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Assessment of safety and effectiveness of non-neurosurgical management for minimal traumatic brain injury (TBI)

  • Jeffrey W. Chen
    Correspondence
    Corresponding authors.
    Affiliations
    Vanderbilt University School of Medicine, Nashville, TN, United States
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  • Aaron Yengo-Kahn
    Correspondence
    Corresponding authors.
    Affiliations
    Department of Neurological Surgery, Vanderbilt University Medical Center, Section of Surgical Sciences, Nashville, TN United States
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  • Silky Chotai
    Affiliations
    Department of Neurological Surgery, Vanderbilt University Medical Center, Section of Surgical Sciences, Nashville, TN United States
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  • Akshay Bhamidipati
    Affiliations
    Vanderbilt University School of Medicine, Nashville, TN, United States
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  • Candice Smith
    Affiliations
    Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, TN United States
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  • Philip Davis
    Affiliations
    Vanderbilt University School of Medicine, Nashville, TN, United States
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  • Rebecca A. Reynolds
    Affiliations
    Department of Neurological Surgery, Vanderbilt University Medical Center, Section of Surgical Sciences, Nashville, TN United States
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  • Mary Peyton Boyd
    Affiliations
    Vanderbilt University School of Medicine, Nashville, TN, United States
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  • Tyler W. Barrett
    Affiliations
    Vanderbilt University School of Medicine, Nashville, TN, United States

    Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
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  • Elizabeth S. Compton
    Affiliations
    Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, TN United States
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  • Bradley M. Dennis
    Affiliations
    Vanderbilt University School of Medicine, Nashville, TN, United States

    Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, TN United States
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  • Michael S. Norris
    Affiliations
    Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, TN United States
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  • Mayur B. Patel
    Affiliations
    Vanderbilt University School of Medicine, Nashville, TN, United States

    Department of Neurological Surgery, Vanderbilt University Medical Center, Section of Surgical Sciences, Nashville, TN United States

    Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, TN United States

    Department of Hearing and Speech Sciences, Vanderbilt University Medical Center, Nashville, TN, United States

    Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, United States

    Surgical Services, Geriatric Research Education and Clinical Centers, Tennessee Valley Healthcare System, United States Department of Veterans Affairs, Nashville, TN, United States

    Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt Brain Institute, United States
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  • Jacob P. Schwarz
    Affiliations
    Vanderbilt University School of Medicine, Nashville, TN, United States

    Department of Neurological Surgery, Vanderbilt University Medical Center, Section of Surgical Sciences, Nashville, TN United States
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  • Nicholas R. Thomason
    Affiliations
    Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, TN United States
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  • Reid C. Thompson
    Affiliations
    Vanderbilt University School of Medicine, Nashville, TN, United States

    Department of Neurological Surgery, Vanderbilt University Medical Center, Section of Surgical Sciences, Nashville, TN United States
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  • Oscar D. Guillamondegui
    Correspondence
    Corresponding authors.
    Affiliations
    Vanderbilt University School of Medicine, Nashville, TN, United States

    Department of Neurological Surgery, Vanderbilt University Medical Center, Section of Surgical Sciences, Nashville, TN United States

    Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, TN United States

    Department of Hearing and Speech Sciences, Vanderbilt University Medical Center, Nashville, TN, United States

    Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, United States
    Search for articles by this author

      Highlights

      • A minimal TBI protocol implemented in level 1 trauma center was found to be safely reduce neurosurgical consultation. Within the study period, there was a significant reduction in neurosurgery consults with no significant change in neurosurgery procedures, operations, or ED revisits.

      Abstract

      Background

      Patients with mild traumatic brain injury (TBI) and intracranial hemorrhage often receive neurosurgical consultation. However, only a small proportion of patients require intervention. Our hypothesis is that low-risk minimal TBI patients managed without immediate neurosurgical consultation will have a reasonable safety and effectiveness outcome profile.

      Methods

      A non-neurosurgical management protocol for adult minimal TBI was implemented at a level I trauma center as an interdisciplinary quality-improvement initiative in November 2018. Minimal TBI was defined as Glasgow Coma Scale (GCS) of 15 secondary to blunt mechanism, without anticoagulant or antiplatelet therapy, and isolated pneumocephalus and/or traumatic subarachnoid hemorrhage on head CT imaging. Safety was assessed by in-hospital mortality, neurosurgical interventions, and ED revisits within two weeks of discharge. Effectiveness was assessed by neurosurgical consult rate and length of stay. Outcomes were compared 8-months pre- and post-protocol implementation.

      Results

      A total of 97 patients were included, of which 49 were pre-protocol and 48 were post-protocol There was no difference in rates of in-hospital mortality [0 (0%) vs 0 (0%)], neurosurgical procedure [1 (2.1%) vs 0 (0%)], operations [0 (0%) vs 0 (0%)], and ED revisits [1 (2.0%) vs 2 (4.2%), p = 0.985] between the periods. There was a significant reduction in neurosurgical consults post-protocol implementation (92% vs 29%, p<0.001).

      Conclusion

      A protocol for minimal TBI patients effectively reduced neurosurgical consultation without changes in safety profile. Such an interdisciplinary management protocol for low-risk neurotrauma can effectively utilize the neurosurgery consult services by stratifying neurologically stable TBI patient.

      Keywords

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