Mild and Moderate Traumatic Brain Injury: Screening, Documentation, and Referral to Concussion Services
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Journal Article
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Elsevier
Abstract
BACKGROUND AND AIM: Screening of traumatic brain injuries (TBI) using different clinical assessment tools would facilitate diagnosis and effective inpatient follow-up. We aimed to describe rates of diagnosis, classification, documentation, and referral practices for TBI inpatients. MATERIAL AND METHODS: In a retrospective cohort study, we reviewed electronic clinical records of adult patients admitted to a hospital ward with head trauma from an emergency department (ED) in 2021. Data included demographics, injury, TBI diagnoses, and referral to concussion services. Factors predicting ED physician documentation and referral to concussion services were identified. RESULTS: Of approximately 34,000 adults admitted from the ED, 1059 presented with head trauma, and 609 (57.5 %) were diagnosed with TBI. There were 553 mild/moderate TBI cases with an incidence rate of 103.4 per 100,000 adult population in Canterbury. 14 % (n = 77) were referred to a concussion service. Predictors of ED-documented TBI included non-isolated head injury (OR:0.60), head CT request (OR:9.12), injured in street/public areas (OR:2.03). Older age and non-isolated head injury decreased odds of concussion service referral (0.96 and 0.46, respectively), while female and ED-documented TBI increased odds of referral (5.8 and 28, respectively). CONCLUSION: Better documentation of mild/moderate TBI might facilitate health care access, with efficient clinical decision making.Description
Keywords
Documentation, Incidence, Referral, Traumatic Brain Injury, Documentation, Incidence, Referral, Traumatic Brain Injury, 4203 Health Services and Systems, 42 Health Sciences, Neurosciences, Physical Injury - Accidents and Adverse Effects, Emergency Care, Traumatic Brain Injury (TBI), Clinical Research, Brain Disorders, Health Services, Traumatic Head and Spine Injury, Minority Health, Injuries and accidents, 3 Good Health and Well Being, 1110 Nursing, 1117 Public Health and Health Services, Nursing, 3202 Clinical sciences, 4203 Health services and systems, 4205 Nursing
Source
Australasian Emergency Care, ISSN: 2589-1375 (Print); 2588-994X (Online), Elsevier, 28(3), 213-220. doi: 10.1016/j.auec.2025.03.007
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© 2025 The Authors. Published by Elsevier Ltd on behalf of College of Emergency Nursing Australasia. This is an open access article under the CC BY
license (http://creativecommons.org/licenses/by/4.0/).