Outcomes of a novel ED observation pathway for mild traumatic brain injury and associated intracranial hemorrhage

Abstract

Background: Recent studies have shown that the majority of non-anticoagulated patients with small subdural or subarachnoid intracranial hemorrhage (ICH) in the setting of mild traumatic brain injury do not experience clinical deterioration or require neurosurgical intervention. We implemented a novel ED observation pathway to reduce unnecessary admissions among patients with ICH in the setting of mild TBI (complicated mild TBI, cmTBI).

Methods: Prospective, single-center study of ED patients presenting to a Level-1 Trauma Center, 4/2016-12/2018.

Inclusion criteria: head injury with GCS ≥ 14, minor positive CT findings (i.e. subdural hematoma <1 cm).

Exclusion criteria: GCS < 14, multi-system trauma procedural intervention or admission, epidural hematoma, skull fracture, seizure, anticoagulant/antiplatelet use beyond aspirin, physician discretion.

Outcomes: pathway completion rate, ED length-of-stay (LOS), neurosurgical intervention, hospital LOS, 7-day return visits.

Results: 138 patients met all pathway criteria and were included in analysis. 113/138 (81.9%) patients were discharged home after observation with mean ED LOS of 17.3 h (median 15.4 h, SD +/- 10.5) including 91/111 (81.9%) patients transferred from outside hospitals (median 18.1 h, SD +/- 11.0). Increased age and aspirin use were correlated with pathway non-completion requiring admission, but not due to hematoma expansion. Among admitted patients, none required neurosurgical intervention. Seven (5.1%) 7-day return visits occurred, 3 (2%) related to initial cmTBI; 1 (0.9%) was admitted for neurologic monitoring.

Conclusions: ED observation for patients with cmTBI resulted in an 82% pathway completion rate, including outside hospital transfers. These results suggest that patients with cmTBI may be safely discharged from the ED after a brief period of observation. Our pathway protocol and implementation involved neurosurgical consultation and the ability to perform repeat neurologic exams in the ED. Future studies should examine the feasibility of non-transfer protocols for appropriately selected patients and access to neurosurgical expertise in the community setting.

Keywords: Emergency department observation; Intracranial hemorrhage; Traumatic brain injury.