Reduction of low clinical value head CTs is a recognized quality initiative among clinical associations, hospitals, and the government. However, in the Emergency Department (ED), over 80% of mild head injured patients still receive a head CT although >90% are found to be negative.1 Nearly 30% of emergency physicians self-reported that they continue to order head CTs for mild head injured patients because of concern for serious diagnosis and/or pressure to meet patient/family expectations.
Nearly all emergency departments (EDs) are experiencing long wait times, patient boarding, and high rates of patients left without being seen (LWBS). Pre-pandemic, the national average for LWBS was 1.1%. Post pandemic, the national average has more than doubled to 2.5%, reaching as high as 10% in some hospitals.1 With more than half of all hospital patients coming through the ED, these factors directly impact patient outcomes, experience, and hospital revenue.
In 2012, the American College of Emergency Physicians (ACEP), like other specialty societies, began a conversation with its members to develop five “Choosing Wisely®” recommendations. One of their first recommendations was to avoid low-value Computed Tomography (CT) scans of the head in patients with minor head injury. ACEP’s multistep process began with input from its Cost-Effective Task Force (Task Force), which administered a survey to ACEP members asking for strategies to “reduce costs and improve value in Emergency Medicine.” The Task Force determined that the evidence was clear; patients with minor head injury that are low risk for intracranial bleeding or skull fracture by decision rules would benefit from a conversation with their clinician on the utility of a head CT.1
For most mild head injured patients that seek care at the Emergency Department a head CT is the traditional assessment tool used. While this makes sense as providers want to rule out the likelihood of the most serious diagnosis (intracranial hemorrhage), which in over 90% of patients scanned will be negative. A single head CT delivers the equivalent radiation as 20 chest X-rays, increasing an individual’s lifetime risk of cancer.
Radiation reduction is a top quality metric for improving patient outcomes. One example can be seen with the HCA system and their Radiation Right program. This program promotes considering alternative exams that can still meet the patient needs while minimizing exposure to ionizing radiation. Choosing Wisely® and the Centers for Medicare and Medicaid (CMS) also have initiatives to reduce radiation exposure. These initiatives are specifically aimed at reducing radiation in the mild head injured patient population, as over 80% of these patients receive a head CT with over 90% of the results negative for a brain bleed.
With over 90% of Emergency Departments (EDs) routinely reporting crowding, nurses are tasked with caring for patients in the ED bays, hallways, and more during their shifts. They balance this crowding and patient needs with fewer resources as staffing shortages are widely known in the post-covid ED. Many hospitals look to fill the void with travel nurses, who now represent 8- 10% of the nursing workforce. This brings its own set of challenges for the hospital team.
The COVID-19 pandemic stretched emergency departments (EDs) beyond their capacity and highlighted the resource needs of the system. Before the pandemic, EDs were already overburdened with increasing visits. More than 60% of all hospitals’ admissions come through the ED and 90% routinely report overcrowding/boarding.
Ninety-five percent of head injured patients that visit the Emergency Department (ED) are considered to be “mild.” Many hospitals employ a fast-track, or similar pathway, for these patients. Their injury is not life threatening, they do not require the resources of more acute patients, and therefore in theory they can be quickly evaluated and discharged.
Many head injured patients arrive in the Emergency Department (ED) expecting a head CT “to be sure” their injury is not severe. Not fully understanding that while a head CT can identify if a brain bleed has occurred, it cannot detect a concussion, patients will often press for a head CT, as they find satisfaction in knowing “something was done” during their visit.
As the world enters year three of COVID-19, patients are returning to the Emergency Department (ED), with volumes approaching pre-pandemic levels. Among those returning are head-injured patients—an ED patient population that has increased 30% in recent years. Seventy percent of these patients are evaluated as treat and release, but many spend up to six hours in the ED because of typical assessment protocols.
When patients arrive at the emergency department (ED) with a suspected head injury, clinicians need to quickly assess for severity and determine next steps. Does the patient have a brain injury—brain bleed, concussion, or both? Understanding what happens to the brain following a head injury can help determine the next steps for assessment and treatment.
Head trauma, of varying degrees, affects millions of Americans each year and results in significant morbidity rates and substantial economic costs to society. According to the Brain Injury Alliance of Connecticut, someone in the United States sustains a traumatic brain injury (TBI) every twenty-one seconds. On average, this equates to approximately 2.5 million TBI-related emergency department visits per year. Mild TBI (mTBI) is the most common type of TBI, accounting for approximately 95% of patients evaluated in the emergency department (ED) for a head injury. MTBI generally is representative of patients who report mild, non-penetrating traumatic injury associated with a brief alteration in brain function. Although mTBI is often considered an incidental and non-threatening injury, severe short and long-term effects have long been established. Additionally, there is broad acceptance that multiple mTBIs can have serious, long-term consequences.
An injury to the head is never a simple matter. Depending on the traumatic brain injury (TBI) diagnosis, it can either be mild, moderate, or severe. Thankfully, the human body has some protection from trauma, such as the human skull, which provides adequate protection for the brain inside it. According to the CDC, 70% to 90% of TBIs evaluated in the Emergency Department (ED) are considered mild traumatic brain injuries (mTBI) or concussions. As such, chances of concussion recovery are greater with early intervention. However, to obtain an objective diagnosis of concussion, patients need immediate medical attention to assess the injury’s severity.
A traumatic brain injury (TBI) is caused by a bump or impact to the head that disrupts the brain's normal function. According to the CDC, most TBIs that occur each year are mild and sometimes called concussions. Mild traumatic brain injuries (mTBI) can cause changes in brain activity, leading to headaches, fatigue, disorientation, and irritability. A concussion is medically defined as a clinical syndrome characterized by immediate and transient alteration in brain function.
Traumatic brain injury (TBI), commonly defined as "a blow or shaking to the head or a penetrating brain injury that disrupts the function of the brain," is a largely unrecognized public health problem and has long been referred to as the “silent epidemic.”1 Mild traumatic brain injury (mTBI), including concussion, is the least severe TBI and the most challenging to diagnose due to little or no visible signs of injury, reliance on self-report of symptoms, the rapid resolution of signs and symptoms, and the absence of objective evidence of a concussion on CT imaging (head CT scans do not detect concussions).2
