Impact of a High Observation Trauma Protocol on Patients with Isolated Traumatic Brain Injury

Area of Science:

• Trauma Surgery
• Neurosurgery
• Geriatric Medicine

Background:

• Geriatric falls resulting in intracranial hemorrhage are increasing nationally.
• A High Observation Trauma (HOT) protocol was implemented for patients with mild intracranial hemorrhage (Glasgow Coma Scale ≥ 14) without midline shift or intraventricular hemorrhage.
• The protocol evolved to include patients on various anticoagulants (HOT I: none, HOT II: antiplatelets/warfarin, HOT III: direct oral anticoagulants).

Purpose of the Study:

• To evaluate the safety and efficacy of the HOT protocol in managing geriatric patients with intracranial hemorrhage.
• To determine if the HOT protocol can reduce intensive care unit (ICU) utilization and associated costs.
• To assess the impact of expanding the HOT protocol to include patients on different types of anticoagulants.

Main Methods:

• A retrospective analysis of the institutional trauma registry was conducted for patients admitted under the HOT protocol.
• Patients were stratified into three groups based on admission date, corresponding to the protocol's evolution (HOT I, II, and III).
• Demographics, anticoagulant use, injury characteristics, length of stay, neurointervention rates, and mortality were compared across the groups.

Main Results:

• The percentage of patients admitted to the floor under the HOT protocol increased significantly over time (35% in HOT I to 81% in HOT III).
• Rates of neurointervention remained consistently low across all HOT protocol groups (3.0% in HOT I, 0.5% in HOT II, 0.4% in HOT III).
• Mortality rates were comparable across the groups (0.6% in HOT I, 0.9% in HOT II, 0.2% in HOT III), with no statistically significant difference (p = 0.33).

Conclusions:

• The HOT protocol effectively identifies appropriate candidates for stepdown unit admission, reducing ICU utilization.
• Expanding the HOT protocol to include patients on anticoagulants was safe and did not lead to an increase in adverse neurosurgical outcomes.
• The HOT protocol demonstrates efficacy in managing select geriatric intracranial hemorrhage patients, potentially leading to cost savings.