Clinical plan aligns with score-recommended disposition pathway
• Score version specified (e.g., HEART score, Wells PE criteria — original vs. simplified)
• Patient population validated for the tool (age, pregnancy, prior diagnosis exclusions)
• Troponin assay type documented for HEART score (conventional vs. high-sensitivity)
• D-dimer threshold specified (standard vs. age-adjusted) for PE pathway
• Score documented in the medical record MDM section
• Override of score-recommended pathway documented with explicit rationale
• Serial scoring documented if applicable (e.g., repeat HEART score with 3-hour troponin)

Guidelines

1. Always document the specific version of each scoring tool used — Wells PE has original and simplified versions with different cutoffs; HEART score troponin criteria differ by assay type.
2. Clinical prediction rules are decision aids, not decision makers — they do not replace clinical judgment, and overriding a score recommendation is acceptable when documented with specific reasoning.
3. Never apply a scoring tool to a population for which it was not validated — the PERC rule is not validated in pregnant patients, Ottawa rules exclude intoxicated patients, and CURB-65 is for community-acquired pneumonia only.
4. Document each individual component, not just the total score — a HEART score of "4" is meaningless without the component breakdown for downstream providers.
5. Use age-adjusted D-dimer thresholds (age × 10 ng/mL for patients >50) — this is endorsed by ACEP and reduces unnecessary CTA by 12% without increasing missed PE.
6. When a score falls at a decision boundary (e.g., HEART 3 vs. 4), document the clinical reasoning for the disposition decision rather than relying solely on the number.
7. Serial scoring (e.g., HEART score at 0 and 3 hours) adds prognostic value — document both calculations with timestamps.
8. Communicate the score and its clinical meaning to the patient during shared decision-making: "Your risk of a major heart event in the next 6 weeks is approximately 1-2% based on your HEART score of 3."