Evaluation of a Low Risk Mild Traumatic Brain Injury and Intracranial Hemorrhage Emergency Department Observation Protocol

Abstract

Objectives

Among emergency physicians, there is wide variation in admitting practices for patients who suffered a mild traumatic brain injury (TBI) with an intracranial hemorrhage (ICH). The purpose of this study was to evaluate the effects of implementing a protocol in the emergency department (ED) observation unit for patients with mild TBI and ICH.

Methods

This retrospective cohort study was approved by the Institutional Review Board. Study subjects were patients ≥18 years of age with an International Classification of Diseases (ICD) code corresponding to a traumatic IC, and admitted to an ED observation unit (EDOU) of an urban, academic level 1 trauma center between February 1, 2015 and January 31, 2017. Patient data and discharge disposition were abstracted from the electronic health record; imaging data from the final neuroradiologist report. To measure kappa, two abstractors independently collected data for presence of neuro deficit from a 10% random sample of the medical charts. Using a multivariable logistic regression model with a propensity score of the probability of placement in the EDOU pre-post protocol implementation as a covariate, we sought to determine the pre-post effects of implementing a protocol on the composite outcome of admission to the floor, intensive care unit (ICU), or operating room (OR) from the EDOU, and the proportion of patients with worsening findings on repeat CT head scan in the EDOU.

Results

A total of 379 patients were identified during the study period; 83 were excluded as they were found to have no ICH on chart review. Interrater reliability kappa statistic was 0.63 for 30 charts. Among the 296 patients who remained eligible and comprised the study population, 143 were in the pre-protocol period; 153 post-protocol. The EDOU protocol was associated with an independently statistically significant decreased odds ratio (OR) for admission or worsening ICH on repeat CT scan (OR 0.45, 95% confidence interval [CI] 0.25, 0.82, p=0.009) in the observation unit. After a stay in the EDOU, 26% (37/143) of patients required an inpatient admission pre-implementation of the protocol and 13% (20/153) of patients required an inpatient admission post-protocol implementation. There was no statistically significant difference in log transformed EDOU length of stay (LOS) between the groups after adjusting for propensity score (p=0.34).

Conclusions

While there was no difference in EDOU LOS, implementing a low risk mild traumatic brain injury and intracranial hemorrhage protocol in the EDOU may decrease the rate of inpatient admissions from the EDOU. A protocol driven observation unit may help physicians by standardizing eligibility criteria and by providing guidance on management. As the propensity score method limits our ability to create a straightforward predictive model, a future larger study should validate the results.

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