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Mild head injury: epidemiology, management, outcome, costs.

1. Introduction

A mild traumatic brain injury is defined as a maximum 20 minutes consciousness loss or as a short period of retrograde amnesia, GCS (Glasgow Coma Scale) score of 13-15, without focal neurological deficits, without seizures and with normal head CT scan. Mild traumatic brain injuries represent 80% of the total traumatic brain injuries. Their management is conducted according to EBIC or WFNS regulations, between which there are minor approach differences. Through their multitude, mild traumatic brain injuries consume an important part of the budget allocated to ED or neurosurgical departments from the emergency hospitals. Romania's GDP percentage increase allocated to the health departments is not reflected in increased care quality as sources of public money waste can be identified.

Our aim is to identify such a waste in the management of patients with mild traumatic brain injuries, analyzing the need and effectiveness of the head CT scan in the ER and in the neurosurgery ward, relevant lesions and the management of patients with traumatic brain injuries.

2. Material and Methods

We identified patients with mild traumatic brain injuries between April and June of 2013, taking into consideration some epidemiological data (age, sex, living environment--urban/rural), causes and investigation methods in the ED (head CT scan, skull X-ray). For patients hospitalized in the neurosurgical departments we noted: risk factors, reasons of hospitalization, signs of neurological worsening, necessity of paraclinical investigations, treatment and outcome. We calculated the returns of randomly chosen patients with mild traumatic brain injuries, the average cost of their hospitalization, and reported the cost of CT scans with the average hospitalization costs of patients with mild traumatic brain injuries.

3. Results

During the three months period of study, 533 patients presented at the ED with mild traumatic brain injuries. Two thirds were men and one third were women; 72.8% were from an urban environment and 27.2% were from a rural environment. Middle aged patients were twice as many as elderly ones (patients over 65 years). These represent a third of the total of patients admitted with mild traumatic brain injuries. Causes of traumatic brain injuries are presented in Table 1; the top three causes are aggressions (57.03%), followed by car accidents (27.01%) and same level falls (6.38%).

Patient's investigations in the ED were carried out by skull X-rays and CT scans in approximately equal proportions, with a slightly higher incidence of CT scans. These investigations pointed out extracranial, facial and intracranial lesions (Table 1). Following the paraclinical investigations we established that 12 patients had intracranial lesions, 5 of which were hemorrhagic brain contusions, 3 small subdural blood collections, 2 cases of traumatic subarachnoid hemorrhages, 1 acute subdural hematoma and 1 intraventricular hemorrhage.

Among the 533 patients who presented at the ED, 198 were admitted in the neurosurgical department, out of which 195 (98.48%) performed head CT scan in the ED and 3 had skull X-rays. 252 patients were sent home and 83 refused admission. Out of the 252 patients who were sent home, 82 (32.54%) had normal head CT scans and the rest presented with normal skull X-rays. Out of the 83 patients who refused admission, 2 (2.4%) presented diffuse cerebral edema on the CT scans and the rest had normal skull X-rays.

Admission was motivated by the presence of the risk factors, clinical symptoms (Marshall type II lesion), as well as the presence of traumatic intracranial lesions revealed by the head CT scan (Table 2). The characteristics of admitted patients are presented in Table 2.

Out of the admitted patients, 194 presented with GCS score of 15 points, 3 with GCS score of 14 points and one patient with GCS score of 13 points. The GCS score of patients who presented at the ED and of admitted patients is presented in table 3. All patients with GCS score of 14 and 13 points were investigated by head CT scan. They were admitted and the CT scan was repeated on the neurosurgical department.

Among the patients with GCS score of 15 points at admission, 275 (51.98%) out of 529 were investigated by head CT scan. 191 patients (69.45%) were admitted with CT scan and 3 with skull X-rays. Out of the 279 patients who were investigated by head CT scan in the ED, 195 (69.89%) were admitted and one patient (0.51%) was operated on for an acute subdural hematoma.

In the neurosurgical department, 3 patients (1.51%) presented neurological deterioration, one of each group of patients with GCS score of 15, 14 and 13 points. One patient was operated on for an acute subdural hematoma. The rest of the patients with intracranial lesions were clinically monitored and also, the head CT scan was repeated when needed, the patients being discharged in an improved condition.

We randomly chose 10 patients, we calculated their financial deductions and we found an average cost per patient of 1536 RON (343 EUR). The costs of the CT scan investigation depending on the positive or negative data which it provides are presented in Table 5.

Medical services reimbursed by the National Health Insurance to the hospital amounted to 1600 RON (357 EUR) per weighted case. The percentage of the CT scan examination is 15.63% out of the discounted services. The cost of a skull X-ray is 30 RON (6.60EUR), which is 1.87% of the discounted services.

4. Discussions

Over 10 million traumatic brain injuries are produced annually worldwide (1). Following the statement of Hippocrates, no trauma "is too trivial to ignore." The patients with mild traumatic brain injuries, who are the majority, represent 80% of the admitted patients with traumatic brain injuries (2). Both EBIC and WFNS developed classifications of traumatic brain injury, as well as recommendations for management (Table 6 and 7).

Epidemiological data of our study is consistent with the literature. Mild traumatic brain injuries prevail among male patients. Since we only refer to mild traumatic brain injuries, their main cause is represented by aggressions (57%), followed by car accidents (27%). In other studies, car accidents represent the main cause both regarding the mild traumatic brain injuries as well as brain traumas overall (3, 4, 5). Figures show a tendency to aggression among our poor educated population. Older patients represent almost a third of the patients with mild traumatic brain injuries. These patients with multiple comorbidities requiring investigations and prolonged hospital admission are resource consumers.

Since the communist period it has been stated that health is the most valuable asset of the society. At a declarative level, the statement remains true, healthy people representing the engine of a society. However, the Romanian health system remained underfunded through the post communist period. According to the study led by Expert Forum together with the Local American Working Group, health financing in Romania is at two thirds of the minimum required. Romania allocates 4% of GDP (Gross Domestic Product) to the health system, percentage below the EU average of 8.6% or 15% of the USA in 2003 and 18% in 2013 (National Health Expenditure Projection).

The historical analysis of the record of budget allocated to the health system in Romania was in 2000 one billion euros and reached in 2012 5.46 billion euros, without an improvement of health services in terms of quality. Complete health services have at least two stages: diagnosis and treatment. In order to have high quality health services, rational use of resources is required in order to support not only the diagnostic stage, but the therapeutic stage of the medical act as well. In order to optimize diagnostic and therapeutic decisions, regarding the financially limited resources, medical guidelines of developed countries should be adapted to the possibilities in Romania and establish a demarcation between what we can afford at every stage of the medical act and what represents a luxury.

In many hospitals in Romania top paraclinical services have been externalized. They provide high quality health services whose costs are supported by the health insurance companies which these imaging services have contracts with. Physicians are encouraged to use these services, both regarding the benefit of the patient, who is diagnosed accurately and quickly, as well as the financial personal gain and the fear of malpractice mistakes. Performances in diagnostic which are not supported by performances in the therapeutic stage lead to maintaining the medical act at a unsatisfactory level. CT scan represents a fast, noninvasive method, available in all county and municipal hospital units.

Our survey data on patients with craniocerebral traumas reveal that CT scan examination was widely used in the ED, on 52% of the patients who were examined. 48% of the patients were examined using the skull X-ray. Skull lesions were identified among 5 patients (0.94%) and intracranial lesions were identified among 12 patients (2.25%).

CT scan examination identified 5 cases of hemorrhagic brain contusions, 2 cases of traumatic subarachnoid hemorrhages, 3 cases of small subdural blood collections and one case of acute subdural hematoma which was operated. One patient with trombocytopenia, diabetes and chronic renal failure presented intraventricular hemorrhage. This patient, aged 90 years old, with GCS 13 points at admission died after 9 days.

Except for 3 patients, all the other patients who were hospitalized benefited from CT scan examination in the ED. Out of the 533 patients who presented at the ED, 279 benefited from CT scan examination, but only 195 were hospitalized. 84 patients were not admitted. Out of these patients, 82 presented a normal cerebral CT scan and were sent home and 2 refused admission even though the CT scan showed diffuse cerebral edema. The remaining 81 patients who refused admission were investigated by skull X-ray. Among the patients who presented at the ED and were investigated by CT scan, 275 presented with GCS score of 15 points. According to the WFNS classification, 118 patients (42.9%) presented medium risk and 157 (57.1%) presented high risk of neurological deterioration.

Although the WFNS classification regarding patients with mild traumatic brain injuries provides their investigation via CT scan or skull X-ray and hospitalization for 3-6 hours or 24 hours if those are negative, the patients included in this study were investigated using the CT scan in 52.34% of the cases and the admitted ones were hospitalized for a longer period, of 3 days. Considering the same group of patients, the EBIC classification recommends CT scan examination during the first 6 hours and 24 hours hospitalization.

Regarding these classifications which are not a hundred percent concordant, having different recommendations for management, ED doctors and neurosurgeons chose overinvestigation and longer hospitalization period in order to avoid accusations of malpractice. This was achieved by increasing the costs of medical services. Among the admitted patients, 3 presented neurological deterioration from the moment of admission, one case out of each group of patients with GCS score of 15, 14 and 13 points. They represent 1.51% of the total number of admissions.

Our study provides contradicting evidence. On one hand, even patients with mild traumatic brain injuries may have intracranial lesions, supporting the need for paraclinical investigations via CT scan and hospital admission. On the other hand, the number of patients with neurological deterioration who require surgery is small.

Regarding the patients with medium risk based on WFNS classification, it is preferred a consuming fund exploration and a longer period of hospital observation. The media attack on the health system determines the doctors to inefficiently spend public money and, regarding the alternative--skull X-ray and 24 hours hospitalization--they prefer examination via CT scan and 48 hours hospitalization.

Regarding the small number of patients with mild traumatic brain injuries with a positive head CT scan, the National Institute of Clinical Excellence of England and Wales (NICE) established in 2009 the following criteria for requesting a CT scan examination for this group of patients: GCS score < 13 points at any moment after the trauma, GCS score > 13-14 points 2 hours after the trauma, suspecting open or clogged skull fracture, signs of skull base fracture, at least one vomiting episode, retrograde amnesia > 30 minutes; regarding the patients with loss of consciousness or posttraumatic amnesia, the CT scan will be done immediately even if the patient: is aged [greater than or equal to] 65 years, presents coagulopathy or presents dangerous lesion mechanism (car accident, more than 1 meter fall).

Miller and Jeret stated that CT scan examination in case of mild traumatic brain injuries is indicated in patients with GCS score < 15 points, when there are skull fractures, clinical signs for skull base fracture, seizures, focal neurological signs or persistent headache (6, 7). In the USA, annually, 800000 patients with mild traumatic brain injuries are examined in various medical facilities and 1200000 are examined in the ED.

In the ED, the evaluation of patients with concussions is often done through the CT scan. Currently in the USA there is a consensus to reserve head CT scan and MRI when there are suspicions of intracerebral structural lesions: prolonged loss of consciousness (> 1 minute), focal neurological deficit, worsening of clinical symptoms. Unlike the USA, in Romania, all patients with mild traumatic brain injuries are examined in the ED and, even though the vast majority presents with GCS score of 15 points, 52% of them were investigated using the CT scan.

In Moore's study only 1% of patients with mild traumatic brain injury underwent surgical intervention (8). We only operated on one patient with acute subdural hematoma out of the 195 patients hospitalized with CT scan performed in the ED (0.51%).

Because of patients' high expectations of having top imagistic procedures, of financial incentives for doctors (in case the CT scan was requested) and of practicing a defensive medicine style, this imagistic method is highly used. However, some consider that 20-50% of top imagistic procedures are not necessary and don't bring useful clinical information (9). Information received from the patient's history and from the neurological examination is neglected and there is a high emphasis on head CT scan examination.

From the expense account examination of patients' hospitalized with mild traumatic brain injuries we found an average cost per patient of 1536 RON. The cost of a head CT scan is 250 RON (56E), which represent approximately 16% of the average cost per patient. Through the CT scan examination intracranial lesions were revealed in 12 patients. The other 183 patients had negative examinations with a total cost of approximately 10248E. To these 183 patients with a total cost of 10248E we can add the 82 patients examined with the CT scan in the ER and sent home. At a cost of 56E/CT scan, the total value would reach 14840E. Could the approximately 15000E be saved by not performing the CT scan examinations on patients? Giving up this cost must be weighed against potential litigation in case of undocumented aggravation. A solution to this problem is performing a serious neurological exam, following the clinical evolution of patients and soliciting a CT scan in case promising information for the management of the patient with mild traumatic brain injury is needed. Amongst these, in our study the majority had GCS=15 points. Recommendations for a head CT scan must be based on clinical evidence obtained through a strict clinical examination which has to be a priority over the imagistic investigation.

Imagistic studies performed in the absence of neurological changes are improbable in bringing positive data (10). The 15000E waste doesn't seem too important for the health systems in developed countries where the cost of the CT exam is high, in the USA $1000. Reported to the 375E which the hospital receives from CNAS per person, it is significant and could be invested not in imagistic investigations in the vast majority and with high probability of negative results, but in the second part of the medical act, the therapeutic one, whose quality can be increased.

Because the health system is confronting with budgetary restrictions, a rational and efficient use of resources with an aim to sustain not only the diagnostic stage but the therapeutic one is needed. Minimizing resources on investigation and treatment of patients with mild traumatic brain injuries can be performed thorough methods of preventing the occurrence of traumatic brain injuries by reducing aggressions and car accidents and also by reducing the prevalence of risk factors.

5. Conclusions

Mild traumatic brain injuries affect people of all ages and, among the traumatic brain injuries in general, they are the most frequent. Their management is conducted according to the recommendations of EBIC or WFNS, among which there are certain differences. The paraclinical investigations, skull X-ray and head CT scan, are used in similar proportions. The imagistic investigations, which are used in an increasingly large percentage because of the fear of malpractice, detect cerebral lesions in a small number of cases. A through neurological monitoring can avoid expensive imagistic over investigation.

Abbreviations

ED = Emergency Department

EBIC = European Brain Injury Consortium

WFNS = World Federation of Neurosurgical Societies

GCS = Glasgow Coma Scale

CT = Computed Tomography

Danil Adam

daniladam950@gmail.com

Carol Davila University of Medicine

Alin Enache

alin82enache@yahoo.com

St Pantelimon Hospital, Bucharest

Cristina Moisescu

cristina_moisescu@yahoo.com

St Pantelimon Hospital, Bucharest

REFERENCES

(1.) Schouten J. W., and A. I. R. Mass (2011), "Epidemiology of Traumatic Brain Injury," in H. R. Winn (ed.), Youmans Neurological Surgery. Philadelphia Elsevier Saunders, 3270-3277.

(2.) Kraus J. V., and D. L. McArthur (1996), "Epidemiologic Aspect of Brain Injury," Neural Clinics 14: 435-450.

(3.) Kalsbeek, W., R. Mc Laurin, B. Harris et al. (1980), "The National Head and Spinal Cord Injury. Survey: Major Findings," Journal of Neurosurgery (Suppl) 63: S19-S31.

(4.) Ring I., G. Berry, and N. Dan (1986), "Epidemilogy and Clincal Outcomes of Neurotrauma in NSW," New Zealand Journal of Surgery 56: 557-566.

(5.) Kraus J., and P. Nourjah (1998), "The Epidemiology of Mild, Uncomplicated Brain Injury," Journal of Trauma 28:1637-1643.

(6.) Miller, J. D. (1990), "Assesing Patients with Head Injury," British Journal of Surgery 77: 241-242.

(7.) Jeret J. S., M. Mandell, B. Anziska et al. (1993), "Clinical Predictors of Abnormality Disclosed by Computed Tomography after Mild Head Trauma," Neurosurgery 32: 9-16.

(8.) Moore, M. M., M. D. Pasquale, and M. Badelino (2012), "Impact of Age and Anticoagulation: Need for Neurosurgical Intervention in Trauma Patients with Mild Traumatic Brain Injury," Journal of Trauma 73: 126-130.

(9.) Brenner, D. J., and E. J. Hall (2007), "Computed Tomography--An Increasing Source of Radiation Exposure," New England Journal of Medicine 357(22): 2277-2284.

(10.) Garret, C. M., A. Bolgin-Freiert, and C. Barteles et al. (2013), "An Evidence Based Approach to the Efficient Use Computer Tomography Imaging in the Neurosurgical Patient," Neurosurgery 73: 209-216.
Table 1 Characteristics of patients who presented at the ED

                                    No.   %

Age              0-18 years old     27    5.07
                 19-64 years old    248   65.29
                 >65 years old      158   29.64
                 Total              533   100

Sex              M                  359   67.35
                 W                  174   32.65

Cause            Aggressions        304   57.03
                 Car accidents      144   27.01
                 Same level fall    34    6.38
                 Unspecified        20    3.75
                 conditions
                 Bike fall          13    2.44
                 Other level fall   10    1.88
                 Accident at work   6     1.13
                 Sports accident    2     0.38

Investigations   Skull X-ray        255   47.84
                 Cerebral CT scan   279   52.35

Revealed         Skull fractures    5     0.94
lesions          Intracranial       12    2.25
                 lesions
                 Scalp abrasions    75    14.07
                 Scalp plagues      127   23.83
                 Epicranian         36    6.75
                 hematoma
                 Facial lesions     287   53.84

Table 2 Characteristics of admitted patients

                                    No.   %

Age             0-18 years old      0     0
                19-64 years old     136   68.69
                >65 years old       62    31.31
                Total               198   100

Risk Factors    Age >65 years       62    31.31
                Alcoholism          37    18.68
                Epilepsy            15    7.57
                Previous            1     0.5
                  neurosurgical
                interventions
                Coagulopathy        6     3.03

Clinical        Headache            142   71.72
symptoms        Vomiting            19    9.6
                Dizziness           73    36.87
                Loss of             63    31.82
                  consciousness
                Retrograde          4     2.02
                  amnesia
                Scalp plagues       71    35.86

Neurological    Motor deficit       1     0.5
  signs

Skull lesions   Cranial fissures    0     0
revealed        Skull fractures     5     2.52
by X-ray          without
or CT scan        clogging

Cerebral        Hemorrhagic         5     2.52
lesions           contusions
revealed        Traumatic           2     1.01
by the            subarachnoid
CT scan           hemorrhage
                Acute subdural      1     0.5
                  hematoma
                Small subdural      3     1.51
                  blood
                  collections
                Intraventricular    1     0.5
                hemorrhage

Length          <24 hours           9     4.55
of Stay         24-48 hours         80    40.4
                48-72 hours         60    30.3
                >72 hours           49    24.75
                Mean                      3.03 days
                  Hospitalization
                  Period

Table 3 The relationship between the GCS
score and the CT scan investigation

GCS               Patients      CT

                  No.   %       No.   %

Patients     15   529   99.25   275   51.98
  in ED      14   3     0.56    3     100
             13   1     0.19    1     100
Admitted     15   194   97.97   191   98.45
  patients   14   3     1.52    3     100
             13   1     0.51    1     100

Table 4 The results of the head CT scan performed
in the ED

                             Number of   Observations
                             patients

            Intracranial     12          Admitted
Positive    lesions
  results   Cerebral edema   2           Refused
                                           admission
            Total            14
Negative    Normal CT scan   82          Sent home
  results   Normal CT scan   183         Admitted
            Total            265

Table 5 The costs of the CT scan investigation

          Number   Costs

                   RON     EUR

CT scan   1        250     56
CT+       14       3500    784
CT-       256      66250   14840

Table 6 EBIC classification of mild traumatic brain injuries

Degree            GCS score               Observations

                  13-15                   Does not include
                                            cases with:
                                          -focal
                                            neurological
                                            deficits
                                          -fractures with
                                            clogging
                                          -CSF fistula
0                 -without loss of
                  consciousness           -sent home
                  -without amnesia

0 with risk       -alcoholism             -head CT scan
  of late         -drugs                  -24 hours
  deterioration   -age (both limits)        hospitalization
                  -epilepsy
                  -history of
                    neurosurgical
                   interventions

1                 -loss of                -head CT scan
                    consciousness < 5       in the first
                    minutes                 6 hours
                  -retrograde amnesia     -24 hours
                  -headache, vomiting       hospitalization
                  -large scalp plagues

2                 -sleepy patients        -head CT scan
                  -GCS score of 14-13     -hospitalization
                  points for 30 minutes     until
                  after the trauma          improvement

Table 7 Neurotraumatology committee of the WFNS model
for mild head injury

               Low      Medium              High
               risk     risk                risk

GCS score      15       15 with             14 or 15 with:
                          clinical          -neurological
                          findings          deficits or
                                            -skull
                                              fracture or
                                            -risk factors
                                              with/
                                              without
                                              clinical
                                              findings

Clinical                Amnesia             Amnesia
  findings              Diffuse             Diffuse headache
               No         headache          Vomiting
                        Vomiting            Loss of
                        Loss of             consciousness
                        consciousness

Neurological   No       No                  Yes
deficits

Cranial        No       No                  Yes
  fracture

Risk factors                                Yes:
                                              coagulopathy,
                                              age > 60 years,
                                              previous
               No       No                    neurosurgical
                                              interventions,
                                              epilepsy,
                                              misuse of
                                              alcohol, drugs

Imaging        No       CT scan/ skull      CT scan
                          X-ray

Disposition    Sent     Hosiptalization:    Hospitalization
                 home   -3-6 h after          (24-48h)
                          the CT scan         followed by
                          examination         home
                        -24 h after skull     observation
                          X-ray followed
                          by home
                          observation
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Author:Adam, Danil; Enache, Alin; Moisescu, Cristina
Publication:American Journal of Medical Research
Article Type:Report
Date:Apr 1, 2014
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