Mild and moderate traumatic brain injury: Screening, documentation, and referral to concussion services.

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.