Improving person-centred decision-making for care home residents with head injury: data-driven, frailty-attuned pathway redesign
Abstract
Introduction
Care home residents taking antithrombotic medication - anticoagulants or antiplatelets – who sustain head injury often attend emergency departments (EDs) to rule out intracranial haemorrhage. Many may be unsuitable for neurosurgery, or may not wish to attend hospital. Locally, there was no agreed pathway to support advance care planning or shared decision-making for care home residents with head injury.
We wished to understand the outcomes of care home residents conveyed to ED with head injury and use these findings to develop a more person-centred pathway.
Method
We undertook a retrospective study of care home residents presenting to Leeds Teaching Hospitals NHS Trust EDs with head injury between October 2022 and March 2024. Data collected included clinical frailty score (CFS), ReSPECT forms, antithrombotic therapy, CT head findings, interventions and medication changes.
Results
409 residents attended with head injuries (median CFS 6). 76.5% had CT head imaging. 18 scanned patients had intracranial haemorrhages (5.8%). No patients underwent neurosurgery. 3 patients had anticoagulation reversal. 68% had an existing ReSPECT form but none covered head injury. 75% were discharged back to their care home from ED. Of those admitted, 89% were admitted under geriatric medicine.
Discussion
Despite frequent CT imaging, care home residents did not receive neurosurgical intervention. We are designing a pathway to support shared decision-making with an aim to reduce conveyance to hospital where no value is added to a person's car
Comments
The finding that 68% of…
The finding that 68% of patients had ReSPECT forms but none addressed head injury is striking. It highlights an urgent educational and operational need to expand on anticipatory care plans to cover more eventualities to avoid unnecessary hospitalisation, particularly seeing as there were no neurosurgical interventions for any of the patients despite a small percentage having the positive finding of intracranial haemorrhage.
Anticoagulation reversal
Think this is a really impactful project that opens up avenues to avoid unnecessary admissions and focus on QOL for frail patients. I'd be interested to know what the groups thoughts are on what the best avenue would be for those patients who are anticoagulated, for whom there is a rationale to consider attendance even if surgical intervention is extremely unlikely given that they may benefit from reversal of their anticoagulant. Or whether the first step is to bind the choice to anticoagulate in the first place to what the patients wishes would be in the event of head trauma?