Outcomes of a nontransfer protocol for mild traumatic brain injury with abnormal head computed tomography in a rural hospital setting.
OBJECTIVE
This study sought to investigate outcomes after a novel nontransfer protocol for mild traumatic brain injuries patients with small intracranial hemorrhage (ICH) in a rural trauma center without neurosurgical capabilities.


METHODS
This was a retrospective cohort study. In 2007, a nontransfer protocol was implemented at a Level III Trauma Center. It included adult patients from April 2007 through December 2012 with mild traumatic brain injury (mTBI) (Glasgow Coma Scale score 13 to 15) and computed tomography (CT) showing small ICH and no coagulopathy. The following ICHs were allowed: 1) minimal or small traumatic subarachnoid hemorrhage, 2) punctuate or minimal superficial cerebral contusion, 3) punctuate or minimal intraparenchymal hemorrhage, or 4) very small subdural hemorrhage (SDH) without mass effect (a very thin smear SDH along the tentorium or falx). CT scans were reviewed by the on-call neurosurgeon at an affiliated Level I Trauma Center, and consensus was obtained on the suitability for nontransfer.


RESULTS
A total of 76 patients were included. The median hospital length of stay was 1 day (interquartile range = 1 day). No patient required a neurosurgical intervention or postadmission transfer to a Level I facility. There were no in-hospital deaths, and all patients were discharged with stable head CTs and in good neurologic condition. Two patients were readmitted for nonprotocol-related reasons: 1 acute-on-chronic SDH 6 weeks postdischarge, and 1 visual eye change with normal CT 2 days postdischarge.


CONCLUSIONS
Our 6-year study corroborates the low neurosurgical rate reported in the literature for mTBI with small ICH. Nontransfer protocols may lead to a more efficient use of hospital resources while providing safe, effective and economical health care.
InterMountain Neurosurgery and Neuroscience, St. Anthony Hospital, Lakewood, USA.
Andrew Stewart
AS
Levy
Trauma Research Department, St. Anthony Hospital, Lakewood, USA.
Alessandro
A
Orlando
Trauma Research Department, St. Anthony Hospital, Lakewood, USA.
Kristin
K
Salottolo
Trauma Services Department, St. Anthony Hospital, Lakewood, USA; College of Osteopathic Medicine, Rocky Vista University, Parker, Colorado, USA.
Charles W
CW
Mains
Trauma Research Department, St. Anthony Hospital, Lakewood, USA; College of Osteopathic Medicine, Rocky Vista University, Parker, Colorado, USA. Electronic address: dbaror@ampiopharma.com.
David
D
Bar-Or
D000293:Adolescent; D000328:Adult; D000368:Aged; D001930:Brain Injuries / Q000000981:diagnostic imaging* / Q000191:economics / Q000601:surgery*; D003365:Costs and Cost Analysis; D004632:Emergency Medical Services; D005123:Eye / Q000503:physiopathology; D005260:Female; D015600:Glasgow Coma Scale; D006780:Hospitals, Rural; D006801:Humans; D015601:Injury Severity Score; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000191:economics / Q000706:statistics & numerical data; D010360:Patient Transfer; D012189:Retrospective Studies; D016019:Survival Analysis; D014057:Tomography, X-Ray Computed; D014193:Trauma Centers; D016896:Treatment Outcome; D014474:Unconsciousness / Q000209:etiology / Q000628:therapy; D055815:Young Adult
Brain injuries; Hemorrhage; Neurosurgery; Outcome assessment