title: Triage Patterns of Traumatic Subarachnoid Hemorrhage: Is Referral to a Tertiary Care Center Necessary?
abstract: OBJECTIVE
  Isolated traumatic subarachnoid hemorrhage (iTSAH) in mild head injuries has more evidence that triage to a tertiary care facility, intensive care unit admission, and repeat imaging is not warranted. Certain factors were identified that predict radiographic and clinical progression in hopes of preventing avoidable cost, which occur with transfer and subsequent management.
  
  
  METHODS
  A retrospective analysis identified 67 patients transferred between January 2010 and December 2014 who met inclusion criteria. Primary outcomes assessing neurosurgical intervention, radiographic, and clinical progression were documented. Secondary outcomes included any operative intervention, length of stay, standardized hospital costs, disposition at discharge, and 30-day mortality.
  
  
  RESULTS
  The mean age of the cohort was 67.7 ± 16.4 years, with most patients (82.1%) having a Glasgow coma score of 15. Warfarin was used in 10 patients (14.9%), although 55.2% were on an antiplatelet or anticoagulation agent. No patient required neurosurgical intervention. One patient, on clopidogrel (Plavix) and warfarin, neurologically declined with radiographic progression. Older age seem to correlate with radiographic progression (P = 0.05). Dementia (P = 0.05) as well as warfarin use (P = 0.06) correlated with clinical progression. Cost in patients without other injuries was associated with warfarin use (P = 0.0002), injury severity scores (P = 0.01), and initial Glasgow coma score (P = 0.0003) on multivariate analysis.
  
  
  CONCLUSIONS
  In this series of patients with mild traumatic brain injury, the rate of neurological deterioration due to expansion of iTSAH in patients is low, regardless of the use of antiplatelets/anticoagulants. Triage to a tertiary care facility generally is not warranted and can prove costly to patients with iTSAH without other injures.
authors.affiliation: Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA. Electronic address: Gates.marcus@mayo.edu.
authors.forename: Marcus
authors.initials: M
authors.lastname: Gates
authors.affiliation: Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
authors.forename: Grant
authors.initials: G
authors.lastname: Mallory
authors.affiliation: Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
authors.forename: Ryan
authors.initials: R
authors.lastname: Planchard
authors.affiliation: Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
authors.forename: Georgia
authors.initials: G
authors.lastname: Nothdurft
authors.affiliation: Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
authors.forename: Christopher
authors.initials: C
authors.lastname: Graffeo
authors.affiliation: Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
authors.forename: John
authors.initials: J
authors.lastname: Atkinson
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007902:Length of Stay / Q000639:trends; D008297:Male; D008875:Middle Aged; D012017:Referral and Consultation / Q000639:trends*; D012189:Retrospective Studies; D020206:Subarachnoid Hemorrhage, Traumatic / Q000175:diagnosis* / Q000453:epidemiology / Q000628:therapy*; D062606:Tertiary Care Centers / Q000639:trends*; D014218:Triage / Q000639:trends*
keywords: Cost effective care; Isolated traumatic subarachnoid hemorrhage; Mild head injury