Evaluation of a team-based approach for emergency department patients with time critical intracranial conditions

Introduction

Many time-critical neurosurgical brain conditions do not meet traditional ED major trauma or stroke team activation criteria and thus do not benefit from the associated expedited imaging and specialist review. To address this, a “Critical Head” protocol was developed. The aim was to determine the effect of this on time to CT scan, neurosurgical intervention (if indicated) and specialist team review.

Method

Quasi-experimental study, involving retrospective analyses of data of all potential Critical Head patients presenting to Wollongong ED from 1 January 2018 to 26 May 2023, with the protocol go-live on 7 March 2023. Descriptive statistics and study outcomes were compared before and after protocol implementation. R Studio 2024 was used for analyses and alpha was set to 0.05.

Results

Two hundred and two patients were included (123 control/pre-intervention, 119 intervention). There was no significant difference in age, sex or presence of intracranial conditions between groups. Median time from triage to CT decreased in the intervention group by 15% (7 min, 47[33,95] to 40[25,66], P = 0.020). There was a 33% (67 min) reduction to surgery start time in the intervention (204[621752] to 137[108247] min, P = 0.042) (urgent neurosurgery). Reductions in time to specialist team reviews were observed in ICU (n = 86, 132[58192] to 42[6103] min, P < 0.001) and neurosurgery (n = 158, 104[69 202] to 44[16111] min, P < 0.001). ICU and hospital length of stay did not differ significantly, nor did Glasgow Coma Outcome Scale score at discharge.

Conclusion

The Critical Head protocol for patients with time-critical intracranial conditions reduced time to CT scan, operative intervention and specialist team review.