Wide Variation in ED Management of Traumatic Brain Injury

Pauline Anderson

June 27, 2017

AMSTERDAM — There's a wide variation among emergency departments across Europe in how they manage mild traumatic brain injury (TBI), even in how they define such an injury, according to results of a new survey.

"We saw a lot of between-center variation in the policies concerning the management of TBI," said lead researcher, Kelly Foks, MD, Erasmus Medical Center, Rotterdam, the Netherlands.

"The survey gives us a better understanding and information about the occurrence of TBI care in centers across Europe," she said, but added that "this is just a start."

Dr Foks presented the study results here at the Congress of the European Academy of Neurology (EAN) 2017.

TBI is a common reason for emergency department (ED) visits. According to the latest figure, the estimated overall incidence of TBI in Europe is 262 per 100,000, said Dr Foks.

Numerous guidelines exist for the management of mild TBI, including those to help decide when to order computed tomography (CT), whether to admit a patient to hospital, and when to reverse anticoagulation treatment.

Researchers sent a survey with multiple questions to principal investigators at 71 centers involved the large and ongoing Collaborative European Neuro-trauma Effectiveness Research in Traumatic Brain Injury (CENTER TBI) study.

The 71 centers represented 20 different European countries. Seven of the centers were in the Netherlands. Most centers (92%) were academic and located in urban areas, and about 68% were level 1 trauma centers.

The survey included 71 questions concerning ED decision-making and admissions. These questions, said Dr Foks, "were all based on literature and expert validation."

To measure reliability of the survey questions, Dr Foks and her colleagues calculated the concordance rate of duplicate questions, which in total was 5%, she said. The median concordance rate of the duplicate questions was 0.85, "which is acceptable," said Dr Foks.

Survey responses revealed many between-center differences in TBI management practices.

Several questions queried centers about how they define TBI using the Glasgow Coma Scale (GCS). To designate patients as having mild TBI, 59% of the centers said they use a GCS score of 13 to 15, but 38% use a GCS score of 14 to 15 and 3% use another score.

For moderate TBI, 56% of centers use a GCS score range of 9 to 12, 32% a GCS score of 9 to 13, and 12% another score.

"So there is variation in the definition already," commented Dr Foks.

Most centers (91%) use a GCS score of 3 to 8 to identify severe TBI, but 9% use another score.

Centers also vary widely in the use of guidelines to help determine whether a patient with mild TBI needs CT or can be safely discharged. About 21% of centers indicated that they don't use any guidelines at all, and 24% of centers use National Institute for Health and Care Excellence guidelines; most of those centers are based in the United Kingdom.

Fewer centers use a guideline "rule," such as the Canadian CT Head Rule (6%) or the CT in Head Injury Patients Rule (6%). About 10% of centers use Scandinavian guidelines, 17% use other international guidelines, and14% use other local guidelines.

Prognostic Biomarkers

The survey also asked respondents whether they routinely use prognostic biomarkers, such as S100B (an astrocytic protein specific to the central nervous system) in clinical practice. Only six centers (9%) said they use biomarkers.

For questions related to hospital admission of patients with mild TBI, respondents were given various scenarios and asked whether under each, they would admit patients "always, often, only if there are other risk factors, or never."

Under certain circumstances, most centers would always admit a patient, including a patient with cerebral spinal fluid leak, CT progression, and new clinically significant CT abnormalities.

"Centers all agree that these patients should always be admitted to hospital," said Dr Foks.

However, there was much more variation for other scenarios. For example, 35% of centers would always admit patients with preinjury anticoagulation, while most would do so only often or only when there are risk factors.

Another question asked centers about initiating an antiepileptic drug (AED) for patients with TBI admitted to a ward who develop early seizures (defined as a seizure within 7 days of the injury). Most centers (55%) reported that they would always start an AED in these patients, but 32% would do so only if the early seizure was accompanied by a CT abnormality, and 10% would never start these drugs.

There were also differences between centers in use of antibiotics in patients with TBI who have cerebral spinal fluid leakage. In these patients, said Dr Foks, there may be a concern about a higher risk for infection.

Here, 37% of centers would start an antibiotic, 15% would start an antibiotic if the patient had a fever, and about half the centers would perform additional diagnostic tests before deciding whether an antibiotic is needed.

Policies also varied concerning discharge and follow-up care. About 79% of centers hand out information on such things as postconcussion symptoms to discharged patients. For patients who were admitted to the hospital, 54% of centers schedule a visit for them at an outpatient clinic, and 24% refer them to a general practitioner.

The next step for Dr Foks and her team is to investigate whether these variations in policies affect patient outcomes.

"For example, we can investigate centers that schedule a visit to an outpatient clinic vs centers that don't and see if this influences patient outcomes," she said. "That is what we are going to do in the near future."

The new results provide "a golden opportunity" to look at these outcomes, commented session co-chair Bas Bloem, MD, PhD, professor of movement disorders, Department of Neurology, Radboud University, Nijmegen, the Netherlands.

But they also mean that existing multicenter studies "can probably be washed down the drain," said Dr Bloem.

"With these differences, it will be impossible to interpret any prior multicenter studies in Europe, or probably anywhere in the world."

Dr Bloem wondered whether the researchers have any long-term plans to "harmonize" TBI care across Europe. Dr Foks said the only purpose of the research is to explore the differences.

Data were obtained in the context of the CENTER-TBI study with support of the European Commission 7th Framework program.

Congress of the European Academy of Neurology (EAN) 2017. Abstract O3223. Presented June 26, 2017.

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