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
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to InjuryAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Epidemiology of mild traumatic brain injury and neurodegenerative disease.Mol Cell Neurosci. 2015; 66: 75-80
- Intensive care unit admission patterns for mild traumatic brain injury in the USA.Neurocrit Care. 2019; 30: 157-170
- Redefining mild traumatic brain injury (mTBI) delineates cost effective triage.Am J Emerg Med. 2020; 38: 1097-1101
- Clinical policy: neuroimaging and decision-making in adult mild traumatic brain injury in the acute setting.Ann Emerg Med. 2008; 52: 714-748
- Pathway-based reduction of repeat head computed tomography for patients with complicated mild traumatic brain injury: implementation and outcomes.Neurosurgery. 2021; 88: 773-778
- Necessity of repeat head CT and ICU monitoring in patients with minimal brain injury.J Trauma. 2009; 66: 1015-1018
- Neurosurgical intervention in patients with mild traumatic brain injury and its effect on neurological outcomes.J Neurosurg. 2016; 124: 538-545
- Mild traumatic brain injuries can be safely managed without neurosurgical consultation: the end of a neurosurgical “Nonsult”.Am Surg. 2018; 84: 652-657
- Minimal-risk traumatic brain injury management without neurosurgical consultation.J Neurocrit Care. 2020; 13: 80-85
- SQUIRE-EDU (Standards for quality improvement reporting excellence in education): publication guidelines for educational improvement.Acad Med. 2019; 94: 1461-1470
- Research electronic data capture (REDCap)–a metadata-driven methodology and workflow process for providing translational research informatics support.J Biomed Inform. 2009; 42: 377-381
- The BIG (brain injury guidelines) project: defining the management of traumatic brain injury by acute care surgeons.J Trauma Acute Care Surg. 2014; 76: 965-969
- Prospective validation of the brain injury guidelines.J Trauma Acute Care Surg. 2014; 77: 984-988
- Changing paradigms in the management of 2184 patients with traumatic brain injury.Ann Surg. 2015; 262: 440-448
- The acute care surgery model: managing traumatic brain injury without an inpatient neurosurgical consultation.J Trauma Acute Care Surg. 2013; 75 (discussion 5): 102-105
- Management of traumatic subarachnoid hemorrhage by the trauma service: is repeat CT scanning and routine neurosurgical consultation necessary?.Trauma Surg Acute Care Open. 2019; 4e000313
- Routine neurosurgical consultation is not necessary in mild blunt traumatic brain injury.J Trauma Acute Care Surg. 2017; 82: 776-780
- Safety and efficacy of brain injury guidelines at a Level III trauma center.J Trauma Acute Care Surg. 2018; 84: 483-489
- Big for small: validating brain injury guidelines in pediatric traumatic brain injury.J Trauma Acute Care Surg. 2017; 83: 1200-1204
- Telemedicine for neurotrauma prevents unnecessary transfers: an update from a nationwide program in albania and analysis of 590 patients.World Neurosurg. 2019; 128 (e340-e6)
Article info
Publication history
Published online: August 05, 2022
Accepted:
August 3,
2022
Identification
Copyright
© 2022 Elsevier Ltd. All rights reserved.
