Does the evidence justify routine transfer of residents of aged care facilities for CT scan after minor head trauma?

Abstract

Background In 2014, the South Australian coroner recommended that residents of residential aged care facilities (RACF) who had sustained a head injury should be transported to emergency departments (ED) for assessment and a head CT scan, with the view to preventing mortality. The evidence base for the recommendation is unclear. Aims To determine the rate of emergent intervention (neurosurgery, transfusion of blood products or reversal of anti‐coagulation) in residents transferred to ED with minor head trauma who had their usual cognitive function on ED assessment. Methods This was a retrospective cohort study by medical records review at two university‐affiliated community ED. Participants were patients from RACF attending ED who had suffered minor head trauma and had their usual cognitive function. Exclusions were altered conscious state, new neurological findings or associated orthopaedic injury requiring hospital admission. The primary outcome was rate of emergent intervention in residents transferred to ED with minor head trauma who had their usual cognitive function on ED assessment. Results A total of 366 patients was studied; median age 86 years, 45% taking anti‐coagulant/anti‐platelet medication. Eighty per cent underwent head CT. Six per cent had intracranial haemorrhage (ICH; 95% CI 4–8.9%). No patient underwent neurosurgery. One had emergent intervention, reversal of anti‐coagulation (0.3%, 95% CI 0.05–1.5%). Conclusion The rate of emergent intervention for ICH in patients from RACF who sustained a minor head trauma but had their normal cognitive function was <1%. None underwent neurosurgical intervention. The low rate of intervention seriously challenges the appropriateness of routine transfer and CT for this patient group.

Impact of the Canadian CT Head Rule Supplemented by the Original Published Minimum Inclusion Criteria to Assist Emergency Department Clinicians’ Assessment of Patients Presenting Post Fall From Residential Aged Care: a Retrospective Audit

“…This is an important consideration, particularly in our local Australian context, given the Aged Care Royal Commission's emphasis on falls prevention 10 and a recent public report from the Coroner's Court in South Australia that encourages CTB scans in any RACF residents with a possible head strike who are on anticoagulation therapy 11 . It is likely that this directive, questioned in a recent publication by Green et al 12 , has resulted in a reduced threshold for care providers in RACF to seek hospital assessment when one of their residents falls. Further research would be required to determine how these factors interrelate.…”

“…These ndings are consistent with similar studies where surgical intervention ranged from 0-5%. 1,12,13 Comparison of rates of medical management for patients presenting with a fall is more di cult, in part due to the heterogenous nature of possible interventions which can also depend upon other existing comorbidities. For example, anticoagulation cessation can be considered a medical intervention in this context but is of course only a potential intervention in those already taking such therapy.…”

Predictors of hospitalisations and emergency department presentations shortly after entering a residential aged care facility in Australia: a retrospective cohort study

“…Individuals taking warfarin who experience a fall or injury may also be transferred to hospital due to concern about bleeding risk. 30 Individuals prescribed these medication classes could benefit from a medication review on entry to the RACF. Closer review of asthma and chronic obstructive pulmonary disease action plans, review of inhaler technique, staff training and flags for vaccinations in electronic medication management systems were recommended in a previous root cause analysis of infection-related hospitalisations from South Australian RACFs.…”

Maze of minor head injury, aged care and emergency medicine

“…It is within the latter context that Green and colleagues have framed their retrospective case series of patients living in RACF attending two Victorian EDs with minor head injury, published in this issue of the Internal Medicine Journal 2 . Strong reference is made by Green et al .…”

“…Maybe all of that assessment can be delivered outside the ED, and Green et al . have proven that interventions in this group are rare 2 . But interventions are not the whole picture.…”