Root Brandon K, Kanter John H, Calnan Dan C, Reyes-Zaragosa Miguel, Gill Harman S, Lanter Patricia L
Section of Neurosurgery Dartmouth-Hitchcock Medical Center Lebanon New Hampshire USA.
Geisel School of Medicine at Dartmouth Hanover New Hampshire USA.
J Am Coll Emerg Physicians Open. 2020 Jun 17;1(4):609-617. doi: 10.1002/emp2.12124. eCollection 2020 Aug.
The management of mild traumatic brain injury (mTBI) with minor radiographic findings traditionally involves hospital admission for monitoring, although this practice is expensive with unclear benefit. We implemented a protocol to manage these patients in our emergency department observation unit (EDOU), hypothesizing that this pathway was cost effective and not associated with any difference in clinical outcome.
mTBI patients with minor radiographic findings were managed under the EDOU protocol over a 3-year period from May 1, 2015 to April 30, 2018 (inclusions: ≥19 years old, isolated acute head trauma, normal neurological exam [except transient alteration in consciousness], and a computed tomography [CT] scan of the head with at least 1 of the following: cerebral contusions <1 cm in maximum extent, convexity subarachnoid hemorrhage, or closed, non-displaced skull fractures). These patients were retrospectively analyzed; clinical outcomes and charges were compared to a control cohort of matched mTBI hospital admissions over the preceding 3 years.
Sixty patients were observed in the EDOU over the 3-year period, and 85 patients were identified for the control cohort. There were no differences in rate of radiographic progression, neurological exam change, or surgical intervention, and the overall incidence of hemorrhagic expansion was low in both groups. The EDOU group had a significantly faster time to interval CT scan (Mean Difference (MD) 3.92 hours, [95%CI 1.65, 6.19]), = 0.001), shorter length of stay (MD 0.59 days [95% CI 0.29, 0.89], = 0.001), and lower encounter charges (MD $3428.51 [95%CI 925.60, 5931.42], = 0.008). There were no differences in 30-day re-admission, 30-day mortality, or delayed chronic subdural formation, although there was a high rate of loss to follow-up in both groups.
Compared to hospital admission, observing mTBI patients with minor radiographic findings in the EDOU was associated with significantly shorter time to interval scanning, shorter length of stay, and lower encounter charges, but no difference in observed clinical outcome. The overall risk of hemorrhagic progression in this subset of mTBI was very low. Using this approach can reduce unnecessary admissions while potentially yielding patient care and economic benefits. When designing a protocol, close attention should be given to clear inclusion criteria and a formal mechanism for patient follow-up.
对于影像学检查结果轻微的轻度创伤性脑损伤（mTBI）患者，传统的治疗方法是收入院进行监测，尽管这种做法成本高昂且益处不明确。我们实施了一项方案，在急诊科观察单元（EDOU）对这些患者进行管理，推测该路径具有成本效益且与临床结局的任何差异均无关。
从2015年5月1日至2018年4月30日的3年期间，按照EDOU方案对影像学检查结果轻微的mTBI患者进行管理（纳入标准：年龄≥19岁、孤立性急性头部创伤、神经系统检查正常[意识短暂改变除外]，以及头部计算机断层扫描（CT）至少有以下一项表现：最大范围<1 cm的脑挫伤、脑凸面蛛网膜下腔出血或闭合性、无移位颅骨骨折）。对这些患者进行回顾性分析；将临床结局和费用与前3年匹配的mTBI住院对照队列进行比较。
在3年期间，EDOU观察了60例患者，确定了85例患者作为对照队列。两组在影像学进展率、神经系统检查变化或手术干预方面均无差异，且两组出血性扩大的总体发生率均较低。EDOU组进行间隔CT扫描的时间显著更快（平均差值（MD）3.92小时，[95%置信区间（CI）1.65，6.19]，P = 0.001），住院时间更短（MD 0.59天[95% CI 0.尊龙人生就是博d88 29，0.89]，P = 0.001），且诊疗费用更低（MD 3428.51美元[95% CI 925.60，5931.42]，P = 0.008）。两组在30天再入院率、30天死亡率或迟发性慢性硬膜下形成方面均无差异，尽管两组的失访率均较高。
与住院治疗相比，在EDOU观察影像学检查结果轻微的mTBI患者，间隔扫描时间显著更短、住院时间更短且诊疗费用更低，但观察到的临床结局无差异。该亚组mTBI出血进展的总体风险非常低。采用这种方法可以减少不必要的住院，同时可能带来患者护理和经济效益。在设计方案时，应密切关注明确的纳入标准和患者随访的正式机制。
