Outcomes of a nontransfer protocol for mild traumatic brain injury with abnormal head computed tomography in a rural hospital setting

Optimising acute non-critical inter-hospital transfers: A review of evidence, practice and patient perspectives

INTRODUCTION

Patients who present to hospital with an acute non-critical illness or injury, which is considered outside the capability framework of that hospital to treat, will require inter-hospital transfer (IHT) to a hospital with a higher level of capability for that condition. Delays in IHT can negatively impact patient care and patient outcomes.

OBJECTIVE

To review and synthesis academic evidence, practitioner insights and patient perspectives on ways to improve IHT from regional to metro hospitals.

DESIGN

A rapid review methodology identified one review and 14 primary studies. Twelve practitioner interviews identified insights into practice and implementation, and the patient perspectives were explored through a citizen panel with 15 participants.

FINDINGS

The rapid review found evidence relating to clinician and patient decision factors, protocols, communication practices and telemedicine. Practitioner interviews revealed challenges in making the initial decision, determining appropriate destinations and dealing with pushback. Adequate support and communication were raised as important to improve IHT. The citizen panel found that the main concern with IHT was delays. Citizen panel participants suggested dedicated transfer teams, education and information transfer systems to improve IHT.

DISCUSSION AND CONCLUSION

Common challenges in IHT include making the initial decision to transfer and communicating with other health services and patients and families. In identifying the appropriateness of transferring acute non-critical patients, clear and effective communication is central to appropriate and timely IHT; this evidence review indicates that education, protocols and information management could make IHT processes smoother.

Characterizing Interhospital Variability in Neurosurgical Interventions for Patients with Mild Traumatic Brain Injury and Intracranial Hemorrhage

The objective of this study was to quantify nation-wide interhospital variation in neurosurgical intervention risk by intracranial hemorrhage (ICH) type in the setting of mild traumatic brain injury (mTBI). This was a retrospective cohort study of adult (≥18 years) trauma patients included in the National Trauma Data Bank from 2007 to 2019 with an emergency department Glasgow Coma Scale score 13-15, diagnosed ICH, no skull fracture. The primary outcome was neurosurgical intervention. Interhospital variation was assessed by examining the best linear unbiased predictors (BLUPs) obtained from mixed-effects logistic regression with random slopes and intercepts for hospitals and covariates for time and 14 demographic, injury, and hospital characteristics; one model per ICH type. Intercept BLUPs are estimates of how different each hospital is from the average hospital (after covariate adjustment). The study population included 49,220 (7%) neurosurgical interventions among 666,842 patients in 1060 hospitals. In 2019, after adjusting for patient case-mix and hospital characteristics, the percentage of hospitals with hemorrhage-specific neurosurgical intervention risk significantly different from the average hospital was as follows: isolated unspecified hemorrhage (0% of 995 hospitals); isolated contusion/laceration (0.54% of 929); isolated epidural hemorrhage (0.39% of 778); isolated subarachnoid hemorrhage (0.10% of 1002); multiple hemorrhages (2.49% of 963); and isolated subdural hemorrhage (16.25% of 1028). In the setting of mTBI, isolated subdural hemorrhages were the only ICH type to have considerable interhospital variability. Causes for this significant variation should be elucidated and might include changing hemorrhage characteristics and practice patterns over time.

Significant National Declines in Neurosurgical Intervention for Mild Traumatic Brain Injury with Intracranial Hemorrhage: A 13-Year Review of the National Trauma Data Bank

There have been large changes over the past several decades to patient demographics in those presenting with mild traumatic brain injury (mTBI) with intracranial hemorrhage (ICH; complicated mTBI) with the potential to affect the use of neurosurgical interventions. The objective of this study was to characterize long-term trends of neurosurgical interventions in patients with complicated mTBI using 13 years of the National Trauma Data Bank (NTDB). This was a retrospective cohort study of adult (≥18 years) trauma patients included in the NTDB from 2007 to 2019 who had an emergency department Glasgow Coma Scale score 13-15, an intracranial hemorrhage (ICH), and no skull fracture. Neurosurgical intervention time trends were quantified for each ICH type using mixed-effects logistic regression with random slopes and intercepts for hospitals, as well as covariates for time and 14 demographic, injury, and hospital characteristics. In total, 666,842 ICH patients across 1060 hospitals were included. The four most common hemorrhages were isolated subdural hemorrhage (36%), isolated subarachnoid hemorrhage (24%), multiple hemorrhage types (24%), and isolated unspecified hemorrhages (9%). Overall, 49,220 (7%) patients received a neurosurgical intervention. After adjustment, the odds of neurosurgical intervention significantly decreased every 10 years by the following odds ratios (odds ratio [95% confidence interval]): 0.85 [0.78, 0.93] for isolated subdural, 0.63 [0.51, 0.77] for isolated subarachnoid, 0.50 [0.41, 0.62] for isolated unspecified, and 0.79 [0.73, 0.86] for multiple hemorrhages. There were no significant temporal trends in neurosurgical intervention odds for isolated epidural hemorrhages (0.87 [0.68, 1.12]) or isolated contusions/lacerations (1.03 [0.75, 1.41]). In the setting of complicated mTBI, the four most common ICH types were associated with significant declines in the odds of neurosurgical intervention over the past decade. It remains unclear whether changing hemorrhage characteristics or practice patterns drove these trends.

External validation of the updated Brain Injury Guidelines for complicated mild traumatic brain injuries: a retrospective cohort study

OBJECTIVE

Approximately 10% of patients with mild traumatic brain injury (mTBI) have intracranial bleeding (complicated mTBI) and 3.5% eventually require neurosurgical intervention, which is mostly available at centers with a higher level of trauma care designation and often requires interhospital transfer. In 2018, the Brain Injury Guidelines (BIG) were updated in the United States to guide emergency department care and patient disposition for complicated mild to moderate TBI. The aim of this study was to validate the sensitivity and specificity of the updated BIG (uBIG) for predicting the need for interhospital transfer in Canadian patients with complicated mTBI.

METHODS

This study took place at three level I trauma centers. Consecutive medical records of patients with complicated mTBI (Glasgow Coma Scale score 13-15) who were aged ≥ 16 years and presented between September 2016 and December 2017 were retrospectively reviewed. Patients with a penetrating trauma and those who had a documented cerebral tumor or aneurysm were excluded. The primary outcome was a combination of neurosurgical intervention and/or mTBI-related death. Sensitivity and specificity analyses were performed.

RESULTS

A total of 477 patients were included, of whom 8.4% received neurosurgical intervention and 3% died as a result of their mTBI. Forty patients (8%) were classified as uBIG-1, 168 (35%) as uBIG-2, and 269 (56%) as uBIG-3. No patients in uBIG-1 underwent neurosurgical intervention or died as a result of their injury. This translates into a sensitivity for predicting the need for a transfer of 100% (95% CI 93.2%-100%) and a specificity of 9.4% (95% CI 6.8%-12.6%). Using the uBIG could potentially reduce the number of transfers by 6% to 25%.

CONCLUSIONS

The patients in uBIG-1 could be safely managed at their initial center without the need for transfer to a center with a higher level of neurotrauma care. Although the uBIG could decrease the number of transfers, further refinement of the criteria could improve its specificity.

Glioblastoma: assessment of the readability and reliability of online information

INTRODUCTION

Glioblastoma Multiforme (GBM) represents one of the most common and most aggressive forms of brain tumours with a poor prognosis. There is often uncertainty around diagnosis and prognosis amongst patients diagnosed with cancer. Most patients rely on internet to access health-related information. The aim of this study was to assess the readability and reliability of online information on GBM.

METHODS

The terms 'Glioblastoma' and 'GBM' were used to search Google and the first 50 websites identified were screened. For each website, the quality of each website was assessed using the DISCERN instrument, the Journal of the American Medical Association (JAMA) benchmark criteria and the Health on the Net Foundation code certification (HON-code). The readability was assessed using the Flesch Reading Ease Score (FRE), the Flesch-Kincaid grade level (FKGL) and the Gunning Fog Index (GFI). The relevant patient information by 4 International patient information websites were also assessed.

RESULTS

Following screening, 31 websites met the inclusion criteria with only four websites displaying the HON-code (12.9%). The median DISCERN score was 43 (range: 17-70) corresponding to 'fair' quality, and the median JAMA benchmark criteria score was 1. Display of the HON-code certificate or the publication date was associated with higher quality websites. The median FRE score corresponded to 'difficult' to read (34.4). The median GFI score (15.9) and FKGL score (13.3) corresponded to a 'college' level of education reading ability. The Cancer Australia online information was the most readable website while Cancer Research UK had the highest quality information.

CONCLUSION

The readability and reliability of online information relating to GBM is inadequate. Health professionals need to provide or guide patients to information that is both readable and reliable.

Pathway-Based Reduction of Repeat Head Computed Tomography for Patients With Complicated Mild Traumatic Brain Injury: Implementation and Outcomes

BACKGROUND

Routine follow-up head imaging in complicated mild traumatic brain injury (cmTBI) patients has not been shown to alter treatment, improve outcomes, or identify patients in need of neurosurgical intervention. We developed a follow-up head computed tomography (CT) triage algorithm for cmTBI patients to decrease the number of routine follow-up head CT scans obtained in this population.

OBJECTIVE

To report our experience with protocol implications and patient outcome.

METHODS

Data on all cmTBI patients presenting from July 1, 2018 to June 31, 2019, to our level 1, tertiary, academic medical center were collected prospectively and analyzed retrospectively. Descriptive analysis was performed.

RESULTS

Of the 178 patients enrolled, 52 (29%) received a follow-up head CT. A total of 27 patients (15%) were scanned because of initial presentation and triaged to the group to receive a routine follow-up head CT. A total of 151 patients (85%) were triaged to the group without routine follow-up head CT scan. Protocol adherence was 89% with 17 violations.

CONCLUSION

Utilizing this protocol, we were able to safely decrease the use of routine follow-up head CT scans in cmTBI patients by 71% without any missed injuries or delayed surgery. Adoption of the protocol was high among all services managing TBI patients.

Assessing the efficacy of mild traumatic brain injury management

OBJECTIVE

Intracranial hemorrhage (ICH) is frequently found on computed tomography (CT) after mild traumatic brain injury (mTBI) prompting transfer to centers with neurosurgical coverage and repeat imaging to confirm hemorrhage stability. Studies suggest routine repeat imaging has little utility in patients with minimal ICH, no anticoagulant/antiplatelet use, and no neurological decline. Additionally, it is unclear which mTBI patients benefit from transfer for neurosurgery consultation. The authors sought to assess the clinical utility and cost effectiveness of routine repeat head CTs and transfer to tertiary centers in patients with low-risk, mTBI.

METHODS

Retrospective evaluation of patients receiving a neurosurgical consultation for TBI during a 4-year period was performed at a level 1 trauma center. Patients were stratified according to risk for neurosurgical intervention based on their initial clinical evaluation and head CT. Only patients with low-risk, mTBI were included.

RESULTS

Of 531 patients, 119 met inclusion criteria. Eighty-eight (74.0 %) received two or more CTs. Direct cost of repeat imaging was $273,374. Thirty-seven (31.1 %) were transferred to our facility from hospitals without neurosurgical coverage, costing $61,384. No patient had neurosurgical intervention or mTBI-related in-hospital mortality despite enlarging ICH on repeat CT in three patients. Two patients had mTBI related 30-day readmission for seizure without ICH expansion.

CONCLUSION

Routine repeat head CT or transfer of low-risk, mTBI patients to a tertiary center did not result in neurosurgical intervention. Serial neurological examinations may be a safe, cost-effective alternative to repeat imaging for select mTBI patients. A large prospective analysis is warranted for further evaluation.

Examining the Emergency Medical Treatment and Active Labor Act: impact on telemedicine for neurotrauma

The Emergency Medical Treatment and Active Labor Act (EMTALA) protects patient access to emergency medical treatment regardless of insurance or socioeconomic status. A significant result of the COVID-19 pandemic has been the rapid acceleration in the adoption of telemedicine services across many facets of healthcare. However, very little literature exists regarding the use of telemedicine in the context of EMTALA. This work aimed to evaluate the potential to expand the usage of telemedicine services for neurotrauma to reduce transfer rates, minimize movement of patients across borders, and alleviate the burden on tertiary care hospitals involved in the care of patients with COVID-19 during a global pandemic. In this paper, the authors outline EMTALA provisions, provide examples of EMTALA violations involving neurosurgical care, and propose guidelines for the creation of telemedicine protocols between referring and consulting institutions.

Inter-facility transfer of patients with traumatic intracranial hemorrhage and GCS 14-15: The pilot study of a screening protocol by neurosurgeon to avoid unnecessary transfers

We sought to evaluate feasibility and cost-reduction potential of a pilot screening program involving neurosurgeon tele-consultation for inter-facility transfer decisions in TBI patients with GCS 14–15 and abnormal CT head at a community hospital. The authors performed a retrospective comparative analysis of two patient cohorts during the pilot at a large hospital system from 2015 to 2017. In “screened” patients (n = 85), images and examination were reviewed remotely by a neurosurgeon who made recommendations regarding transfer to a level 1 trauma center. In the “unscreened” group (n = 39), all patients were transferred. Baseline patient characteristics, outcomes, and costs were reviewed. Patient demographics were similar between cohorts. Traumatic subarachnoid hemorrhage was more common in screened patients (29.4% vs 12.8%, P = 0.02). The presence of midline shift >5 mm was comparable between groups. Among screened patients, 5 were transferred (5.8%) and one required evacuation of chronic subdural hematoma. In unscreened patients, 7 required evacuation of subdural hematoma. None of the screened patients who were not transferred deteriorated. Screened patients had significantly reduced average total cost compared to unscreened patients ($2,003 vs. $4,482, P = 0.03) despite similar lengths of stay (2.6 vs. 2.7 days, P = 0.85). In non-surgical patients, costs were less in the screened group ($2,025 vs. $2,939), although statistically insignificant (P = 0.38).

In this pilot study, remote review of images and examination by a neurosurgeon was feasible to avoid unnecessary transfer of patients with traumatic intracranial hemorrhage and GCS 14–15. The true potential in cost-reduction will be realized in system-wide large-scale implementation.

Outcomes of a novel ED observation pathway for mild traumatic brain injury and associated intracranial hemorrhage

BACKGROUND

Recent studies have shown that the majority of non-anticoagulated patients with small subdural or subarachnoid intracranial hemorrhage (ICH) in the setting of mild traumatic brain injury do not experience clinical deterioration or require neurosurgical intervention. We implemented a novel ED observation pathway to reduce unnecessary admissions among patients with ICH in the setting of mild TBI (complicated mild TBI, cmTBI).

METHODS

Prospective, single-center study of ED patients presenting to a Level-1 Trauma Center, 4/2016-12/2018.

INCLUSION CRITERIA

head injury with GCS ≥ 14, minor positive CT findings (i.e. subdural hematoma <1 cm).

EXCLUSION CRITERIA

GCS < 14, multi-system trauma procedural intervention or admission, epidural hematoma, skull fracture, seizure, anticoagulant/antiplatelet use beyond aspirin, physician discretion.

OUTCOMES

pathway completion rate, ED length-of-stay (LOS), neurosurgical intervention, hospital LOS, 7-day return visits.

RESULTS

138 patients met all pathway criteria and were included in analysis. 113/138 (81.9%) patients were discharged home after observation with mean ED LOS of 17.3 h (median 15.4 h, SD +/- 10.5) including 91/111 (81.9%) patients transferred from outside hospitals (median 18.1 h, SD +/- 11.0). Increased age and aspirin use were correlated with pathway non-completion requiring admission, but not due to hematoma expansion. Among admitted patients, none required neurosurgical intervention. Seven (5.1%) 7-day return visits occurred, 3 (2%) related to initial cmTBI; 1 (0.9%) was admitted for neurologic monitoring.

CONCLUSIONS

ED observation for patients with cmTBI resulted in an 82% pathway completion rate, including outside hospital transfers. These results suggest that patients with cmTBI may be safely discharged from the ED after a brief period of observation. Our pathway protocol and implementation involved neurosurgical consultation and the ability to perform repeat neurologic exams in the ED. Future studies should examine the feasibility of non-transfer protocols for appropriately selected patients and access to neurosurgical expertise in the community setting.

Repeat Head CT for Neurologically Stable Patients With Mild Traumatic Subarachnoid Hemorrhage During Interfacility Transfer and Follow-Up Does Not Alter Patient Care [Formula: see text]

PURPOSE

To evaluate the impact of repeat head computed tomography (CT) during (1) interfacility transfer and (2) inpatient and/or outpatient follow-up on management, cost-effectiveness, and radiation dose in neurologically stable patients with mild traumatic subarachnoid hemorrhage (tSAH).

MATERIAL AND METHODS

This is a single-center retrospective study evaluating patients with mild tSAH presenting between January 2017 and July 2019. A total of 101 and 140 patients met the eligibility criteria for the first and second subgroups, respectively. Common inclusion criteria were isolated mild tSAH, Glasgow Coma Scale between 13 and 15, and neurological stability. Additional inclusion criteria for the first subgroup were availability of brain imaging at the outside institution prior to transfer and the second subgroup was the availability of follow-up imaging.

RESULTS

In the first subgroup, 76.20% of patients had stable SAH, 18.80% had reduced SAH, while 5% had an interval increase in SAH. None required any surgical intervention. Additional per-patient mean radiation exposure was 1.77 ± 0.26 mSv. In the second subgroup, all 140 patients had complete resolution of tSAH. One patient had a new tiny subdural hemorrhage, which subsequently resolved on follow-up. The additional mean radiation exposure was 2.47 ± 1.29 mSv. A total of 256 avoidable CT scans were performed resulting in excess health care costs of about US$531 696.

CONCLUSION

In neurologically stable isolated tSAH patients, repeat brain imaging during interfacility transfer and inpatient and/or outpatient follow-up do not alter patient management despite increased health care costs and radiation burden.

Which factors influence the decision to transfer patients with traumatic brain injury to a neurosurgery unit in a major trauma network?

Objectives: Within the pan London Major Trauma System many patients with minor or non-life threatening traumatic brain injury (TBI) remain at their local hospital and are not transferred to a major trauma centre (MTC). Our aim was to identify factors that influence the decision to transfer patients with TBI to a neurosurgical centre.Methods: This is a single centre prospective cohort study of all patients with TBI referred to our neurosurgery unit from regional acute hospitals over a 4-month period (Sept 2016-Jan 2017). Our primary outcome was transferred to a neurosurgical centre. We identified the following factors that may predict decision to transfer: patient demographics, transfer distance, antithrombotic therapy and severity of TBI based on initial Glasgow Coma Scale (GCS) and Marshall CT score. A multivariable logistic regression analysis was performed.Results: A total of 339 patients were referred from regional hospitals with TBI and of these, 53 (15.6%) were transferred to our hospital. The mean age of patients referred was 70.6 years, 62.5% were men and 43% on antithrombotic drugs. Eighty-six percent of patients had mild TBI (GCS 13-15) on initial assessment and 79% had a Marshall CT score of 2. The adjusted analysis revealed only higher age, higher Marshall Score, the presence of chronic subdural haematoma (CSDH), the presence of contusion(s) and fracture(s) predicted transfer (p<.05). Subgroup analysis consistently showed a higher Marshall score predicted transfer (p<.05).Conclusions: In our cohort higher Marshall score consistently predicted transfer to our neurosurgical centre. Presenting GCS, transfer distance and antithrombotic therapy did not influence decision to transfer.

Concussion and Mild-Traumatic Brain Injury in Rural Settings: Epidemiology and Specific Health Care Considerations

Background  Mild-traumatic brain injury (mTBI) and concussions cause significant morbidity. To date, synthesis of specific health care disparities and gaps in care for rural mTBI/concussion patients remains needed. Methods  A comprehensive literature search was performed using PubMed database for English articles with keywords "rural" and ("concussion" or "mild traumatic brain injury") from 1991 to 2019. Eighteen articles focusing on rural epidemiology ( n = 5), management/cost ( n = 5), military ( n = 2), and concussion prevention/return to play ( n = 6) were included. Results  mTBI/concussion incidence was higher in rural compared with urban areas. Compared with urban patients, rural patients were at increased risk for vehicular injuries, lifetime number of concussions, admissions for observation without neuroimaging, and injury-related costs. Rural patients were less likely to utilize ambulatory and mental health services following mTBI/concussion. Rural secondary schools had decreased access to certified personnel for concussion evaluation, and decreased use of standardized assessment instruments/neurocognitive testing. While school coaches were aware of return-to-play laws, mTBI/concussion education rates for athletes and parents were suboptimal in both settings. Rural veterans were at increased risk for postconcussive symptoms and posttraumatic stress. Telemedicine in rural/low-resource areas is an emerging tool for rapid evaluation, triage, and follow-up. Conclusions  Rural patients are at unique risk for mTBI/concussions and health care costs. Barriers to care include lower socioeconomic status, longer distances to regional medical center, and decreased availability of neuroimaging and consultants. Due to socioeconomic and distance barriers, rural schools are less able to recruit personnel certified for concussion evaluation. Telemedicine is an emerging tool for remote triage and evaluation.

Secondary Overtriage in Patients with Complicated Mild Traumatic Brain Injury: An Observational Study and Socioeconomic Analysis of 1447 Hospitalizations

BACKGROUND

Secondary overtriage is a problematic phenomenon because it creates unnecessary expense and potentially results in the mismanagement of healthcare resources. The rates of secondary overtriage among patients with complicated mild traumatic brain injury (cmTBI) are unknown.

OBJECTIVE

To determine the rate of secondary overtriage among patients with cmTBI using the institutional trauma registry.

METHODS

An observational study using retrospective analysis of 1447 hospitalizations including all consecutive patients with cmTBI between 2004 and 2013. Data on age, sex, race/ethnicity, insurance status, GCS, Injury Severity Score (ISS), Trauma Injury Severity Score, transfer mode, overall length of stay (LOS), LOS within intensive care unit, and total charges were collected and analyzed.

RESULTS

Overall, the rate of secondary overtriage among patients with cmTBI was 17.2%. These patients tended to be younger (median: 41 vs 60.5 yr; P < .001), have a lower ISS (9 vs 16; P < .001), and were more likely to be discharged home or leave against medical advice.

CONCLUSION

Our findings provide evidence to the growing body of literature suggesting that not all patients with cmTBI need to be transferred to a tertiary care center. In our study, these transfers ultimately incurred a total cost of $13 294 ($1337 transfer cost) per patient.

Mild traumatic brain injuries with minor intracranial hemorrhage: Can they Be safely managed in the community? - A cohort study

BACKGROUND

Patients with mild traumatic brain injury (mTBI) are frequently transferred to level 1 trauma centers (L1TC) if they have minor findings on a computerized tomographic scan of the head due to the absence of continuous neurosurgical coverage in community hospitals (CH). We hypothesized that such patients can be safely managed at community hospitals with a qualified Trauma team.

METHODS

This is a multicentered Retrospective Cohort Study. Patients with mild Traumatic Brain Injury (defined as Glasgow Coma Scale [GCS] 13-15 at presentation) and with minor findings on head Computerized Tomography (CT) presenting at a L1TC or 4 Community Hospitals between March 1st, 2012 and February 28th, 2014 were included. All these community hospitals are Level III Trauma center with a well-organized trauma team. Minor CT findings were defined as 1) epidural hematoma<2 mm; 2) subarachnoid hemorrhage<2 mm; 3) subdural hematoma<4 mm; 4) intraparenchymal hemorrhage<5 mm; 5) minor pneumocephalus; or 6) linear or minimally depressed skull fracture. Our primary end point was the need for TBI specific interventions in 3 groups of patients: 1) direct admission to the L1TC (L1TC group), 2) those admitted at one of the 4 CH (CH group), and 3) those transferred from CH to L1TC (TRANSFER group). TBI-specific interventions were defined as intracranial pressure monitor (ICP) placement, hyperosmolar therapy, or neurosurgical operation. Our secondary aim was to demonstrate that these patients can be safely managed in Community Hospitals with qualified Trauma teams. We also sought to identify the clinical outcomes in these three groups of patients - in terms of mortality and complications.

RESULTS

A total of 191 patients were included - 39 CH, 64 L1TC and 88 TRANSFER. There was no difference among the groups in terms of TBI-specific interventions: one TRANSFER, four L1TC, and no CH patients required hyperosmolar therapy (p = 0.277). None of the patients required placement of an intracranial pressure monitoring device (ICP) or a neurosurgical operation and complications and mortality rates were similar among the groups.

CONCLUSIONS

Patients with mild TBI and minor findings on head CT can be safely managed at CH with qualified Trauma Teams.

LEVEL OF EVIDENCE

Therapeutic/Care Management Study, Level IVhbv.

Isolated subdural hematomas in mild traumatic brain injury. Part 1: the association between radiographic characteristics and neurosurgical intervention

OBJECTIVE

Isolated subdural hematomas (iSDHs) are one of the most common intracranial hemorrhage (ICH) types in the population with mild traumatic brain injury (mTBI; Glasgow Coma Scale score 13-15), account for 66%-75% of all neurosurgical procedures, and have one of the highest neurosurgical intervention rates. The objective of this study was to examine how quantitative hemorrhage characteristics of iSDHs in patients with mTBI at admission are associated with subsequent neurosurgical intervention.

METHODS

This was a 3.5-year, retrospective observational cohort study at a Level I trauma center. All adult trauma patients with mTBI and iSDHs were included in the study. Maximum length and thickness (in mm) of acute SDHs, the presence of acute-on-chronic SDH, mass effect, and other hemorrhage-related variables were double-data entered; discrepant results were adjudicated after a maximum of 4 reviews. Patients with coagulopathy, skull fractures, no acute hemorrhage, a non-SDH ICH, or who did not undergo imaging on admission were excluded. The primary outcome was neurosurgical intervention (craniotomy, burr hole, catheter drainage of SDH, placement of intracranial pressure monitor, shunt, or ventriculostomy). Multivariate stepwise logistic regression was used to identify significant covariates and to assess interactions.

RESULTS

A total of 176 patients were included in our study: 28 patients did and 148 patients did not receive a neurosurgical intervention. Increasing head Abbreviated Injury Scale score was significantly associated with neurosurgical interventions. There was a strong correlation between the first 3 reviews on maximum hemorrhage length (R2 = 0.82) and maximum hemorrhage thickness (R2 = 0.80). The neurosurgical intervention group had a mean maximum SDH length and thickness that were 61 mm longer and 13 mm thicker than those of the nonneurosurgical intervention group (p < 0.001 for both). After adjusting for the presence of an acute-on-chronic hemorrhage, for every 1-mm increase in the thickness of an iSDH, the odds of a neurosurgical intervention increase by 32% (95% CI 1.16-1.50). There were no interventions for any SDH with a maximum thickness ≤ 5 mm on initial presenting scan.

CONCLUSIONS

This is the first study to quantify the odds of a neurosurgical intervention based on hemorrhage characteristics in patients with an iSDH and mTBI. Once validated in a second population, these data can be used to better inform patients and families of the risk of future neurosurgical intervention, and to evaluate the necessity of interhospital transfers.

Isolated subdural hematomas in mild traumatic brain injury. Part 2: a preliminary clinical decision support tool for neurosurgical intervention

OBJECTIVE

A paucity of studies have examined neurosurgical interventions in the mild traumatic brain injury (mTBI) population with intracranial hemorrhage (ICH). Furthermore, it is not understood how the dimensions of an ICH relate to the risk of a neurosurgical intervention. These limitations contribute to a lack of treatment guidelines. Isolated subdural hematomas (iSDHs) are the most prevalent ICH in mTBI, carry the highest neurosurgical intervention rate, and account for an overwhelming majority of all neurosurgical interventions. Decision criteria in this population could benefit from understanding the risk of requiring neurosurgical intervention. The aim of this study was to quantify the risk of neurosurgical intervention based on the dimensions of an iSDH in the setting of mTBI.

METHODS

This was a 3.5-year, retrospective observational cohort study at a Level I trauma center. All adult (≥ 18 years) trauma patients with mTBI and iSDH were included in the study. Maximum length and thickness (in mm) of acute SDHs, the presence of acute-on-chronic (AOC) SDH, mass effect, and other hemorrhage-related variables were double-data entered; discrepant results were adjudicated after a maximum of 4 reviews. Patients with coagulopathy, skull fractures, no acute hemorrhage, a non-SDH ICH, or who did not undergo imaging on admission were excluded. Tentorial SDHs were not measured. The primary outcome was neurosurgical intervention (craniotomy, burr holes, intracranial pressure monitor placement, shunt, ventriculostomy, or SDH evacuation). Multivariate stepwise logistic regression was used to identify significant covariates, to assess interactions, and to create the scoring system.

RESULTS

There were a total of 176 patients included in our study: 28 patients did and 148 did not receive a neurosurgical intervention. There were no significant differences between neurosurgical intervention groups in 11 demographic and 22 comorbid variables. Patients with neurosurgical intervention had significantly longer and thicker SDHs than nonsurgical controls. Logistic regression identified thickness and AOC hemorrhage as being the most important variables in predicting neurosurgical intervention; SDH length was not. Risk of neurosurgical intervention was calculated based on the SDH thickness and presence of an AOC hemorrhage from a multivariable logistic regression model (area under the receiver operating characteristic curve 0.94, 95% CI 0.90-0.97; p < 0.001). With a decision point of 2.35% risk, we predicted neurosurgical intervention with 100% sensitivity, 100% negative predictive value, and 53% specificity.

CONCLUSIONS

This is the first study to quantify the risk of neurosurgical intervention based on hemorrhage characteristics in patients with mTBI and iSDH. Once validated in a second population, these data can be used to inform the necessity of interhospital transfers and neurosurgical consultations.

A retrospective review of patients with significant traumatic brain injury transported by emergency medical services within the south east of England

Introduction:

Traumatic brain injury (TBI) will be a leading cause of death and disability within the Western world by 2020. Currently, 80% of all TBI patients in England are transported to hospital by an ambulance service. The aim of this retrospective study is to compare TBI patients transported to a major trauma centre (MTC) against those transported to a trauma unit (TU).

Method:

All patients with a primary injury of TBI who were transported to hospital by South East Coast Ambulance Service NHS Foundation Trust (SECAmb) from 1 January 2016 to 31 December 2016 and entered into the Trauma Audit & Research Network (TARN) registry were reviewed. Patients were stratified by hospital designation (MTC or TU). Severity of TBI was categorised using the patients’ pre-hospital Glasgow Coma Scale (GCS) and Abbreviated Injury Score (AIS) Head. The outcomes of interest were 30-day mortality and Glasgow Outcome Score (GOS) at discharge.

Results:

Between 1 January and 31 December 2016, 549 TBI patients were identified in the TARN database as being transported by SECAmb to either an MTC or a TU. The majority of patients were transported to a TU (77.96%), and the median age of the TU cohort was older than the MTC group (TU 82.15 IQR 16.73 vs. MTC 62.1 IQR 42.6). The median Injury Severity Score (ISS) was greater in the MTC cohort (22 IQR 10 vs. 17 IQR 9), where falls from height and road traffic collisions (RTCs) contributed to 50.51% of all injuries. Within the TU cohort, falls from less than 2 metres (standing height) were the main mechanism of injury (MOI) (77.62%). The median length of hospital stay (LOS) was longer in the MTC cohort compared to the TU cohort (10 IQR 13.25 vs. 8 IQR 14).

Conclusion:

The high proportion of mild TBI and absence of reliable triage guidelines make it difficult for ambulance clinicians to identify patients who will benefit from transport to an MTC. Future research should focus on how TBI triage influences outcomes and how ambulance services can better identify patients with a TBI and who would benefit from specialist care.

Rapid Discharge After Interfacility Transfer for Mild Traumatic Intracranial Hemorrhage: Frequency and Associated Factors

Introduction

Traumatic intracranial hemorrhage (TIH), brain injury with radiographic hemorrhage, is a common emergency department (ED) presentation, and encompasses a wide range of clinical syndromes. Patients with moderate and severe neurotrauma (Glasgow Coma Scale [GCS] < 13) with intracranial hemorrhage require care at a trauma center with neurosurgical capabilities. However, many patients with mild traumatic intracranial hemorrhage (mTIH), defined as radiographic bleeding and GCS ≥ 13, do not require operative intervention or intensive care unit monitoring, but are still routinely transferred to tertiary care centers. We hypothesized that a significant proportion of patients are managed non-operatively and are discharged within 24 hours of admission.

Methods

This was a retrospective, observational study of consecutive patients age ≥ 16 years, GCS ≥ 13 who were transferred to an urban, medical school-affiliated, 100,000 annual visit ED over a seven-year period with blunt isolated mTIH. The primary outcome was discharge within 24 hours of admission. We measured rates of neurosurgical intervention, computed tomography hemorrhage progression, and neurologic deterioration as well as other demographic and clinical variables.

Results

There were 1079 transferred patients with isolated mTIH. Of these, 92.4% were treated non-operatively and 35.8% were discharged within 24 hours of presentation to the tertiary ED. Patient characteristics associated with rapid discharge after transfer include a GCS of 15 (odds ratio [OR] 2.9, 95% confidence interval [CI], 1.9 – 4.4), subdural hematoma ≤ 6mm (OR 3.1, 95% CI, 2.2 – 4.5) or the presence of an isolated subarachnoid hemorrhage (OR 1.7, 95% CI, 1.3 – 2.4). Of patients with length of stay < 24 hours, 79.8% were discharged directly from the ED or ED observation unit.

Conclusion

Patients transferred to tertiary care centers are frequently discharged after brief observation without intervention. Risk can be predicted by clinical and radiographic data. Further prospective research is required to determine a safe cohort of patients who could be managed at community sites.

Optimization of Resource Allocation after Implementation of Mild Traumatic Brain Injury Treatment Protocol

The purpose of this study was to assess resource utilization after implementation of a mild traumatic brain injury (TBI) treatment protocol. A retrospective review was conducted of patients with isolated mild TBI before and after implementation of a mild TBI treatment protocol in May 2015. Patients admitted from June 2014 to February 2017, aged 18 to 89 years, presenting with a Glasgow coma score of 13 to 15, with an isolated small intracerebral hemorrhage on CT without midline shift, and not coagulopathic were evaluated. According to the protocol, patients were admitted to a non-intensive care unit (ICU) ward, without routine neurosurgical consultation or repeat head CT unless clinically indicated. Hospital length of stay (LOS), ICU LOS, rate of neurosurgical consultation, rate of repeat head CT within 24 hours of admission, and associated costs were evaluated. Forty-six patients were identified in the preprotocol group and 97 in the protocol group. The protocol group had a shorter hospital LOS (1.46 vs 2.04 days, P = 0.0034), shorter ICU LOS (0.02 vs 0.37 days, P < 0.0001), lower rates of repeat head CT (2.06% vs 39.13%, P < 0.0001), and neurosurgical consultations (1.03% vs 28.26%, P < 0.0001). Decreased charges derived from fewer repeat head CT and neurosurgical consultations were observed from $43.98 to $844.04 per patient. There were no inpatient mortalities and no progressions of injury requiring unplanned admission to the ICU or operative intervention. Efficient delivery of care is paramount in modern medicine and this study demonstrates that the mild TBI treatment protocol significantly decreased resource utilization without jeopardizing patient safety.

Evaluation of a Low-risk Mild Traumatic Brain Injury and Intracranial Hemorrhage Emergency Department Observation Protocol

OBJECTIVES

Among emergency physicians, there is wide variation in admitting practices for patients who suffered a mild traumatic brain injury (TBI) with an intracranial hemorrhage (ICH). The purpose of this study was to evaluate the effects of implementing a protocol in the emergency department (ED) observation unit for patients with mild TBI and ICH.

METHODS

This retrospective cohort study was approved by the institutional review board. Study subjects were patients ≥ 18 years of age with an International Classification of Diseases code corresponding to a traumatic ICH and admitted to an ED observation unit (EDOU) of an urban, academic Level I trauma center between February 1, 2015, and January 31, 2017. Patient data and discharge disposition were abstracted from the electronic health record, and imaging data, from the final neuroradiologist report. To measure kappa, two abstractors independently collected data for presence of neuro deficit from a 10% random sample of the medical charts. Using a multivariable logistic regression model with a propensity score of the probability of placement in the EDOU before and after protocol implementation as a covariate, we sought to determine the pre-post effects of implementing a protocol on the composite outcome of admission to the floor, intensive care unit, or operating room from the EDOU and the proportion of patients with worsening findings on repeat computed tomography (CT) head scan in the EDOU.

RESULTS

A total of 379 patients were identified during the study period; 83 were excluded as they were found to have no ICH on chart review. Inter-rater reliability kappa statistic was 0.63 for 30 charts. Among the 296 patients who remained eligible and comprised the study population, 143 were in the preprotocol period and 153 after protocol implementation. The EDOU protocol was associated with an independently statistically significant decreased odds ratio (OR) for admission or worsening ICH on repeat CT scan (OR = 0.45, 95% confidence interval [CI] = 0.25-0.82, p = 0.009) in the observation unit. After a stay in the EDOU, 26% (37/143) of patients required an inpatient admission before implementation of the protocol and 13% (20/153) of patients required an inpatient admission after protocol implementation. There was no statistically significant difference in log transformed EDOU length of stay (LOS) between the groups after adjusting for propensity score (p = 0.34).

CONCLUSIONS

While there was no difference in EDOU LOS, implementing a low-risk mild TBI and ICH protocol in the EDOU may decrease the rate of inpatient admissions from the EDOU. A protocol-driven observation unit may help physicians by standardizing eligibility criteria and by providing guidance on management. As the propensity score method limits our ability to create a straightforward predictive model, a future larger study should validate the results.

The Risk of Deterioration in GCS13-15 Patients with Traumatic Brain Injury Identified by Computed Tomography Imaging: A Systematic Review and Meta-Analysis

The optimal management of mild traumatic brain injury (TBI) patients with injuries identified by computed tomography (CT) brain scan is unclear. Some guidelines recommend hospital admission for an observation period of at least 24 h. Others argue that selected lower-risk patients can be discharged from the Emergency Department (ED). The objective of our review and meta-analysis was to estimate the risk of death, neurosurgical intervention, and clinical deterioration in mild TBI patients with injuries identified by CT brain scan, and assess which patient factors affect the risk of these outcomes. A systematic review and meta-analysis adhering to PRISMA standards of protocol and reporting were conducted. Study selection was performed by two independent reviewers. Meta-analysis using a random effects model was undertaken to estimate pooled risks for: clinical deterioration, neurosurgical intervention, and death. Meta-regression was used to explore between-study variation in outcome estimates using study population characteristics. Forty-nine primary studies and five reviews were identified that met the inclusion criteria. The estimated pooled risk for the outcomes of interest were: clinical deterioration 11.7% (95% confidence interval [CI]: 11.7%-15.8%), neurosurgical intervention 3.5% (95% CI: 2.2%-4.9%), and death 1.4% (95% CI: 0.8%-2.2%). Twenty-one studies presented within-study estimates of the effect of patient factors. Meta-regression of study characteristics and pooling of within-study estimates of risk factor effect found the following factors significantly affected the risk for adverse outcomes: age, initial Glasgow Coma Scale (GCS), type of injury, and anti-coagulation. The generalizability of many studies was limited due to population selection. Mild TBI patients with injuries identified by CT brain scan have a small but clinically important risk for serious adverse outcomes. This review has identified several prognostic factors; research is needed to derive and validate a usable clinical decision rule so that low-risk patients can be safely discharged from the ED.

Epidemiology of Mild Traumatic Brain Injury with Intracranial Hemorrhage: Focusing Predictive Models for Neurosurgical Intervention

OBJECTIVE

To outline differences in neurosurgical intervention (NI) rates between intracranial hemorrhage (ICH) types in mild traumatic brain injuries and help identify which ICH types are most likely to benefit from creation of predictive models for NI.

METHODS

A multicenter retrospective study of adult patients spanning 3 years at 4 U.S. trauma centers was performed. Patients were included if they presented with mild traumatic brain injury (Glasgow Coma Scale score 13-15) with head CT scan positive for ICH. Patients were excluded for skull fractures, "unspecified hemorrhage," or coagulopathy. Primary outcome was NI. Stepwise multivariable logistic regression models were built to analyze the independent association between ICH variables and outcome measures.

RESULTS

The study comprised 1876 patients. NI rate was 6.7%. There was a significant difference in rate of NI by ICH type. Subdural hematomas had the highest rate of NI (15.5%) and accounted for 78% of all NIs. Isolated subarachnoid hemorrhages had the lowest, nonzero, NI rate (0.19%). Logistic regression models identified ICH type as the most influential independent variable when examining NI. A model predicting NI for isolated subarachnoid hemorrhages would require 26,928 patients, but a model predicting NI for isolated subdural hematomas would require only 328 patients.

CONCLUSIONS

This study highlighted disparate NI rates among ICH types in patients with mild traumatic brain injury and identified mild, isolated subdural hematomas as most appropriate for construction of predictive NI models. Increased health care efficiency will be driven by accurate understanding of risk, which can come only from accurate predictive models.

Changing paradigms in the management of 2184 patients with traumatic brain injury

OBJECTIVES

The aim of this study was to assess the change in trends in the management of traumatic brain injury (TBI) at a level I trauma center and the utilization of resources as a result of this change in management.

BACKGROUND

The management of TBI has been evolving with trends toward management of minimally injured patients with intracranial hemorrhage exclusively by trauma surgeons.

METHODS

A 5-year (2009-2014) prospective database on all patients with TBI (skull fracture/intracranial hemorrhage on head computed tomography) presenting to a level I trauma center was analyzed for patient demographics, injuries, admission physiology, computed tomographic scan results, and hospital outcomes. These records were matched to the institutional registry and hospital financial database.

RESULTS

A total of 2184 patients were included with median (interquartile range) Glasgow Coma Scale score of 15 (12-15), and median (interquartile range) head-abbreviated injury scale score of 3 (2-4). The distribution of types and size of intracranial bleeds remained unchanged throughout the study period. The proportion of TBI managed exclusively by trauma surgeons increased significantly over the years from 6.8% to 40.1% (P < 0.001). Proportion of patients who received neurosurgical consultations (P < 0.001) and repeat head computed tomographic scans (P < 0.001), hospital length of stay (P = 0.028), and costs (P < 0.001) decreased significantly over time. The overall mortality rate (18.5%) and rate of intervention (14.1%) remained unchanged.

CONCLUSIONS

TBI patients can be selectively managed without initially involving neurosurgeons safely in a cost-effective manner, resulting in more effective use of precious resources.

Impaired coagulation is a risk factor for clinical and radiologic deterioration in patients with traumatic brain injury and isolated traumatic subarachnoid hemorrhage

BACKGROUND

Isolated traumatic subarachnoid hemorrhage (itSAH) is found in approximately 25% of all patients with mild traumatic brain injury (TBI). The aim of this study was to analyze the clinical course and identify risk factors for potential clinical and radiologic deterioration in consideration of impaired coagulation in patients with itSAH.

METHODS

A retrospective analysis of 735 patients with TBI resulting in a pathologic computer-assisted tomography (CAT) was performed. Only those patients with itSAH and Glasgow Coma Scale (GCS) of greater than 8 points and follow-up CAT scan were included. Patients with hemorrhage in any other brain compartment (subdural, epidural, and intracerebral) were excluded. Impaired coagulation was operationally defined.

RESULTS

Of the 735 patients, 89 met the inclusion criteria. The majority of these patients experienced mild TBI. The rate of radiologic expansion or conversion of the SAH was 28.1%. The rate of clinical deterioration was 6.7%. Neither the initial pattern of itSAH on different intracranial localizations nor the number of sulci involved in the itSAH was associated with clinical worsening. The rate of patients with impaired coagulation was 38%; 17.9% of all patients showed elevated international normalized ratio (INR). Radiologic and clinical deterioration was significantly associated with elevated INR. INR was shown to be independent of age in a logistic regression analysis.

CONCLUSION

TBI patients with itSAH and impaired coagulation especially those who showed elevated INR are at risk of clinical and radiologic deterioration. Despite coagulation status, routine repetition of cranial CAT scan is advised in patients with itSAH to detect potential radiologic worsening, which if occurring should result in close clinical monitoring.

LEVEL OF EVIDENCE

Therapeutic study, level IV; prognostic study, level III.

Falcine and Tentorial Subdural Hematomas May Not Routinely Require Transfer to a Tertiary Care Center

BACKGROUND

Patients with subdural hematomas (SDH) are frequently transferred to tertiary care centers. Although many prognostic factors, treatment strategies, and outcomes for convexity SDH have been reported, little is known about falcine and tentorial SDH.

OBJECTIVES

To describe features and outcomes of isolated falcine and tentorial SDH.

METHODS

We reviewed clinical/radiographic findings, treatment, length of stay (LOS), and outcome of adult patients transferred to a tertiary care center for acute SDH. Characteristics of patients with isolated falcine/tentorial SDH and outcomes (favorable [discharge to home/acute rehabilitation] vs. unfavorable [death/hospice/skilled nursing facility/long term care]) were assessed with univariate analyses.

RESULTS

Of 210 patients with SDH, mean age was 69.5 years; 117 were male; 98 (47%) underwent surgical SDH evacuation. Twenty-seven patients had isolated falcine or tentorial SDH, with known traumatic etiology in 23. None of the falcine/tentorial SDH patients required surgery or intubation. Compared with convexity SDH, patients with falcine/tentorial SDH were younger (59.7 vs. 70.9 years, p = 0.01), had higher admission Glasgow Coma Scale scores at the referring (p = 0.01) and receiving facility (p = 0.004), and shorter median intensive care unit LOS (1 vs. 3, p < 0.0001). All patients (100%) with falcine/tentorial SDH had favorable outcome vs. 68% with convexity SDH (p = 0.0005).

CONCLUSION

Isolated tentorial/falcine SDH without associated neurological deficits represent a benign entity among acute SDH, with no need for surgical intervention, short LOS, and favorable outcome. Our data indicate that for these patients, in the absence of complicating factors, transfer to a tertiary care center may not be routinely indicated.

Role of Microvascular Disruption in Brain Damage from Traumatic Brain Injury

Traumatic brain injury (TBI) is acquired from an external force, which can inflict devastating effects to the brain vasculature and neighboring neuronal cells. Disruption of vasculature is a primary effect that can lead to a host of secondary injury cascades. The primary effects of TBI are rapidly occurring while secondary effects can be activated at later time points and may be more amenable to targeting. Primary effects of TBI include diffuse axonal shearing, changes in blood-brain barrier (BBB) permeability, and brain contusions. These mechanical events, especially changes to the BBB, can induce calcium perturbations within brain cells producing secondary effects, which include cellular stress, inflammation, and apoptosis. These secondary effects can be potentially targeted to preserve the tissue surviving the initial impact of TBI. In the past, TBI research had focused on neurons without any regard for glial cells and the cerebrovasculature. Now a greater emphasis is being placed on the vasculature and the neurovascular unit following TBI. A paradigm shift in the importance of the vascular response to injury has opened new avenues of drug-treatment strategies for TBI. However, a connection between the vascular response to TBI and the development of chronic disease has yet to be elucidated. Long-term cognitive deficits are common amongst those sustaining severe or multiple mild TBIs. Understanding the mechanisms of cellular responses following TBI is important to prevent the development of neuropsychiatric symptoms. With appropriate intervention following TBI, the vascular network can perhaps be maintained and the cellular repair process possibly improved to aid in the recovery of cellular homeostasis.