University of Minnesota Medical School, University of Minnesota, Minneapolis, MN.
Department of Emergency Medicine, North Memorial Health Hospital, Robbinsdale, MN.
J Am Coll Surg. 2020 Sep;231(3):361-367.e2. doi: 10.1016/j.jamcollsurg.2020.05.023. Epub 2020 Jun 16.
Traumatic brain injury (TBI) is the leading cause of elderly trauma admissions. Previous research identified that each minute delay to TBI diagnosis was associated with a 2% mortality increase, delaying treatment to older patients (age ≥70 years) who do not meet trauma activation criteria. A TBI protocol and clinical decision support intervention (CDS-I) were developed to reduce time to imaging in older patients with head trauma not meeting trauma activation criteria.
An emergency department (ED) head CT protocol and CDS-I were developed and implemented to facilitate rapid imaging of older patients. Patients age ≥ 70 years, with TBI and receiving anticoagulation, met inclusion criteria. The primary outcomes measure was time from ED arrival to head CT imaging comparing before (PRE: January 1, 2016 to December 31, 2016) vs after (POST: August 1, 2018 to April 3, 2019) protocol implementation. Negative binomial regression models evaluated the association of intervention on time to imaging. LOWESS (locally weighted scatterplot smoothing) was used to evaluate the association of intervention on mortality over time.
The study examined 451 patients (269 PRE and 182 POST). Positive head CTs were seen in 78 (17.3%), and 57 of 78 (73%) patients had a Glasgow Coma Scale > 13. POST-intervention decreased time to head CT from 56 to 27 minutes (interquartile range [IQR] PRE: 32 to 93 to POST:16 to 44, p < 0.001) and POST-intervention patients had reduced hospital length of stay (incidence rate ratio [IRR] 0.83, 95% CI 0.72 to 0.86, p = 0.01).
A significant proportion of older patients receiving anticoagulation, but not meeting trauma activation criteria, had positive CT findings. Implementation of a rapid triage protocol with CDS-I reduced time to imaging and may reduce mortality in the highest-risk populations.
创伤性脑损伤（TBI）是导致老年创伤患者入院的主要原因。先前的研究表明，TBI 诊断每延迟一分钟，死亡率就会增加 2%，这对不符合创伤激活标准的老年患者（年龄≥70 岁）的治疗造成了延误。为了减少不符合创伤激活标准的老年头部创伤患者的影像学检查时间，我们制定并实施了 TBI 方案和临床决策支持干预（CDS-I）。
制定并实施了急诊部（ED）头部 CT 方案和 CDS-I，以方便对老年患者进行快速影像学检查。年龄≥70 岁、TBI 且正在接受抗凝治疗的患者符合纳入标准。主要结局测量指标是从 ED 到达至头部 CT 成像的时间，比较实施方案前后（PRE：2016 年 1 月 1 日至 2016 年 12 月 31 日；POST：2018 年 8 月 1 日至 2019 年 4 月 3 日）。使用负二项回归模型评估干预措施对成像时间的影响。使用局部加权散点平滑（LOWESS）评估干预措施对死亡率随时间变化的影响。
本研究共纳入了 451 例患者（269 例 PRE 和 182 例 POST）。78 例患者头部 CT 阳性（17.3%），78 例患者中有 57 例（73%）格拉斯哥昏迷量表评分＞13。与干预前相比，干预后头部 CT 时间从 56 分钟缩短至 27 分钟（PRE：32 至 93 分钟至 POST：16 至 44 分钟，p＜0.001），且干预后患者的住院时间缩短（发病率比[IRR]0.83，95%置信区间[CI]0.72 至 0.86，p=0.01）。
相当一部分接受抗凝治疗但不符合创伤激活标准的老年患者头部 CT 检查结果为阳性。快速分诊方案与 CDS-I 的实施减少了影像学检查的时间，可能降低了高危人群的死亡率。
