Clinical Decision Support Intervention and Time to Imaging in Older Patients with Traumatic Brain Injury.

BACKGROUND: Traumatic brain injury (TBI) is the leading cause of elderly trauma admissions. Previous research identified that each minute delay to TBI diagnosis was associated with a 2% mortality increase, delaying treatment to older patients (age ≥70 years) who do not meet trauma activation criteria. A TBI protocol and clinical decision support intervention (CDS-I) were developed to reduce time to imaging in older patients with head trauma not meeting trauma activation criteria. STUDY DESIGN: An emergency department (ED) head CT protocol and CDS-I were developed and implemented to facilitate rapid imaging of older patients. Patients age ≥ 70 years, with TBI and receiving anticoagulation, met inclusion criteria. The primary outcomes measure was time from ED arrival to head CT imaging comparing before (PRE: January 1, 2016 to December 31, 2016) vs after (POST: August 1, 2018 to April 3, 2019) protocol implementation. Negative binomial regression models evaluated the association of intervention on time to imaging. LOWESS (locally weighted scatterplot smoothing) was used to evaluate the association of intervention on mortality over time. RESULTS: The study examined 451 patients (269 PRE and 182 POST). Positive head CTs were seen in 78 (17.3%), and 57 of 78 (73%) patients had a Glasgow Coma Scale > 13. POST-intervention decreased time to head CT from 56 to 27 minutes (interquartile range [IQR] PRE: 32 to 93 to POST:16 to 44, p < 0.001) and POST-intervention patients had reduced hospital length of stay (incidence rate ratio [IRR] 0.83, 95% CI 0.72 to 0.86, p = 0.01). CONCLUSIONS: A significant proportion of older patients receiving anticoagulation, but not meeting trauma activation criteria, had positive CT findings. Implementation of a rapid triage protocol with CDS-I reduced time to imaging and may reduce mortality in the highest-risk populations.

Early Imaging Associated With Improved Survival in Older Patients With Mild Traumatic Brain Injuries.

BACKGROUND: Traumatic brain injury (TBI) is a leading cause of trauma-related death and disability. Computed tomography (CT) imaging of the head is essential for diagnosis of intracranial hemorrhage. This study aimed to identify optimal time to imaging and its impact on mortality for older patients with mild TBIs. MATERIALS AND METHODS: State-wide quality collaborative data were used from level I-II trauma centers. Inclusion criteria were ICD-9/10 codes for head trauma, age ≥50, admission/emergency department Glasgow Coma Scale ≥14, injury severity score ≤20, nonfull trauma activation, and head CT imaging time between 5 and 90 min of arrival. Locally weighted scatterplot smoothing plot data were used to dichotomize patients into early and late head CT imaging cohorts. Multivariable logistic regression and negative binomial models were used to evaluate the effect of early verses late head CT on clinical outcomes. The primary outcome was in-hospital mortality. RESULTS: Mortality nadired at 35 min. Each 1-min delay in CT imaging resulted in a 2% increase in mortality (P = 0.002). Early patients had significantly reduced in-hospital mortality (P = 0.03), shorter emergency department length of stay (P < 0.001), and were more likely to receive fresh frozen plasma within 4 h if anticoagulated (P = 0.03). Teaching, high-volume, and level 2 trauma centers were all less likely to provide early head CTs (all P < 0.05). CONCLUSIONS: Delay in head CT imaging in the setting of potential mild TBI was associated with an increase in mortality. A delay in diagnosis cascades into delays in delivery of therapeutic interventions. Head CT within 35 min should be evaluated as a quality metric for older patients with mild TBI.

High prevalence of prior contact sports play and concussion among orthopedic and neurosurgical department chairs.

OBJECTIVE Increased understanding of the consequences of traumatic brain injury has heightened concerns about youth participation in contact sports. This study investigated the prevalence of high school and collegiate contact sports play and concussion history among surgical department chairs. METHODS A cross-sectional survey was administered to 107 orthopedic and 74 neurosurgery chairs. Responses were compared to published historical population norms for contact sports (high school 27.74%, collegiate 1.44%), football (high school 10.91%, collegiate 0.76%), and concussion prevalence (12%). One-proportion Z-tests, chi-square tests, and binary logistic regression were used to analyze differences. RESULTS High school contact sports participation was 2.35-fold higher (65.3%, p < 0.001) for orthopedic chairs and 1.73-fold higher (47.9%, p = 0.0018) for neurosurgery chairs than for their high school peers. Collegiate contact sports play was 31.0-fold higher (44.7%, p < 0.001) for orthopedic chairs and 15.1-fold higher (21.7%, p < 0.001) for neurosurgery chairs than for their college peers. Orthopedic chairs had a 4.30-fold higher rate of high school football participation (46.9%, p < 0.001) while neurosurgery chairs reported a 3.05-fold higher rate (33.3%, p < 0.001) than their high school peers. Orthopedic chairs reported a 28.1-fold higher rate of collegiate football participation (21.3%, p < 0.001) and neurosurgery chairs reported an 8.58-fold higher rate (6.5%, p < 0.001) compared to their college peers. The rate at which orthopedic (42.6%, p < 0.001) and neurosurgical (42.4%, p < 0.001) chairs reported having at least 1 concussion in their lifetime was significantly higher than the reported prevalence in the general population. After correction for worst possible ascertainment bias, all results except high school contact sports participation remained significant. CONCLUSIONS The high prevalence of youth contact sports play and concussion among surgical specialty chairs affirms that individuals in careers requiring high motor and cognitive function frequently played contact sports. The association highlights the need to further examine the relationships between contact sports and potential long-term benefits as well as risks of sport-related injury.