Which older emergency patients are at risk of intracranial bleeding after a fall? A protocol to derive a clinical decision rule for the emergency department

Kerstin de Wit, Mathew Mercuri, Natasha Clayton, Andrew Worster, Eric Mercier, Marcel Emond, Catherine Varner, Shelley L McLeod, Debra Eagles, Ian Stiell, David Barbic, Judy Morris, Rebecca Jeanmonod, Yoan Kagoma, Ashkan Shoamanesh, Paul T Engels, Sunjay Sharma, Clive Kearon, Alexandra Papaioannou, Sameer Parpia, Network of Canadian Emergency Researchers, Kerstin de Wit, Mathew Mercuri, Natasha Clayton, Andrew Worster, Eric Mercier, Marcel Emond, Catherine Varner, Shelley L McLeod, Debra Eagles, Ian Stiell, David Barbic, Judy Morris, Rebecca Jeanmonod, Yoan Kagoma, Ashkan Shoamanesh, Paul T Engels, Sunjay Sharma, Clive Kearon, Alexandra Papaioannou, Sameer Parpia, Network of Canadian Emergency Researchers

Abstract

Introduction: Falling on level ground is now the most common cause of traumatic intracranial bleeding worldwide. Older adults frequently present to the emergency department (ED) after falling. It can be challenging for clinicians to determine who requires brain imaging to rule out traumatic intracranial bleeding, and often head injury decision rules do not apply to older adults who fall. The goal of our study is to derive a clinical decision rule, which will identify older adults who present to the ED after a fall who do not have clinically important intracranial bleeding.

Methods and analysis: This is a prospective cohort study enrolling patients aged 65 years or older, who present to the ED of 11 hospitals in Canada and the USA within 48 hours of having a fall. Patients are included if they fall on level ground, off a chair, toilet seat or out of bed. The primary outcome is the diagnosis of clinically important intracranial bleeding within 42 days of the index ED visit. An independent adjudication committee will determine the primary outcome, blinded to all other data. We are collecting data on 17 potential predictor variables. The treating physician completes a study data form at the time of initial assessment, prior to brain imaging. Data extraction is supplemented by an independent, structured electronic medical record review. We will perform binary recursive partitioning using Classification and Regression Trees to derive a clinical decision rule.

Ethics and dissemination: The study was initially approved by the Hamilton Integrated Research Ethics Committee and subsequently approved by the research ethics boards governing all participating sites. We will disseminate our results by journal publication, presentation at international meetings and social media.

Trial registration number: NCT03745755.

Keywords: accident & emergency medicine; diagnostic radiology; geriatric medicine; trauma management.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

References

    1. Van den Brand CL, Karger LB, Nijman ST, et al. . Traumatic brain injury in the Netherlands, trends in emergency department visits, hospitalization and mortality between 1998 and 2012. Eur J Emerg Med 2017;06:06. 10.1097/MEJ.0000000000000457
    1. Haring RS, Narang K, Canner JK, et al. . Traumatic brain injury in the elderly: morbidity and mortality trends and risk factors. J Surg Res 2015;195:1–9. 10.1016/j.jss.2015.01.017
    1. McIntyre A, Mehta S, Aubut J, et al. . Mortality among older adults after a traumatic brain injury: a meta-analysis. Brain Inj 2013;27:31–40. 10.3109/02699052.2012.700086
    1. Chan V, Colantonio A, Chen A. A population based perspective of acquired brain injury in older adults: how do they happen? Brain Injury 2012;26:548–9.
    1. Kerr ZY, Harmon KJ, Marshall SW, et al. . The epidemiology of traumatic brain injuries treated in emergency departments in North Carolina, 2010-2011. N C Med J 2014;75:8–14. 10.18043/ncm.75.1.8
    1. Albrecht JS, Hirshon JM, McCunn M, et al. . Increased rates of mild traumatic brain injury among older adults in US emergency departments, 2009-2010. J Head Trauma Rehabil 2016;31:E1–7. 10.1097/HTR.0000000000000190
    1. Fu WW, Fu TS, Jing R, et al. . Predictors of falls and mortality among elderly adults with traumatic brain injury: a nationwide, population-based study. PLoS One 2017;12:e0175868. (no pagination). 10.1371/journal.pone.0175868
    1. Peeters W, van den Brande R, Polinder S, et al. . Epidemiology of traumatic brain injury in Europe. Acta Neurochir 2015;157:1683–96. 10.1007/s00701-015-2512-7
    1. Hastings DL, Brieding M, Lee R. Falls and traumatic brain injuries in older adults: a worsening trend. J Am Geriatr Soc 2017;65:S8.
    1. Sung K-C, Liang F-W, Cheng T-J, et al. . Trends in unintentional fall-related traumatic brain injury death rates in older adults in the United States, 1980-2010: a joinpoint analysis. J Neurotrauma 2015;32:1078–82. 10.1089/neu.2014.3509
    1. Fletcher AE, Khalid S, Mallonee S. The epidemiology of severe traumatic brain injury among persons 65 years of age and older in Oklahoma, 1992-2003. Brain Inj 2007;21:691–9. 10.1080/02699050701426873
    1. Chisholm KM, Harruff RC. Elderly deaths due to ground-level falls. Am J Forensic Med Pathol 2010;31:350–4. 10.1097/PAF.0b013e3181f69c87
    1. Brazinova A, Mauritz W, Majdan M, et al. . Fatal traumatic brain injury in older adults in Austria 1980-2012: an analysis of 33 years. Age Ageing 2015;44:502–6. 10.1093/ageing/afu194
    1. Shankar KN, Liu SW, Ganz DA. Trends and characteristics of emergency department visits for fall-related injuries in older adults, 2003-2010. West J Emerg Med 2017;18:785–93. 10.5811/westjem.2017.5.33615
    1. Hartholt KA, Van Lieshout EMM, Polinder S, et al. . Rapid increase in hospitalizations resulting from fall-related traumatic head injury in older adults in the Netherlands 1986-2008. J Neurotrauma 2011;28:739–44. 10.1089/neu.2010.1488
    1. Korhonen N, Niemi S, Parkkari J, et al. . Incidence of fall-related traumatic brain injuries among older Finnish adults between 1970 and 2011. JAMA 2013;309:1891–2. 10.1001/jama.2013.3356
    1. Verma SK, Willetts JL, Corns HL, et al. . Falls and fall-related injuries among community-dwelling adults in the United States. PLoS One 2016;11:e0150939. no pagination. 10.1371/journal.pone.0150939
    1. Stiell IG, Wells GA, Vandemheen K, et al. . The Canadian CT head rule for patients with minor head injury. The Lancet 2001;357:1391–6. 10.1016/S0140-6736(00)04561-X
    1. de Wit K, Merali Z, Kagoma YK, et al. . Incidence of intracranial bleeding in seniors presenting to the emergency department after a fall: a systematic review. Injury 2020;51:157–63. 10.1016/j.injury.2019.12.036
    1. Kelen G, Peterson S, Pronovost P. In the name of patient safety, let's burden the emergency department more. Ann Emerg Med 2016;67:737–40. 10.1016/j.annemergmed.2015.11.031
    1. Émond M, Grenier D, Morin J, et al. . Emergency department stay associated delirium in older patients. Can Geriatr J 2017;20:10–14. 10.5770/cgj.20.246
    1. Stiell IG, Wells GA, Vandemheen KL, et al. . The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA 2001;286:1841–8. 10.1001/jama.286.15.1841
    1. Wells PS, Anderson DR, Rodger M, et al. . Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and D-dimer. Ann Intern Med 2001;135:98–107. 10.7326/0003-4819-135-2-200107170-00010
    1. Thiruganasambandamoorthy V, Stiell IG, Sivilotti MLA, et al. . Risk stratification of adult emergency department syncope patients to predict short-term serious outcomes after discharge (RiSEDS) study. BMC Emerg Med 2014;14:8 10.1186/1471-227X-14-8
    1. Stiell IG, Wells GA. Methodologic standards for the development of clinical decision rules in emergency medicine. Ann Emerg Med 1999;33:437–47. 10.1016/S0196-0644(99)70309-4
    1. Collins GS, Reitsma JB, Altman DG, et al. . Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD): the TRIPOD statement. Ann Intern Med 2015;162:55–63. 10.7326/M14-0697
    1. Selvanayagam N, Mowbray F, Clayton N, et al. . Reliability of patient-reported outcome measures: hemorrhage, anticoagulant, antiplatelet medication use 2021;5:e12501. 10.1002/rth2.12501
    1. de Wit K, Parpia S, Varner C, et al. . Clinical predictors of intracranial bleeding in older adults who have fallen: a cohort study. J Am Geriatr Soc 2020;68:970–6. 10.1111/jgs.16338
    1. Schulman S, Kearon C. The SOCOAOTS, standardization Committee of the International Society on T, haemostasis. Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients. J Thromb Haemost 2005;3:692–4. 10.1111/j.1538-7836.2005.01204.x
    1. Rockwood K, Song X, MacKnight C, et al. . A global clinical measure of fitness and frailty in elderly people. CMAJ 2005;173:489–95. 10.1503/cmaj.050051
    1. Lawless JF, Singhal K. Efficient screening of Nonnormal regression models. Biometrics 1978;34:318–27. 10.2307/2530022
    1. Harrell F. Regression modeling strategies with applications to linear models, logistic regression, and survival analysis. New York: Springer, 2001.
    1. Mallett S, Royston P, Dutton S, et al. . Reporting methods in studies developing prognostic models in cancer: a review. BMC Med 2010;8:20. 10.1186/1741-7015-8-20
    1. Pavlou M, Ambler G, Seaman SR, et al. . How to develop a more accurate risk prediction model when there are few events. BMJ 2015;351:h3868. 10.1136/bmj.h3868
    1. Harris PA, Taylor R, Thielke R, et al. . Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42:377–81. 10.1016/j.jbi.2008.08.010
    1. Harris PA, Taylor R, Minor BL, et al. . The REDCap Consortium: building an international community of software platform partners. J Biomed Inform 2019;95:103208. 10.1016/j.jbi.2019.103208

Source: PubMed

Sponsors et collaborateurs

Les conditions médicales

Interventions en matière de drogue

3
S'abonner