Electronic medical record study of the rate of CT and MRI scanning of female victims of nonfatal strangulation for identification of brain injury

Background: In the US, 1 in 6 adult women will experience non-fatal strangulation (NFS) such as choking or suffocation in their lifetimes. NFS is a severe form of intimate partner violence (IPV), characterized by external pressure on the neck that can lead to hypoxic injuries which can be classified as a type of injury to the brain including traumatic brain injury (TBI). Brain injuries are best identified through CT and MRI scanning, MRI being far superior. To date the appropriate, standardized care for NFS victims allows for clinician’s judgement as to the medical necessity of CT or MRI scans to identify brain injury. It is unknown the extent to which clinicians seek those scans after an assault diagnosis in women.

Objective: This study aims to assess the rate of documented CT and MRI imaging procedures (representing a clinician decision to assess for brain injury beyond physical assessment) among female patients with a documented diagnosis of strangulation from assault.

Methods: The data was extracted from Cerner Health Facts, one of the largest HIPAA-compliant relational databases. To extract female patients most likely to have suffered from domestic assault, we used the ICD9 code 994.7 and ICD9 code E963 to clearly identify those patients suffering from assault strangulation. We limited age to 13 years and older. Patients with unknown age were excluded.

Results: The data query (from the Cerner Realdataset) identified 160 female patients aged 13 to 65 (M = 32, Std dev = 13.61) . Twelve women (7.5%) received a CT of head (combined CPT codes 87.03 and 70450) and none were coded as receiving an MRI of the head. Frequency of treatment location was as follows: 95 (59%) in the emergency room, 45 (28%) in inpatient care, 7 (4%) in observation unit, and 6 (4%) in an outpatient clinic.

Conclusion: The sample size of the study was extremely low given the 85+ million unique patients in the dataset; our conclusion was that physicians do not code for NSF assault, making studying treatment of assault victims difficult. Therefore, next steps in understanding treatment of NFS victims will include treatment of NFS broadly.

Using the frequency of CT and MRI scans as a proxy for clinical interest in understanding and identifying injury to the brain after strangulation,it appears that brain injury detection through imaging is not yet a routine focus, suggesting that the standard of care for NFS patients’ needs further establishment. Since there is no standardized care requiring scanning (even though brain injury can occur without external strangulation signs), we cannot conclude inappropriate treatment was delivered. Changes to appropriate care standards may be necessary.

Given the extremely low rate of CT or MRI imaging at the initial time of treatment, we wonder what educational discharge material patients are provided to raise their awareness of their risk of brain injury. To explore patient education, these researchers are currently conducting an OSU CHS IRB approved study of Oklahoma hospital systems’ embedded patient education provided post asphyxiation and strangulation.