Low rate of delayed deterioration requiring surgical treatment in patients transferred to a tertiary care center for mild traumatic brain injury

Clinical factors associated with delayed emergency department visit in intracranial traumatic brain injury: from a multicenter injury surveillance registry

INTRODUCTION

Early diagnosis and intervention by visiting the emergency department (ED) are important for traumatic brain injury (TBI). We evaluate the factors associated with delayed ED visits in patients with intracranial TBI.

METHODS

A retrospective multicenter observational study using the ED-based injury in-depth surveillance database (EDIIS) was designed. Patients with intracranial TBI with an alert mentality at ED presentation from 2014 to 2019 were enrolled. Patients were categorized into four groups according to ED visit time after injury (<1 h, 1-3 h, 3-12 h, and >12 h). ED visits after 12 h were defined as delayed ED visits. The factors associated with delayed ED visits were identified using multivariable logistic regression analysis.

RESULTS

Among 15,620 patients with TBI enrolled in the final analysis, 2,190 (14.0%) visited the ED 12 h after injury. Multivariable analysis identified the following factors as independent predictors for delayed ED visit such as unintentionally struck by or against an object or unintentional fall as a trauma mechanism, injury during ordinary activities, indoor injury, injury during nighttime, winter season, combined subdural hemorrhage and epidural hemorrhage.

CONCLUSION

In patients with intracranial TBI with an alert mentality, multiple factors related to patient demographics and injury characteristics were associated with the time interval from injury to ED visit.

Successful conservative management of a large acute epidural hematoma in a patient with arrested hydrocephalus: A case report

Background:

Arrested hydrocephalus is a condition wherein congenital hydrocephalus spontaneously ceases to progress due to a balance between production and absorption of cerebrospinal fluid. These patients rarely present with pressure symptoms so conservative treatment may be instituted. There are, however, little data on the long-term outcomes of these patients and how they present in the presence of other intracranial pathologies as they transition into adulthood. We aim to add to the growing knowledge about the management of patients with arrested hydrocephalus who have sustained traumatic hematomas.

Case Description:

To the best of our knowledge, we present the only reported case of a 34-year-old female with arrested hydrocephalus who sustained an acute epidural hematoma secondary to a fall and underwent a conservative management. She was asymptomatic except for mild headache that started on the 3^rd day postinjury and was thus treated conservatively with favorable outcomes. A review of literature showed that adults with arrested hydrocephalus may develop intracranial hematomas after head injuries despite them manifesting with little or no symptoms. The hydrocephalus may have provided them with a form of internal decompression thus delaying symptomatology.

Conclusion:

Clinicians should be vigilant as these patients will present with either delayed or completely without neurologic symptomology. Tailored and individualized management of other intracranial pathologies should be adapted in this subset of patients.

The association between hematologic parameters and intracranial injuries in pediatric patients with traumatic brain injury

OBJECTIVE

Analyzing the association between hematologic parameters and abnormal cranial computerized tomography (CT) findings after head trauma.

MATERIAL AND METHODS

A total of 287 children with isolated traumatic brain injury (TBI) were divided into the 'normal' (NG), 'linear fracture' (LFG) and 'intraparenchymal injury' groups (IPG) based on head CT findings. Demographical/clinical data and laboratory results were obtained from medical records.

RESULTS

The neutrophil-lymphocyte ratio was markedly higher in the LFG (p = 0.010 and p = 0.016, respectively) and IPG (p = 0.004 and p < 0.001, respectively) compared with NG. Lower lymphocyte-monocyte ratio (p = 0.044) and higher red cell distribution width-platelet ratio (RPR) (p = 0.030) were associated with intraparenchymal injuries. Patients requiring neurosurgical intervention had higher neutrophil-lymphocyte ratio (p = 0.026) and RPR values (p = 0.031) and lower platelet counts (p = 0.035). Lower levels of erythrocytes (p = 0.005), hemoglobin (p = 0.003) and hematocrit (p = 0.002) were associated with severe TBI and unfavorable outcome (p = 0.012, p = 0.004 and p = 0.006, respectively).

CONCLUSIONS

Hematologic parameters are useful in predicting the presence of abnormal cranial CT findings in children with TBI in association with injury severity; surgery need and clinical outcome.

Understanding secondary overtriage for neurosurgical patients in a rural tertiary care setting

OBJECTIVE

Excessive interfacility transfer to a tertiary care facility of minimally injured patients for subspecialty evaluation leads to overuse of resources and is referred to as secondary overtriage (SO). Little is known regarding the epidemiology of SO in rural settings, particularly for patients with a mild head injury who may be safely managed without admission to level I trauma centers.

METHODS

In order to determine the rate of SO for neurosurgical patients with Glasgow Coma Scale (GCS) of 13-15 referred to a rural level 1 trauma center, we conducted a retrospective chart review of 224 patients evaluated for potential transfer to Dartmouth-Hitchcock Medical Center from January 1, 2014 through December 31, 2014. SO was defined as any admission where a patient was transferred from an outside facility, had a length of stay shorter than 48 h, did not require neurosurgical intervention, and was alive at the time of discharge.

RESULTS

Of the 224 patients evaluated, 163 patients were transferred. Of the 163 patients included in this study, 43 (26.4%) met criteria for SO, 59 (36.2%) patients met criteria for intervention, and 61 (37.2%) patients met criteria for observation.

CONCLUSIONS

Approximately a quarter of the total patients who are transferred to a rural level I trauma center for neurosurgical evaluation are minimally injured, do not require neurosurgical intervention, and are discharged within 48 h of presentation. Management at their referring facility with remote neurosurgical consultation is likely safe in this population. Understanding the rate of SO in neurosurgical patients and risk factors present in this group can better guide future transfer policies at rural medical centers.

Current Trends in Mild Traumatic Brain Injury

In this review, we provide an overview of the current research and treatment of all types of traumatic brain injury (TBI) before illustrating the need for improved care specific to mild TBI patients. Contemporary issues pertaining to acute care of mild TBI including prognostication, neurosurgical intervention, repeat radiographic imaging, reversal of antiplatelet and anticoagulation medications, and cost savings initiatives are reviewed. Lastly, the effect of COVID-19 on TBI is addressed.

Low-value injury admissions in an integrated Canadian trauma system: A multicentre cohort study

BACKGROUND

Injury represents 260 000 hospitalisations and $27 billion in healthcare costs each year in Canada. Evidence suggests that there is significant variation in the prevalence of hospital admissions among emergency department presentations between countries and providers, but we lack data specific to injury admissions. We aimed to estimate the prevalence of potentially low-value injury admissions following injury in a Canadian provincial trauma system, identify diagnostic groups contributing most to low-value admissions and assess inter-hospital variation.

METHODS

We conducted a retrospective multicentre cohort study based on all injury admissions in the Québec trauma system (2013-2018). Using literature and expert consultation, we developed criteria to identify potentially low-value injury admissions. We used a multilevel logistic regression model to evaluate inter-hospital variation in the prevalence of low-value injury admissions with intraclass correlation coefficients (ICC). We stratified our analyses by age (1-15; 16-64; 65-74; 75+ years).

RESULTS

The prevalence of low-value injury admissions was 16% (n = 19 163) among all patients, 26% (2136) in children, 11% (4695) in young adults and 19% (12 345) in older adults. Diagnostic groups contributing most to low-value admissions were mild traumatic brain injury in children (48% of low-value paediatric injury admissions; n = 922), superficial injuries (14%, n = 660) or minor spinal injuries (14%, n = 634) in adults aged 16-64 and superficial injuries in adults aged 65+ (22%, n = 2771). We observed strong inter-hospital variation in the prevalence of low-value injury admissions (ICC = 37%).

CONCLUSION

One out of six hospital admissions following injury may be of low value. Children with mild traumatic brain injury and adults with superficial injuries could be good targets for future research efforts seeking to reduce healthcare services overuse. Inter-hospital variation indicates there may be an opportunity to reduce low-value injury admissions with appropriate interventions targeting modifications in care processes.

Predictors of neurosurgical intervention in complicated mild traumatic brain injury patients: a retrospective cohort study

OBJECTIVES

To determine the predicting demographic, clinical and radiological factors for neurosurgical intervention in complicated mild traumatic brain injury (mTBI) patients.

METHODS

Design: retrospective multicenter cohort study. Participants: patients aged ≥16 presenting to all level-I trauma centers in Quebec between 09/2016 and 12/2017 with mTBI(GCS 13-15) and complication on initial head CT (intracranial hemorrhage/skull fracture). Procedure: Consecutive medical records were reviewed and separated into two groups: no neurosurgical intervention and neurosurgical intervention (NSI). Main outcome: neurosurgical intervention. Analysis: multiple logistic regression model.

RESULTS

Four hundred and seventy-eight patients were included and 40 underwent NSI. One patient had radiological deterioration but no clinical deterioration prior to surgery. Subdural hemorrhage ≥4 mm width (OR:3.755 [95% CI:1.290-10.928]) and midline shift (OR:7.507 [95% CI: 3.317-16.989]) increased the risk of NSI. Subarachnoid hemorrhage was associated with a lower risk of NSI (OR:0.312 [95% CI: 0.136-0.713]). All other intracranial hemorrhages were not associated with NSI.

CONCLUSION

Radiological deterioration was not associated with the incidence of NSI. Subdural hemorrhage and midline shift should be predicting factors for neurosurgery. Some patients with isolated findings such as subarachnoid hemorrhage could be safely managed in their original center without being transferred to a level-I trauma center.

Step up to the Brain Injury Guidelines league: Adoption of Brain Injury Guidelines at a Level III trauma center, A pilot study

Introduction

The Brain Injury Guidelines (BIG) direct surgeons to implement risk-stratified treatment plans for patients with traumatic brain injury (TBI). BIG categorize patients into one of three severity categories, from lowest to highest risk (BIG 1, BIG 2, and BIG 3). BIG empowers physicians to implement standardized treatment plans that limit unnecessary hospitalizations, repeat imaging, and neurosurgical consultation. These guidelines have been studied in Level I trauma centers, but their clinical application has never been studied in a Level III trauma center. In this pilot study, we sought to determine if the BIG can be implemented in a regional trauma center where patients with less severe brain injuries are locally evaluated and treated.

Methods

All TBI patients at a Level III trauma center were stratified using the BIG criteria, where BIG 1 and BIG 2 patients were managed locally and BIG 3 patients were transferred to a Level I trauma center. We conducted a retrospective review using the local trauma database and electronic medical records over a 1-year period when BIG were first protocolized. The primary endpoint included deaths, complications, readmissions, and length of stay.

Results

There were 6 (12.2%) BIG 1, 5 (10.2%) BIG 2, and 38 (77.6%) BIG 3 patients evaluated at the Level III trauma center. All BIG 1 and BIG 2 patients remained at the Level III trauma center, and 33 of the 38 BIG 3 patients were transferred. There were no complications, readmissions, or unexpected transfers within the BIG 1 or BIG 2 patient cohorts.

Conclusion

The BIG criteria can be successfully implemented in a Level III trauma center. A collaborative transfer agreement with a Level I trauma center reduces unnecessary transfers without negatively affecting patient care. The BIG criteria should be considered for well-developed regional trauma systems.

Pathway-Based Reduction of Repeat Head Computed Tomography for Patients With Complicated Mild Traumatic Brain Injury: Implementation and Outcomes

BACKGROUND

Routine follow-up head imaging in complicated mild traumatic brain injury (cmTBI) patients has not been shown to alter treatment, improve outcomes, or identify patients in need of neurosurgical intervention. We developed a follow-up head computed tomography (CT) triage algorithm for cmTBI patients to decrease the number of routine follow-up head CT scans obtained in this population.

OBJECTIVE

To report our experience with protocol implications and patient outcome.

METHODS

Data on all cmTBI patients presenting from July 1, 2018 to June 31, 2019, to our level 1, tertiary, academic medical center were collected prospectively and analyzed retrospectively. Descriptive analysis was performed.

RESULTS

Of the 178 patients enrolled, 52 (29%) received a follow-up head CT. A total of 27 patients (15%) were scanned because of initial presentation and triaged to the group to receive a routine follow-up head CT. A total of 151 patients (85%) were triaged to the group without routine follow-up head CT scan. Protocol adherence was 89% with 17 violations.

CONCLUSION

Utilizing this protocol, we were able to safely decrease the use of routine follow-up head CT scans in cmTBI patients by 71% without any missed injuries or delayed surgery. Adoption of the protocol was high among all services managing TBI patients.

Traumatic Epidural and Subdural Hematoma: Epidemiology, Outcome, and Dating

Epidural hematomas (EDHs) and subdural hematomas (SDHs), or so-called extra-axial bleedings, are common clinical entities after a traumatic brain injury (TBI). A forensic pathologist often analyzes cases of traumatic EDHs or SDHs due to road accidents, suicides, homicides, assaults, domestic or on-the-job accidents, and even in a medical responsibility scenario. The aim of this review is to give an overview of the published data in the medical literature, useful to forensic pathologists. We mainly focused on the data from the last 15 years, and considered the most updated protocols and diagnostic-therapeutic tools. This study reviews the epidemiology, outcome, and dating of extra-axial hematomas in the adult population; studies on the controversial interdural hematoma are also included.

Examining the Emergency Medical Treatment and Active Labor Act: impact on telemedicine for neurotrauma

The Emergency Medical Treatment and Active Labor Act (EMTALA) protects patient access to emergency medical treatment regardless of insurance or socioeconomic status. A significant result of the COVID-19 pandemic has been the rapid acceleration in the adoption of telemedicine services across many facets of healthcare. However, very little literature exists regarding the use of telemedicine in the context of EMTALA. This work aimed to evaluate the potential to expand the usage of telemedicine services for neurotrauma to reduce transfer rates, minimize movement of patients across borders, and alleviate the burden on tertiary care hospitals involved in the care of patients with COVID-19 during a global pandemic. In this paper, the authors outline EMTALA provisions, provide examples of EMTALA violations involving neurosurgical care, and propose guidelines for the creation of telemedicine protocols between referring and consulting institutions.

Inter-facility transfer of patients with traumatic intracranial hemorrhage and GCS 14-15: The pilot study of a screening protocol by neurosurgeon to avoid unnecessary transfers

We sought to evaluate feasibility and cost-reduction potential of a pilot screening program involving neurosurgeon tele-consultation for inter-facility transfer decisions in TBI patients with GCS 14–15 and abnormal CT head at a community hospital. The authors performed a retrospective comparative analysis of two patient cohorts during the pilot at a large hospital system from 2015 to 2017. In “screened” patients (n = 85), images and examination were reviewed remotely by a neurosurgeon who made recommendations regarding transfer to a level 1 trauma center. In the “unscreened” group (n = 39), all patients were transferred. Baseline patient characteristics, outcomes, and costs were reviewed. Patient demographics were similar between cohorts. Traumatic subarachnoid hemorrhage was more common in screened patients (29.4% vs 12.8%, P = 0.02). The presence of midline shift >5 mm was comparable between groups. Among screened patients, 5 were transferred (5.8%) and one required evacuation of chronic subdural hematoma. In unscreened patients, 7 required evacuation of subdural hematoma. None of the screened patients who were not transferred deteriorated. Screened patients had significantly reduced average total cost compared to unscreened patients ($2,003 vs. $4,482, P = 0.03) despite similar lengths of stay (2.6 vs. 2.7 days, P = 0.85). In non-surgical patients, costs were less in the screened group ($2,025 vs. $2,939), although statistically insignificant (P = 0.38).

In this pilot study, remote review of images and examination by a neurosurgeon was feasible to avoid unnecessary transfer of patients with traumatic intracranial hemorrhage and GCS 14–15. The true potential in cost-reduction will be realized in system-wide large-scale implementation.

Filled to the brim: The characteristics of over-triage at a level I trauma center

BACKGROUND

Interfacility transfers are necessary and valuable for the trauma system, but despite regional guidelines, many patients are inappropriately transferred. We evaluated over-triage at our Level I center and identified risk factors for over-triage.

METHODS

Retrospective analysis at our Level I urban trauma center assessed patients transferred from regional facilities during 2017. Over-triage was defined as patients discharged <48 h without procedures. Exclusion criteria were leaving against medical advice or no outside records.

RESULTS

Overall, 2352 patients met criteria. Nine hundred thirty (39.5%) with complete hospital records were discharged in <48 h; 498 (53.5%) received no procedural intervention and 909 (97.7%) were ultimately discharged home.

CONCLUSION

Many patients are inappropriately transferred to tertiary care centers without a definitive need for advanced services. Studies are needed to improve triage criteria without increasing under-triage.

The Price of Always Saying Yes: A Cost Analysis of Secondary Overtriage to an Urban Level I Trauma Center

Level I trauma centers serve as a community resource, with most centers using an inclusive transfer policy that may result in overtriage. The financial burden this imparts on an urban trauma system has not been well examined. We sought to examine the incidence of secondary overtriage (SOT) at an urban Level I trauma center. This was a retrospective study from an urban Level I trauma center examining patients admitted as trauma transfers (TT) from 2010 to 2014. SOT was defined as patients not meeting the “Orange Book” transfer criteria and who had a length of stay of <48 hours. Average ED and transport charges were calculated for total transfer charges. A total of 2397 TT were treated. The number of TT increased over the study interval. The mean age of TT was 59.7 years (SD ± 26.4 years); patients were predominantly male (59.2%), white (83.2%), with at least one comorbidity (71.5%). Blunt trauma accounted for 96.8 per cent of admissions with a median Injury Severity Score of nine (IQR: 5–16). Predominant injuries were isolated closed head trauma (61.4%), skin/soft tissue injury (18.9%), and spinal injury (17.6%). SOT was 48.2 per cent and increased yearly (P < 0.001). The median trauma center charge for SOT was ($27,072; IQR: $20,089–34,087), whereas ED charges were ($40,440; IQR: $26,150–65,125), resulting in a total cost of $67,512/patient. A liberal TT policy results in a high SOT rate adding significant unnecessary costs to the health-care system. Efforts to establish transfer guidelines may allow for significant cost savings without compromising care.

Isolated subdural hematomas in mild traumatic brain injury. Part 1: the association between radiographic characteristics and neurosurgical intervention

OBJECTIVE

Isolated subdural hematomas (iSDHs) are one of the most common intracranial hemorrhage (ICH) types in the population with mild traumatic brain injury (mTBI; Glasgow Coma Scale score 13-15), account for 66%-75% of all neurosurgical procedures, and have one of the highest neurosurgical intervention rates. The objective of this study was to examine how quantitative hemorrhage characteristics of iSDHs in patients with mTBI at admission are associated with subsequent neurosurgical intervention.

METHODS

This was a 3.5-year, retrospective observational cohort study at a Level I trauma center. All adult trauma patients with mTBI and iSDHs were included in the study. Maximum length and thickness (in mm) of acute SDHs, the presence of acute-on-chronic SDH, mass effect, and other hemorrhage-related variables were double-data entered; discrepant results were adjudicated after a maximum of 4 reviews. Patients with coagulopathy, skull fractures, no acute hemorrhage, a non-SDH ICH, or who did not undergo imaging on admission were excluded. The primary outcome was neurosurgical intervention (craniotomy, burr hole, catheter drainage of SDH, placement of intracranial pressure monitor, shunt, or ventriculostomy). Multivariate stepwise logistic regression was used to identify significant covariates and to assess interactions.

RESULTS

A total of 176 patients were included in our study: 28 patients did and 148 patients did not receive a neurosurgical intervention. Increasing head Abbreviated Injury Scale score was significantly associated with neurosurgical interventions. There was a strong correlation between the first 3 reviews on maximum hemorrhage length (R2 = 0.82) and maximum hemorrhage thickness (R2 = 0.80). The neurosurgical intervention group had a mean maximum SDH length and thickness that were 61 mm longer and 13 mm thicker than those of the nonneurosurgical intervention group (p < 0.001 for both). After adjusting for the presence of an acute-on-chronic hemorrhage, for every 1-mm increase in the thickness of an iSDH, the odds of a neurosurgical intervention increase by 32% (95% CI 1.16-1.50). There were no interventions for any SDH with a maximum thickness ≤ 5 mm on initial presenting scan.

CONCLUSIONS

This is the first study to quantify the odds of a neurosurgical intervention based on hemorrhage characteristics in patients with an iSDH and mTBI. Once validated in a second population, these data can be used to better inform patients and families of the risk of future neurosurgical intervention, and to evaluate the necessity of interhospital transfers.

The Risk of Deterioration in GCS13-15 Patients with Traumatic Brain Injury Identified by Computed Tomography Imaging: A Systematic Review and Meta-Analysis

The optimal management of mild traumatic brain injury (TBI) patients with injuries identified by computed tomography (CT) brain scan is unclear. Some guidelines recommend hospital admission for an observation period of at least 24 h. Others argue that selected lower-risk patients can be discharged from the Emergency Department (ED). The objective of our review and meta-analysis was to estimate the risk of death, neurosurgical intervention, and clinical deterioration in mild TBI patients with injuries identified by CT brain scan, and assess which patient factors affect the risk of these outcomes. A systematic review and meta-analysis adhering to PRISMA standards of protocol and reporting were conducted. Study selection was performed by two independent reviewers. Meta-analysis using a random effects model was undertaken to estimate pooled risks for: clinical deterioration, neurosurgical intervention, and death. Meta-regression was used to explore between-study variation in outcome estimates using study population characteristics. Forty-nine primary studies and five reviews were identified that met the inclusion criteria. The estimated pooled risk for the outcomes of interest were: clinical deterioration 11.7% (95% confidence interval [CI]: 11.7%-15.8%), neurosurgical intervention 3.5% (95% CI: 2.2%-4.9%), and death 1.4% (95% CI: 0.8%-2.2%). Twenty-one studies presented within-study estimates of the effect of patient factors. Meta-regression of study characteristics and pooling of within-study estimates of risk factor effect found the following factors significantly affected the risk for adverse outcomes: age, initial Glasgow Coma Scale (GCS), type of injury, and anti-coagulation. The generalizability of many studies was limited due to population selection. Mild TBI patients with injuries identified by CT brain scan have a small but clinically important risk for serious adverse outcomes. This review has identified several prognostic factors; research is needed to derive and validate a usable clinical decision rule so that low-risk patients can be safely discharged from the ED.

Influence of severity of traumatic brain injury at hospital admission on clinical outcomes

ABSTRACT Traumatic brain injury (TBI) is a public health problem with high mortality and socioeconomic repercussions. We aimed to investigate the influence of TBI severity on the length of mechanical ventilation (MV) stay and length of hospital stay and on the prevalence of tracheostomy, pneumonia, neurosurgery and death. This retrospective, observational study evaluated medical records of 67 patients with TBI admitted to Irmandade da Santa Casa de Misericórdia de São Paulo. Severity was determined according to the Glasgow Coma Scale (GCS): mild (13-15 points; 36 patients; 53.7%), moderate (9-12 points; 14 patients; 20.9%) or severe (3-8 points; 17 patients; 25.4%). Severe TBI patients had higher prevalence of tracheostomy, pneumonia and neurosurgery. No significant differences were observed between TBI severity, mortality and length of MV stay. However, TBI severity influenced the length of hospital stay. TBI severity at admission, evaluated according to the GCS, influenced the prevalence of tracheostomy, pneumonia, neurosurgery and was associated to prolonged hospital stay.

Epidemiology of Mild Traumatic Brain Injury with Intracranial Hemorrhage: Focusing Predictive Models for Neurosurgical Intervention

OBJECTIVE

To outline differences in neurosurgical intervention (NI) rates between intracranial hemorrhage (ICH) types in mild traumatic brain injuries and help identify which ICH types are most likely to benefit from creation of predictive models for NI.

METHODS

A multicenter retrospective study of adult patients spanning 3 years at 4 U.S. trauma centers was performed. Patients were included if they presented with mild traumatic brain injury (Glasgow Coma Scale score 13-15) with head CT scan positive for ICH. Patients were excluded for skull fractures, "unspecified hemorrhage," or coagulopathy. Primary outcome was NI. Stepwise multivariable logistic regression models were built to analyze the independent association between ICH variables and outcome measures.

RESULTS

The study comprised 1876 patients. NI rate was 6.7%. There was a significant difference in rate of NI by ICH type. Subdural hematomas had the highest rate of NI (15.5%) and accounted for 78% of all NIs. Isolated subarachnoid hemorrhages had the lowest, nonzero, NI rate (0.19%). Logistic regression models identified ICH type as the most influential independent variable when examining NI. A model predicting NI for isolated subarachnoid hemorrhages would require 26,928 patients, but a model predicting NI for isolated subdural hematomas would require only 328 patients.

CONCLUSIONS

This study highlighted disparate NI rates among ICH types in patients with mild traumatic brain injury and identified mild, isolated subdural hematomas as most appropriate for construction of predictive NI models. Increased health care efficiency will be driven by accurate understanding of risk, which can come only from accurate predictive models.

Complicated Mild Traumatic Brain Injury and the Need for Imaging Surveillance

OBJECTIVE

To evaluate the need for repeat head computed tomography (CT) in patients with complicated mild traumatic brain injury (TBI) determined nonoperative after the first head CT.

METHODS

A total of 380 patients with mild TBI and a positive head CT not needing surgery were included. Changes between first and second head CT were categorized as decreased, increased, or stable.

RESULTS

Three patients required neurosurgical intervention (0.8%) after the second CT. There were no significant differences in demographics including age, gender, alcohol consumption, anticoagulation status, time between first and second CT, Glasgow Coma Scale score at admission and discharge, and incidence of subarachnoid hemorrhage, epidural hematoma, contusion, or skull fractures between the operated and nonoperated groups. All patients in the operated group had subdural hematoma compared with 40.8% in the nonoperated group (P = 0.07). All operated patients showed symptoms of neurologic worsening after initial head CT, compared with 2.7% in the nonoperated group (P < 0.001). Moreover, patients who showed neurologic worsening were more likely to show increased intracranial bleeding on repeat head CT, whereas patients who did not show neurologic worsening were more likely to show decreased or stable intracranial bleeding (P = 0.04).

CONCLUSIONS

Routine repeat head CT in patients with complicated mild TBI is very low yield to predict need for delayed surgical intervention. Instead, serial neurologic examination and observation over the first 8 hours after the injury is recommended. A second CT scan should be obtained only in patients who have neurologic worsening.

Glial Fibrillary Acidic Protein and Ubiquitin C-Terminal Hydrolase-L1 Are Not Specific Biomarkers for Mild CT-Negative Traumatic Brain Injury

Glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase-L1 (UCH-L1) have been studied as potential biomarkers of mild traumatic brain injury (mTBI). We report the levels of GFAP and UCH-L1 in patients with acute orthopedic injuries without central nervous system involvement, and relate them to the type of extracranial injury, head magnetic resonance imaging (MRI) findings, and levels of GFAP and UCH-L1 in patients with CT-negative mTBI. Serum UCH-L1 and GFAP were longitudinally measured from 73 patients with acute orthopedic injury on arrival and on days 1, 2, 3, 7 after admission, and on the follow-up visit 3-10 months after the injury. The injury types were recorded, and 71% patients underwent also head MRI. The results were compared with those found in patients with CT-negative mTBI (n = 93). The levels of GFAP were higher in patients with acute orthopedic trauma than in patients with CT-negative mTBI (p = 0.026) on arrival; however, no differences were found on the following days. The levels of UCH-L1 were not significantly different between these two groups at any measured point of time. Levels of GFAP and UCH-L1 were not able to distinguish patients with CT-negative mTBI from patients with orthopedic trauma. Patients with orthopedic trauma and high levels of UCH-L1 or GFAP values may be falsely diagnosed as having a concomitant mTBI, predisposing them to unwarranted diagnostics and unnecessary brain imaging. This casts a significant doubt on the diagnostic value of GFAP and UCH-L1 in cases with mTBI.

Do Age and Anticoagulants Affect the Natural History of Acute Subdural Hematomas?

Acute subdural hematoma is a serious complication following traumatic brain injury. Large volume hematomas or those with underlying brain injury can cause mass effect, midline shift, and eventually herniation of the brain. Acute subdural hematomas in the young are associated with high-energy trauma and often have underlying contusions, while acute subdural hematomas in the elderly are associated with minor trauma and an absence of underlying contusions, even though the elderly are more likely to be on anticoagulants or anti-platelet therapy. In the young patients with high impact injuries the hematomas tend to be small and the underlying brain injury and swelling is responsible for the increased intracranial pressure and midline shift. In the elderly, the injuries are low impact (e.g fall from standing), the underlying brain is intact, and the volume of the hematoma itself produces symptoms. In addition the use of anticoagulants and antiplatelet agents in the elderly population has been thought to be a poor prognostic indicator and is considered to be responsible for larger hematomas and poor outcome. When managed conservatively, acute subdural hematomas can sometimes progress to chronic subdural hematoma formation, further enlargement, seizures, and progressive midline shift. Another potential difference in the young and the elderly is brain atrophy, which increases the potential space to accommodate a larger hematoma. It is not known if these two groups differ in other ways that might have implications for treatment or prognosis. In this paper, we investigate the clinical course of 80 patients admitted to our institution with acute subdural hematomas, to identify differences in patients above or below the age of 65 years. The natural progression/resolution of acute subdural hematomas was mapped by measuring volume expansion/regression over time. In this retrospective chart review, we investigated clinical baseline metrics and subsequent volumetric expansion outcomes between patients < 65 years old (N=44) and those > 65 years old (N=36). Volume was estimated by the ABC/2 method. We observed a statistically significant difference between groups in use of anticoagulants χ² =40.305 with p < 0.001, corrective platelet administration χ² =19.380 with p < 0.001, gender χ² =14.573 with p < 0.001, and Glasgow Coma Scale with χ² =23.125 (p=0.026). Overall outcomes were similar in the two groups. Younger patients on average had worse presenting GCS scores, but recovered comparable to older patients. No significant difference in rate of volume expansion, resolution time, or need for surgical treatment was seen between these two groups. We conclude that the initial volume, size, and severity of subdural hematoma determined by the Glasgow Coma Scale score is more likely to predict surgery or future expansion than age of the patient. Patients on oral anti-coagulants that are given appropriate medical reversal agents early do quite well and no impact on the eventual outcome could be demonstrated. Further work is needed to establish better predictors of future volume expansion, and progression to chronic subdural hematoma based on improved severity scales.

Utility of clinical decision rule for intensive care unit admission in patients with traumatic intracranial hemorrhage

BACKGROUND

Recent literature suggests the majority of traumatic intracranial hemorrhage does not require intervention. One recently described clinical decision rule was sensitive in identifying patients requiring critical care interventions in an urban setting. We sought to validate its effectiveness in our predominately rural setting.

METHODS

A retrospective study was conducted of adult patients with traumatic intracranial hemorrhage. The rule, based on age, initial Glasgow coma scale score, and presence of a non-isolated head injury, was applied to externally validate the previously reported findings.

RESULTS

In our population, the rule displayed a sensitivity of 0.923, specificity of 0.251, positive predictive value of 0.393, and negative predictive value of 0.862. The area under curve was 0.587. While our population has a similar adjusted head injury severity score as that from which the rule was developed, significant differences in age and intracranial hemorrhage pattern were noted.

CONCLUSIONS

The rule displayed decreased performance in our population, most likely secondary to differences in age and intracranial hemorrhage patterns. Prospective evaluation and cost-savings analysis are appropriate subsequent steps for the rule.

The nonsurgical nature of patients with subarachnoid or intraparenchymal hemorrhage associated with mild traumatic brain injury

OBJECT

Mild traumatic brain injury (mTBI), as defined by Glasgow Coma Scale (GCS) score of 13 or higher, is a common problem in the United States and worldwide, estimated to affect more than 1 million patients yearly. When associated with intracranial hemorrhage, it is a common reason for neurosurgical consultation and transfer to tertiary care centers. The authors set out to investigate the clinical implications of subarachnoid hemorrhage (SAH) and/or intraparenchymal hemorrhage (IPH) associated with mTBI in hopes of standardization of mTBI clinical care and optimization of resource allocation.

METHODS

The authors performed a retrospective review of 500 consecutively treated patients with mTBI and SAH and/or IPH admitted to a Level I trauma center in Alabama between May 2003 and May 2013. They performed a review of medical records to confirm the diagnosis, determine neurological condition at admission, and assess for episodes of neurological decline or brain injury–related complications including altered mental status, seizures, and hyponatremia.

RESULTS

Of the 500 patients for whom data were reviewed, 304 (60.8%) were male and 196 (39.2%) were female. Average age was 46.3 years. Overall, 63 patients (12.6%) had isolated IPH, 411 (82.2%) had isolated SAH, and 26 (5.2%) had radiographic evidence of both IPH and SAH. One hundred forty-five patients (29%) were transferred an average distance of 64.5 miles. The authors identified no patients who experienced neurological worsening during their hospital course. Two patients experienced hyponatremia that required treatment with sodium supplementation.

CONCLUSIONS

Patients with the constellation of SAH and/or IPH and mTBI do not require neurosurgical consultation, and these findings should not be used as the sole criteria to justify transfer to tertiary referral centers.

Falcine and Tentorial Subdural Hematomas May Not Routinely Require Transfer to a Tertiary Care Center

BACKGROUND

Patients with subdural hematomas (SDH) are frequently transferred to tertiary care centers. Although many prognostic factors, treatment strategies, and outcomes for convexity SDH have been reported, little is known about falcine and tentorial SDH.

OBJECTIVES

To describe features and outcomes of isolated falcine and tentorial SDH.

METHODS

We reviewed clinical/radiographic findings, treatment, length of stay (LOS), and outcome of adult patients transferred to a tertiary care center for acute SDH. Characteristics of patients with isolated falcine/tentorial SDH and outcomes (favorable [discharge to home/acute rehabilitation] vs. unfavorable [death/hospice/skilled nursing facility/long term care]) were assessed with univariate analyses.

RESULTS

Of 210 patients with SDH, mean age was 69.5 years; 117 were male; 98 (47%) underwent surgical SDH evacuation. Twenty-seven patients had isolated falcine or tentorial SDH, with known traumatic etiology in 23. None of the falcine/tentorial SDH patients required surgery or intubation. Compared with convexity SDH, patients with falcine/tentorial SDH were younger (59.7 vs. 70.9 years, p = 0.01), had higher admission Glasgow Coma Scale scores at the referring (p = 0.01) and receiving facility (p = 0.004), and shorter median intensive care unit LOS (1 vs. 3, p < 0.0001). All patients (100%) with falcine/tentorial SDH had favorable outcome vs. 68% with convexity SDH (p = 0.0005).

CONCLUSION

Isolated tentorial/falcine SDH without associated neurological deficits represent a benign entity among acute SDH, with no need for surgical intervention, short LOS, and favorable outcome. Our data indicate that for these patients, in the absence of complicating factors, transfer to a tertiary care center may not be routinely indicated.

Understanding Why Patients Return to the Emergency Department after Mild Traumatic Brain Injury within 72 Hours

INTRODUCTION

Although there are approximately 1.1 million case presentations of mild traumatic brain injury (mTBI) in the emergency department (ED) each year, little data is available to clinicians to identify patients who are at risk for poor outcomes, including 72-hour ED return after discharge. An understanding of patients at risk for ED return visits during the hyperacute phase following head injury would allow ED providers to develop clinical interventions that reduce its occurrence and improve outcomes.

METHODS

This institutional review board-approved consecutive cohort study collected injury and outcome variables on adults with the purpose of identifying positive predictors for 72-hour ED return visits in mTBI patients.

RESULTS

Of 2,787 mTBI patients, 145 (5%) returned unexpectedly to the ED within 72 hours of hospital discharge. Positive predictors for ED return visits included being male (p=0.0298), being black (p=0.0456), having a lower prehospital Glasgow Coma Score (p=0.0335), suffering the injury due to a motor vehicle collision (p=0.0065), or having a bleed on head computed tomography (CT) (p=0.0334). ED return visits were not significantly associated with age, fracture on head CT, or symptomology following head trauma. Patients with return visits most commonly reported post-concussion syndrome (43.1%), pain (18.7%), and recall for further clinical evaluation (14.6%) as the reason for return. Of the 124 patients who returned to the ED within 72 hours, one out of five were admitted to the hospital for further care, with five requiring intensive care unit stays and four undergoing neurosurgery.

CONCLUSION

Approximately 5% of adult patients who present to the ED for mTBI will return within 72 hours of discharge for further care. Clinicians should identify at-risk individuals during their initial visits and attempt to provide anticipatory guidance when possible.

Necessity of monitoring after negative head CT in acute head injury

OBJECTIVE

The main objective of this study was to evaluate the incidence of delayed complications in acute head injury (HI) patients with an initial normal head computed tomography (CT).

MATERIALS AND METHODS

This retrospective study included 3023 consecutive patients who underwent head CT due to an acute HI at the Emergency Department (ED) of Tampere University Hospital (August 2010-July 2012). Regardless of clinical injury severity, the patients with a normal head CT were selected (n=2444, 80.9%). The medical records of these patients were reviewed to identify the individuals with a serious clinically significant complication related to the primary HI. The time window considered was the following 72h after the primary head CT. A repeated head CT in the hospital ward, death, or return to the ED were indicative of a possible complication.

RESULTS

The majority (n=1811, 74.1%) of the patients with a negative head CT were discharged home and 1.1% (n=27) of these patients returned to ED within 72h post-CT. A repeated head CT was performed on 12 (44.4%) of the returned patients and none of the scans revealed an acute lesion. Of the 632 (25.9%) CT-negative patients admitted to the hospital ward from the ED, a head CT was repeated in 46 (7.3%) patients within 72h as part of routine practice. In the repeated CT sample, only one (0.2%) patient had a traumatic intracranial lesion. This lesion did not need neurosurgical intervention. The overall complication rate was 0.04%.

CONCLUSION

In the present study, which includes head injuries of all severity, the probability of delayed life-threatening complications was negligible when the primary CT scan revealed no acute traumatic lesions.

Mild traumatic brain injury defined by Glasgow Coma Scale: Is it really mild?

INTRODUCTION

Conventionally, a Glasgow Coma Scale (GCS) score of 13-15 defines mild traumatic brain injury (mTBI). The aim of this study was to identify the factors that predict progression on repeat head computed tomography (RHCT) and neurosurgical intervention (NSI) in patients categorized as mild TBI with intracranial injury (intracranial haemorrhage and/or skull fracture).

METHODS

This study performed a retrospective chart review of all patients with traumatic brain injury who presented to a level 1 trauma centre. Patients with blunt TBI, an intracranial injury and admission GCS of 13-15 without anti-platelet and anti-coagulation therapy were included. The outcome measures were: progression on RHCT and need for neurosurgical intervention (craniotomy and/or craniectomy).

RESULTS

A total of 1800 patients were reviewed, of which 876 patients were included. One hundred and fifteen (13.1%) patients had progression on RHCT scan. Progression on RHCT was 8-times more likely in patients with subdural haemorrhage ≥10 mm, 5-times more likely with epidural haemorrhage ≥10 mm and 3-times more likely with base deficit ≥4. Forty-seven patients underwent a neurosurgical intervention. Patients with displaced skull fracture were 10-times more likely and patients with base deficit >4 were 21-times more likely to have a neurosurgical intervention.

CONCLUSION

In patients with intracranial injury, a mild GCS score (GCS 13-15) in patients with an intracranial injury does not preclude progression on repeat head CT and the need for a neurosurgical intervention. Base deficit greater than four and displaced skull fracture are the greatest predictors for neurosurgical intervention in patients with mild TBI and an intracranial injury.

The Effectiveness Evaluation of Helicopter Ambulance Transport among Neurotrauma Patients in Korea

Objective

Helicopter ambulance transport (HAT) is a highly resource-intensive facility that is a well-established part of the trauma transport system in many developed countries. Here, we review the benefit of HAT for neurosurgical patients in Korea.

Methods

This retrospective study followed neurotrauma patients who were transferred by HAT to a single emergency trauma center over a period of 2 years. The clinical benefits of HAT were measured according to the necessity of emergency surgical intervention and the differences in the time taken to transport patients by ground ambulance transport (GAT) and HAT.

Results

Ninety-nine patients were transferred to a single university hospital using HAT, of whom 32 were taken to the neurosurgery department. Of these 32 patients, 10 (31.3%) needed neurosurgical intervention, 14 (43.8%) needed non-neurosurgical intervention, 3 (9.4%) required both, and 11 (34.4%) did not require any intervention. The transfer time was faster using HAT than the estimated time needed for GAT, although for a relatively close distance (<50 km) without ground obstacles (mountain or sea) HAT did not improve transfer time. The cost comparison showed that HAT was more expensive than GAT (3,292,000 vs. 84,000 KRW, p<0.001).

Conclusion

In this Korean-based study, we found that HAT has a clinical benefit for neurotrauma cases involving a transfer from a distant site or an isolated area. A more precise triage for using HAT should be considered to prevent overuse of this expensive transport method.

Delayed neurological deterioration after mild head injury: cause, temporal course, and outcomes

BACKGROUND

Mild head injury (MHI) complicated by an intracranial hemorrhage (ICH) is a common cause of hospital admission after head trauma. Most patients are treated nonoperatively, remain neurologically stable, and are discharged uneventfully. However, a small percentage of patients suffer delayed neurological deterioration (DND). Little is known about the characteristics of DND after an MHI complicated by ICH.

OBJECTIVE

To identify the cause, temporal course, and outcomes of patients who deteriorated neurologically after presenting with MHI and ICH.

METHODS

A retrospective review was performed of all adult patients presenting over 54 consecutive months with MHI and ICH. Patients who were treated nonoperatively after initial head computed tomography and had a subsequent DND (Glasgow Coma Scale score decrease ≥2) were identified. Demographics, neurological status, clinical course, radiographic findings, and outcome data were collected.

RESULTS

Over 54 months, 757 patients with MHI plus ICH were admitted for observation; of these, 31 (4.1%) experienced DND. Eighty-seven percent of patients deteriorated within 24 hours after admission. Twenty-one patients (68%) deteriorated as a result of progressive intracranial hemorrhage, and 10 patients (32%) deteriorated as a result of medical causes. Seven patients (23%) died. Variables significantly associated with mortality included age > 60 years, coagulopathy, and change in Marshall computed tomography classification.

CONCLUSION

The incidence of delayed neurological deterioration after MHI with ICH is low and usually occurs within 24 hours after admission. It results in significant morbidity and mortality if it is the result of progressive intracranial hemorrhage. Further research is needed to identify risk factors that can allow early detection and improve outcomes in these patients.

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.

Factors predicting early deterioration in mild brain trauma: a prospective study

PRIMARY OBJECTIVE

To evaluate risk factors for clinical deterioration in mild traumatic brain injury.

RESEARCH DESIGN

Prospective cross-sectional.

METHODS AND PROCEDURES

This study evaluated 203 patients with mild traumatic brain injury. A brain computed tomography scan was performed in all patients and they were observed for 6-48 hours.

MAIN OUTCOMES AND RESULTS

Among these patients, 2.5% had cerebral contusions and the most common sites for contusions were frontal lobes; 94% of patients had no hematoma in the initial scan, while 3% had subgaleal haematoma, 1.5% had subdural haematoma, 1% showed subarachnoid haemorrhage, 0.5% intracerebral haemorrhage and 0.5% epidural haemorrhage. GCS was 15 in 96.6% and 13-14 in 3.4%. GCS deteriorated in three (1.5%). Presence of coagulopathy, anticoagulant drug use, GCS of 13-14 and increased age predicted further deterioration. Among CT findings, those with midline shift, cerebral contusion and diffuse cerebral oedema deteriorated more. Among different haematoma types, only SDH predicted a worse outcome.

CONCLUSIONS

Although deterioration rarely occurs in patients with mild brain injury, those with coagulopathy, anticoagulant drug use, GCS of 13-14, increased age, midline shift, cerebral contusions, diffuse cerebral oedema and SDH were more prone to deterioration.

Acute evaluation of pediatric patients with minor traumatic brain injury

PURPOSE OF REVIEW

This review focuses on minor traumatic brain injury (TBI), evaluates the most recent literature regarding clinical prediction rules for the use of cranial computed tomography (CT) in children presenting with minor TBI, reviews the evidence on the need for hospitalization in children with minor TBI, and evaluates the role of S100B testing.

RECENT FINDINGS

The majority of children presenting to an emergency department (ED) after TBI have a Glasgow Coma Scale (GCS) of 14-15, and the rate of clinically significant intracranial injury is exceedingly rare. Nevertheless, the number of cranial CTs performed in the US has increased dramatically over the past two decades. Several clinical prediction rules have been developed to aid the clinician in identifying children with low-risk TBI, but only the Pediatric Emergency Care Applied Research Network (PECARN) rules have been sufficiently validated to warrant clinical application. Two recent studies provide evidence that children with low-risk TBI can be safely discharged from the ED and do not require prolonged hospitalization for neurologic observation. Lastly, studies evaluating the diagnostic utility of S100B in patients with TBI have shown that it may be a useful adjunct to the clinical evaluation and aid in minimizing neuroimaging.

SUMMARY

Clinical prediction rules, most notably the PECARN rules, can be applied to determine children with low-risk TBI and help decrease unnecessary CT use and hospitalizations. S100B testing requires further investigation, but may serve as an adjunct in determining children with low-risk TBI.

Interfacility helicopter ambulance transport of neurosurgical patients: observations, utilization, and outcomes from a quaternary level care hospital

Background

The clinical benefit of helicopter transport over ground transportation for interfacility transport is unproven. We sought to determine actual practice patterns, utilization, and outcomes of patients undergoing interfacility transport for neurosurgical conditions.

Methodology/Principal Findings

We retrospectively examined all interfacility helicopter transfers to a single trauma center during 2008. We restricted our analysis to those transfers leading either to admission to the neurosurgical service or to formal consultation upon arrival. Major exclusion criteria included transport from the scene, death during transport, and transport to any area of the hospital other than the emergency department. The primary outcome was time interval to invasive intervention. Secondary outcomes were estimated ground transportation times from the referring hospital, admitting disposition, and discharge disposition. Of 526 candidate interfacility helicopter transfers to our emergency department in 2008, we identified 167 meeting study criteria. Seventy-five (45%) of these patients underwent neurosurgical intervention. The median time to neurosurgical intervention ranged from 1.0 to 117.8 hours, varying depending on the diagnosis. For 101 (60%) of the patients, estimated driving time from the referring institution was less than one hour. Four patients (2%) expired in the emergency department, and 34 patients (20%) were admitted to a non-ICU setting. Six patients were discharged home within 24 hours. For those admitted, in-hospital mortality was 28%.

Conclusions/Significance

Many patients undergoing interfacility transfer for neurosurgical evaluation are inappropriately triaged to helicopter transport, as evidenced by actual times to intervention at the accepting institution and estimated ground transportation times from the referring institution. In a time when there is growing interest in health care cost containment, practitioners must exercise discretion in the selection of patients for air ambulance transport—particularly when it may not bear influence on clinical outcome. Neurosurgical evaluation via telemedicine may be one strategy for improving air transport triage.

Web-based morbidity and mortality conferencing: a model for rural medical education

Transfer of patients from rural emergency departments to tertiary centers can improve outcomes. The transfer process is complex and often ad hoc, inefficient, duplicative, and frustrating to both patients and providers. Suboptimal transfer undermines quality of care, raises costs, and delays services. Unfortunately, the same barriers that make transfer necessary (limited resources, geographic isolation) also hamper effective review. In this article, we describe a Web-based, interactive morbidity and mortality conference series in which providers reviewed cases transferred from rural emergency departments to a tertiary center. Six case-review conferences were conducted over 8 months. Each involved an average of 20 providers representing a total of 7 hospitals. Learning resources (ie, care protocols, best practice reviews, literature reviews) were developed collaboratively and disseminated among participating hospitals following the case-review conferences. Participant responses were highly favorable: 100% found the case reviews "very useful" or "useful" and 100% strongly agreed that the reviews would improve quality of patient care. We conclude that Web-based technology can efficiently facilitate review of transfers and has the potential to positively impact patient care. Future studies should utilize standard validated survey instruments of a larger number of participants to better understand the impact of this intervention.