Journal Article

Derivation of the Falls Decision Rule to exclude intracranial bleeding without head CT in older adults who have fallen

Papaioannou, Alexandra, Jeanmonod, Rebecca, Émond, Marcel, Mercier, Éric, Morris, Judy, Eagles, Debra, McLeod, Shelley, Worster, Andrew, Kagoma, Yoan K., Ali, Mariyam, Mercuri, Mathew, Varner, Catherine, Shoamanesh, Ashkan, Engels, Paul, Clayton, Natasha, Stiell, Ian, Buchanan, Ian M., de Wit, Kerstin, Sharma, Sunjay, Barbic, David, Parpia, Sameer

2023

Overview

Ground-level falls are common among older adults and are the most frequent cause of traumatic intracranial bleeding. The aim of this study was to derive a clinical decision rule that safely excludes clinically important intracranial bleeding in older adults who present to the emergency department after a fall, without the need for a computed tomography (CT) scan of the head. This prospective cohort study in 11 emergency departments in Canada and the United States enrolled patients aged 65 years or older who presented after falling from standing on level ground, off a chair or toilet seat, or out of bed. We collected data on 17 potential predictor variables. The primary outcome was the diagnosis of clinically important intracranial bleeding within 42 days of the index emergency department visit. An independent adjudication committee, blinded to baseline data, determined the primary outcome. We derived a clinical decision rule using logistic regression. The cohort included 4308 participants, with a median age of 83 years; 2770 (64%) were female, 1119 (26%) took anticoagulant medication and 1567 (36%) took antiplatelet medication. Of the participants, 139 (3.2%) received a diagnosis of clinically important intracranial bleeding. We developed a decision rule indicating that no head CT is required if there is no history of head injury on falling; no amnesia of the fall; no new abnormality on neurologic examination; and the Clinical Frailty Scale score is less than 5. Rule sensitivity was 98.6% (95% confidence interval [CI] 94.9%–99.6%), specificity was 20.3% (95% CI 19.1%–21.5%) and negative predictive value was 99.8% (95% CI 99.2%–99.9%). We derived a Falls Decision Rule, which requires external validation, followed by clinical impact assessment. Trial registration: ClinicalTrials. gov, no. NCT03745755.

• Publisher: Elsevier Inc,CMA Impact Inc,CMA Impact, Inc
• Subject: Adults / Aged / Aged, 80 and over / Amnesia / Anticoagulants / Anticoagulants (Medicine) / Bats / Cohort analysis / Complications and side effects / Consciousness / Craniocerebral Trauma - diagnostic imaging / CT imaging / Decision making / Departments / Diagnosis / Emergency medical care / Emergency Service, Hospital / Evaluation / Fainting / Falls (Accidents) / Female / Head injuries / Health aspects / Hospitals / Humans / Internal Medicine / Intracranial Hemorrhages - diagnostic imaging / Male / Medical imaging / Medical prognosis / Neurosurgery / Older people / Patient assessment / Physiological aspects / Prospective Studies / Regression analysis / Risk factors / Tomography / Tomography, X-Ray Computed / Variables