- Describe your topic.
- Is a follow-up head CT scan necessary in patients with complicated mild traumatic brain injury (cmTBI)? The population of interest is adult patients with a cmTBI. Complicated mild TBI is defined as a Glasgow Coma Scale (GCS) score of 15, 14, or 13, and a head CT positive for intracranial blood or a skull fracture. The intracranial finding could be a subdural or epidural hematoma, traumatic subarachnoid hemorrhage, or contusion. Most of these hemorrhages are small and less than 1% of this patient population needs a neurosurgical intervention. If after the first head CT the patient is deemed nonoperative by the neurosurgeon, the patient is admitted to the hospital or observed in the emergency department and 90% undergo a routine follow-up head CT scan. Routine follow-up head CT scans rarely lead to a change in treatment or neurosurgical intervention. I want to argue that the routine follow-up head CT scan in cmTBI is clinically unnecessary, exposes the patient to unnecessary radiation, and generates undue medical expenses.
- Describe why this topic is important.
- The topic is important because the use of routine follow-up head CT scans rarely leads to a change in treatment or neurosurgical intervention. In a prospective observation cohort study, only 0.3% of patients had a neurosurgical intervention after a second head CT scan. However, these follow-up scans were prompted by a neurological deterioration. The practice paradigm of a follow-up CT scan following cmTBI is so ingrained in emergency physicians, acute care surgeons, and neurosurgeons that special attention to the problem and strong evidence are needed to change this practice. Further, cmTBI represents a significant disease burden. About 3 million TBI-related emergency department visits, hospitalizations, and deaths occurred in 2013 the United States. About 500,000 patients fall into the cmTBI category. What is more, over the span of six years (2007–2013), rates of TBI-related ED visits increased by 47%. The use of head CT increased over the past decade in part because of defensive medicine and in part because of patient requests. In addition, CT scan quality improved dramatically over the past 2 decades. We now can detect very small hemorrhages in the brain that trigger observation, admission, neurosurgical consultation, and repeat head CT. This compares to past practice in which the diagnosis of cmTBI was never made and the patient was discharged without follow-up CT scan and no resulting negative sequelae. Higher TBI awareness, lower thresholds to obtain a head CT scan, and better CT scanners resulted in an increasing number of patients getting unnecessary second CT scans.
- Tell us why you are suggesting this topic.
- I am a neurosurgeon and director of neurotrauma at a level 1 trauma center in an academic hospital. Over-triage in TBI has been a research interest of mine because I see the problem every day in my practice and I would like to improve the system. Every day, I see on average 5 patients who, under the current treatment paradigm, have a second head CT scan ordered. In my 17 years practicing neurosurgery, I have never operated on a patient with cmTBI after a routine follow-up head CT. I am currently in the middle of changing this treatment algorithm but am encountering some resistance from my peers (especially emergency medicine physicians). This is a national problem that if addressed on a larger scale could have a huge impact.
- Target Date.
- 2019-07-01
- Describe what you are doing currently and what you are hoping will change because of a new evidence report.
- The current treatment paradigm for cmTBI is to obtain a neurosurgery consultation to see if the patient is operative. If after the first head CT the patient is deemed nonoperative, the patient is admitted to the hospital or observed in the emergency department. About 90% of these patients undergo a routine follow-up head CT scan within 6 to 24 hours of the first CT scan. In a prospective observation cohort study, only 0.3% of patients had a neurosurgical intervention after a second head CT scan. However, these follow-up scans were prompted by neurological deterioration. Routine follow-up head CT scans rarely lead to a change in treatment or neurosurgical intervention. Evidence exists that routine follow-up head CT scans in cmTBI do not change management, but this practice is very ingrained in neurosurgery and especially among emergency medicine physicians. Most often the follow-up head CT scans are performed for the physician to see that everything is “fine” and the hemorrhage has not changed. In actuality, the neurological exam is more important to follow, but the CT scan/report is more concrete. Therefore, physicians who are not as familiar with the neurological exam rely on CT scans more than neurological exams. In addition to a lack of evidence supporting follow-up CT scans in patients with cmTBI, I would argue that the follow-up CT scan is performed to decrease medical liability. An evidence report will give neurosurgeons the necessary confidence to change their practice and convince others to support them rather than fight the change.
- How will you or your group use the information from a new evidence report?
- Our current guidelines for ED observation of cmTBI patients ask for a follow-up head CT scan. An evidence report would support a change to this policy and facilitate education of physicians uncomfortable with this paradigm change. I am working in an academic institution and quality improvement projects such as this are readily accepted and embraced. What is more, an evidence report could bring about similar change in community hospitals and small rural hospitals.
- How would you or your group plan to disseminate information from the report? Who would you plan to disseminate it to?
- First, we would disseminate findings in our hospital system and next to hospitals with which we have a transfer agreement. Next, the evidence report should be disseminated nationally at trauma surgeon, emergency medicine, and neurosurgery meetings. In addition, a webinar could be organized and supported by all three stakeholders to reach an even wider audience.
- Do you know of organizations that could use an evidence report to change clinical practice? Are you a part of, or have you been in contact with, any organizations that might implement the research findings of an evidence report?
- I am currently on the executive committee of the Congress of Neurological Surgeons (CNS). The main mission of the CNS is education and guideline development. The CNS would be an ideal venue through which to disseminate the findings. The healthcare system I work in would be ideal in implementing the research findings.
- Information About You: (optional)
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- Provide a description of your role or perspective.
- Director or Neurtrauma, Neurosurgeon
- If you are you making a suggestion on behalf of an organization, please state the name of the organization.
- Please tell us how you heard about the Effective Health Care Program.
