Elderly Head Trauma Pts

[thegenius]

Do any of your protocols at your shops include allowing nursing to order CT Heads on all elderly w or w/o anticoagulation, and a GCS 15, who comes in with suspected (or actual) head trauma?

Is there a single paper that scanning these people ASAP improves morbidity?

Note these are pts that don't meet limited trauma or full trauma activations (or whatever they are called at your shop).

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[thegenius]

I found one:

Techar K, Nguyen A, Lorenzo RM, Yang S, Thielen B, Cain-Nielsen A, Hemmila MR, Tignanelli CJ. Early Imaging Associated With Improved Survival in Older Patients With Mild Traumatic Brain Injuries. J Surg Res. 2019 Oct;242:4-10. doi: 10.1016/j.jss.2019.04.006. Epub 2019 May 3. PMID: 31059948.

But I don't have access to it. Seems totally suspect though because they looked at all over 7 years and identified only 32 patients in the ED, of which 24 were discharged from the ED.

We get 32 patients a month.

 

[BoardingDoc]

Do any of your protocols at your shops include allowing nursing to order CT Heads on all elderly w or w/o anticoagulation, and a GCS 15, who comes in with suspected (or actual) head trauma?

Is there a single paper that scanning these people ASAP improves morbidity?

Note these are pts that don't meet limited trauma or full trauma activations (or whatever they are called at your shop).

We don't have a protocol for it, but the triage RN will frequently ask if I want them to order a head CT on someone in triage like that.

Also, I'm extremely liberal when it comes to sending people home without a bunch of tests. That said, even I scan literally every 80 year old who comes in because they hit their head. Are you advocating not to?

 

[southerndoc]

We have a code CHIP (closed head injury protocol). APPs meet the patient at the ambulance door and screen them. They either order head CT immediately and patient goes straight from ambulance stretcher to CT, or they upgrade the patient to an activated trauma alert if they have other significant injuries. This is only for patients on anticoagulants/antiplatelet agents who have external signs of head trauma (laceration, contusion, abrasion). Age >18.

Our door-to-CT time is <5 minutes and door-to-reversal agent is <40 mins. Before they were in the 60+ and 120+ range.

We don't have a separate protocol for elderly patients not on blood thinners.

 

[thegenius]

We don't have a protocol for it, but the triage RN will frequently ask if I want them to order a head CT on someone in triage like that.

Also, I'm extremely liberal when it comes to sending people home without a bunch of tests. That said, even I scan literally every 80 year old who comes in because they hit their head. Are you advocating not to?

No. And we (our forum) have already had a heated discussion on this topic.

I'm just wondering if there is any evidence that scanning these low risk peeps quickly actually does anything besides gum up the CT scanner.

And yes I don't like RN's ordering tests, for the most part (some don't bother me). And part of it is strictly due to physician emasculation.

 

[thegenius]

We have a code CHIP (closed head injury protocol). APPs meet the patient at the ambulance door and screen them. They either order head CT immediately and patient goes straight from ambulance stretcher to CT, or they upgrade the patient to an activated trauma alert if they have other significant injuries. This is only for patients on anticoagulants/antiplatelet agents who have external signs of head trauma (laceration, contusion, abrasion). Age >18.

Our door-to-CT time is <5 minutes and door-to-reversal agent is <40 mins. Before they were in the 60+ and 120+ range.

We don't have a separate protocol for elderly patients not on blood thinners.

I would support this general protocol. positive external signs of head trauma and on anticoagulation. And I see that it's PA ordered, not RN.
(Still wonder though whether this improves outcomes)

 

[southerndoc]

I would support this general protocol. positive external signs of head trauma and on anticoagulation. And I see that it's PA ordered, not RN.
(Still wonder though whether this improves outcomes)

So far it looks like it does, but we're still collecting data. The reduction in door-to-CT, door-to-radiology report, and door-to-reversal agent has been reduced dramatically.

 

[BJJVP]

So far it looks like it does, but we're still collecting data. The reduction in door-to-CT, door-to-radiology report, and door-to-reversal agent has been reduced dramatically.

I wouldn't be surprised at all if outcomes improved with the protocol. However, I think for most critical conditions, having a pathway that puts pressure on the system to order the diagnostic test and intiate treatments sooner will probably always be of benefit. The real question is do we really want to add another official protocol with metrics, fallouts, certified centers, RN chart auditers, bundled payments, etc? Have we completely given up on having adequate staffing that would allow physicians to inidividually prioritize who should get what tests/treatments at any given time? Actually, don't answer that question lol

 

[thegenius]

So far it looks like it does, but we're still collecting data. The reduction in door-to-CT, door-to-radiology report, and door-to-reversal agent has been reduced dramatically.

Sure those metrics you quote should get better. But these are systems outcomes that aren't nearly as important as patient-oriented outcomes. If we have stat CTs protocols for presumed kidney stones or stat US for pregnant vag bleeding, they would all be disposed quicker too.

The important patient metrics in this case would be reduced death (and will be hard to see a signal in this low risk cohort), reduced admission rates, reduced admission times, reduced need for neurosurgical intervention. the door to reversal agent I can see as being probably important. These are all that really matter.

I'm not trying to be critical here. I think having a protocol of any [visible head trauma] + [on anticoagulation] gets stat CT makes sense. But we are prioritizing these patients for CT over those who need CT Chest Dissection protocols, CTH for stroke, and CT for other stuff.

 

[southerndoc]

Sure those metrics you quote should get better. But these are systems outcomes that aren't nearly as important as patient-oriented outcomes. If we have stat CTs protocols for presumed kidney stones or stat US for pregnant vag bleeding, they would all be disposed quicker too.

The important patient metrics in this case would be reduced death (and will be hard to see a signal in this low risk cohort), reduced admission rates, reduced admission times, reduced need for neurosurgical intervention. the door to reversal agent I can see as being probably important. These are all that really matter.

I'm not trying to be critical here. I think having a protocol of any [visible head trauma] + [on anticoagulation] gets stat CT makes sense. But we are prioritizing these patients for CT over those who need CT Chest Dissection protocols, CTH for stroke, and CT for other stuff.

We are still collecting the data, but the post I mentioned earlier was referring to a reduction in mortality/operative intervention. I can't speak to the specifics of the mortality/morbidity data yet, but the reduction is there. I was speaking to what I can (statistically significant reductions in the metrics I posted above).

 

[xaelia]

We have a code CHIP (closed head injury protocol). APPs meet the patient at the ambulance door and screen them. They either order head CT immediately and patient goes straight from ambulance stretcher to CT, or they upgrade the patient to an activated trauma alert if they have other significant injuries. This is only for patients on anticoagulants/antiplatelet agents who have external signs of head trauma (laceration, contusion, abrasion). Age >18.

Our door-to-CT time is <5 minutes and door-to-reversal agent is <40 mins. Before they were in the 60+ and 120+ range.

We don't have a separate protocol for elderly patients not on blood thinners.

A substantial chunk of our anticoagulated head injuries are walk-ins – called the nurse hotline, told to go to hospital etc. – what do you do with them?

I'm in broad agreement with those above who look at the ED as a zero-sum environment, and sucking resources away for a prompt scan of a GCS 15 head injury is degrading someone else's outcome in another area. Obviously, if there are free resources sitting idle, this is a fine process improvement.