SAN DIEGO – Many patients with traumatic brain injury (TBI) can be safely managed by trauma surgeons or intensive care physicians, if a guideline-based individual protocol is followed. In a recent single-center study using this protocol, charges fell, repeat imaging decreased, and patient outcomes did not suffer when neurosurgery consults were reserved for individuals with more severe brain injuries.
Every year, emergency departments see 2.5 million visits for traumatic brain injuries ranging from concussions to devastating open injuries, and 11% of those seen are hospitalized. Still, only 10% of patients with TBI will require neurosurgical intervention, Dr. Bellal Joseph of the University of Arizona said at the annual meeting of the American Surgical Association.
Dr. Bellal Jospeh
Finding a way to conserve resources is important, said Dr. Joseph, since the total number of emergency department visits for TBI is increasing, but resources remain constrained: neurosurgeons are in shorter supply than ever. Further, TBI management may not be changed by numerous repeat head CTs, which are costly and can expose patients to significant amounts of radiation.
Dr. Joseph and his coinvestigators at the University of Arizona had previously developed Brain Injury Guidelines (BIG), which would mandate repeat head CTs and neurosurgery consults only for larger intracranial bleeds and displaced skull fractures. The guidelines are used as part of an individualized protocol that includes overall clinical assessment and patient-specific factors, such as anticoagulation status and whether the patient was intoxicated at the time of injury.
After a period of education regarding the guidelines, the University of Arizona’s Level I trauma center – the only one in the state – implemented BIG use in 2012. For the 5-year period from 2009 to 2014 encompassing implementation of the guidelines, investigators followed all patients admitted for TBI and tracked use of hospital resources and patient outcomes during the study period.
A total of 2,184 patients with TBI were included in the study, divided into five cohorts by year of admission, and stratified by severity of brain injury. Patients were included if they were admitted for TBI from the emergency department and the initial head CT found a skull fracture or intracranial hemorrhage. Dr. Bellal and his colleagues collected data regarding the number of neurosurgery consults, repeat head CTs, and patient demographic and injury characteristics. They tracked patient outcomes including in-hospital mortality, any progression on repeat head CT, and patient disposition on discharge.
TBI injuries were classified by Glasgow Coma Scale scoring (13-15 for mild TBI; 9-12 for moderate; and less than 8 for severe).
Over time, the proportion of patients with severe brain injury who received repeat head CTs did not change significantly. However, scans for those with less severe injury declined significantly, with a marked drop in repeat head CTs seen at the time of implementation of the BIG guidelines (P < .001 for mild and P = .012 for moderate brain injuries).
Similarly, 100% of patients with severe TBI received a neurosurgical consult in each year of the study period, but the number of consults declined significantly for those with mild and moderate injuries (P < .001 for both mild and moderate injuries).
Hospital length of stay decreased from a mean 6.2 days to 4.7 at the end of the study period (P = .028), and total hospital costs fell by nearly half, from a total $8.1 million for the 2009-2010 cohort to $4.3 million for the 2013-2014 cohort (P < .001).
Mortality, discharge score on the Glasgow Coma scale, and the proportion of patients discharged to home after their hospital stay did not change significantly over the study period.
Study limitations included potential lack of generalizability to smaller or more rural centers, and the potential for confounding by changes in other institutional factors over the study period. The study did not track long-term neurologic or quality of life outcomes.
Discussant Dr. Karen Brasel of Oregon Health & Science University, Portland, said that the study is the latest in a series of reports in the TBI field that speak to the need to avoid “knee-jerk use of resources based on diagnosis alone.” She cautioned that it is still important to examine individual patient outcomes for the few patients who did not receive a neurosurgery consult but then deteriorated, to better evaluate who is at most risk for poor outcomes.
Still, said Dr. Joseph, a “guideline-based individualized protocol for traumatic brain injury can help reduce the burden on neurological services. Life changes, and so does medicine.”
The authors reported no conflicts of interest.