The acute care surgery model: managing traumatic brain injury without an inpatient neurosurgical consultation.

BACKGROUND: Neurosurgical services are a limited resource and effective use of them would improve the health care system. Acute care surgeons (ACS) are accustomed to treating mild traumatic brain injury (TBI) including those with minor radiographic intracranial injuries. We hypothesized that ACS safely manage mild TBI with intracranial hemorrhage (ICH) on head computed tomographic (CT) scan without neurosurgical consultation (NC).
METHODS: We performed a retrospective analysis on all TBI patients with positive findings on head CT scan managed without NC during a 2-year period. Propensity scoring matched NC to no-NC patients on a 1:2 ratio for Glasgow Coma Scale (GCS) score, head Abbreviated Injury Scale (h-AIS) score, neurological examination, age, Injury Severity Score (ISS), findings of initial head CT scan including type and size of ICH.
RESULTS: A total of 270 patients with mild TBI and positive CT scan findings were included (90 with NC and 180 without NC). Sixty-three percent were male, and mean (SD) age was 39 (25) years. The median GCS was 15 (13-15), and the h-AIS score was 2 (1-3). In both groups, there was no neurosurgical intervention, in-hospital mortality, or 30-day readmission. In the no-NC group, 8% of the patients had postdischarge emergency department (ED) visits compared with 4% of the NC group (p = 0.5). All patients with postdischarge ED visits in both groups were discharged home from the ED.
CONCLUSION: ACS can manage mild TBI with ICH without obtaining an inpatient NC. Further guidelines should be established to help identify which patients meet criteria to be safely managed without NC. LEVEL OF EVIDENCE: Care management/therapeutic study, level IV.