Emergency department management of mild traumatic brain injury in the USA.

OBJECTIVE: To describe the emergency department (ED) management of isolated mild traumatic brain injury (TBI) in the USA and to examine variation in care across age and insurance types. METHODS: A secondary analysis of ED visits for isolated mild TBI in the National Hospital Ambulatory Medical Care Survey 1998-2000 was performed. Mild TBI was defined by International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9) codes for skull fracture, concussion, intracranial injury (unspecified), and head injury (unspecified). Available ED care variables were analysed by patient age and insurance categories using multivariate logistic regression. RESULTS: The incidence of isolated mild TBI cases attending ED was 153,296 per year, or 56.4/100,000 people. Of the patients with isolated mild TBI, 44.3% underwent computed tomography, 23.9% underwent other non-extremity, non-chest x rays, 17.1% received wound care and 14.1% received intravenous fluids. However, only 43.8% had an assessment of pain. Of those with documented pain, only 45.5% received analgesics in the ED. Nearly 38% were discharged without recommendations for specific follow up. Several aspects of ED care varied by age but not by insurance type. CONCLUSION: Substantial ED resources are devoted to the care of isolated mild TBI. The present study identified deficiencies in and variation around several important aspects of ED care. The development of guidelines specific for mild TBI could reduce variation and improve emergency care for this injury.

Predicting postconcussion syndrome after minor traumatic brain injury.

BACKGROUND: Up to 50% of patients with minor traumatic brain injury (mTBI) develop postconcussion syndrome (PCS). A decision rule to stratify risk for PCS is needed. OBJECTIVE: To identify mTBI patients at low and high risk of PCS by comparing the predictive values of variables generated by logistic regression (LR) and recursive partitioning (RP). METHODS: This was a prospective, observational study of 69 mTBI patients aged >16 years presenting to the emergency department of a university teaching hospital. Minor TBI was defined as loss of consciousness <10 minutes or amnesia, Glasgow Coma Scale score (GCS) of 15, no skull fracture on physical examination, nonfocal neurologic exam, and no brain injury on computed tomography if one was done. Clinical/demographic data and the results of a brief neurobehavioral test battery were collected for all patients. The presence of PCS was determined by a validated telephone questionnaire at one month after initial presentation. All variables were subjected to both LR and RP. RESULTS: Fifty-eight percent had PCS at one month after initial presentation. Low risk: PCS occurred in 9% of men scoring >24 on the Hopkins Verbal Learning A (HVLA) (by LR) and in 9% of those injured in sports scoring >22 on HVLA (RP). High risk: PCS occurred in 89% of women scoring <9 on the Digit Span test (LR) and in 92% of those injured via falls or motor vehicle collision scoring <11.5 on HVLB2 (RP). CONCLUSIONS: Despite the high incidence of PCS, we were able to identify a low-risk subgroup with an average PCS risk of <10% and a high-risk subgroup with a PCS risk of approximately 90%. Combining results from LR and RP expanded the number of patients able to be classified as high/low risk. Prospective validation is necessary.

Knowledge of concussion guidelines among practitioners caring for children.

The objective of this study in Rochester, NY was to determine clinicians' knowledge of the Colorado Medical Society Guidelines (CMSG) on return to contact sports after a concussion. A survey was mailed to 1,140 pediatric, family practice, and emergency physicians, as well as 302 pediatric and family practice nurse practitioners in the Rochester, NY, area. Participants were given 3 hypothetical concussion scenarios and asked to pick 1 of 4 multiple-choice time intervals for when they would advise return to contact sports. Answers were compared with the latest version of the CMSG. The survey response rate was 57%. Only 7.6% responded correctly for Grade 1 concussion scenario, 56% for the Grade 2 scenario, and 28% for the Grade 3 scenario. Only 5.6% listed the CMSG as the source of the return-to-play advice they gave. Thus, respondents' knowledge of the CMSG was low, with few giving return-to-play advice consistent with the CMSG and even fewer acknowledging the CMSG as the source of such advice. Improving the availability of the CMSG may improve clinicians' knowledge and use of these guidelines.

Teaching emergency medicine residents evidence-based critical appraisal skills: a controlled trial.

STUDY OBJECTIVES: To compare the performance of an evidence-based medicine (EBM) approach and a traditional approach to teaching critical appraisal skills to emergency medicine residents. METHODS: This was a prospective, case-controlled trial of 32 emergency medicine residents (16 control and 16 intervention). Intervention residents were exposed to a monthly, 1-hour journal club using an EBM approach to critical appraisal over the course of 1 year. Control residents were exposed to a traditional, unstructured journal club, also monthly. Both groups were given a factitious article to evaluate in an essay format before and after the 12-month study period. The Wilcoxon rank sum test was used to compare mean improvement in test scores for each group. RESULTS: The mean improvement in test scores was 1.80 for the control group and 1.53 for the intervention group; these values were not significantly different (P =.90). The difference in mean change in test score between the 2 groups was.27 points. CONCLUSION: Compared with a traditional approach, an EBM approach to teaching critical appraisal did not appear to improve the critical appraisal skills of emergency medicine residents. However, because of the small number of subjects studied, small differences in critical appraisal skill improvement cannot be ruled out.

Test ordering guidelines can alter ordering patterns in an academic emergency department.

To determine the impact of an educational program designed to modify test ordering behavior in an academic Emergency Department (ED), an observational, before-and-after study was conducted at a university tertiary referral center and Emergency Medicine (EM) residency site. Test ordering standards were developed by EM faculty, RNs, and NPs based upon group consensus and published data. The standards were given to all ED staff beginning February 1996, and included in the evidence-based medicine orientation and educational program for all residents and medical students prior to beginning their rotation. No restrictions were placed on actual test ordering. The number of laboratory tests (total and individual) ordered per 100 patients decreased significantly after the educational program began for: total testing, CBC, and liver function test (LFT). In addition, declines during individual months for these tests were statistically significant. Prothrombin time and blood culture testing showed no significant decreases in test ordering frequency. Chemistry test ordering frequency showed statistically significant increases. Overall, approximately $50,000 was saved by decreasing test ordering. Test ordering behavior can be modified and maintained by an educational program and may have significant economic effects.

Epidemiology and predictors of post-concussive syndrome after minor head injury in an emergency population.

OBJECTIVE: To determine if clinical variables or neurobehavioural test (NBT) scores obtained in the ED within 24 hours of minor head injury (MHI) predict the development of postconcussive syndrome (PCS). METHODS: Prospective, observational study of 71 MHI patients and 60 orthopaedic controls. MHI defined as loss of consciousness < 10 minutes or amnesia, GCS 15, no skull fracture or new neurologic focality on PE, and no brain injury on CT (if done). All patients received a seven part NBT battery in the ED. Telephone follow-up was done at 1, 3 and 6 months to determine if patients met the DSM IV definition of PCS. ANALYSIS: Stepwise, multivariate, logistic regression. RESULTS: Predictors of PCS at 1 month were female gender (OR = 7.8; 95% CI = 41.6, 1.98), presence of both retrograde and anterograde amnesia (OR = 0.055; CI = 0.002, 0.47), Digit Span Forward Scores (OR = 0.748; CI = 0.52, 1.03) and Hopkins Verbal Learning A scores (OR = 0.786; CI = 0.65, 0.91); at 3 months, presence of both retrograde and anterograde amnesia (OR = 0.13; CI = 0.0, 0.93), Digit Span Forward Scores (OR = 0.744; CI = 0.58, 0.94). No variables fit the model at 6 months. 92% of males scoring > 25 on Hopkins Verbal Learning A did not have PCS at 1 month, and 89% of females scoring < 9 on Digit Span Forward did have PCS at 1 month. CONCLUSIONS: Gender and two NBTs can help predict PCS after MHI.

Do admitted patients held in the emergency department impact the throughput of treat-and-release patients?

OBJECTIVE: To examine the impact of reducing ED "boarders" (through the use of a short-stay inpatient medicine unit) on the amount of time that treat-and-release patients spend in the ED. METHODS: A retrospective analysis of hours spent in the ED was made at a university hospital teaching ED for treat-and-release patients in 4 clinical categories: chest pain, asthma exacerbation, sickle-cell crisis, and seizure. The average hours per patient spent in the ED during the 4-month intervals before (August-November 1993) and after (August-November 1994) the establishment of the short-stay medicine unit were compared. Data were analyzed using the 2-tailed, unpaired t-test. RESULTS: This short-stay inpatient medicine unit received on average 135 patients per month from the ED, with an average length of stay of 2.4 days. The mean (+/-SD) number of admitted patients per day waiting in the ED > 8 hours for an inpatient bed dropped from 9.6 +/- 4.2., before the institution of this unit, to 2.3 +/- 2.6. There was a significant reduction in the average number of hours spent in the ED by treat-and-release patients with chest pain (from 7.3 +/- 6.0 to 5.5 +/- 4.8 hr/patient, p < 0.001) and asthma exacerbation (from 5.0 +/- 3.6 to 4.2 +/- 2.9 hr/patient, p < 0.05), but not with sickle-cell crisis or seizure, after the implementation of the short-stay unit. CONCLUSION: Reducing the number of admitted patients waiting in the ED for inpatients beds, in this case by establishment of a short-stay medicine unit, is associated with a decrease in the interval that treat-and-release patients spend in the ED.