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Decision Support Tool to Judiciously Assign High-Frequency Neurologic Examinations in Traumatic Brain Injury.
Peter Bryant1, Aaron Yengo-Kahn2, Candice Smith1
1Division of Trauma And Surgical Critical Care, Vanderbilt University Medical Center Nashville, Tennessee.
The Journal of Surgical Research
|September 12, 2022
Summary
Hourly neurologic examinations for traumatic brain injury (TBI) are often overassigned. A new algorithm can reduce these examinations by over 6,000 without compromising patient safety, optimizing TBI management.
Area of Science:
- Neurosurgery
- Neurology
- Critical Care Medicine
Background:
- Management of traumatic brain injury (TBI) relies on serial neurologic examinations to detect changes requiring neurosurgical intervention.
- Current practice often involves hourly examinations, raising questions about their necessity and potential overuse.
Purpose of the Study:
- To develop and validate a decision tree algorithm for judiciously assigning hourly neurologic examinations in TBI patients.
- To reduce the burden of frequent examinations without compromising patient safety.
Main Methods:
- Retrospective cohort study of 830 TBI patients admitted to a Level 1 trauma center.
- Exclusion of patients with penetrating TBI, immediate/planned interventions, or nonsurvivable injuries.
- Chi-square automatic interaction detection (CHAID) used to identify risk factors for unplanned procedures.
Main Results:
- A total of 287 patients (35%) received hourly examinations; 17 (2%) had unplanned procedures, mostly on hourly exams.
- Factors predicting unplanned procedures included mixed intracranial hemorrhage, midline shift, poor initial neurologic exam (GCS ≤8), and intubation.
- The decision tree algorithm showed excellent discrimination (AUC=0.915) for identifying patients at risk of unplanned procedures.
Conclusions:
- A 4-factor algorithm can optimize the assignment of neuro examinations.
- Implementing this algorithm can substantially reduce the frequency of neuro examinations.
- The proposed approach aims to reduce examination burden while maintaining patient safety in TBI management.
