Development of a Clinical Decision Rule for the Early Safe Discharge of Patients with Mild Traumatic Brain Injury and Findings on Computed Tomography Brain Scan: A Retrospective Cohort Study.

International guidelines recommend routine hospital admission for all patients with mild traumatic brain injury (TBI) who have injuries on computed tomography (CT) brain scan. Only a small proportion of these patients require neurosurgical or critical care intervention. We aimed to develop an accurate clinical decision rule to identify low-risk patients safe for discharge from the emergency department (ED) and facilitate earlier referral of those requiring intervention. A retrospective cohort study of case notes of patients admitted with initial Glasgow Coma Scale 13-15 and injuries identified by CT was completed. Data on a primary outcome measure of clinically important deterioration (indicating need for hospital admission) and secondary outcome of neurosurgery, intensive care unit admission, or intubation (indicating need for neurosurgical admission) were collected. Multi-variable logistic regression was used to derive models and a risk score predicting deterioration using routinely reported clinical and radiological candidate variables identified in a systematic review. We compared the performance of this new risk score with the Brain Injury Guideline (BIG) criteria, derived in the United States. A total of 1699 patients were included from three English major trauma centers. A total of 27.7% (95% confidence interval [CI], 25.5-29.9) met the primary and 13.1% (95% CI, 11.6-14.8) met the secondary outcomes of deterioration. The derived clinical decision rule suggests that patients with simple skull fractures or intracranial bleeding <5 mm in diameter who are fully conscious could be safely discharged from the ED. The decision rule achieved a sensitivity of 99.5% (95% CI, 98.1-99.9) and specificity of 7.4% (95% CI, 6.0-9.1) to the primary outcome. The BIG criteria achieved the same sensitivity, but lower specificity (5%). Our empirical models showed good predictive performance and outperformed the BIG criteria. This would potentially allow ED discharge of 1 in 20 patients currently admitted for observation. However, prospective external validation and economic evaluation are required.

What difference can a year make? Findings from a survey exploring student, alumni and supervisor experiences of an intercalated degree in emergency care.

BACKGROUND: One third of UK medical students undertake an intercalated degree, typically in traditional academic disciplines. It is less usual for students to undertake intercalated degrees that are directly aligned to a clinical speciality with longitudinal placements. This cross sectional survey aims to explore the self-reported experiences of students, alumni and supervisors associated with a clinically oriented intercalated degree in emergency care featuring a longitudinal placement in a hospital emergency department over a 9-month academic year. Themes for exploration include student clinical and academic development, effect on career choice, supervisor experience and the effect on host institutions. METHODS: Current students, previous alumni, and clinical placement supervisors associated with a single intercalated degree programme in urgent and emergency care since 2005 were identified from records and using social media. Separate online surveys were then developed and distributed to current students/ previous alumni and consultant physician supervisors, between May and August 2016. Results are presented using basic descriptive statistics and selected free text comments. RESULTS: Responses were obtained from 37 out of 46 contactable students, and 14 out of 24 supervisors (80 and 63%, respectively). Students self-reported increased confidence in across a range of clinical and procedural competencies. Supervisors rated student competence in clinical, inter-professional and academic writing skills to be commensurate with, or in many cases exceeding, the level expected of a final year medical student. Supervisors reported a range of benefits to their own professional and personal development from supervising students, which included improved teaching and mentoring skills, providing intellectual challenge, and helping with the completion of audits and service improvement projects. CONCLUSIONS: Students report the acquisition of a range of clinical, academic, and inter-professional skills following their intercalated BSc year. A positive experience was reported by supervisors, extending to host institutions. Students reported feeling more enthusiastic about emergency medicine careers on completion. However, as students embarking on this degree naturally bring pre-existing interest in the area, it is not possible to attribute causation to these associations. Further investigation is also required to determine the longer term effect of clinically oriented intercalated degrees on career choice.