Can patients with brain herniation on cranial computed tomography have a normal neurologic exam?

Utility of Repeat Head Computed Tomography for Intracranial Hemorrhage After Trauma and Importance of Direct Patient Care

At many institutions, it is common practice for trauma patients with traumatic intracranial hemorrhage (ICH) to receive routine repeat head computed tomographic (CT) scans after the initial CT scan, regardless of symptoms, to evaluate progression of the injury. The purpose of this study was to assess quantifiable risk factors (age, anticoagulation, gender) that could place patients at greater risk for progression of injury, thus requiring surgical intervention (craniotomy, craniectomy) for which serial CT scanning would be useful. From January 2014 to June 2015, a total of 211 patients presented with traumatic ICH and 198 were eligible for inclusion. Twenty-six patients required operative intervention for ICH. One of 26 patients went to the operating room as a result of repeat head CT scans without associated mental status change, change in neurological examination, or associated symptoms such as nausea or vomiting. Significant changes in patient management due to routine repeat CT scans were not observed. There were no statistically significant risk factors identified to place patients at higher risk for progression of disease. The data from this analysis emphasized the importance of nursing care in identifying and relaying changes in patient condition to the trauma team.

Association Between Patient and Emergency Department Operational Characteristics and Patient Satisfaction Scores in a Pediatric Population

BACKGROUND

Emergency departments (EDs) are seeing an increase in the importance of patient satisfaction scores, yet little is known about their association with patient and operational characteristics.

OBJECTIVES

This study aimed to identify patient and operational characteristics associated with patient satisfaction scores.

METHODS

This was a retrospective analysis of data from Press Ganey patient satisfaction surveys of pediatric patients (<18 years) and their families, discharged from the ED of a single, academic, pediatric ED from December 2009 to May 2013. A linear mixed-effects regression model was used to identify significant associations while taking the clustering within patients and physicians into account. Outcome variables included scores for overall experience (0-10), wait time to be seen by a provider (0-100), and likelihood to recommend (0-100). The ED characteristics considered included daily census, proportion of left without being seen, average length of stay (LOS), and total boarding hours, as well as time of day by shift, door-to-room time, and discharge LOS. Patient characteristics included patient age, sex, race, person completing survey, survey language, survey method (mailed or online), payer type, mode of arrival, distance to hospital, weekend or weekday visit, and difference of patient-reported LOS to actual LOS. Only statistically significant variables were included in the final model.

RESULTS

A total of 810 pediatric surveys were included for analysis. The overall mean (SD) was 8.7 (2.0) for overall experience, 84.0 (23.5) for waiting time to be seen by a provider, and 90.1 (22.2) for likelihood to recommend. The score for overall experience was highly correlated with likelihood to recommend (r = 0.90) and less strongly correlated with score for waiting time (r = 0.58). In the final models, increased door-to-room time was associated with a significant decrease in scores for all 3 outcome variables. In addition, a difference between perceived and actual LOS (>2 hours) was significantly associated with lower scores in overall experience and likelihood to recommend, whereas surveys completed online had higher scores for waiting time to see a provider compared with mailed.

CONCLUSIONS

Emergency departments looking to increase satisfaction scores should focus efforts on decreasing door-to-room times.

Association among Emergency Department Volume Changes, Length of Stay, and Leaving Before Treatment Complete

The authors examined the association between the size of an emergency department (ED), volume increases over time, length of stay (LOS), and left before treatment complete (LBTC). EDs participating in the Emergency Department Benchmarking Alliance providing at least two years of data from 2004 to 2011 were included in the analysis. The impact of volume on LOS and LBTC varied depending on annual ED volume. Based on this, EDs can anticipate better how changes in volume will impact patient throughput in the future.

Head computed tomography interpretation in trauma: a primer

Noncontrast computed tomography (CT) provides important diagnostic information for patients with traumatic brain injury. A systematic approach to image interpretation optimizes detection of pathologic air, fractures, hemorrhagic lesions, brain parenchymal injury, and abnormal cerebrospinal fluid spaces. Bone and brain windows should be reviewed to enhance injury detection. Findings of midline shift and mass effect should be noted as well as findings of increased intracranial pressure such as hydrocephalus and cerebral edema, because these may immediately influence management. Compared with CT, magnetic resonance imaging may provide more sensitive detection of diffuse axonal injury but has no proven improvement in clinical outcomes. This article discusses key CT interpretation skills and reviews important traumatic brain injuries that can be discerned on head CT. It focuses on imaging findings that may deserve immediate surgical intervention. In addition, the article reviews the limits of noncontrast CT and discusses some advanced imaging modalities that may reveal subtle injury patterns not seen with CT scan.