A clinical decision rule to predict adult patients with traumatic intracranial haemorrhage who do not require intensive care unit admission

Objective: To derive a clinical decision rule to identify adult emergency department (ED) patients with traumatic intracranial haemorrhage (tICH) who are at low risk for requiring critical care resources during hospitalization.

Methods: This is a retrospective cohort study of patients (≥ 18 years) with tICH presenting to the ED. The need for intensive care unit (ICU) admission was defined as the presence of a critical care intervention including: intubation, neurosurgical intervention, blood product transfusion, vasopressor or inotrope administration, invasive monitoring for haemodynamic instability, emergent treatment for arrhythmia, therapeutic angiography, and cardiopulmonary resuscitation. The decision rule was derived using binary recursive partitioning.

Results: A total of 432 patients were identified (median age 48 years) of which 174 patients (40%) had a critical care intervention. We performed binary recursive partitioning with Classification and Regression Trees (CART) software to develop the clinical decision rule. Patients with a normal mental status (Glasgow Coma Score=15), isolated head injury, and age<65 were considered low risk for a critical care intervention. The derived rule had a sensitivity of 98% (95% confidence interval [CI] 94-99), a specificity of 50% (95% CI 44-56), a positive predictive value of 57% (95% CI 51-62), and a negative predictive value of 97% (95% CI 93-99). The area under the curve for the decision rule was 0.74 (95% CI 0.70-0.77).

Conclusions: This clinical decision rule identifies low risk adult ED patients with tICH who do not need ICU admission. Further validation and refinement of these findings would allow for more appropriate ICU resource utilisation.