Predictors of post-traumatic complication of mild brain injury in anticoagulated patients: DOACs are safer than VKAs.

Although mild traumatic brain injury (MTBI) in people on oral anticoagulant treatment (OAT) is a frequent challenge for Emergency Department (ED), strong guidelines recommendations are lacking. In the attempt to assess the safety profile of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs), we have recruited 473 patients with a MTBI on OAT (43.6% males; age 81.8 ± 8.7 years), admitted to the Pisa's University Hospital ED (Jan 2016-Oct 2018). All patients underwent a head CT scan with those with no sign of acute bleedings remaining under clinical observation for the ensuing 24 h. Fifty patients (10.6%, 95% CI: 8.1-13.7%) had immediate intracranial hemorrhage (ICH), with a prevalence of patient-important outcomes due to immediate ICH of 1.1% (95% CI 0.4-2.4%); 3 patients died (0.6%, 95% CI 0.2-1.8) and 2 required neurosurgical intervention. Immediate ICHs were more frequent in VKA-treated than in DOAC-treated patients (15.9 vs. 6.4%. RR 2.5. 95%CI 1.4-4.4. p < 0.05). Multivariate analysis identified that post-traumatic amnesia, evidence of trauma above clavicles, high blood glucose, high blood pressure (BP) at arrival, and low prothrombin activity were predictors of immediate ICH. The prevalence of delayed ICH was 1.0% (95%CI 0.4-2.5%) without differences between DOACs and VKAs. Despite ICH being a frequent complication of MTBI in patients on OAT, immediate and delayed patient-important outcomes are rare. DOACs have a better safety profile than VKAs. Simple clinical parameters such as blood pressure at arrival or blood glucose might provide useful predictors of immediate ICH.Trial registration number: 11924_CIPRIANO. Local ethics committee approval number 33096.

Intracranial hemorrhage in anticoagulated patients with mild traumatic brain injury: significant differences between direct oral anticoagulants and vitamin K antagonists.

Prognosis after mild traumatic brain injury (MTBI) on oral anticoagulant therapy (OAT) is uncertain. We evaluated the rate of immediate and delayed traumatic intracranial hemorrhage (ICH) comparing vitamin K antagonists (VKAs) to direct oral anticoagulants (DOACs) and the safety of a clinical management protocol. In this single-center prospective observational study, we enrolled 220 patients on OAT with MTBI. After a first negative CT scan, asymptomatic patients underwent a close neurological observation; if neurologically stable, they were discharged without a second CT scan and followed up for 1 month. Out of the 220 patients, 206 met the inclusion criteria. 23 of them (11.2%) had a positive first CT scan for ICH. Only 1 (0.5%, 95% CI 0.0-1.4%) died because of ICH; no one required neurosurgical intervention. The observed prevalence rate of immediate ICH resulted statistically higher in VKAs-treated patients compared to those treated with DOACs (15.7 vs. 4.7%, RR 3.34, 95% CI 1.18-9.46, P < 0.05). In the 1-month follow-up, 5 out of the 183 patients with a negative CT scan were lost. Out of the remaining 178 patients, only 3 showed a delayed ICH (1.7%, 95% CI 0.0-3.6%), 1 of them died (0.6%, 95% CI 0.5-1.7%) and the others did not require neurosurgical intervention. DOACs resulted safer than VKAs also in the setting of MTBI. In our observation, the rate of delayed hemorrhage was relatively low. Patients presenting with a negative first CT scan and without neurological deterioration could be safely discharged after a short period of in-ward observation with a low rate of complications and without a second CT scan.

Improving vital sign documentation at triage: an emergency department quality improvement project.

BACKGROUND: Improving the quality and safety of patients seen in an emergency department (ED) has become a priority in Italy. The Tuscan Regional Health Ministry has supported quality improvement projects in several Tuscan EDs in cooperation with Harvard Medical International and Harvard Medical School. OBJECTIVE: To improve the triage process, we assessed the completeness of documenting the vital signs of patients seen at triage in the ED of the University Hospital Santa Chiara, Pisa, Italy. At the University Hospital of Pisa's ED, triage is based on 5 categories, each identified by a color: white (lowest priority), blue, green, yellow, and red (highest priority). For patients triaged as "yellow," blood pressure, heart rate, and oxygen saturation are considered mandatory vital signs and important components of a complete patient record. The aims of this project were as follows: 1) to assess the percentage of patients seen during ED triage in whom vital signs were recorded in the clinical record, 2) to analyze the reasons for missing vital sign data, and 3) to design and implement a strategy to improve the percentage of patients in whom vital signs were recorded. METHODS: This project began in November 2005 with the identification of a multidisciplinary ED Quality Team. Faculty from Harvard Medical School provided a 2-day training course on the methods and tools of clinical quality improvement. After the training, the team defined their improvement project. The clinical quality improvement project followed a Plan-Do-Study-Act cycle. Preintervention and postintervention data collection consisted of a retrospective analysis of one-third of all patients triaged in the "yellow" category who were admitted to the ED during 1 month, randomly selected using a computer-generated list. RESULTS: A total of 245 clinical records in the preintervention (March 2006) and 251 (April-May 2007) during the postintervention were included. We found that in 77.9% (191/245) of these records, vital signs were correctly recorded during the preintervention period. Patients with limb trauma and those with abdominal complaints represented the vast majority of patients in whom vital sign data were missing. The postintervention data revealed an improvement in the documentation of mandatory vital signs from 77.9% to 87.9%. CONCLUSIONS: Creating a multidisciplinary team and implementing a formal quality improvement project improved vital sign documentation at triage for a group of patients seen during ED triage in 1 Italian hospital.