Ethnic and Racial Disparities in Emergency Department Care for Mild Traumatic Brain Injury

OBJECTIVES: To identify racial, ethnic, and gender disparities in the emergency department (ED) care for mild traumatic brain injury (mTBI). METHODS: A secondary analysis of ED visits in the National Hospital Ambulatory Medical Care Survey for the years 1998 through 2000 was performed. Cases of mTBI were identified using ICD-9 codes 800.0, 800.5, 850.9, 801.5, 803.0, 803.5, 804.0, 804.5, 850.0, 850.1, 850.5, 850.9, 854.0, and 959.01. ED care variables related to imaging, procedures, treatments, and disposition were analyzed along racial, ethnic, and gender categories. The relationship between race, ethnicity, and selected ED care variables was analyzed using multivariate logistic regression with control for associated injuries, geographic region, and insurance type. RESULTS: The incidence of mTBI was highest among men (590/100,000), Native Americans/Alaska Natives (1026.2/100,000), and non-Hispanics (391.1/100,000). After controlling for important confounders, Hispanics were more likely than non-Hispanics to receive a nasogastric tube (OR, 6.36; 95% CI = 1.2 to 33.6); nonwhites were more likely to receive ED care by a resident (OR, 3.09; 95% CI = 1.9 to 5.0) and less likely to be sent back to the referring physician after ED discharge (OR, 0.47; 95% CI = 0.3 to 0.9). Men and women received equivalent ED care. CONCLUSIONS: There are significant racial and ethnic but not gender disparities in ED care for mTBI. The causes of these disparities and the relationship between these disparities and post-mTBI outcome need to be examined.     

Evaluation of a Low‐risk Mild Traumatic Brain Injury and Intracranial Hemorrhage Emergency Department Observation Protocol

Objectives

Among emergency physicians, there is wide variation in admitting practices for patients who suffered a mild traumatic brain injury (TBI) with an intracranial hemorrhage (ICH). The purpose of this study was to evaluate the effects of implementing a protocol in the emergency department (ED) observation unit for patients with mild TBI and ICH.

Methods

This retrospective cohort study was approved by the institutional review board. Study subjects were patients ≥ 18 years of age with an International Classification of Diseases code corresponding to a traumatic ICH and admitted to an ED observation unit (EDOU) of an urban, academic Level I trauma center between February 1, 2015, and January 31, 2017. Patient data and discharge disposition were abstracted from the electronic health record, and imaging data, from the final neuroradiologist report. To measure kappa, two abstractors independently collected data for presence of neuro deficit from a 10% random sample of the medical charts. Using a multivariable logistic regression model with a propensity score of the probability of placement in the EDOU before and after protocol implementation as a covariate, we sought to determine the pre‐post effects of implementing a protocol on the composite outcome of admission to the floor, intensive care unit, or operating room from the EDOU and the proportion of patients with worsening findings on repeat computed tomography (CT) head scan in the EDOU.

Results

A total of 379 patients were identified during the study period; 83 were excluded as they were found to have no ICH on chart review. Inter‐rater reliability kappa statistic was 0.63 for 30 charts. Among the 296 patients who remained eligible and comprised the study population, 143 were in the preprotocol period and 153 after protocol implementation. The EDOU protocol was associated with an independently statistically significant decreased odds ratio (OR) for admission or worsening ICH on repeat CT scan (OR = 0.45, 95% confidence interval [CI] = 0.25–0.82, p = 0.009) in the observation unit. After a stay in the EDOU, 26% (37/143) of patients required an inpatient admission before implementation of the protocol and 13% (20/153) of patients required an inpatient admission after protocol implementation. There was no statistically significant difference in log transformed EDOU length of stay (LOS) between the groups after adjusting for propensity score (p = 0.34).

Conclusions

While there was no difference in EDOU LOS, implementing a low‐risk mild TBI and ICH protocol in the EDOU may decrease the rate of inpatient admissions from the EDOU. A protocol‐driven observation unit may help physicians by standardizing eligibility criteria and by providing guidance on management. As the propensity score method limits our ability to create a straightforward predictive model, a future larger study should validate the results.

     

Mild Traumatic Brain Injury and Substance Use

An evidence review of mild TBI (mTBI) sequela was undertaken to explore associations between mTBI and substance use in college students. The pilot study included a convenience sample of college students. The results did not support a statistically significant relationship between mTBI and substance use disorders (SUDs). These findings were contradictory from existing and emerging evidence; however, the magnitude of this relationship remains unclear and further supports the need for continued research.     

Screening for Mild Traumatic Brain Injury in the Presence of Psychiatric Comorbidities

Chapman JC, Andersen AM, Roselli LA, Meyers NM, Pincus JH. Screening for mild traumatic brain injury in the presence of psychiatric comorbidities.

Objective

To determine whether or not a battery of neurobehavioral tests, the Brief Objective Neurobehavioral Detector (BOND), could detect mild traumatic brain injury (mTBI) among a group of psychiatric inpatients with numerous substance-related and medical comorbidities. The 16-item BOND is comprised of neurologic examination tasks and has been shown to correlate with radiologic and cognitive findings in previous studies.

Design

Masked comparison.

Setting

Inpatient psychiatric unit at the Veterans Affairs Medical Center in Washington, DC.

Participants

Patients (N=51) sequentially admitted for suicidal ideation in the context of various psychiatric disorders.

Interventions

No intervention.

Main Outcome Measure

BOND total and subtest scores.

Results

Forty-three patients were eligible and analyzed. Twenty-seven had sustained an mTBI in the distant past, and 16 had never sustained a traumatic brain injury (TBI) (non-TBI group). On average, the mTBI group demonstrated a significantly greater number of abnormal subtests on the BOND (mean, 7.22) than did the non-TBI group (mean, 4.50; P=.003). Although the BOND significantly correlated with the presence of mTBI, it did not correlate with any of the psychiatric, substance-related, or medical comorbidities. Multiple regressions indicated that the BOND total score was not explained by age, posttraumatic stress disorder diagnosis, or any combination of the psychiatric, substance-related, or medical comorbidities. High rates of sensitivity (70%) and specificity (69%) were found.

Conclusions

The results of this pilot study suggest that the inexpensive, brief, and objective BOND instrument may be a useful screening tool for the detection of subtle neurologic brain abnormalities after mTBI, even in the presence of substantial comorbidities.     

Work Productivity Loss After Mild Traumatic Brain Injury

Objectives

To examine the completeness of return to work (RTW) and the degree of productivity loss in individuals who do achieve a complete RTW after mild traumatic brain injury (MTBI).

亚低温脑保护在重型创伤性颅脑损伤治疗中的应用

目的探讨亚低温脑保护在重型创伤性颅脑损伤患者治疗中的作用。方法选自2010年1月～2012年5月收治的148例入院时Glasgow昏迷评分(GCS)≤8分无其他严重并发症的重型颅脑损伤患者。随机分为亚低温组与对照组各74例,亚低温组患者入院后行亚低温治疗,对照组接受常规治疗。对两组患者的治疗效果依据Glasgow预后评分(GOS)。结果亚低温组治疗结束后GCS评分明显高于对照组(P<0.05)。亚低温组恢复良好52例,中残11例,重残及植物生存8例,死亡3例。对照组恢复良好25例,中残19例,重残及植物生存23例,死亡7例。结论通过亚低温治疗使重型创伤性颅脑损伤患者的预后得到良好改善。     

Psychoeducation as Precision Health in Military-Related Mild Traumatic Brain Injury

A significant proportion of Service Members and Veterans (SMVs) experience at least 1 mild traumatic brain injury during military activities (mil-mTBI), which can result in enduring cognitive symptoms. Although multiple cognitive rehabilitation (CR) interventions have been developed for this population, patient psychoeducation focusing on biopsychosocial relationships and health behaviors is often cited as the first line of defense for mil-mTBI sequelae. However, theoretical and conceptual foundations of these psychoeducational techniques are not well articulated. This raises questions about the potency of attempts to boost health literacy in affected SMVs, who represent a highly heterogeneous patient population within a special cultural milieu. To elucidate the significance of this problem and identify opportunities for improvement, we view the psychoeducation of SMVs through the lens of educational principles described in serious mental illness, where “psychoeducation” was first formally defined, as well as contextual and phenomenological aspects of mil-mTBI that may complicate treatment efforts. To advance psychoeducation research and practice in mil-mTBI, we discuss how treatment theory, which seeks to link active treatment ingredients with specific therapeutic targets, and an associated conceptual framework for medical rehabilitation—the Rehabilitation Treatment Specification System—can be leveraged to personalize educational content, integrate it into multicomponent CR interventions, and evaluate its effectiveness.     

Prolonged Emergency Department Length of Stay is Not Associated with Worse Outcomes in Traumatic Brain Injury

Background

Data suggest that prolonged Emergency Department length of stay (EDLOS) has a detrimental effect on outcomes in some critically ill patients. However, the relationship between EDLOS and outcomes in traumatic brain injury (TBI) has not been examined.

Objective

Our objective was to determine the effect of EDLOS on neurologic outcomes in TBI patients.

Methods

We performed a retrospective analysis of a prospectively identified cohort of patients with moderate (Glasgow Coma Scale [GCS] score 9–13) and severe (GCS ≤ 8) TBI who presented to a Level 1 trauma center (2006–2010). Inclusion criteria were transfer to the intensive care unit (ICU) or operating room (OR) from the ED. Primary outcome was Glasgow Outcome Scale (GOS) score, a measure of neurologic function, at discharge. We used a proportional odds model to control for significant predictors of GOS in univariate analysis.

Results

Two hundred and twenty-four patients were included in the analysis, 77 (34%) of which were transferred to the OR. Median EDLOS was 3.3 h and 81.2% of patients had a GOS score ≤3 (e.g., severe disability, vegetative, or deceased). In multivariable analyses, EDLOS was not associated with GOS score in either ICU bound (p = 0.57) or OR bound (p = 0.11) patients. Younger age, pupil reactivity, and absence of intubation were independent predictors of good outcomes in the ICU group. In OR patients, predictors of higher GOS score included presence of an epidural hemorrhage, absence of midline shift, and pupil reactivity.

Conclusions

Our study demonstrates that EDLOS was not associated with poor outcomes in patients with moderate to severe TBI who required intensive care or early operative intervention in an academic Level 1 trauma center.     

Emergency Department Visits,Related Hospitalizations,and Reasons for Emergency Department Utilization After Traumatic Spinal Cord Injury

ObjectiveTo identify the self-reported frequency of emergency department (ED) visits, ED-related hospitalizations, and reasons for ED visits among people with traumatic spinal cord injury (SCI) and compare them with general population data from the same geographic area.DesignCross-sectional.SettingA specialty hospital in the Southeastern United States.ParticipantsThe participants (N=648) were community-dwelling adults (18 years and older) with a traumatic SCI, who were at least 1 year postinjury. A comparison group of 9728 individuals from the general population was retrieved from the 2017 National Health Interview Survey (NHIS).InterventionsNot applicable.Main Outcome MeasuresParticipants completed self-report assessments on ED visits, ED hospitalizations, and reasons for ED visits in the past 12 months using items from the NHIS.ResultsA total of 37% of participants with SCI reported at least 1 ED visit, and 18% reported at least 1 ED hospitalization in the past 12 months. Among those having at least 1 ED visit, 49% were admitted to hospitals. After controlling for sex, age, and race/ethnicity, participants with SCI were 151% more likely to visit the ED (odds ratio [OR], 2.51) and 249% more likely to have at least 1 ED hospitalization than the NHIS sample (OR, 3.49). Persons with SCI had a higher percentage of ED visits because of severe health conditions, reported an ED was the closest provider, and were more likely to arrive by ambulance. NHIS participants were more likely to visit the ED because no other option was available.ConclusionsCompared with those in the general population, individuals with SCI have substantially higher rates of ED visits, yet ED visits are not regularly assessed within the SCI Model Systems. ED visits may indicate the need for intervention beyond the acute condition leading directly to the ED visits and an opportunity to link individuals with resources needed to maintain function in the community.