The BIG (brain injury guidelines) project

Joseph, Bellal; Friese, Randall S.; Sadoun, Moutamn; Aziz, Hassan; Kulvatunyou, Narong; Pandit, Viraj; Wynne, Julie; Tang, Andrew; OʼKeeffe, Terence; Rhee, Peter

doi:10.1097/ta.0000000000000161

Cited by 140 publications

(91 citation statements)

References 15 publications

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“… 42 Three studies presented the Brain Injury Guidelines (BIG) risk stratification tool. 9 , 27 , 109 As this tool was applied to all TBI patients and initial GCS forms part of risk stratification, these studies contributed to the narrative synthesis.…”

Section: Resultsmentioning

confidence: 99%

“…Thirty-six studies reported neurosurgical outcomes. 6–9 , 27 , 30 , 37 , 52 , 54 , 57 , 60 , 62 , 63 , 65 , 66 , 73–78 , 86 , 90 , 93 , 97–102 , 104 , 106 , 109 , 114 , 125 , 130 , 139 Figure 5 presents the estimates of the proportion of patients who underwent a neurosurgical procedure stratified by the GCS inclusion criteria. Reported neurosurgical intervention prevalence ranged between 0 and 26% (median 3.1%).…”

Section: Resultsmentioning

confidence: 99%

“…1 A U.S. group based in Arizona has produced the BIG consensus-derived statement that identifies a population with low-risk clinical characteristics and intra-cranial injuries similar to those presented by the CCHR authors. 109 They propose such patients are safe for discharge after 6 h of ED observation. 9 , 27 , 109 …”

Section: Discussionmentioning

confidence: 99%

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

Marincowitz

Lecky

Townend

et al. 2018

Journal of Neurotrauma

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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.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

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

Marincowitz

Lecky

Townend

et al. 2018

Journal of Neurotrauma

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“…4,8 While most prior studies examined transfers of trauma patients. 6,7,9 our study was unique in that we included all patients transferred to the neurosurgical service, thus capturing a large number of patients transferred for neoplasms, spine-related complaints, and other non-traumatic pathology. Finally, we found that PATs were more likely to have Medicare and less likely to have private insurance, which we did not initially postulate.…”

Section: Discussionmentioning

confidence: 99%

Identification and Cost of Potentially Avoidable Transfers to a Tertiary Care Neurosurgery Service

et al. 2016

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Background Thousands of neurosurgical emergencies are transferred yearly to tertiary care facilities to assume a higher level of care. Several studies have examined how neurosurgical transfers influence patient outcomes, but characteristics of potentially avoidable transfers have yet to be investigated. Objective To identify whether potentially avoidable transfers represent a significant portion of transfers to a tertiary neurosurgical facility. Methods In this cohort study, we evaluated 916 neurosurgical patients transferred to a tertiary care facility over a 2-year period. Transfers were classified as potentially avoidable when no neurosurgical diagnostic test, intervention, or intensive monitoring was deemed necessary (n=180). The remaining transfers were classified as justifiable (n=736). The main outcomes and measures were age, sex, diagnosis, insurance status, intervention, distance of transfer, length of hospital and intensive care unit (ICU) stay, mortality, discharge disposition, and cost. Results Nearly 20% of transfers were identified as being potentially avoidable. While some of these patients had suffered devastating, irrecoverable neurologic insults, many had innocuous conditions that did not require transfer to a higher level of care. Justifiable transfers tend to involve patients with non-traumatic intracranial hemorrhage and cranial neoplasm. Both groups were admitted to the intensive care unit at the same rate (approximately 70% of patients). Finally, the direct transportation cost of potentially avoidable transfers was $1.46 million over 2 years. Conclusion This study identified frequency and expense of potentially avoidable transfers. There is a need for closer examination of the clinical and financial implications of potentially avoidable transfers.

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“… 1 Although patients at risk for TBI are identified clinically at the time of initial presentation, the specific diagnosis is virtually always made with a head CT scan. 2 Patients with TBI and a negative CT are usually observed clinically, though some who pose special risks, such as those who are on systemic anticoagulation, 3 may have a CT scan repeated early in their course.…”

Section: Introductionmentioning

confidence: 99%

Routine repeat head CT may not be necessary for patients with mild TBI

Rosen

Luy²,

Deane

et al. 2018

Trauma Surg Acute Care Open

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BackgroundRoutine repeat cranial CT (RHCT) is standard of care for CT-verified traumatic brain injury (TBI). Despite mixed evidence, those with mild TBI are subject to radiation and expense from serial CT scans. Thus, we investigated the necessity and utility of RHCT for patients with mild TBI. We hypothesized that repeat head CT in these patients would not alter patient care or outcomes.MethodsWe retrospectively studied patients suffering from mild TBI (Glasgow Coma Scale (GCS) score 13–15) and treated at the R Adams Cowley Shock Trauma Center from November 2014 through January 2015. The primary outcome was the need for surgical intervention. Outcomes were compared using paired Student’s t-test, and stratified by injury on initial CT, GCS change, demographics, and presenting vital signs (mean ± SD).ResultsEighty-five patients met inclusion criteria with an average initial GCS score=14.6±0.57. Our center sees about 2800 patients with TBI per year, or about 230 per month. This includes patients with concussions. This sample represents about 30% of patients with TBI seen during the study period. Ten patients required operation (four based on initial CT and others for worsening GCS, headaches, large unresolving injury). There was progression of injury on repeat CT scan in only two patients that required operation, and this accompanied clinical deterioration. The mean brain Abbreviated Injury Scale (AIS) score was 4.8±0.3 for surgical patients on initial CT scan compared with 3.4±0.6 (P<0.001) for non-surgical patients. Initial CT subdural hematoma size was 1.1±0.6 cm for surgical patients compared with 0.49±0.3 cm (P=0.05) for non-surgical patients. There was no significant difference between intervention groups in terms of other intracranial injuries, demographics, vital signs, or change in GCS. Overall, 75 patients that did not require surgical intervention received RHCT. At $340 per CT, $51 000 was spent on unnecessary imaging ($367 000/year, extrapolated).DiscussionIn an environment of increased scrutiny on healthcare expenditures, it is necessary to question dogma and eliminate unnecessary cost. Our data questions the use of routine repeat head CT scans in every patient with anatomic TBI and suggests that clinically stable patients with small injury can simply be followed clinically.Level of evidenceLevel III.

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The BIG (brain injury guidelines) project

Abstract: Epidemiologic study, level III.

Cited by 140 publications

References 15 publications

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

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

Identification and Cost of Potentially Avoidable Transfers to a Tertiary Care Neurosurgery Service

Routine repeat head CT may not be necessary for patients with mild TBI

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