Background There is international variation in hospital admission practices for patients with mild traumatic brain injury (TBI) and injuries on CT scan. Only a small proportion of patients require neurosurgical intervention, while many guidelines recommend routine admission of all patients. We aim to validate the Hull Salford Cambridge Decision Rule (HSC DR) and the Brain Injury Guidelines (BIG) criteria to select low-risk patients for discharge from the emergency department.
Method A cohort from 18 countries of Glasgow Coma Scale 13–15 patients with injuries on CT imaging was identified from the multicentre Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) Study (conducted from 2014 to 2017) for secondary analysis. A composite outcome measure encompassing need for ongoing hospital admission was used, including seizure activity, death, intubation, neurosurgical intervention and neurological deterioration. We assessed the performance of our previously derived prognostic model, the HSC DR and the BIG criteria at predicting deterioration in this validation cohort.
Results Among 1047 patients meeting the inclusion criteria, 267 (26%) deteriorated. Our prognostic model achieved a C-statistic of 0.81 (95% CI: 0.78 to 0.84). The HSC DR achieved a sensitivity of 100% (95% CI: 97% to 100%) and specificity of only 4.7% (95% CI: 3.3% to 6.5%) for deterioration. Using the BIG criteria for discharge from the ED achieved a higher specificity (13.3%, 95% CI: 10.9% to 16.1%) and lower sensitivity (94.6%, 95% CI: 90.5% to 97%), with 12/105 patients recommended for discharge subsequently deteriorating, compared with 0/34 with the HSC DR.
Conclusion Our decision rule would have allowed 3.5% of patients to be discharged, none of whom would have deteriorated. Use of the BIG criteria may select patients for discharge who have too high a risk of subsequent deterioration to be used clinically. Further validation and implementation studies are required to support use in clinical practice.
Data availability statement
The data used for this study were obtained from the CENTER-TBI Study database. Data are available upon request to the CENTER-TBI investigators (https://www.center-tbi.eu/data).
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Handling editor Katie Walker
Contributors The idea for the study was conceived by CM, TS and FL. The analysis was completed by CM with specialist statistical advice from BG and ES and specialist clinical advice from FL. All authors contributed to interpretation of results and read and approved the final manuscript.
Funding Data used in preparation of this manuscript were obtained in the context of CENTER-TBI, a large collaborative project, with the support of the European Union Seventh Framework Programme (EC grant 602150). Full list of participants and investigators are provided in online supplemental material 9. Additional funding was obtained from the Hannelore Kohl Stiftung (Germany), One Mind (USA) and Integra LifeSciences Corporation (USA). FL and ES were supported by the European Union Framework 7 Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (EC grant 602150). FL was also supported by the NHS Trusts ‘Trauma Audit and Research Network—www.tarn.ac.uk’. CM is a National Institute for Health Research (NIHR) Clinical Lecturer in Emergency Medicine. This publication presents independent research funded by the NIHR and University of Sheffield.
Disclaimer This publication presents independent research funded by the NIHR and University of Sheffield. The views expressed are those of the author(s) and not necessarily those of the University of Sheffield, the NHS, the NIHR or the Department of Health and Social Care.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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