Management of Minor Traumatic Brain Injury in an ED Observation Unit

Matthew A. Wheatley, MD; Shikha Kapil, MD; Amanda Lewis, MSSc, PA-C; Jessica Walsh O'Sullivan, MD; Joshua Armentrout, MD; Tim P. Moran, PhD; Anwar Osborne, MD, MPM; Brooks L. Moore, MD; Bryan Morse, MD; Peter Rhee, MD; Faiz Ahmad, MD; Hany Atallah, MD


Western J Emerg Med. 2021;22(4):943-950. 

In This Article


This is a retrospective cross-sectional study performed at a Level I trauma center. Initial workup in the acute phase of care was provided primarily by the emergency medicine (EM) team consisting of an EM attending and either an EM resident or an EM advanced practice provider. Here, the trauma team was either activated to co-manage patients based on pre-set protocols or consulted at the discretion of the EM attending.

The EDOU mTBI protocol was created by a multidisciplinary team of physicians from the trauma surgery service, EM, and neurosurgery. The EDOU protocol was based on the BIG protocol.[11,18] We altered the protocol slightly to exclude epidural hematomas based on institutional expert opinion. This practice change was implemented as a quality improvement project first piloted September 1–December 31, 2016. In this phase, patients who met BIG 1 criteria (Table 1) were eligible for the EDOU protocol. Trauma and neurosurgical consultations were required for each patient. Beginning January 1, 2017, patients who met BIG 1 or 2 criteria were permitted in the EDOU. Trauma and neurosurgical consultations were at the discretion of the EM attending in all phases of care. Patients who were unable to ambulate independently, had intractable pain or vomiting, or other significant traumatic injuries were considered ineligible for EDOU. The guidelines for this protocol are summarized in Table 2.

Interventions in the EDOU consisted of neurologic checks every two hours for up to 23 hours. These standard assessments, performed by nursing, involve testing for level of alertness, orientation, and gross deficits in limbs. Evidence of decreased mental status, seizure, or focal neurologic deficit prompted an emergent repeat HCT and consultation with both trauma surgery and neurosurgery. Symptoms were controlled with antiemetics and analgesics as needed. In the absence of clinical deterioration, repeat HCT was ordered at the discretion of the EDOU team. Patients were discharged home if symptoms were controlled with oral medication and they were able to eat and perform activities of daily living unassisted. Patients who were unable to do this were converted to inpatient status. They were admitted to the trauma service if they needed further treatment for their head injuries. Some were admitted to internal medicine due to occult medical issues that were identified during observation.

The intervention group was identified through an EDOU census report generated through the electronic health record (EHR). Because the EHR allowed use of the discrete variable "EDOU Pathway" it was not necessary to use International Classification of Diseases, 10th Modification (ICD-10) codes to identify all the patients in the EDOU on this pathway. The database was queried for all patients on the mTBI protocol from its inception on September 1, 2016, through August 31, 2019. The report provides patient level ED and EDOU LOS data as well as final disposition: inpatient conversion or discharge from EDOU. Trained chart abstractors (EM residents) obtained age, gender, mechanism of injury, initial HCT reading by radiologist, TIH category as determined by trauma surgeons, disposition from the EDOU (be it admission or discharge to home), and follow-up information. Length of stay for the intervention group was calculated on the EHR report unless specified below. We defined ED LOS as patient arrival until they physically left the department. Length of stay in the EDOU was calculated as time of arrival in the EDOU until the time of the admission or discharge order in the EHR. Admission and discharge order times were manually abstracted via chart review. Total LOS was calculated as the sum of ED and EDOU LOS.

The comparison group was made up of patients admitted to the trauma service for TIH from September 1, 2015–August 31, 2016. Patients were identified by querying the trauma registry for all patients who were admitted with a primary diagnosis of TIH based on ICD-10 code. The trauma registry is a database maintained by the Trauma and Acute Care Surgery service. Minor TBI inclusion criteria were retrospectively applied to these patients to select the group that would have been eligible for EDOU. Trained chart abstractors obtained demographic, imaging, disposition, and follow-up information on comparison group patients. Although the group for comparison was derived from the registry database at our institution and the intervention group was derived from an EHR report, ultimately the chart abstractors used the same EHR system (Epic Systems Corporation, Verona, WI) to obtain the results used in the analyses.

We described LOS using medians and interquartile ranges. All other variables were described using counts and percentages. The primary research question regarded whether the mTBI protocol reduced the median LOS. This was tested using quantile regressions. Quantile evaluates the association between some predictor and a given quantile/percentile of the outcome while controlling for other variables (eg, whether an intervention reduces the 50th percentile/median or 75th percentile of an outcome). Adjusted analyses controlled for the effects of age, gender, mechanism of injury, neurosurgery consultation, repeat HCT, and BIG level. We computed P-values and 95% confidence intervals (CI) as bootstrapped estimates (10,000 resamples). Categorical patient characteristics were compared across groups using the χ 2 test. Analyses were conducted using R v. 3.5.2 (R Foundation for Statistical Computing, Vienna, Austria).