What a headache! Reviewing mild traumatic brain injury management in a new trauma service

Mild traumatic brain injury (mild TBI) is a common, poorly managed condition with an underestimated impact and inadequate follow-up. This study aimed to assess local practice in terms of assessment and follow-up.

A retrospective review of all patients presenting to Christchurch Hospital between 1 August 2019 and 30 September 2019 with ICD-10 coded diagnosis of head trauma was conducted. Patients younger than 16 or older than 80 years who had a concurrent medical illness or who did not meet diagnostic criteria for mild TBI were excluded. This was to minimise diagnostic uncertainty where patients may have had mild TBI like symptoms due to alternate pathology. Primary outcomes included documentation of post-traumatic amnesia (PTA) with the Abbreviated Westmead Post-Traumatic Amnesia Scale (A-WPTAS), provision of mild TBI information, the proportion referred for follow-up and the proportion followed up at the mild TBI clinic. Demographic data included age, sex, ethnicity, mechanism of injury, admission service and rate of admission.

A total of 525 patients were identified, with 239 patients included. Median age was 29 years (IQR 22-50) and 65.3% (n=156) were male. The most common mechanisms of injury were falls (25.5%, n=61) and assault (25.5%, n=61). The most-commonly recorded diagnosis was head injury (41.4%, n=99), followed by concussion (34.3%, n=82). A-WPTAS was documented for 4.2% of patients (n=10). The provision of written mild TBI advice to patients was documented in 61.5% of cases (n=147). On discharge, no follow-up was documented for 63.6% of patients (n=152). In those with documented follow-up, 23.4% (n=56) was with a general practitioner (GP) and 5.4% (n=13) were referred to mild TBI clinic. Review of Accident Corporation Commission (ACC) records identified claims for 80.3% (n=192) of the cohort. Of these, 11.5% (n=22) received a payment for mild TBI services and 2.1% (n=4) had their service provided by Christchurch Hospital.

The results suggest that current management of mild TBI at Christchurch Hospital needs improvement. Accurate diagnostic coding allows patients to access ACC-funded clinics. The utilisation rates of these clinics confirm that the frequency of specialist follow-up is low, which is in keeping with the international literature. Furthermore, given the strongly predictive nature of post-traumatic amnesia for outcomes, the low rate of A-WPTAS assessment is concerning. These results suggest that a mild TBI protocol is needed to standardise assessment, management and follow-up.