Derivation of a clinical decision rule to guide the interhospital transfer of patients with blunt traumatic brain injury.
OBJECTIVE
To derive a clinical decision rule for people with traumatic brain injury (TBI) that enables early identification of patients requiring specialised trauma care.


METHODS
We collected data from 1999 through 2003 on a retrospective cohort of consecutive people aged 18-65 years with a serious head injury (AIS > or =3), transported directly from the scene of injury, and evaluated in the ED. Information on 22 demographical, physiological, radiographic, and lab variables was collected. Resource based "high therapeutic intensity" measures occurring within 72 hours of ED arrival (the outcome measure) were identified a priori and included: neurosurgical intervention, exploratory laparotomy, intensive care interventions, or death. We used classification and regression tree analysis to derive and cross validate the decision rule.


RESULTS
504 consecutive trauma patients were identified as having a serious head injury: 246 (49%) required at least one of the HTI measures. Five ED variables (GCS, respiratory rate, age, temperature, and pulse rate) identified subjects requiring at least one of the HTI measures with 94% sensitivity (95% CI 91 to 97%) and 63% specificity (95% CI 57 to 69%) in the derivation sample, and 90% sensitivity and 55% specificity using cross validation.


CONCLUSIONS
This decision rule identified among a cohort of head injured patients evaluated in the ED the majority of those who urgently required specialised trauma care. The rule will require prospective validation in injured people presenting to non-tertiary care hospitals before implementation can be recommended.
Newgard
C D
CD
Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon 97239-3098, USA. newgardc@ohsu.edu
Hedges
J R
JR
Stone
J V
JV
Lenfesty
B
B
Diggs
B
B
Arthur
M
M
Mullins
R J
RJ
D000293:Adolescent; D000328:Adult; D000368:Aged; D001930:Brain Injuries / Q000628:therapy*; D003661:Decision Support Techniques; D004636:Emergency Service, Hospital; D004812:Epidemiologic Methods; D016489:Head Injuries, Closed / Q000628:therapy*; D006801:Humans; D008875:Middle Aged; D009922:Oregon; D010360:Patient Transfer / Q000458:organization & administration*; D015599:Trauma Severity Indices