Management of traumatically injured patients in the emergency department observation unit

Management of the mild traumatic brain injured patient using a multidisciplinary observation unit protocol

OBJECTIVES

We developed an ED based multidisciplinary observation unit (OU) protocol for patients with mild traumatic brain injury (mTBI). We describe the cohort of patients who were placed in the ED OU and we evaluated if changes to our inclusion and exclusion criteria should be made.

METHODS

We conducted a retrospective cohort study to evaluate subjects who were admitted to the mTBI observation protocol. We included adults within 24 h of sustaining an mTBI with a Glasgow Coma Scale (GCS) of 14 or 15 who had pre-specified head CT findings, and did not meet exclusion criteria. Predictors of need for hospital admission after completing the OU protocol were determined using multivariable logistic regression analysis.

RESULTS

The mean age was 49 (SD 23), 58 (33%) were female, and 136 (78%) were Caucasian. No subjects discharged home required a surgical intervention or ICU admission, and there were no deaths in discharged or admitted subjects. 28 subjects (16%) were admitted to the hospital following their OU stay. Subjects admitted were older (mean age: 56 vs. 48, p = 0.1) and had a higher proportion of traumatic bleeds on head CT (85% vs. 76%, p = 0.3). In multivariable logistic regression, GCS of 15 (aOR 4.24), African-American race (aOR 5.84), and no comorbid cardiac disease predicted discharge home after the observation protocol (aOR 0.28).

CONCLUSIONS

A period of observation for a pre-defined cohort of patients with mTBI provided a triage plan that could allow appropriate patient management without requiring admission in the majority of subjects.

Identifying patients with mild traumatic intracranial hemorrhage at low risk of decompensation who are safe for ED observation

BACKGROUND

Patients with traumatic intracranial hemorrhage and mild traumatic brain injury (mTIH) receive broadly variable care which often includes transfer to a trauma center, neurosurgery consultation and ICU admission. However, there may be a low risk cohort of patients who can be managed without utilizing such significant resources.

OBJECTIVE

Describe mTIH patients who are at low risk of clinical or radiographic decompensation and can be safely managed in an ED observation unit (EDOU).

METHODS

Retrospective evaluation of patients age≥16, GCS≥13 with ICH on CT. Primary outcomes included clinical/neurologic deterioration, CT worsening or need for neurosurgery.

RESULTS

1185 consecutive patients were studied. 814 were admitted and 371 observed patients (OP) were monitored in the EDOU or discharged from the ED after a period of observation. None of the OP deteriorated clinically. 299 OP (81%) had a single lesion on CT; 72 had mixed lesions. 120 patients had isolated subarachnoid hemorrhage (iSAH) and they did uniformly well. Of the 119 OP who had subdural hematoma (SDH), 6 had worsening CT scans and 3 underwent burr hole drainage procedures as inpatients due to persistent SDH without new deficit. Of the 39 OP who had cerebral contusions, 3 had worsening CT scans and one required NSG admission. No patient returned to the ED with a complication. Follow-up was obtained on 81% of OP. 2 patients with SDH required burr hole procedure >2weeks after discharge.

CONCLUSIONS

Patients with mTIH, particularly those with iSAH, have very low rates of clinical or radiographic deterioration and may be safe for monitoring in an emergency department observation unit.

State of the art: emergency department observation units

Hospitals and emergency departments face the challenges of escalating healthcare costs, mismatched resource utilization, concern over avoidable admissions, and hospital and emergency department overcrowding. One approach that has been used by hospitals to address these issues is the use of emergency department observation units. Research in this setting has increased in recent years, leading to a better understanding of the role of these units and their unique benefits. These benefits have been proven for health systems as a whole and for several acute conditions including chest pain, asthma, syncope, transient ischemic attack, atrial fibrillation, heart failure, abdominal pain, and more. Benefits include a decrease in diagnostic uncertainty, lower cost and resource utilization, improved patient satisfaction, and clinical outcomes that are comparable to admitted patients. As more hospitals begin to use observation units, there is a need for further education and research in how to optimize the use of emergency department observation units. The purpose of this article is to provide a general overview of observation units, including advancements and research in this field.

Variability of ICU use in adult patients with minor traumatic intracranial hemorrhage

STUDY OBJECTIVE

Patients with minor traumatic intracranial hemorrhage are frequently admitted to the ICU, although many never require critical care interventions. To describe ICU resource use in minor traumatic intracranial hemorrhage, we assess (1) the variability of ICU use in a cohort of patients with minor traumatic intracranial hemorrhage across multiple trauma centers, and (2) the proportion of adult patients with traumatic intracranial hemorrhage who are admitted to the ICU and never receive a critical care intervention during hospitalization. In addition, we evaluate the association between ICU admission and key independent variables.

METHODS

A structured, historical cohort study of adult patients (aged 18 years and older) with minor traumatic intracranial hemorrhage was conducted within a consortium of 8 Level I trauma centers in the western United States from January 2005 to June 2010. The study population included patients with minor traumatic intracranial hemorrhage, defined as an emergency department (ED) Glasgow Coma Scale (GCS) score of 15 (normal mental status) and an Injury Severity Score less than 16 (no other major organ injury). The primary outcome measure was initial ICU admission. The secondary outcome measure was a critical care intervention during hospitalization. Critical care interventions included mechanical ventilation, neurosurgical intervention, transfusion of blood products, vasopressor or inotrope administration, and invasive hemodynamic monitoring. ED disposition and the proportion of ICU patients not receiving a critical care intervention were compared across sites with descriptive statistics. The association between ICU admission and predetermined independent variables was analyzed with multivariable regression.

RESULTS

Among 11,240 adult patients with traumatic intracranial hemorrhage, 1,412 (13%) had minor traumatic intracranial hemorrhage and complete ED disposition data (mean age 48 years; SD 20 years). ICU use within this cohort across sites ranged from 50% to 97%. Overall, 847 of 888 patients (95%) with minor traumatic intracranial hemorrhage who were admitted to the ICU did not receive a critical care intervention during hospitalization (range between sites 80% to 100%). Three of 524 (0.6%) patients discharged home or admitted to the observation unit or ward received a critical care intervention. After controlling for severity of injury (age, blood pressure, and Injury Severity Score), study site was independently associated with ICU admission (odds ratios ranged from 1.5 to 30; overall effect P<.001).

CONCLUSION

Across a consortium of trauma centers in the western United States, there was wide variability in ICU use within a cohort of patients with minor traumatic intracranial hemorrhage. Moreover, a large proportion of patients admitted to the ICU never required a critical care intervention, indicating the potential to improve use of critical care resources in patients with minor traumatic intracranial hemorrhage.

Pulmonary trauma emergency department evaluation and management

Pulmonary trauma is a significant cause of morbidity and mortality in the United States. It is imperative for the emergency physician to identify promptly patients who require immediate therapy. In patients who have limited injuries, literature shows that often conservative management provides improved outcome. As the exposure to automobiles and firearms continues to increase in the setting of improved prehospital management, the emergency physician will encounter an increasing amount of pulmonary trauma. This rise in respiratory injuries will require a more aggressive approach of patients with minimal morbidity and mortality. A systematic approach to respiratory injuries is crucial to improving patient outcomes.