The ACT Alert: Preliminary Results of a Novel Protocol to Assess Geriatric Head Trauma Patients on Anticoagulation

Abstract

In busy emergency departments (EDs), elderly patients on anticoagulation (AC) sustaining minor injuries who are triaged to a lower priority for evaluation are at risk for potentially serious consequences. We sought to determine if a novel ED protocol prioritizes workup and improves outcome. In a Pennsylvania-verified Level II trauma center, the ACT (AntiCoagulation and Trauma) Alert was implemented in March 2012. Triage parameters include: age 65 years or older, AC agents, Glasgow Coma Score (GCS) 13 or greater, and head trauma 24 hours or less. ACT Alerts are announced overhead in the ED and require assessment by an ED physician, nurse, and phlebotomist in 15 minutes or less. Furthermore, they necessitate Point of Care international normalized ratio (INR) 20 minutes or less and head computed tomography (CT) scan 30 minutes or less. Positive CT findings mandate trauma service consultation. ACT Alert patients from March to December 2012 were compared with ED patients 65 years or older, GCS 13 or greater, on AC with the same chief complaints as ACT Alerts from June 2011 to February 2012 (control). A P value ≤ 0.05 was considered significant. Of 752 study patients, 415 were ACT and 337 were controls. There were no significant differences between groups in age, elevated INR, or head bleeds. ACT patients had significantly shorter median times from ED arrival to INR (ACT 13 minutes vs control 80 minutes; P < 0.001) and to head CT (ACT 35 minutes vs control 65 minutes; P < 0.001). Of admitted patients, ACT had a significantly shorter median length of stay (LOS) (ACT 3.7 days vs control 5.0 days; P < 0.001). Although trends toward improved outcome were noted, no statistically significant differences were identified. The ACT Alert improves ED throughput and reduces hospital LOS while effectively identifying at-risk, mildly head injured geriatric patients on AC.