Discordance between Documented Criteria and Documented Diagnosis of Traumatic Brain Injury in the Emergency Department

Abstract

Accurate diagnosis of traumatic brain injury (TBI) is critical to ensure that patients receive appropriate follow-up care, avoid risk of subsequent injury, and are aware of possible long-term consequences. However, diagnosis of TBI, particularly in the emergency department (ED), can be difficult because the symptoms of TBI are vague and nonspecific, and patients with suspected TBI may present with additional injuries that require immediate medical attention. We performed a retrospective chart review to evaluate accuracy of TBI diagnosis in the ED. Records of 1641 patients presenting to the ED with suspected TBI and a head computed tomography (CT) were reviewed. We found only 47% of patients meeting the American Congress of Rehabilitation Medicine criteria for TBI received a documented ED diagnosis of TBI in medical records. After controlling for demographic and clinical factors, patients presenting at a level I trauma center, with cause of injury other than fall, without CT findings of TBI, and without loss of consciousness were more likely to lack documented diagnosis despite meeting diagnostic criteria for TBI. A greater proportion of patients without documented ED diagnosis of TBI were discharged home compared to those with a documented diagnosis of TBI (58% vs. 40%; p < 0.001). Together, these data suggest that many patients who have sustained a TBI are discharged home from the ED without a documented diagnosis of TBI, and that improved awareness and implementation of diagnostic criteria for TBI is important in the ED and for in-and outpatient providers.

Traumatic microbleeds suggest vascular injury and predict disability in traumatic brain injury

“…Patients presenting to the emergency department at level I (Medstar Washington Hospital Center) and level II (Johns Hopkins Suburban Hospital) trauma centres in the Washington, DC metropolitan area with (i) documented mechanism of trauma to the head; or (ii) suspicion of head injury concerning enough to trigger a CT for clinical purposes, were screened for enrolment in an observational protocol; the Traumatic Head Injury Neuroimaging Classification (THINC) study (clinicaltrials.gov NCT01132937). A multiphase screening approach under a HIPAA waiver of authorization was used by research staff to screen all patients presenting to the emergency department for suspected TBI to avoid investigator bias or exclude patients who lacked a clinical diagnosis of TBI (Cota et al, 2018). Written informed consent was obtained from the patients or their surrogates prior to any study procedures.…”

Cytotoxic Edema Associated with Hemorrhage Predicts Poor Outcome after Traumatic Brain Injury

“…Approximately 50% of those presenting to two civilian emergency departments with criteria for mild TBI were not initially recognized as having TBI. 47 While in sports and the military implementation of standard screening protocols has improved identification of patients, in the general population even many of those recognized as having mild TBI with ongoing symptoms do not receive appropriate education and follow-up care. 48 This lack of early identification and education, except in the most severely impaired, may contribute to worse outcomes.…”

Assessing the Severity of Traumatic Brain Injury—Time for a Change?

“…Perhaps unsurprisingly, there is often poor concordance between GCS and PTA. Many patients with TBI who might by GCS criteria alone be considered mild have prolonged PTA durations, indicating a more severe injury [ 25 , 26 ]. These two tools provide complementary information about brain function and often lead to quite different estimates of clinical severity.…”