Agreement between blood gas analysis and laboratory analysis for sodium, potassium and haemoglobin concentrations shows acceptable agreement for use in time critical clinical decision-making in ED.
Background
In 2014, the South Australian coroner recommended that residents of residential aged care facilities (RACF) who had sustained a head injury should be transported to emergency departments (ED) for assessment and a head CT scan, with the view to preventing mortality. The evidence base for the recommendation is unclear.
Aims
To determine the rate of emergent intervention (neurosurgery, transfusion of blood products or reversal of anti‐coagulation) in residents transferred to ED with minor head trauma who had their usual cognitive function on ED assessment.
Methods
This was a retrospective cohort study by medical records review at two university‐affiliated community ED. Participants were patients from RACF attending ED who had suffered minor head trauma and had their usual cognitive function. Exclusions were altered conscious state, new neurological findings or associated orthopaedic injury requiring hospital admission. The primary outcome was rate of emergent intervention in residents transferred to ED with minor head trauma who had their usual cognitive function on ED assessment.
Results
A total of 366 patients was studied; median age 86 years, 45% taking anti‐coagulant/anti‐platelet medication. Eighty per cent underwent head CT. Six per cent had intracranial haemorrhage (ICH; 95% CI 4–8.9%). No patient underwent neurosurgery. One had emergent intervention, reversal of anti‐coagulation (0.3%, 95% CI 0.05–1.5%).
Conclusion
The rate of emergent intervention for ICH in patients from RACF who sustained a minor head trauma but had their normal cognitive function was <1%. None underwent neurosurgical intervention. The low rate of intervention seriously challenges the appropriateness of routine transfer and CT for this patient group.
Introduction:
Because TIA increases the risk of subsequent stroke, rapid TIA management is key to stroke prevention. Controversy remains regarding the appropriate site of care for TIA patients. Recent literature shows high variability in care processes, admission rates, timeliness of interventions, cost of care, and outcomes, regardless of site of care. We developed a rapid TIA management process in our Clinical Decision Unit (CDU) to reduce cost and adverse outcomes. TIA patients that present to our ED are admitted to the CDU, but transfer patients with TIA are admitted to the inpatient unit (IPU).
Methods:
Retrospectively, we identified TIA cases by ICD coding, and reviewed records from 4/1/2012 to 3/31/2016 for patients in the CDU and in the IPU. We compared length of stay (LOS), cost of care, readmission rates, and TIA/stroke recurrence between the two groups. Statistical analysis included Chi-square and Wilcoxon two-sample test for recurrence and readmission rates, and generalized linear modeling and Poisson analysis for LOS and cost analysis.
Results:
A total of 731 patients presented for TIA management in the study period; 393 in CDU, and 338 in IPU. There was no statistical difference in age or sex between the two groups. Mean LOS (hours) in CDU vs IPU was 15 vs 108 (p<0.001), respectively. Total cost of care in CDU vs IPU was $3,835 vs $11,904 (p<0.001), respectively. Univariate analysis showed no appreciable difference in recurrent TIA or stroke rates; multivariate analysis of stroke recurrence for CDU (1.0%) vs IPU (3.6%) did show a small difference (p=0.024). When factoring in reduction of stroke recurrence, the final cost savings of the CDU program equaled $8,258 per patient. There was no difference in readmission rates between the two groups.
Conclusion:
Using a rapid TIA management protocol yielded a significantly lower LOS and cost per patient. This may justify an avoidance of inpatient admission for TIA patients.
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