Areas for Improvement in the Treatment of Fall-Related Intracranial Bleeding in Older Adults

Thank you Bryan, genuinely. This is exactly the tension we sat with when we were interpreting our own findings, and I'm glad this poster has made it visible enough for someone to ask it aloud.

On the Oxford position: I have to be honest that we don't have a formal steer from the neurosurgical centre specifically in this age group. What I can tell you is that in all five of our GCS <8 patients, a neurosurgical discussion was held and documented via the Online Acute Referral System (OARS), and in none of those cases was transfer recommended. I'd be interested to hear how Oxford approach this in older frail patients, because that conversation would be useful for our next cycle. From what Dr Anthony Cox just said in the 10:30 talk, its sounds like these neurosurgical meetings tend to rule out patients on ground of frail pretty quickly. 

On our own team's position: the data makes it hard for us to advocate for blanket transfer in this cohort. Two of our five patients were on a palliative pathway within days of admission. The other three had active goals-of-care conversations that shaped their management locally, with specialist input by phone. Transferring an 80 or 86 year old, away from their family, to receive supportive care that we can deliver with remote neurosurgical advice - it's a difficult ask to justify on patient-centred grounds, and our data doesn't give us a reason to think we got that wrong. I'd like to see the availability of a middle meningeal embolisation service for these conservatively managed patients. 

On the guideline itself: I think you've put your finger on something important. NG232 is a guideline for intracranial bleeding across all age groups, and it wasn't written with the frail octogenarian falls patient primarily in mind. What it doesn't yet give us is clear guidance on the goals-of-care conversation that has to happen first in this population. Until it does, we'd argue that the more meaningful quality metric isn't whether transfer happened, but whether that specialist discussion was documented and informed the plan. That's what we've been capturing prospectively and will report on in the next cycle.

What we genuinely can't answer from this dataset is whether any of our non-transferred patients would have had a meaningfully better outcome with in-person specialist neurological care. That's a real question, and it's probably one that needs a network study to answer properly. If that's a conversation worth having at network level - we'd very much want to be part of it.

Thank you - great question, and no, ICB was far from the only injury in many cases. Around half our patients had associated injuries documented — we had limb fractures in 10, skull fractures in 10, central or spinal injuries in 14, and soft tissue injuries in 11. There were some significant polytrauma cases in there - cervical spine fractures, haemopneumothorax, NOF fractures alongside the head injury. So the transfer question gets even more complicated when you factor in that some of these patients had injuries that needed managing locally regardless.

And yes - I suspect what you're describing is exactly what we see. The practical reality at a DGH is that the conversation with the neurosurgical centre happens, the advice is sensible and usually manage locally. However the friction around physical transfer — logistics, family, fitness for transfer, bed availability — means transfer rarely happens even when it theoretically should. It would be really interesting to know whether your experience mirrors ours on the GCS threshold question specifically.

Thank you and yes, we're seeing exactly the same demographic pressure at Royal Berkshire, so this feels very familiar.

On the MTU question yes, the Royal Berkshire Hospital (Reading) is not a Trauma Unit within the Thames Valley Trauma Network, and the Major Trauma Centre for the region is the John Radcliffe Hospital in Oxford. Despite a local CT head SOP, we still find they often miss the window.

On TXA - there are limits to our data. We captured whether TXA was given at any time point during the patient journey including pre-hospitably, but we can't tell you from this dataset whether those patients received pre-hospital TXA, whether the full 2g was given, or the breakdown of timing. Thank you for highlighting the importance, and we can build it into the next cycle, so watch this space.

We did capture data on reversal, which didn't make it to the poster here. Of the 12 patients who received Beriplex, 7 were on a NOAC and 5 were on Warfarin, which suggests PCC reversal was happening in practice, all had a documented haematology discussion. Warfarin was reversed in all cases, however only a portion of the total patients on NOACs were reversed 12/19 admitted on a NOAC.

On transfer - I'd push back slightly on the framing. We're not advocating transferring all patients who meet criteria. The quote “Transfer would benefit anyone with a GCS <8 irrespective of the need for neurosurgery" is taken from the NICE guideline 232 1.8.1. It's an ambitious sentiment which we know is far from practice. Our finding is that specialist neurosurgical discussion happened in all appropriate GCS <8 cases, and in all cases the clinical decision was to manage locally with remote input. In a frail elderly cohort, transferring patients away from their families for supportive care that can be delivered locally with a phone call is very hard to justify. We're very much aligned with you on resource stewardship. I think we could make better use of local resources, with recognition that we often manage stroke at a high level in DGH, it feels like we have resources locally and just need clear local strategy. If MTCs would define in NICE guidance what TU "local management" could look like we can advocate for ourselves to be equipped the service resembling what we see in Stroke Units.