Maze of minor head injury, aged care and emergency medicine

The most common emergency department (ED) episode of care is straightforward. A patient suffers acute symptoms attributable to an illness or injury and autonomously chooses to attend the ED. The expectation is that the patient will subsequently accrue some net health benefit from their choice. It has been argued that the transfer of a person living in a residential aged care facility (RACF) to an ED is complex and not nearly as clear cut as the typical episode described earlier. First, the patient is often not part of the decision to transfer. Second, many transfers are done without any expectation or possibility that it will benefit the patient themselves – rather the ED attendance represents poor care planning, inadequate RACF staffing, a lack of alternative health options or medicolegal risk mitigation.1 It is within the latter context that Green and colleagues have framed their retrospective case series of patients living in RACF attending two Victorian EDs with minor head injury, published in this issue of the Internal Medicine Journal.2 Strong reference is made by Green et al. to the recommendations of the South Australian Coroner investigating the death of a RACF resident from an acute subdural haematoma following a fall, and a subsequent industry alert issued by the Commonwealth government. In Green's series of 368 patients, only one had significant emergency intervention and none had surgery. There were two in-hospital deaths. The conclusion of the authors seems justifiable: the very low proportion of cases where management is changed on the basis of the transfer does not support the key coronial recommendation that ‘implementation of a policy in which nursing home patients who suffer a fall resulting in a minor head injury should be referred to hospital for assessment’ be considered (http://www.courts.sa.gov.au/CoronersFindings/Pages/Findings-for-2016.aspx). A closer consideration of the paper in the context of what is known about falls from standing height, however, shows how byzantine these issues are. Falls are the leading cause of trauma mortality and disability in Australia, and head injury accounts for nearly half of all falls deaths.3 If emergency medicine is concerned with major trauma, falls are mainstream business. Tellingly, 80% of patients in the Green case series had a cranial computed tomography (CT) scan in the ED. At the very least, this suggests emergency physicians rely heavily on a CT to assess minor head injury in populations where history and exam is challenging, such as people living with dementia. The authors in fact raise this point, discussing alternative pathways to obtain a CT for a RACF resident. In the experience of many working in RACF, accessing such alternatives (private radiology clinics, mobile CT scanners) is less straightforward and convenient than using a hospital ED. Frail older people are at risk of iatrogenic harm from even brief stays in an ED.4, 5 The RACF population in Australia is enlarging, increasing in medical complexity and vulnerability, and currently the subject of a Commonwealth Royal Commission. The patient whose death was being investigated by the coroner is familiar to everyone working with RACF residents, described as ‘a frail aged lady with dementia. She was immobile in the sense that she could not walk without assistance …. She required full care at the facility. It was necessary for her to be hydraulically lifted in and out of bed’. The potential that such patients will derive improved quality of life from neurosurgical drainage of an acute subdural haemorrhage is negligible. It is therefore perfectly reasonable to posit that where possible, transfers to hospital from RACF should be minimised and confined to situations where the benefits of transfer clearly exceed the risk. Collaborative and advance care planning in RACF remains the cornerstone of all successful hospital avoidance programmes.6 However, would it also not be a part solution to redesign ED so they are less likely to cause harm to older patients, especially the most vulnerable old7? Among the nurses working, and the relatives of those living, in RACF there is a strong preference for residents attending ED in acute medical events independent of commonly measured care metrics such as waiting time or rates of adverse clinical outcomes.8 Is one explanation for that preference the same as it would be for any person attending ED, such as the typical encounter described at the start of this editorial? The speciality of emergency medicine provides rapid access to assessment and diagnostics that provide prognostic risk information and, commonly, reassurance to the patient that their illness or injury is not time critical or life threatening. Maybe all of that assessment can be delivered outside the ED, and Green et al. have proven that interventions in this group are rare.2 But interventions are not the whole picture.