Out-of-Hospital Triage of Older Adults With Head Injury: A Retrospective Study of the Effect of Adding "Anticoagulation or Antiplatelet Medication Use" as a Criterion

Daniel Nishijima, Samuel D. Gaona, Trent Waechter, Ric Maloney, Troy Bair, Adam Blitz, Andrew R. Elms, Roel D. Farrales, Calvin Howard, James Montoya, Jeneita M. Bell, Mark Faul, David R. Vinson, Hernando Garzon, James F Holmes Jr, Dustin W. Ballard

Research output: Contribution to journalArticle

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Abstract

Study objective: Field triage guidelines recommend that emergency medical services (EMS) providers consider transport of head-injured older adults with anticoagulation use to trauma centers. However, the triage patterns and the incidence of intracranial hemorrhage or neurosurgery in these patients are unknown. Our objective is to describe the characteristics and outcomes of older adults with head trauma who are transported by EMS, particularly for patients who do not meet physiologic, anatomic, or mechanism-of-injury (steps 1 to 3) field triage criteria but are receiving anticoagulant or antiplatelet medications. Methods: This was a retrospective study at 5 EMS agencies and 11 hospitals (4 trauma centers, 7 nontrauma centers). Patients aged 55 years or older with head trauma who were transported by EMS were included. The primary outcome was the presence of intracranial hemorrhage. The secondary outcome was a composite measure of inhospital death or neurosurgery. Results: Of the 2,110 patients included, 131 (6%) had intracranial hemorrhage and 41 (2%) had inhospital death or neurosurgery. There were 162 patients (8%) with steps 1 to 3 criteria. Of the remaining 1,948 patients without steps 1 to 3 criteria, 566 (29%) had anticoagulant or antiplatelet use. Of these patients, 52 (9%) had traumatic intracranial hemorrhage and 15 (3%) died or had neurosurgery. The sensitivity (adjusted for clustering by EMS agency) of steps 1 to 3 criteria was 19.8% (26/131; 95% confidence interval [CI] 5.5% to 51.2%) for identifying traumatic intracranial hemorrhage and 34.1% (14/41; 95% CI 9.9% to 70.1%) for death or neurosurgery. The additional criterion of anticoagulant or antiplatelet use improved the sensitivity for intracranial hemorrhage (78/131; 59.5%; 95% CI 42.9% to 74.2%) and death or neurosurgery (29/41; 70.7%; 95% CI 61.0% to 78.9%). Conclusion: Relatively few patients met steps 1 to 3 triage criteria. For individuals who did not have steps 1 to 3 criteria, nearly 30% had anticoagulant or antiplatelet use. A relatively high proportion of these patients had intracranial hemorrhage, but a much smaller proportion died or had neurosurgery during hospitalization. Use of steps 1 to 3 triage criteria alone is not sufficient in identifying intracranial hemorrhage and death or neurosurgery in this patient population. The additional criterion of anticoagulant or antiplatelet use improves the sensitivity of the instrument, with only a modest decrease in specificity.

Original languageEnglish (US)
JournalAnnals of Emergency Medicine
DOIs
StateAccepted/In press - Oct 9 2016

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Triage
Craniocerebral Trauma
Neurosurgery
Retrospective Studies
Intracranial Hemorrhages
Emergency Medical Services
Anticoagulants
Traumatic Intracranial Hemorrhage
Confidence Intervals
Trauma Centers
Cluster Analysis
Hospitalization
Head
Guidelines

ASJC Scopus subject areas

  • Emergency Medicine

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Out-of-Hospital Triage of Older Adults With Head Injury : A Retrospective Study of the Effect of Adding "Anticoagulation or Antiplatelet Medication Use" as a Criterion. / Nishijima, Daniel; Gaona, Samuel D.; Waechter, Trent; Maloney, Ric; Bair, Troy; Blitz, Adam; Elms, Andrew R.; Farrales, Roel D.; Howard, Calvin; Montoya, James; Bell, Jeneita M.; Faul, Mark; Vinson, David R.; Garzon, Hernando; Holmes Jr, James F; Ballard, Dustin W.

In: Annals of Emergency Medicine, 09.10.2016.

Research output: Contribution to journalArticle

Nishijima, Daniel ; Gaona, Samuel D. ; Waechter, Trent ; Maloney, Ric ; Bair, Troy ; Blitz, Adam ; Elms, Andrew R. ; Farrales, Roel D. ; Howard, Calvin ; Montoya, James ; Bell, Jeneita M. ; Faul, Mark ; Vinson, David R. ; Garzon, Hernando ; Holmes Jr, James F ; Ballard, Dustin W. / Out-of-Hospital Triage of Older Adults With Head Injury : A Retrospective Study of the Effect of Adding "Anticoagulation or Antiplatelet Medication Use" as a Criterion. In: Annals of Emergency Medicine. 2016.
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title = "Out-of-Hospital Triage of Older Adults With Head Injury: A Retrospective Study of the Effect of Adding {"}Anticoagulation or Antiplatelet Medication Use{"} as a Criterion",
abstract = "Study objective: Field triage guidelines recommend that emergency medical services (EMS) providers consider transport of head-injured older adults with anticoagulation use to trauma centers. However, the triage patterns and the incidence of intracranial hemorrhage or neurosurgery in these patients are unknown. Our objective is to describe the characteristics and outcomes of older adults with head trauma who are transported by EMS, particularly for patients who do not meet physiologic, anatomic, or mechanism-of-injury (steps 1 to 3) field triage criteria but are receiving anticoagulant or antiplatelet medications. Methods: This was a retrospective study at 5 EMS agencies and 11 hospitals (4 trauma centers, 7 nontrauma centers). Patients aged 55 years or older with head trauma who were transported by EMS were included. The primary outcome was the presence of intracranial hemorrhage. The secondary outcome was a composite measure of inhospital death or neurosurgery. Results: Of the 2,110 patients included, 131 (6{\%}) had intracranial hemorrhage and 41 (2{\%}) had inhospital death or neurosurgery. There were 162 patients (8{\%}) with steps 1 to 3 criteria. Of the remaining 1,948 patients without steps 1 to 3 criteria, 566 (29{\%}) had anticoagulant or antiplatelet use. Of these patients, 52 (9{\%}) had traumatic intracranial hemorrhage and 15 (3{\%}) died or had neurosurgery. The sensitivity (adjusted for clustering by EMS agency) of steps 1 to 3 criteria was 19.8{\%} (26/131; 95{\%} confidence interval [CI] 5.5{\%} to 51.2{\%}) for identifying traumatic intracranial hemorrhage and 34.1{\%} (14/41; 95{\%} CI 9.9{\%} to 70.1{\%}) for death or neurosurgery. The additional criterion of anticoagulant or antiplatelet use improved the sensitivity for intracranial hemorrhage (78/131; 59.5{\%}; 95{\%} CI 42.9{\%} to 74.2{\%}) and death or neurosurgery (29/41; 70.7{\%}; 95{\%} CI 61.0{\%} to 78.9{\%}). Conclusion: Relatively few patients met steps 1 to 3 triage criteria. For individuals who did not have steps 1 to 3 criteria, nearly 30{\%} had anticoagulant or antiplatelet use. A relatively high proportion of these patients had intracranial hemorrhage, but a much smaller proportion died or had neurosurgery during hospitalization. Use of steps 1 to 3 triage criteria alone is not sufficient in identifying intracranial hemorrhage and death or neurosurgery in this patient population. The additional criterion of anticoagulant or antiplatelet use improves the sensitivity of the instrument, with only a modest decrease in specificity.",
author = "Daniel Nishijima and Gaona, {Samuel D.} and Trent Waechter and Ric Maloney and Troy Bair and Adam Blitz and Elms, {Andrew R.} and Farrales, {Roel D.} and Calvin Howard and James Montoya and Bell, {Jeneita M.} and Mark Faul and Vinson, {David R.} and Hernando Garzon and {Holmes Jr}, {James F} and Ballard, {Dustin W.}",
year = "2016",
month = "10",
day = "9",
doi = "10.1016/j.annemergmed.2016.12.018",
language = "English (US)",
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T1 - Out-of-Hospital Triage of Older Adults With Head Injury

T2 - A Retrospective Study of the Effect of Adding "Anticoagulation or Antiplatelet Medication Use" as a Criterion

AU - Nishijima, Daniel

AU - Gaona, Samuel D.

AU - Waechter, Trent

AU - Maloney, Ric

AU - Bair, Troy

AU - Blitz, Adam

AU - Elms, Andrew R.

AU - Farrales, Roel D.

AU - Howard, Calvin

AU - Montoya, James

AU - Bell, Jeneita M.

AU - Faul, Mark

AU - Vinson, David R.

AU - Garzon, Hernando

AU - Holmes Jr, James F

AU - Ballard, Dustin W.

PY - 2016/10/9

Y1 - 2016/10/9

N2 - Study objective: Field triage guidelines recommend that emergency medical services (EMS) providers consider transport of head-injured older adults with anticoagulation use to trauma centers. However, the triage patterns and the incidence of intracranial hemorrhage or neurosurgery in these patients are unknown. Our objective is to describe the characteristics and outcomes of older adults with head trauma who are transported by EMS, particularly for patients who do not meet physiologic, anatomic, or mechanism-of-injury (steps 1 to 3) field triage criteria but are receiving anticoagulant or antiplatelet medications. Methods: This was a retrospective study at 5 EMS agencies and 11 hospitals (4 trauma centers, 7 nontrauma centers). Patients aged 55 years or older with head trauma who were transported by EMS were included. The primary outcome was the presence of intracranial hemorrhage. The secondary outcome was a composite measure of inhospital death or neurosurgery. Results: Of the 2,110 patients included, 131 (6%) had intracranial hemorrhage and 41 (2%) had inhospital death or neurosurgery. There were 162 patients (8%) with steps 1 to 3 criteria. Of the remaining 1,948 patients without steps 1 to 3 criteria, 566 (29%) had anticoagulant or antiplatelet use. Of these patients, 52 (9%) had traumatic intracranial hemorrhage and 15 (3%) died or had neurosurgery. The sensitivity (adjusted for clustering by EMS agency) of steps 1 to 3 criteria was 19.8% (26/131; 95% confidence interval [CI] 5.5% to 51.2%) for identifying traumatic intracranial hemorrhage and 34.1% (14/41; 95% CI 9.9% to 70.1%) for death or neurosurgery. The additional criterion of anticoagulant or antiplatelet use improved the sensitivity for intracranial hemorrhage (78/131; 59.5%; 95% CI 42.9% to 74.2%) and death or neurosurgery (29/41; 70.7%; 95% CI 61.0% to 78.9%). Conclusion: Relatively few patients met steps 1 to 3 triage criteria. For individuals who did not have steps 1 to 3 criteria, nearly 30% had anticoagulant or antiplatelet use. A relatively high proportion of these patients had intracranial hemorrhage, but a much smaller proportion died or had neurosurgery during hospitalization. Use of steps 1 to 3 triage criteria alone is not sufficient in identifying intracranial hemorrhage and death or neurosurgery in this patient population. The additional criterion of anticoagulant or antiplatelet use improves the sensitivity of the instrument, with only a modest decrease in specificity.

AB - Study objective: Field triage guidelines recommend that emergency medical services (EMS) providers consider transport of head-injured older adults with anticoagulation use to trauma centers. However, the triage patterns and the incidence of intracranial hemorrhage or neurosurgery in these patients are unknown. Our objective is to describe the characteristics and outcomes of older adults with head trauma who are transported by EMS, particularly for patients who do not meet physiologic, anatomic, or mechanism-of-injury (steps 1 to 3) field triage criteria but are receiving anticoagulant or antiplatelet medications. Methods: This was a retrospective study at 5 EMS agencies and 11 hospitals (4 trauma centers, 7 nontrauma centers). Patients aged 55 years or older with head trauma who were transported by EMS were included. The primary outcome was the presence of intracranial hemorrhage. The secondary outcome was a composite measure of inhospital death or neurosurgery. Results: Of the 2,110 patients included, 131 (6%) had intracranial hemorrhage and 41 (2%) had inhospital death or neurosurgery. There were 162 patients (8%) with steps 1 to 3 criteria. Of the remaining 1,948 patients without steps 1 to 3 criteria, 566 (29%) had anticoagulant or antiplatelet use. Of these patients, 52 (9%) had traumatic intracranial hemorrhage and 15 (3%) died or had neurosurgery. The sensitivity (adjusted for clustering by EMS agency) of steps 1 to 3 criteria was 19.8% (26/131; 95% confidence interval [CI] 5.5% to 51.2%) for identifying traumatic intracranial hemorrhage and 34.1% (14/41; 95% CI 9.9% to 70.1%) for death or neurosurgery. The additional criterion of anticoagulant or antiplatelet use improved the sensitivity for intracranial hemorrhage (78/131; 59.5%; 95% CI 42.9% to 74.2%) and death or neurosurgery (29/41; 70.7%; 95% CI 61.0% to 78.9%). Conclusion: Relatively few patients met steps 1 to 3 triage criteria. For individuals who did not have steps 1 to 3 criteria, nearly 30% had anticoagulant or antiplatelet use. A relatively high proportion of these patients had intracranial hemorrhage, but a much smaller proportion died or had neurosurgery during hospitalization. Use of steps 1 to 3 triage criteria alone is not sufficient in identifying intracranial hemorrhage and death or neurosurgery in this patient population. The additional criterion of anticoagulant or antiplatelet use improves the sensitivity of the instrument, with only a modest decrease in specificity.

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