Brain Injury Guidelines

[southerndoc]

I'm trying to gauge what other providers do with regards to patients with simple (<4 mm) EDH, SDH, tSAH, or ICH who are not intoxicated, have a GCS of 15, and who are not on an anticoagulant or antiplatelet agent (including aspirin).

Does your ED follow Brain Injury Guidelines (Joseph, et al) for BIG 1 patients?

If so, what do you do? Are patients staying in the ER and discharged with/without a repeat head CT, are they admitted or placed in observation status by ED providers or another service, or do you transfer them out?

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[RPedigo]

In our emergency department, all patients with acute, traumatic intracranial hemorrhages are admitted to acute care surgery / trauma, regardless of size or type of hemorrhage. This is based on the preference of our acute care and trauma surgeons. We do have in-house neurosurgery, so we do not have any need to transfer any types of patients out. These data look promising and I might bring it up to our trauma committee to see if we should make any practice changes based on this!

 

[southerndoc]

Our neurosurgeons are wanting us to adopt it. A survey from the ED directors academy listserv seems to suggest that only 15% of hospitals manage these patients exclusively in the ED. Ironically, a friend on faculty at the place where the guidelines were developed says they don't even follow the guidelines.

I'm concerned that it's never been prospectively validated at an outside institution by ED providers. Reducing admissions would be ideal in places where bed utilization/boarding is an issue.

 

[CliveStaples]

At my residency site, BIG 1 patients without other needs for admission would be observed in the ER and then discharged. You'd be amazed how few of these actually exist though. Most of these patients are at least on aspirin which rockets them up to BIG 3 land.

At my current community site without neurosurgical coverage, I've yet to have a BIG 1. I assume that my trauma surgeon would be uncomfortable managing it independently and would want me to send it to the tertiary care center, but I do think they may refuse it if it's clearly a BIG 1 and they're at capacity (I.e. no surgical emergency). I don't think I'd want to keep the patient in the ER for observation but an overnight stay with our trauma surgeon seems like it would be appropriate.

All that said, I don't think the BIG criteria were developed for the purpose of ER physicians determining disposition like it was used in my residency program. I really think it was designed so that trauma surgeons would have more standardized indications for when they needed to consult their neurosurgeon. In light of this, I don't feel very comfortable unilaterally discharging these people at my current job (with the protection of academia, I'd be more liberal).

 

[pkwraith]

In my residency site (Trauma 1), everyone gets admitted to Neuro ICU stepdown unit for their 6hour ct (and usualy DC from there in 12 hours0. No neursurgery consult (they would hang up on you). No trauma consult unless multi system.

In my current site (Community, 2x Trauma 1), everyone gets a Trauma consult and a Neurosurgery consult and admitted to STICU to trauma. A lot of unnecessary consults but that's local practice (and you will get Peer Reviewed for not pan-consulting).

In my personal (obviously anecdotal) experience, I have never seen any complications or worsening in these patients.

 

[WildEMDoc]

My site, level 1 county/academic, we fully adopted about 6 months ago
BIG 1 = ER only, no NSG consultation, observation period at our discretion
BIG 2 = ER w/ NSG consultation, admission to ED observation or medicine hospitalist depending on circumstances of injury
BIG 3 = NSG admits floor/imc/icu

 

[clibby]

Yeah...I'm not going to discharge a head bleed of any kind without a neurosurgeon on that chart.

 

[deleted547339]

In fellowship - 100% went to the icu for neurochecks.
As faculty, nsgy tells us to send them home, but they never staff these consults at nights (they only seem to come in at night). We usually admit to medicine for interval scan.

 

[southerndoc]

Yeah...I'm not going to discharge a head bleed of any kind without a neurosurgeon on that chart.

I think we have a good system whereby the hospitalist admits BIG1 patients and neurosurgery consults. I think neurosurgery is trying to limit the number of consults. We've found that a good number of BIG1 patients need additional resources upon discharge, which may prolong their ED stay. Sometimes it's a frequent fall situation that needs to go to a STR or needs support at home.

Nonetheless, we're definitely open to doing it. I'm trying to run the numbers now to see exactly how many patients would qualify.

 

[CliveStaples]

Recognize that BIG criteria is really just pushed by Neurosurgeons to limit the amount of times they're consulted at big academic centers. At my old institution it was:

BIG1 - 6hr ED Obs and dc. No repeat head CT. Since a lot of these patients were transfers, it wasn't uncommon for them to already be at their 6 hours of observation by assessment. Families love being transferred an hour away only to be told they can now be discharged because an ER intern has blessed them.

BIG2 - Admission to the trauma surgery service for observation. No repeat head CT.

BIG3 - Neurosurgical consultation and admission to either the Neurosurgical or Trauma Surgery team, depending on the presence of other injuries and how angry the admitting general surgery resident was to be admitting yet another isolated head trauma. They got repeat 6hr head CTs.

 

[bravotwozero]

Yeah at my shop, which doesn't have on call neurosurgery, any ICH is getting transferred to the mothership, no questions asked.

 

[Groove]

I'm trying to gauge what other providers do with regards to patients with simple (<4 mm) EDH, SDH, tSAH, or ICH who are not intoxicated, have a GCS of 15, and who are not on an anticoagulant or antiplatelet agent (including aspirin).

Does your ED follow Brain Injury Guidelines (Joseph, et al) for BIG 1 patients?

If so, what do you do? Are patients staying in the ER and discharged with/without a repeat head CT, are they admitted or placed in observation status by ED providers or another service, or do you transfer them out?

So, let me get this straight... You guys want to implement this based on a single study in 2014 that has not been put through the rigors of appropriate validation studies nor has enjoyed widespread adoption in the EM community to constitute standard of care? It sounds like your neurosurgeons are only thinking about reducing their consult load and getting more REM sleep during the night. Of course, because they "swing the big stick" in the hospital, I'm sure they are pushing this through with gusto and the entire hospital is swallowing it hook line and sinker. Personally, I would fight this tooth and nail. If I'm to ever send out a head bleed, it's going to be with a neurosurgeon's note on the chart. If you had a bad outcome, you are hosed.

I'd play dirty. You should involve risk management and legal and invite them to your next meeting citing concerns for implementing a policy that has not enjoyed widespread adoption in your field and is bereft of validation studies in a high risk patient population at risk for significant morbidity/mortality and likely to result in lawsuits difficult to defend as well as sizable cash awards/settlements.

I'm not saying the guidelines are bad, I've just never worked anywhere that implemented them. I'm sure as hell not going to make a drastic change in practice on a high risk pt population based on a single study from 2014. We admit 100% head bleeds. They all get re-scanned in the a.m. I get zero push back from NSGY. I would never discharge one without NSGY evaluating in the ED and writing a note.

 

[southerndoc]

No reason to play dirty. We likely will turn this into a prospective study to validate their findings. 150k/yr volume shouldn't take too long. Basically randomize them to traditional management vs ED management.

This hasn't been validated with ED physicians, but has been validated retrospectively and at a Level III trauma center (again, not by ED physicians).

I agree, it's not well studied. My philosophy is that you shouldn't be the first nor the last to adopt something. Either extreme end runs risk of litigation.

 

[WilcoWorld]

I've worked in 3 ED's:
1- admit all ICH
2 - discharge BIG 1 type patients after repeat scan & discussion with NSurg
3 - currently moving from admitting all ICH towards ED Obs stay with NSurg consultation

 

[WilcoWorld]

Can I just say - calling the most benign ICH cases "BIG 1" was a terrible marketing choice.

 

[RoyBasch]

I'm a simple man, you got acute blood on the brain, your spend at least one night in the hospital and a neurological surgeon consults comments on your care. The mechanics of how this happens vary depending on the facility I'm at. When I'm at my level 1 trauma center, admit to trauma, NSG consult. When I'm at a non-trauma center (but secondary care facility) I admit to medicine (provided no other significant injuries) with NSG consult. At my critical access hospital patients are transferred to a level 1 or 2 trauma center, and I presume NSG is consulted by those facilities.

 

[RoyBasch]

(they only seem to come in at night).

Truth.

I feel like head bleeds are the consummate night shift pathology.

This may have something to do with why the neurological surgeons are trying to write guidelines that involve not having to consult them.

 

[Mushdoc]

I also wonder about quality of radiologist reading the scans. Overnight at an academic center its residents and in the community it may be telerads with neurorads not checking either until the day time

 

[clibby]

This is completely reasonable. I mostly agree, but I also have no problem with gradually revising practice patterns to discharging minor traumatic SAH from the ED following brief observation plus/minus repeat CT. They just don't decompensate receiving any sort of neurosurgical intervention that changes outcomes. We can't keep admitting many of the things that we have often in the past including EKG/troponin negative chest pain workups, low-moderate risk TIA workups and low-risk syncopal episodes. With a growing population that is increasingly older and more reliant on the ED, volumes in the ED have kept growing (at least pre-COVID, and likely post-COVID). We keep showing that these diagnoses don't really benefit from hospital admission and have risks like hospital acquired infections and the downside of financial costs to patients who pay (self-pay or insurance) or don't pay (to society through increased premiums). Cardiac stress tests haven't really shown benefit. Cardiac catheterizations outside of STEMIs haven't really shown benefit. Why do we keep admitting chest pain with negative testing? It's because we want to pass the hot potato. At the end of the day every patient is a ticking time bomb (we all die). I'm comfortable with discharging patients with thorough ED workups. There is a good chance of getting sued and I don't believe there is significant value in some admissions to some patients other than just trying to cover yourself. This philosophy carries over in my mind to minor traumatic SAH. Currently I admit all of them, because that's the local practice pattern. If the evidence is validated with more of a leg to stand on, then I wouldn't have a problem if the standard of care shifted. I also feel comfortable with this after discharging all of the minor traumatic SAH transferred from outlying facilities following a negative repeat head CT and neurosurgical consultation in the ED during residency. Would I still transfer if I was in a critical access hospital (which I have worked), you betcha. In the future that may change though. Staying rigid is what makes you fall behind and become one of those outdated physicians that we never liked back when we were training.

I agree with everything you are saying. However, until med-mal is fixed and adequate follow-up is actually possible, I'm not taking that risk. If we fix med-mal or create a new standard of care endorsed by ACEP and the specialty associated with the high risk diagnosis, then I am more than happy to change. A chest pain that is d/c without stress testing who has an MI is a slam dunk case; that same patient who had a negative stress test, but still had an MI has little case. Same thing with head bleeds, TIAs, etc. Its not that the evidence is the best in every scenario, but the liability is a concern and follow-up for most of these patients is not always great so they can't get those outpatient studies. If the consultant wants to take some liability or impart some wisdom I don't have by coming to the ED and blessing them for me, then I will discharge right there, but I am not going down on a sinking ship alone. I'm usually not admitting just to pass the buck to the hospitalist; I admit/obs to get a consultant to see them non emergently or get a test prior to discharge given the time pressures of the ED. If the hospitalist wants to keep them for 3 days for other consults or a consultant wants to do a procedure inpatient, that wasn't always the intent of the ED doc.

 

[n2b8me]

I'm a simple man, you got acute blood on the brain, your spend at least one night in the hospital and a neurological surgeon consults comments on your care.

This is truth.
Hospitalist admits and brain surgeon gives recs from the phone. Also the neurologist can see patient prior to discharge.
I've never heard of BIG 1, 2 or 3.

 

[WilcoWorld]

I totally sympathize with the above posters' reservations. This practice requires buy in from Neurosurgery with a hospital policy on the books, as well as a robust followup system which will need to be coordinated by a nurse navigator and a social worker. I would definitely recommend against an EP adopting this practice on their own.

That said, here's a little timeline of my life in EM so far:

2000 - it's malpractice to discharge someone after a single negative cardiac enzyme
2005 - if you order a CT to evaluate headache, you've obligated yourself to doing an LP
2010 - you want me to manage DVT's as an outpatient? what if they get a PE?
2015 - you want me to discharge stable PE patients? heresy!
2020 - you're telling me that low risk ICH patients without any deficits who have a stable exam don't need to be admitted?

Medicine changes. You can keep up with the literature and adapt your practice to new standards, or you can become your group's "that guy".

 

[RustedFox]

Someone please post a TL DNR version of these BIG criteria.

 

[bravotwozero]

I totally sympathize with the above posters' reservations. This practice requires buy in from Neurosurgery with a hospital policy on the books, as well as a robust followup system which will need to be coordinated by a nurse navigator and a social worker. I would definitely recommend against an EP adopting this practice on their own.

That said, here's a little timeline of my life in EM so far:

2000 - it's malpractice to discharge someone after a single negative cardiac enzyme
2005 - if you order a CT to evaluate headache, you've obligated yourself to doing an LP
2010 - you want me to manage DVT's as an outpatient? what if they get a PE?
2015 - you want me to discharge stable PE patients? heresy!
2020 - you're telling me that low risk ICH patients without any deficits who have a stable exam don't need to be admitted?

Medicine changes. We can keep up with the literature and adapt our practice to new standards, or you can become your group's "that guy".

I do remember hearing that in Canada they have been discharging stable ICH's with close follow up. Could be wrong, though.

 

[WilcoWorld]

I do remember hearing that in Canada they have been discharging stable ICH's with close follow up. Could be wrong, though.

It's a real thing. You're not wrong.

 

[Arcan57]

Questions:
1) Why are you admitting BIG 2 if you're not going to do a repeat CT scan or get NSGY ink on chart?
2) There are many EDs where a 6-hr obs stay is flagrantly impractical. Did they have a population that was looking good then crumped at 5 hr 59 min?
3) Did adding aspirin to the DOAC, coumadin, plavix axis really change the predictive power of the model?
4) Does this relationship hold up for all (adult) patient ages and all time from injury to initial CT scan ranges?

 

[dadaddadaBATMAN]

A lot of people have highlighted valid reservations about this proposal, one of my own is follow up. There was a push at my residency from the trauma service to admit anyone who had loc for observation so they could get pt/ot/social work consulted to help manage consequences of tbi.

For the most part I think this was a flagrant attempt to earn $ and inflate the numbers for our trauma service, but I do think that a small proportion of patients actually benefit from this, and I think people who *actually* have blood in the brain where it’s not supposed to be and not some bs loc are more likely to be in that population. Especially the elderly who are falling enough to have this happen to them aspirin or no aspirin.

I’d also agree with the posters above that the number of true “big1” patients is pretty low (mostly due to antiplatelet and intoxication exclusions)

 

[RoyBasch]

A lot of people have highlighted valid reservations about this proposal, one of my own is follow up. There was a push at my residency from the trauma service to admit anyone who had loc for observation so they could get pt/ot/social work consulted to help manage consequences of tbi.

For the most part I think this was a flagrant attempt to earn $ and inflate the numbers for our trauma service, but I do think that a small proportion of patients actually benefit from this, and I think people who *actually* have blood in the brain where it’s not supposed to be and not some bs loc are more likely to be in that population. Especially the elderly who are falling enough to have this happen to them aspirin or no aspirin.

I’d also agree with the posters above that the number of true “big1” patients is pretty low (mostly due to antiplatelet and intoxication exclusions)

This always mystified me, but at my level 1 trauma center, any traumatic LOC is an automatic admit, even if the HCT (and they are DEFINITELY getting a CT head if there is any LOC, Canadian rules or otherwise be damned) is negative and even if no antiplatelet or anticoagulant use.

This is one reason I do not see many trauma centers in particular buying into these guidelines anytime soon. I mean if they are lighting up ER physicians at QI meetings for having the audacity to discharge traumas with LOC by history, I feel if you dc a confirmed head bleed it would be a serious conversation about "continued fitness to practice at this institution of excellence."

 

[RoyBasch]

You practice in a very conservative environment. I've worked at plenty of institutions and everywhere I've worked folks frequently discharged patients despite history of LOC. I've discharged people with LOC on anticoagulation with negative imaging and absence of supra-therapeutic coagulopathy. The Canadian and NEXUS head CT criteria don't even include LOC when deciding upon imaging (I recognize you alluded to this). You are also potentially unnecessarily radiating people (not a huge deal) with mild head trauma if they report subjective LOC without any other red flags. The "I closed my eyes when I hit my head" doesn't count as LOC. The BIG study showed that there isn't any meaningful intervention provided for BIG 1 patients. The odds of a patient experiencing LOC, without other risk factors, with negative head CT imaging, later developing intracranial hemorrhage that requires neurosurgical intervention is incredibly low, as close to 0% as you can get. You have to be comfortable with a little risk to practice EM, otherwise you bog down the system. Also, where is the excitement if no risk?!

Just to be clear, I have no problem discharging a patient with a head injury whose only concerning feature is LOC. And I also do not feel in adults LOC is a particularly significant factor at all in risk stratifying head injuries. I certainly do not feel a need to CT everyone. I feel pretty well supported by validated well established clinical decision rules in doing so.

But as soon as trauma gets involved they apply their own criteria (not necessarily evidence based), scan the head (and not unusually the whole body after) and the patient is admitted by them. Whatever, it's their service they can do what they want.

I have been practicing long enough that I recognize keeping consultants--and trauma consultants when at trauma centers in particular--happy is fairly essential to having a long career at a given institution. You can argue guidelines with these people until you're blue in the face, if they have a common practice pattern for a given clinical situation, it's probably best to toe that line.

I suppose you're right, I do not find there to be any "excitement" in sitting down in front other department's QI committees to answer their concerns or entertain their administrative complaints.

 

[southerndoc]

You practice in a very conservative environment. I've worked at plenty of institutions and everywhere I've worked folks frequently discharged patients despite history of LOC. I've discharged people with LOC on anticoagulation with negative imaging and absence of supra-therapeutic coagulopathy. The Canadian and NEXUS head CT criteria don't even include LOC when deciding upon imaging (I recognize you alluded to this). You are also potentially unnecessarily radiating people (not a huge deal) with mild head trauma if they report subjective LOC without any other red flags. The "I closed my eyes when I hit my head" doesn't count as LOC. The BIG study showed that there isn't any meaningful intervention provided for BIG 1 patients. The odds of a patient experiencing LOC, without other risk factors, with negative head CT imaging, later developing intracranial hemorrhage that requires neurosurgical intervention is incredibly low, as close to 0% as you can get. You have to be comfortable with a little risk to practice EM, otherwise you bog down the system. Also, where is the excitement if no risk?!

I agree that admitting all head injured patients with LOC is very conservative. What percentage of those patients end up with developing bleeds or requiring surgery? You can argue admitting head injured patients on NOACs or warfarin who have LOC, but I cannot see the reason behind admitting all CHI's with LOC except to pad trauma admissions and increase revenue to the hospital.

Regarding the head injury rules, they were only investigating people who had LOC. It was only recently that the Canadian head CT rules were validated for patients not losing consciousness.

 

[WilcoWorld]

This always mystified me, but at my level 1 trauma center, any traumatic LOC is an automatic admit, even if the HCT (and they are DEFINITELY getting a CT head if there is any LOC, Canadian rules or otherwise be damned) is negative and even if no antiplatelet or anticoagulant use.

This is one reason I do not see many trauma centers in particular buying into these guidelines anytime soon. I mean if they are lighting up ER physicians at QI meetings for having the audacity to discharge traumas with LOC by history, I feel if you dc a confirmed head bleed it would be a serious conversation about "continued fitness to practice at this institution of excellence."

No offense, but that sounds bonkers. For me, an otherwise well head injury + brief LOC is is about a 15 minute room-to-discharge. I'll even dc them from triage if we're backed up. Been practicing this way for years & I think I've had maybe 2 bounce back for symptom management (HA/nausea) and zero adverse outcomes.

 

[turkeyjerky]

No offense, but that sounds bonkers. For me, an otherwise well head injury + brief LOC is is about a 15 minute room-to-discharge. I'll even dc them from triage if we're backed up. Been practicing this way for years & I think I've had maybe 2 bounce back for symptom management (HA/nausea) and zero adverse outcomes.

Yeah, I don't even ask about LOC. (well maybe I do, but I put as much credence into it as 'how are you doing today ma'am" ). Some trauma centers do crazy stuff. One of my shops just became a level 1 this year. The trauma service admits all minor head injuries on plavix or aspirin for obs and repeat head CT.