Years since first academic appointment: Less than 5 years
Title: The Falls study
Full author list: Kerstin de Wit, Clive Kearon, Andrew Worster
Background
Seniors accounted for 16.1% of Canadians in July 2015, with a predicted rise over the next decade of baby boom seniors. Elderly frequently present to the Emergency department with falls and half of all deaths from falls in the elderly are caused by head injuries.
It can be difficult for Emergency department physicians to determine which seniors should have a head CT scan after falling, and practices vary. Increasingly, elderly patients are prescribed anticoagulant and / or antiplatelet medications. Furthermore, elderly who fall are often dehydrated with other acute illnesses such as kidney injury and infection. Currently there is no way to determine who is at risk of intracranial bleeding and who requires a CT head scan. If every patient underwent CT scanning, there would be a significant burden on radiology services, long delays in the Emergency department and only a very small proportion of positive scans.
Aim
This is a prospective cohort study to evaluate clinical predictors of intracranial bleeding in elderly patients who present to the emergency department after a fall.
Methods
Patients ≥ age 65, who present to the Emergency department following a fall. Inclusion criteria are having had a fall from standing, sitting, out of bed or down ≤2 steps within the last 48 hours. Exclusion criteria include major trauma resuscitations such as motor vehicle collisions or falls from a height.
Consent is obtained from the patient or their substitute decision maker. If consent is not possible to obtain, for example the patient has dementia and no relatives can be contacted, the patient is followed by retrospective chart review alone (research ethics board approved).
Primary outcome: The incidence of intracranial bleeding (including subdural, subarachnoid, extradural, intracerebral and cerebral contusion) at presentation or during the following 6 weeks.
Measurement of the primary outcome: CT head scanning will be left to the discretion of the treating physician. Patients are followed for a total of 6 weeks by scrutinizing the hospital records, and by interviewing the patient or their carer by telephone at 6 weeks. An independent adjudication panel (consisting of a neurologist, a neurosurgeon and an emergency physician) will review all cases where an intracranial bleed was thought possible, or was diagnosed.
Secondary outcome: We will analyze the pre-specified hypotheses that modification of the Canadian CT head rule with the addition of anticoagulant use, will differentiate between elderly patients who fall and sustain an intracranial bleed, and those who do not sustain an intracranial bleed.
We will report [the proportion with intracranial bleeding and a modified Canadian CT head (mCCTH) score of 3 or more] and [the proportion with intracranial bleeding and a mCCTH score of 2 or less].
Tertiary outcome: Regression model analysis of all collected variables to create an alternative new Falls CT rule.
Progress
The Falls Study started in two Hamilton Health Sciences Emergency Departments on the 12th December 2015. To date a total of 1,007 patients have been identified and 511 have completed follow up.
QUESTIONS
- Where should I apply for multicentre funding?
- I do not think that the modified Canadian head CT rule will be predictive of intracranial bleed, but have been advised to keep it in the protocol to give a structured approach. Do you agree?
- Would your emergency department like to participate in a multicentre study?