Not every trauma patient with a radiographic head injury requires transfer for neurosurgical evaluation: Application of the brain injury guidelines to patients transferred to a level 1 trauma center

Capron, Gweniviere; Voights, Mary Beth; Moore, Henry R.; Wall, Derek B.

doi:10.1016/j.amjsurg.2017.09.002

Cited by 22 publications

(11 citation statements)

References 6 publications

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“…This study extends the current knowledge regarding patients with moderate TBI [24], as we have demonstrated that 60% of the patients admitted to GHs were managed entirely at the GH. Several studies have investigated the opportunities for the management of patients with TBI without transfer to a neurosurgical department, but most of these studies have only included patients with mild TBI or have health care systems not readily comparable to the Scandinavian health care model [25][26][27]. On both the national and international levels, there is a lack of guidelines offering nuanced recommendations for the management of moderate and severe TBI at the GH level.…”

Section: Discussionmentioning

confidence: 99%

Moderate and severe traumatic brain injury in general hospitals: a ten-year population-based retrospective cohort study in central Norway

Rahim

Laugsand

Fyllingen

et al. 2022

Scand J Trauma Resusc Emerg Med

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Background Patients with moderate and severe traumatic brain injury (TBI) are admitted to general hospitals (GHs) without neurosurgical services, but few studies have addressed the management of these patients. This study aimed to describe these patients, the rate of and reasons for managing patients entirely at the GH, and differences between patients managed entirely at the GH (GH group) and patients transferred to the regional trauma centre (RTC group). We specifically examined the characteristics of elderly patients. Methods Patients with moderate (Glasgow Coma Scale score 9–13) and severe (score ≤ 8) TBIs who were admitted to one of the seven GHs without neurosurgical services in central Norway between 01.10.2004 and 01.10.2014 were retrospectively identified. Demographic, injury-related and outcome data were collected from medical records. Head CT scans were reviewed. Results Among 274 patients admitted to GHs, 137 (50%) were in the GH group. The transferral rate was 58% for severe TBI and 40% for moderate TBI. Compared to the RTC group, patients in the GH group were older (median age: 78 years vs. 54 years, p < 0.001), more often had a preinjury disability (50% vs. 39%, p = 0.037), and more often had moderate TBI (52% vs. 35%, p = 0.005). The six-month case fatality rate was low (8%) in the GH group when transferral was considered unnecessary due to a low risk of further deterioration and high (90%, median age: 87 years) when neurosurgical intervention was considered nonbeneficial. Only 16% of patients ≥ 80 years old were transferred to the RTC. For this age group, the in-hospital case fatality rate was 67% in the GH group and 36% in the RTC group and 84% and 73%, respectively, at 6 months. Conclusions Half of the patients were managed entirely at a GH, and these were mainly patients considered to have a low risk of further deterioration, patients with moderate TBI, and elderly patients. Less than two of ten patients ≥ 80 years old were transferred, and survival was poor regardless of the transferral status.

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Section: Discussionmentioning

confidence: 99%

Moderate and severe traumatic brain injury in general hospitals: a ten-year population-based retrospective cohort study in central Norway

Rahim

Laugsand

Fyllingen

et al. 2022

Scand J Trauma Resusc Emerg Med

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“…While these studies and others [16] , [17] reviewed potential transfer avoidance in post hoc analyses, others attempted to implement systems to actively avoid unnecessary transfers [10] , [18] . Capron et al utilized the Brain Injury Guidelines (BIG) criteria; patients in the BIG 1 category (i.e., normal neurologic examination, not on antiplatelet or anticoagulation medications, with small (less than4 mm) intracranial hemorrhage) were deemed safe for avoidance of transfer [19] . In their report, neurosurgeons were not involved in the decision-making process.…”

Section: Discussionmentioning

confidence: 99%

“…In our report, only 28.7% of screened patients correlate with the BIG 1 category because 5.9% and 78.8% of our patients avoiding transfer had an abnormal neurological exam (i.e., GCS = 14) and used antiplatelet/anticoagulation medications, respectively. This suggests that involvement of a neurosurgeon in the screening process may be beneficial, although this has been disputed [19] , [20] . In our series, none of the screened patients avoiding transfer later deteriorated.…”

Section: Discussionmentioning

confidence: 99%

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

Alan

Kim

Agarwal

et al. 2020

Journal of Clinical Neuroscience

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“…Some validation studies also modified the BIG criteria so that any patient with an initial GCS <15 was admitted to hospital. 22 The USA TBI population used for these studies also appears to be lower risk with a lower reported average age, anti-coagulant use and neurosurgical intervention rate. 4 23 The risk of deterioration when discharging a patient from the ED that is acceptable to patients and clinicians is subjective.…”

Section: Comparison To Previous Literaturementioning

confidence: 99%

Performance of the Hull Salford Cambridge Decision Rule (HSC DR) for early discharge of patients with findings on CT scan of the brain: a CENTER-TBI validation study

et al. 2021

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BackgroundThere is international variation in hospital admission practices for patients with mild traumatic brain injury (TBI) and injuries on CT scan. Only a small proportion of patients require neurosurgical intervention, while many guidelines recommend routine admission of all patients. We aim to validate the Hull Salford Cambridge Decision Rule (HSC DR) and the Brain Injury Guidelines (BIG) criteria to select low-risk patients for discharge from the emergency department.MethodA cohort from 18 countries of Glasgow Coma Scale 13–15 patients with injuries on CT imaging was identified from the multicentre Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) Study (conducted from 2014 to 2017) for secondary analysis. A composite outcome measure encompassing need for ongoing hospital admission was used, including seizure activity, death, intubation, neurosurgical intervention and neurological deterioration. We assessed the performance of our previously derived prognostic model, the HSC DR and the BIG criteria at predicting deterioration in this validation cohort.ResultsAmong 1047 patients meeting the inclusion criteria, 267 (26%) deteriorated. Our prognostic model achieved a C-statistic of 0.81 (95% CI: 0.78 to 0.84). The HSC DR achieved a sensitivity of 100% (95% CI: 97% to 100%) and specificity of only 4.7% (95% CI: 3.3% to 6.5%) for deterioration. Using the BIG criteria for discharge from the ED achieved a higher specificity (13.3%, 95% CI: 10.9% to 16.1%) and lower sensitivity (94.6%, 95% CI: 90.5% to 97%), with 12/105 patients recommended for discharge subsequently deteriorating, compared with 0/34 with the HSC DR.ConclusionOur decision rule would have allowed 3.5% of patients to be discharged, none of whom would have deteriorated. Use of the BIG criteria may select patients for discharge who have too high a risk of subsequent deterioration to be used clinically. Further validation and implementation studies are required to support use in clinical practice.

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Not every trauma patient with a radiographic head injury requires transfer for neurosurgical evaluation: Application of the brain injury guidelines to patients transferred to a level 1 trauma center

Cited by 22 publications

References 6 publications

Moderate and severe traumatic brain injury in general hospitals: a ten-year population-based retrospective cohort study in central Norway

Moderate and severe traumatic brain injury in general hospitals: a ten-year population-based retrospective cohort study in central Norway

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

Performance of the Hull Salford Cambridge Decision Rule (HSC DR) for early discharge of patients with findings on CT scan of the brain: a CENTER-TBI validation study

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