Computerise Tomography of the Brain in Older Adults Presenting with Minor head injury within the Irish Emergency Department Setting

Background The NICE guidelines are used to rationalise the referrals for brain imaging in older adults (OA). Despite NICE recommending a CT brain (CBT) for all patients over 65 on a direct-acting oral anticoagulant (DOAC), research has shown that the risk of adverse outcomes following mild head injury (MHI) in patients taking DOACs appears low. The aim of this project was to examine the incidence of CTB use in OA presenting to the Emergency department (ED) with MHI and compare the CT referral rates between nursing home residents (NHR) and non-nursing home residents (NNHR). Methods A chart audit of OA who presented to ED within a six month period with a primary complaint of fall, with either a suspected or confirmed head strike was completed. Exclusion criteria included witnessed seizures, Glasgow coma scale of < 14 at triage or extensive head lacerations or a presumed cardiac cause to the fall. Audit included a review of whether: a CT brain was completed, did the OA meet the NICE criteria for CT Brain, was the patient on a DOAC, GCS and 4AT, CTB result, neurosurgical consultation +/- intervention, discharge destination. Results 186 OA (93 NHR and 93 NNHR) were included in the audit. Overall, 64% of patients received a CT Brain, of which only 45% met the NICE criteria for CT Brain. 6% of CT scans displayed evidence of ICH. The rate of referral for CTB was similar between NHR (62%) and NNHR (67%). A higher percentage of NHR met the NICE criteria than NNHR (55% vs 37%). 100% of NHR were discharged home compared to 77% of NNHR. Conclusion Regardless of whether these patients were prescribed a DOAC, results suggest that a significant number of CTB are being completed without a clear clinical rational or a justified benefit to the patient.