An alternative admission pathway to the Emergency Department for older people after fall with head injury: A service evaluation

Introduction

Following the NICE head injury guideline update in 2023, the Older Persons Same Day Emergency Care Unit (OSDEC) at Portsmouth Hospitals University NHS Trust updated the admission criteria to include older people (>85 years or >75 years with Parkinson’s Disease) presenting with fall and head injury (without any other significant trauma) on anticoagulation or antiplatelet medications (excluding aspirin monotherapy). Older people are admitted directly to OSDEC from ambulance/community services or are admitted from the Emergency Department (ED). This service evaluation aims to determine the effectiveness and safety following the change in admission criteria.

Methods

Older people who presented with fall and suspected head injury between October 2023 to March 2024 were included by reviewing ambulance records, electronic medical records and discharge summaries.

Results

A total of 161 older people (mean age=92 years, median Clinical Frailty Score=6) on anticoagulation/antiplatelet medications presented with fall and potential head injury. Nearly all (N=160, 99%) had a GCS of ≥14 on admission. CT head imaging was conducted in 126 (78%) older people of which 89 had imaging completed in ED, 37 in OSDEC and one on the inpatient ward. Only two (1%) older people had evidence of traumatic brain injury (TBI) on CT head. Same-day discharge was achieved in 64 (40%) patients, anticoagulation was stopped for eleven (7%) patients. Nine (6%) older people were readmitted within 7 days, unrelated to their head injury. Three older people died during their onward admissions with no evidence of TBI on CT head imaging.

Conclusion

OSDEC is a safe alternative direct admission pathway for older people presenting with a fall and head injury on anticoagulation and/or antiplatelet medications. This reduces time spent in ED, increases timely access to senior decision-makers regarding need for CT head imaging, allows multidisciplinary falls review and shared decision-making discussions around anticoagulation/antiplatelet medications.