Variability of ICU Use in Adult Patients With Minor Traumatic Intracranial Hemorrhage - 24/04/13

Doi : 10.1016/j.annemergmed.2012.08.024

Daniel K. Nishijima, MD, MAS ^a,^⁎ , Jason S. Haukoos, MD, MSc ^c, Craig D. Newgard, MD, MPH ^d, Kristan Staudenmayer, MD ^e, Nathan White, MD ^f, David Slattery, MD ^g, Preston C. Maxim, MD ^h, Christopher A. Gee, MD, MPH ⁱ, Renee Y. Hsia, MD, MSc ^h, Joy A. Melnikow, MD, MPH ^b, James F. Holmes, MD, MPH ^a
^a Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, CA
^b Department of Family and Community Medicine, UC Davis School of Medicine, Sacramento, CA
^c Department of Emergency Medicine, Denver Health Medical Center, Denver, CO
^d Department of Emergency Medicine, Oregon Health and Science University, Portland, OR
^e Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
^f Division of Emergency Medicine, University of Washington School of Medicine, Seattle, WA
^g Department of Emergency Medicine, University of Nevada School of Medicine, Las Vegas, NV
^h Department of Emergency Medicine, UCSF School of Medicine, San Francisco, CA
ⁱ Division of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT

Address for correspondence: Daniel K. Nishijima, MD, MAS

Résumé

Study objective

Patients with minor traumatic intracranial hemorrhage are frequently admitted to the ICU, although many never require critical care interventions. To describe ICU resource use in minor traumatic intracranial hemorrhage, we assess (1) the variability of ICU use in a cohort of patients with minor traumatic intracranial hemorrhage across multiple trauma centers, and (2) the proportion of adult patients with traumatic intracranial hemorrhage who are admitted to the ICU and never receive a critical care intervention during hospitalization. In addition, we evaluate the association between ICU admission and key independent variables.

Methods

A structured, historical cohort study of adult patients (aged 18 years and older) with minor traumatic intracranial hemorrhage was conducted within a consortium of 8 Level I trauma centers in the western United States from January 2005 to June 2010. The study population included patients with minor traumatic intracranial hemorrhage, defined as an emergency department (ED) Glasgow Coma Scale (GCS) score of 15 (normal mental status) and an Injury Severity Score less than 16 (no other major organ injury). The primary outcome measure was initial ICU admission. The secondary outcome measure was a critical care intervention during hospitalization. Critical care interventions included mechanical ventilation, neurosurgical intervention, transfusion of blood products, vasopressor or inotrope administration, and invasive hemodynamic monitoring. ED disposition and the proportion of ICU patients not receiving a critical care intervention were compared across sites with descriptive statistics. The association between ICU admission and predetermined independent variables was analyzed with multivariable regression.

Results

Among 11,240 adult patients with traumatic intracranial hemorrhage, 1,412 (13%) had minor traumatic intracranial hemorrhage and complete ED disposition data (mean age 48 years; SD 20 years). ICU use within this cohort across sites ranged from 50% to 97%. Overall, 847 of 888 patients (95%) with minor traumatic intracranial hemorrhage who were admitted to the ICU did not receive a critical care intervention during hospitalization (range between sites 80% to 100%). Three of 524 (0.6%) patients discharged home or admitted to the observation unit or ward received a critical care intervention. After controlling for severity of injury (age, blood pressure, and Injury Severity Score), study site was independently associated with ICU admission (odds ratios ranged from 1.5 to 30; overall effect P<.001).

Conclusion

Across a consortium of trauma centers in the western United States, there was wide variability in ICU use within a cohort of patients with minor traumatic intracranial hemorrhage. Moreover, a large proportion of patients admitted to the ICU never required a critical care intervention, indicating the potential to improve use of critical care resources in patients with minor traumatic intracranial hemorrhage.

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Plan

Introduction

Background

Importance

Goals of This Investigation

Materials and Methods

Study Design and Setting

Selection of Participants

Data Collection and Processing

Outcome Measures

Primary Data Analysis

Results

Characteristics of Study Subjects

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	Please see page 510 for the Editor's Capsule Summary of this article.
	Supervising editor: Robert D. Welch, MD, MS.
	Author contributions: DKN and JFH conceived the study, obtained research funding, and analyzed the data. All authors contributed to the design of the study. DKN, JSH, CDN, KS, DS, and CAG conducted data collection and supervised conduct of the study. DN drafted the article, and all authors contributed to its revision. DKN takes responsibility for the paper as a whole.
	Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. This project was supported by the UC Davis Clinical and Translational Science Center (grant UL1 RR024146), Colorado Clinical and Translational Science Institute (grant UL1 RR025780), Oregon Clinical and Translational Research Institute (grant UL1 RR024140), Stanford Center for Clinical and Translational Education and Research (grant 1UL1 RR025744), Institute of Translational Health Sciences at the University of Washington (grant UL1 RR025014), University of Utah Center for Clinical and Translational Science (grants UL1-RR025764 and C06-RR11234), UCSF Clinical and Translational Science Institute (grant UL1 RR024131), and the Robert Wood Johnson Foundation (RWJF) Physician Faculty Scholars Program. All Clinical and Translational Science Awards are from the National Center for Research Resources (now National Center for Advancing Translational Sciences [NCATS]), a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research. The NIH and the RWJF had no role in the design and conduct of the study, in the analysis or interpretation of the data, or in the preparation of the data. Dr. Nishijima had full access to all the data and had final responsibility for the decision to submit for publication. The views expressed in this article are solely the responsibility of the authors and do not necessarily represent the official view of NCATS or NIH. Information on NCATS is available at www.ncats.nih.gov. Information on Re-engineering the Clinical Research Enterprise can be obtained from overview-translational.asp.
	Publication date: Available online September 27, 2012.