Falls and anticoagulation; a "NICE" opportunity to step away from CT scanning?

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Dr R Mallinson1, Dr E Reid2, Dr S Gilson2, Dr K Morris2, Dr R Kitchener3 and Dr J Brown1

1 Queen Alexandra Hospital, Portsmouth, 2 University Hospital Southampton, 3 University Hospital Dorset

Abstract

With an ageing population, the number of older people attending emergency departments with head injuries is increasing. 2023 NICE guidelines advise to consider a CT scan for these patients who have sustained a head injury and have no other indication for a CT head scan but are on anticoagulation treatment or antiplatelet treatment. However, there are time, financial and personal costs of hospital conveyance to facilitate scanning to both individuals and the wider system.

Method

Across two UK, South coast hospitals, retrospective review of requests for CT brains from 1964 patients over 80years old were performed. Patients who underwent a full trauma scan of which CT head was part or had other criteria within NICE guidelines to preform scanning were excluded. This resulted in 624 patients who underwent CT head scan purely because of the use of anticoagulation in head injury. CT head reports were then reviewed for traumatic findings and notes viewed for treatments.

Results

In 4 consecutive months of 2021 at Southampton, 302 scans were preformed and in 6 consecutive months of 2023 at Portsmouth emergency departments 322 scans were performed. Only 10 cases across both sites had a traumatic bleed on CTB report. None of the 10 cases underwent surgical intervention. Discussions around decisions to pause and the duration of pause of anticoagulation medication was inconsistent, despite neurosurgical advice in all.

Conclusion

With advancing age and frailty, it is likely that a significant proportion of patients over 80 undergoing a CT head scan for traumatic injury would not be for surgical intervention in the event of an acute bleed. With long waiting times in emergency departments, it may not be in the patient’s best interest to be subjected to the process of CT imaging when the only indication is anticoagulant use. Clear decisions around goals of care and shared risk-benefit discussions may reduce scanning burden for both individuals and the wider system.