Derivation of a clinical decision rule to guide the interhospital transfer of patients with blunt traumatic brain injury

Abstract

Objective: To derive a clinical decision rule for people with traumatic brain injury (TBI) that enables early identification of patients requiring specialised trauma care. Methods: We collected data from 1999 through 2003 on a retrospective cohort of consecutive people aged 18-65 years with a serious head injury (AIS >3), transported directly from the scene of injury, and evaluated in the ED. Information on 22 demographical, physiological, radiographic, and lab variables was collected. Resource based ''high therapeutic intensity'' measures occurring within 72 hours of ED arrival (the outcome measure) were identified a priori and included: neurosurgical intervention, exploratory laparotomy, intensive care interventions, or death. We used classification and regression tree analysis to derive and cross validate the decision rule. Results: 504 consecutive trauma patients were identified as having a serious head injury: 246 (49%) required at least one of the HTI measures. Five ED variables (GCS, respiratory rate, age, temperature, and pulse rate) identified subjects requiring at least one of the HTI measures with 94% sensitivity (95% CI 91 to 97%) and 63% specificity (95% CI 57 to 69%) in the derivation sample, and 90% sensitivity and 55% specificity using cross validation. Conclusions: This decision rule identified among a cohort of head injured patients evaluated in the ED the majority of those who urgently required specialised trauma care. The rule will require prospective validation in injured people presenting to non-tertiary care hospitals before implementation can be recommended.

Factors predicting mortality in victims of blunt trauma brain injury in emergency department settings

“…In support of our findings, a recent study whose purpose was to formulate a decision rule for interhospital transfer of TBI patients found that five variables (initial ED GCS score, initial ED respiratory rate, initial ED temperature, initial ED pulse and patient age) could be used to identify patients requiring timely high therapeutic intensity measures and that the decision tree based on these variables was 94% sensitive and 63% specific 14. Initial blood pressure, brain herniation, SDH, SAH on initial CT scan and transfer from other hospitals may also be mortality risks, but more data are needed to confirm this possibility.…”

Early Neurosurgical Procedures Enhance Survival in Blunt Head Injury: Propensity Score Analysis

“…Variables for inclusion in the propensity score were limited to those available in the dataset (9). The use of supplemental variables commonly included in decisionmaking specifically related to neurosurgical procedures (e.g., blood alcohol level, pre-injury use of warfarin, repeat CT scan findings, and GCS score at 6 -12 h after presentation) may strengthen a propensity score for predicting early neurosurgical procedures.…”

“…Patients with penetrating brain injury and those who died within 90 min of ED arrival also were excluded. In addition, a portion of the study population was used in an earlier article describing a decision rule to identify patients requiring high-intensity therapeutic interventions (i.e., patients with high resource needs) at the Level-1 trauma center (9).…”

“…All variables of interest were explicitly defined a priori on a standardized data collection instrument. We held monthly meetings with the chart abstractors during the period of data collection and routinely checked inter-rater reliability measures for data abstraction to ensure consistency of data abstraction and data entry (9).…”

Low rate of delayed deterioration requiring surgical treatment in patients transferred to a tertiary care center for mild traumatic brain injury

“…18 The limited availability of beds and resources, therefore, must be prioritized to these severely injured patients.…”