Computed Tomography Head Ordering Practices in Residential Aged Care Facility Residents Presenting to Emergency Department After an Unwitnessed Fall

Objective:
To determine CT head imaging rates, yield and emergent intervention rate (neurosurgery, cessation or reversal of anticoagulants) in residential aged care facility (RACF) residents presenting to ED with an unwitnessed fall. Secondary objectives included a description of shared decision-making discussions with patients or substitute decision makers regarding ED transfer and CT head imaging.

Methods:
Retrospective cross-sectional study of residential aged care residents aged over 65 years presenting with unwitnessed falls at two university-affiliated tertiary EDs between 1 January and 30 June 2024. Dual independent data extraction of medical records assessed CT imaging use and yield, which was defined as new intracranial haemorrhage on the radiology report. Change of management and shared decision-making were defined by documentation in the medical record. Data analyses were descriptive, and associations were reported using the odds ratio with 95% confidence intervals.

Results:
Of 398 patients, 235 (59%) underwent CTH imaging and intracranial haemorrhage was identified in 10 patients (4.3%). No patients underwent neurosurgery. Anticoagulation was ceased in four patients. Shared decision-making was documented for hospital transfer in 14.1% of patients, 13.8% of patients receiving CTH and 25.1% among patients who did not undergo imaging. Patients with signs of head injury, on anticoagulation or evidence of polytrauma were more likely to receive a CTH.

Conclusions:
CT head imaging was common among RACF residents with unwitnessed falls despite low diagnostic yield and infrequent changes in management, with no neurosurgical intervention in our cohort. Limited documentation of SDM calls for stronger integration of meaningful patient-centred discussions to reduce avoidable transfers and imaging.