Managing Craniomaxillofacial Injury Without Inpatient Consult: Outcomes and Patient Cost Savings.

BACKGROUND: We hypothesized that trauma surgeons can safely selectively manage traumatic craniomaxillofacial injuries (CMF) without specialist consult, thereby decreasing the overall cost burden to patients. METHODS: A 4-year retrospective analysis of all CMF fractures diagnosed on facial CT scans. CMF consultation was compared with no-CMF consultation. Demographics, injury severity, and specialty consultation charges were recorded. Penetrating injuries, skull fractures, or patients completing inpatient craniofacial surgery were excluded. RESULTS: 303 patients were studied (124 CMF consultation vs 179 no-CMF consultation), mean age was 47.8 years, with 70% males. Mean Glasgow Coma Scale and Injury Severity Score (ISS) was 14 ± 3.4 and 10 ± 9, respectively. Patients with CMF consults had higher ISS (P < .001) and needed surgery on admission (P < .001), while no-CMF consults had shorter length of stay (P < .002). No in-hospital mortality or 30-day readmission rates were related to no-CMF consult. Total patient charges saved with no-CMF consultation was $26 539.96. DISCUSSION: Trauma surgeons can selectively manage acute CMF injuries without inpatient specialist consultation. Additional guidelines can be established to avoid tertiary transfers for specialty consultation and decrease patient charges.

When to Admit to Observation: Predicting Length of Stay for Anticoagulated Elderly Fall Victims.

BACKGROUND: Geriatric patients who fall while taking an anticoagulant have a small but significant risk of delayed intracranial hemorrhage requiring observation for 24 h. However, the medical complexity associated with geriatric care may necessitate a longer stay in the hospital. Little is known about the factors associated with a successful observational status stay (<2 d) for this population. MATERIALS AND METHODS: Elderly patients who fell while taking an anticoagulant admitted from 2012 to 2017 at an ACS level II trauma center were included in a retrospective cohort study to determine what factors were associated with a stay consistent with observational status. INCLUSION CRITERIA: age> 65 y old, negative initial head CT, and one of the following: INR>3.5 if on warfarin, GCS<14, external signs of trauma, or focal neurological deficits. RESULTS: The cohort included 369 patients. Factors associated with decreased likelihood of successful observational status included the need for services after discharge such as an extended care facility (OR 0.06, 95% CI 0.02-0.19, P < 0.001) or visiting nurse agency services (OR 0.27, 95% CI 0.10-0.75, P < 0.001), a dementia diagnosis (OR 0.17, 95% CI 0.04-0.70, P = 0.014), increasing number of medications (OR 0.91, 95% CI 0.84-0.99, P = 0.031), and the use of coumadin (OR 0.28, 95% CI 0.12-0.70, P = 0.006). CONCLUSIONS: For trauma providers, knowing your patient's medication use and particularly type of anticoagulant, comorbidities including dementia, and likely need for services after discharge will help guide the decision to admit the patient for what may be a reasonably lengthy stay versus a brief observation in the hospital for elderly fall victims on anticoagulation.

Prudent care of head trauma in the elderly: a case report.

INTRODUCTION: Severe traumatic brain injury is a major public health problem that accounts for one-third of all deaths due to trauma in the United States. This case report illustrates some of the challenges faced by the elderly in accessing essential emergency services for traumatic brain injury. CASE PRESENTATION: A 74-year-old Caucasian man presented with head trauma at his local acute care hospital (level III/IV) in Canada at 2:30 PM. He was triaged at 4:00 PM and was seen by the emergency room physician at 4:50 PM. His vital signs were normal, and his Glasgow Coma Scale score was 15/15 upon admission. A computed tomography-based diagnosis of acute subdural hematoma was subsequently made by a radiologist at 5:00 PM. A neurosurgical transfer was requested to the nearby tertiary trauma center (level I/II), but was initially refused by the neurosurgical resident on call. The patient's condition slowly deteriorated until he became unconscious at 7:45 PM. The patient was intubated and transferred to the neurosurgical unit at 8:34 PM. He was seen by a consultant neurosurgeon at 9:30 PM, but surgery (craniotomy) was deemed not viable, given the patient's age and the fact that his pupils were now fixed and dilated (Glasgow Coma Scale score 3/15). The patient was taken off life support at 1:00 AM the following morning and died shortly thereafter. The patient's family made a formal complaint, but the decision by an independent medical review panel was that "the patient's care was prudent, timely and professional." CONCLUSIONS: Geriatric patients with severe head injury are less likely than their younger counterparts to be transferred to neurosurgical trauma centers. Protocol-driven care of the elderly can reduce mortality due to head trauma through the application of the Brain Trauma Foundation guidelines.

Head injuries following television-related accidents in the pediatric population.

OBJECT: Current data indicate the rate of head injuries in children caused by falling televisions is increasing. The authors describe these injuries and the cost incurred by them. METHODS: In a single-institution retrospective review, all children treated for a television-related injury at LeBonheur Children's Hospital, a Level I pediatric trauma center, between 2009 and 2013 were identified through the institution's trauma registry. The type, mechanism, and severity of cranial injuries, surgical interventions, outcome, and costs were examined. RESULTS: Twenty-six patients were treated for a television-related injury during the study period. Most injuries (22 cases, 85%) occurred in children aged 2-4 years (mean age 3.3 years), and 19 (73%) of the 26 patients were male. Head injuries occurred in 20 patients (77%); these injuries ranged from concussion to skull fractures and subdural, subarachnoid, and intraparenchymal hemorrhages. The average Glasgow Coma Scale score on admission was 12 (range 7-15), and 3 patients (12%) had neurological deficits. Surgical intervention was required in 5 cases (19%). The majority of patients made a full recovery. There were no deaths. The total cost for television-related injuries was $1.4 million, with an average cost of $53,893 per accident. CONCLUSIONS: A high occurrence of head injuries was seen following television-related accidents in young children. This injury is ideal for a public education campaign targeting parents, health care workers, and television manufacturers.

Serum S100B determination in the management of pediatric mild traumatic brain injury.

BACKGROUND: The place of serum S100B measurement in mild traumatic brain injury (mTBI) management is still controversial. Our prospective study aimed to evaluate its utility in the largest child cohort described to date. METHODS: Children younger than 16 years presenting at a pediatric emergency department within 3 h after TBI were enrolled prospectively for blood sampling to determine serum S100B concentrations. The following information was collected: TBI severity determined by using the Masters classification [1: minimal or Glasgow Coma Scale (GCS) 15, 2: mild or GCS 13-15, and 3: severe or GCS <13]; whether hospitalized or not; good or bad clinical evolution (CE); whether cranial computed tomography (CCT) was prescribed; and related presence (CCT+) or absence (CCT-) of lesions. RESULTS: For the 446 children enrolled, the median concentrations of S100B were 0.21, 0.31, and 0.44 µg/L in Masters groups 1, 2, and 3, respectively, with a statistically significant difference between these groups (P < 0.05). In Masters group 2, 65 CCT scans were carried out. Measurement of S100B identified patients as CCT+ with 100% (95% CI 85-100) sensitivity and 33% (95% CI 20-50) specificity. Of the 424 children scored Masters 1 or 2, 21 presented "bad CE." S100B identified bad CE patients with 100% (95% CI 84-100) sensitivity and 36% (95% CI 31-41) specificity. Of the 242 children hospitalized, 81 presented an S100B concentration within the reference interval. CONCLUSIONS: Serum S100B determination during the first 3 h of management of children with mTBI has the potential to reduce the number of CCT scans, thereby avoiding unnecessary irradiation, and to save hospitalization costs.

Screening for blunt cerebrovascular injuries is cost-effective.

BACKGROUND: Screening for blunt carotid and vertebral injury (BCVI) is increasing without a clear understanding of whether the chosen screening approach is cost-effective. We hypothesized that screening for BCVI using computed tomography angiography (CTA) was cost-effective in populations at high risk for BCVI. METHODS: A decision analysis was performed modeling current BCVI screening approaches: no screening, duplex ultrasound, magnetic resonance angiography, angiography, and CTA. Treatment options included antiplatelet therapy, anticoagulation, stents for pseudoaneurysm, and no treatment. Probability estimates for incidence of injury and stroke, sensitivity and specificity of the screening modality, and type of treatment were taken from published data. Average wholesale price and medicare reimbursement costs were used. Two populations were analyzed; high-risk and overall blunt trauma populations. Two perspectives were taken; societal (including lifetime stroke costs) and institutional (ignoring lifetime stroke costs). RESULTS: In the high-risk population, from a societal perspective, CTA has the lowest cost and stroke rate; $3,727 per patient screened with a 1% stroke rate. No treatment has the highest cost and stroke rate. From an institutional perspective, no screening is the least costly option but has an 11% stroke rate. Duplex ultrasound is the most cost-effective screening modality; $8,940 per stroke prevented. CONCLUSION: From the societal perspective, CTA is the most cost-effective screening strategy for patients at high risk for BCVI. From an institutional perspective, CTA prevents the most strokes at a reasonable cost.

Decision making in the face of uncertainty and resource constraints: examples from trauma imaging.

The purpose of this review is to illustrate how tools and concepts from decision and cost-effectiveness analyses can be used to help make decisions in the face of uncertainty and resource constraints, select appropriate subjects for imaging, choose between competing imaging modalities, and prioritize future research. Examples from trauma imaging illustrate the use of the presented tools. The author advocates the PROACTIVE approach in deciding which imaging strategies are cost-effective (PRO for defining the problem, reframing the problem from multiple perspectives, and focusing on the objective; ACT for expanding the alternatives, considering the consequences and associated chances of each alternative, and identifying the trade-offs involved; IVE for integrating the evidence and values, optimizing the value of interest, and exploring uncertainty). Simulation models play an important role in the assessment of imaging strategies by helping to identify alternative strategies and to integrate the best-available evidence related to risks, benefits, patient values, and costs. Exploring the uncertainty in the evidence and assessing the value of obtaining more information can help prioritize future research and guide study design.

Management of brain-injured patients by an evidence-based medicine protocol improves outcomes and decreases hospital charges.

OBJECTIVE: Traumatic brain injury (TBI) is the leading cause of death from blunt trauma, with an estimated cost to society of over dollar 40 billion annually. Evidence-based guidelines for TBI care have been widely discussed, but in-hospital treatment of these patients has been highly variable. The purpose of this study was to determine whether management of TBI patients according to a protocol based on the Brain Trauma Foundation (BTF) guidelines would reduce mortality, length of stay, charges, and disability. METHODS: In 1995, a protocol following the BTF guidelines was developed by members of the Level I trauma center's interdisciplinary neurotrauma task force. Inclusion criteria for the protocol were blunt head injury, age > 14 years, and Glasgow Coma Scale score < or = 8. An extensive educational process was conducted to develop compliance among all disciplines for this new management strategy. A historical control group of patients eligible for the protocol was identified by retrospective analysis of trauma registry data for 1991 to 1994. Mortality, intensive care unit days, total hospital days, total charges, Rancho Los Amigos Scores, and Glasgow Outcome Scale scores were compared. RESULTS: Between 1991 and 2000, over 7,000 blunt TBI patients were managed by the Trauma Service. Of these, 830 met the inclusion criteria for the TBI protocol and lived > 48 hours. After implementation, initial analysis of the 1995-96 cohort indicated only 50% compliance with the protocol. By 1997, compliance had risen to 88%. Patients were therefore compared as three groups: before the protocol (1991-94, n = 219), during low compliance (1995-96, n = 188), and during high compliance (1997-2000, n = 423). Groups did not differ significantly on Injury Severity Score, head Abbreviated Injury Scale score, or age (p > 0.05). Admission Glasgow Coma Scale score was slightly higher in the 1991-94 cohort (4.0 vs. 3.5, p = 0.001). From 1991-94 to 1997-2000, intensive care unit stay was reduced by 1.8 days (p = 0.021) and total hospital stay was reduced by 5.4 days (p < 0.001). The charge reduction (calculated in 1997 dollars) per patient for the length of stay decrease was dollar 6,577 in 1995-96 and dollar 8,266 in 1997-2000 (p = 0.002). This represents a total reduction over 6 years of dollar 4.7 million in charges. In addition, the overall mortality rate showed a reduction of 4.0% from 1991-94 to 1997-2000 (17.8% vs. 13.8%), although this was not statistically significant. On the basis of the Glasgow Outcome Scale score, in 1997-2000, 61.5% of the patients had either a "good recovery" or only "moderate disability," compared with 503% in 1995-96 and 43.3% in 1991-94 (p < 0.001). The Rancho Los Amigos Scores showed a similar trend, with 56.6% of the 1997-2000 patients having appropriate responses at 10 to 14 days, compared with only 44.0% of the 1995-96 patients and 43.9% of the 1991-94 patients (p = 0.004). CONCLUSION: Adherence to a protocol based on the BTF guidelines can result in a significant decrease in hospital days and charges for TBI patients who live > 48 hours. In addition, mortality and outcome may be significantly affected. This analysis suggests that increased efforts to improve adherence to national guidelines may have a significant impact on head injury care outcomes and could dramatically reduce the substantial financial resources that are currently consumed in the acute care phases for this injury.

Clinical efficacy of serial computed tomographic scanning in severe closed head injury patients.

BACKGROUND: The purpose of this study was to determine whether serial computed tomographic (CT) scans of the head serve to prompt operative intervention. After the initial and 24- to 48-hour repeat scans, if no operative intervention has been performed, further serial scans are ordered on a planned basis or on the basis of changes in clinical status. METHODS: This study is a retrospective review from January 1996 to December 2000. Results of the initial, follow-up, and serial CT scans were recorded for the 51 patients who met the inclusion/exclusion criteria. RESULTS: One hundred seventeen (53.4%) serial CT scans were ordered. No urgent operative interventions were performed on the basis of the serial CT scans. Three scans (2.56%) led to nonurgent neurosurgical intervention. CONCLUSION: In severe head-injured patients who are nonneurosurgical candidates on the basis of initial and repeat CT scans, serial head CT scans have little clinical efficacy and do not lead to urgent operative intervention.

A review of outcome after moderate and severe closed head injury with an introduction to life care planning.

Forensic consultation regarding moderate and severe closed head injury (CHI) generally focuses on determination of severity of residual deficits and the implications of these deficits for future health care needs, personal independence, and employment. This information can be used to develop a life care plan that describes the patient's needs for continued medical care, rehabilitation, and daily assistance or supervision and estimates the long-term costs for these services. This article provides brief reviews of CHI classification, epidemiology, residual deficits, expected outcomes, and factors predictive of outcome. An introduction to the process of developing a life care plan is presented.

[Minimal craniocerebral trauma]. / Das minimale Schädelhirntrauma.

The patient with mild head injury is the most frequently hospitalised trauma patient. The costs for this treatment are enormous. Guidelines for managing the patients are changing for the last 20 years. Haematoma rates of 10% have been shown with CT scans in prospective studies for patients with GCS 14/15 and normal neurological examination. One out of ten of these patients had to undergo craniotomy. CT scans have shown to reduce costs if done on all patients with mild head injury and discharged with normal findings. Patients with skull fractures and age over 65 years are at higher risk, but not patients with loss of consciousness and post traumatic amnesia. We suggest CT scans on all patients. If a CT scan is not available we recommend to observe the patient for 24 hours in the hospital. If a patient with GCS 15 is to be discharged, an information leaflet with instructions for surveillance at home should be given to the patients and to the care taker.

Cervical spine screening with CT in trauma patients: a cost-effectiveness analysis.

PURPOSE: To investigate the cost-effectiveness of computed tomography (CT) relative to radiography for cervical spine screening in trauma patients. MATERIALS AND METHODS: A decision analysis model was constructed to compare the incremental cost-effectiveness of radiography and CT as primary cervical spine screening modalities in trauma patients. Analyses were performed from a societal perspective, and probability and cost estimates from the literature and institutional experience were used. In separate cost-effectiveness analyses, hypothetical cohorts of trauma patients from three defined clinical scenarios were considered: high, moderate, and low risk for cervical spine fracture. Outcome measures included cases of paralysis prevented, total cost of screening strategies, and incremental cost-effectiveness ratios. RESULTS: In high-risk patients, screening with CT is a dominant strategy that prevents cases of paralysis and saves money for society. In moderate-risk patients, screening with CT is cost-effective with reference-case assumptions and within the range of most sensitivity analyses. In the low-risk group, CT screening helps prevent cases of paralysis, but the incremental cost-effectiveness ratio is high (> $80,000 per quality-adjusted life year). CONCLUSION: CT is the preferred cervical spine screening modality in trauma patients at high and moderate risk for cervical spine fracture.

Minor head trauma.

This article reviews the persisting difficulty and the importance of the diagnosis of minor head trauma. The diagnosis has been complicated by pervasive disagreement regarding diagnostic criteria. This is primarily a result of the fact that evidence for actual injury is hard to obtain in minor cases because most symptoms tend to be subjective and have high base rates in the normal, uninjured population. At the same time, the diagnostic decision has important implications for patients in terms of treatment, expectancy for future function and lifestyle, and compensation for injuries. Decision theory leads us to the awareness of diagnostic errors. In addition to correct determination, the clinician can make an error of not diagnosing an injury when it has in fact occurred or making a positive diagnosis where there is no injury. The optimal strategy is to set the cutoff at the midpoint of these two error probabilities. The clinician may be willing to make one error rather than the other depending on the cost and bias involved. The second error is more likely to be made when the clinician stands as a strong advocate for the patient and willing to provide any help necessary to encourage treatment, give patients a rationale for understanding their symptoms, and help them obtain compensation for injuries. This can also lead to significant overdiagnosis of injury. The first error is more likely to be made when the clinician recognizes the potential for increasing costs to the health-care industry, the court system, and increasing personal injury claims. He or she may also recognize the vulnerability to the risk for symptom invalidity, the perpetuation of patient symptoms through suggestion, and the need for a biologic explanation for life stressors and preexisting emotional and personality constraints. It can be argued that the most objective diagnostic opinion, uninfluenced by the above biases, should ultimately be in the best interest of the patient, the clinician, legal consultants, and society. Based on the findings in this chapter, at least four symptom constellations can be identified. These have differing probabilities for residual symptoms of minor head trauma and include the following: 1. These patients' symptoms clearly meet the criteria from Table 2. This includes several findings from 1 to 10 of Table 1, together with abnormal neuropsychologic testing on the AIR, General Neuropsychological Deficit Scale, or other indicators of diminished cortical integrity. This group of patients shows a very strong probability of having experienced a brain injury and for showing residual symptoms of minor head trauma. 2. These patients have experienced concussional symptoms (e.g., headache, mild confusion, and balance and visual symptoms) that were documented at the time of injury but sustained no or brief (< 15 seconds) LOC or PTA and, therefore, do not qualify for the diagnosis in Table 2. They may still have several symptoms from Table 1, including objective findings from neuroscanning and variable neuropsychologic testing, especially in measures of attention and delayed recall. This group also shows a high probability for residual, unresolved concussional, and related symptoms. 3. These patients may have shown evidence of concussional symptoms at the time of injury, with no or brief LOC, PTA, or other symptoms from Table 1 (1-10). They continue to show persistent symptoms after 6 months to 1 year. With this group, there is a strong probability that emotional, motivational and premorbid personality factors are either causing or supporting these residual symptoms. 4. In these patients, clearly identifiable postconcussive symptoms at the time of injury are not easy to identify, and perhaps headache is the only reported symptom. There was no LOC or PTA, and virtually none of symptoms 1 to 10 in Table 1 are observed. These patients show strong evidence of symptom invalidity on MMPI-2 or other measures, and marked somatoform, depression, anx

Routine early CT-scan is cost saving after minor head injury.

Significant hospital resources are invested in early detection of intracranial complications after minor head injuries (MHI). This study focuses on economic aspects of MHI management. 88 MHI patients underwent routine early CT-scan and at least 24 h in-hospital observation. The cost of this management was calculated, and compared to estimated costs of three alternative management protocols. CT-scans demonstrated intracranial lesions in eight (9%) patients, but none required neurosurgical intervention. The expense of our management was Norwegian Kroner (NOK) 576,136. An alternative management protocol including routing early CT-scan and discharge of patients with normal CT-findings, Glasgow coma score > or = 14 and no neurological deficits, was found to be safe, and estimated to reduce costs with 43% to NOK 326,669. It is concluded that routine early CT-scan is the most reliable and cost saving management procedure after MHI.

Money matters: a meta-analytic review of the effects of financial incentives on recovery after closed-head injury.

OBJECTIVE: The authors evaluated the impact of financial incentives on disability, symptoms, and objective findings after closed-head injury. METHOD: Meta-analysis was used to review the literature. Seventeen reports, covering 18 study groups and a total of 2,353 subjects, contained data from which effect sizes could be calculated. Effect sizes were aggregated after weighting for group size. After discussion, there was 100% agreement between the authors on all calculations. RESULTS: A moderate overall effect size, 0.47, was found. The effect was particularly strong for mild head trauma. The data showed more abnormality and disability in patients with financial incentives despite less severe injuries. CONCLUSIONS: Clinical evaluation of patients after closed-head injury, particularly mild head trauma, must include consideration of the effect of financial incentives on symptoms and disability.

Social-economic impact of head injury.

The socio-economic costs of traffic road accidents were analysed data epidemiological studies and compared with reported data. The costs are calculated as a function of accident type and vehicle involved, severity of head trauma, patients individual characteristics, type of care--intensive and emergency services, other hospital bed costs, including recovering and rehabilitation such as in-and out-patient services. Finally the costs of repairing materials (cars, walls, roads, etc.) are also estimated. The author concludes that the medical doctor must take part in compiling the statistics so as to be able to discuss the economics of injury and the social priorities.