Head injury triage, assessment, investigation and early management of head injury in infants, children and adults (update) Implementing NICE guidance December.

Head injurytriage, assessment, investigation and early

management of head injury in infants, children and adults (update)

Implementing NICE guidance

December 2007

NICE clinical guideline 56

Updated guidance

This guideline replaces ‘Head injury: triage, assessment, investigation and early management of head injury in infants, children and adults’ (NICE clinical guideline 4, 2003)

There was sufficient new evidence to prompt an update to be carried out which means changes in clinical practice

There are new and amended recommendations

Changing clinical practice

NICE guidelines are based on the best available evidence

The Department of Health asks NHS organisations to work towards implementing NICE guidelines

What this presentation covers

Background

Key recommendations

Implementation advice

Costs and savings

Resources from NICE

Background:why this guideline matters

An estimated 20% of head injury patients attending emergency departments in England and Wales are admitted to hospital

The guideline offers best practice for the care of all patients who present with a suspected or confirmed traumatic head injury

The guideline provides separate advice for adults and children (including infants)

It offers advice on the management of those patients who may be unaware of an injury because of intoxication or other causes

Definitions used in this guidance

Unless otherwise stated:

•infants are under 1 year of age•children are 1–15 years•adults are 16 years or older

‘Head injury’ is defined as any trauma to the head, other than superficial injuries to the face

‘Clinically important brain or cervical spine injury’ is defined as any acute finding revealed on imaging following assessment of risk factors

Key recommendations

Initial assessment in the emergency department

Urgency of imaging

Admission• Criteria for admission• When to involve the neurosurgeon

Organisation of transfer of patients between referring hospital and neuroscience unit

Advice about long-term problems and support services

All patients presenting to an ED with a head injury should be assessed by a trained member of staff within 15 minutes of arrival at hospital

This assessment should establish whether they are high risk or low risk for clinically important brain injury and/or cervical spine injury

Initial assessment in the emergency department (ED)

CT of the head should be performed and analysed within 1 hour of imaging request in patients who have any of these risk factors:

•Glasgow Coma Scale (GCS) < 13 on initial assessment in A&E or < 15 at 2 hours after injury

•Suspected open or depressed skull fracture or any sign of basal skull fracture

•Two or more episodes of vomiting in adults; three or more in children

•Post-traumatic seizure

•Coagulopathy, providing that some loss of consciousness or amnesia has been experienced

•Focal neurological deficit

Urgency of imaging: head CT

Urgency of imaging: head CT

Patients who have any of the risk factors below, and none of the risk factors on the previous slide should have CT imaging of the head performed within 8 hours of the injury:

• Amnesia for > 30 minutes of events before impact (assessment unlikely to be possible in any child aged under

5 years)

• Age 65 years, providing that some loss of consciousness or amnesia has been experienced

• Dangerous mechanism of injury (e.g. a fall from a height of > 1 metre or 5 stairs), providing that some loss of consciousness or amnesia has been

experienced

Children under 10 years of age with GCS of 8 or less should have CT imaging of the cervical spine within 1 hour of presentation or when they are sufficiently stable

Imaging of the cervical spine in all patients should be performed within 1 hour of a request having been received by the radiology department or when the patient is sufficiently stable

Where a request for urgent CT imaging of the head (within 1 hour) has also been received, the cervical spine imaging should be carried out simultaneously

Urgency of imaging:cervical spine CT

Patients with a head injury requiring hospital admission, should be admitted under a team led by a consultant who has had higher specialist training in head injury

The consultant and his/her team should have competence in assessment, observation and indications for imaging; inpatient management; indications for transfer to a neuroscience unit; and hospital discharge and follow up

Admission

New, clinically significant abnormalities on imaging

Patient has not returned to GCS 15 after imaging, regardless of the imaging results

Criteria for CT scanning fulfilled, but scan not done within appropriate period, either because CT not available or because patient not sufficiently cooperative to allow scanning

Continuing worrying signs (e.g. persistent vomiting)

Other sources of concern (e.g. drug intoxication, other injuries, non accidental injury)

Admission: Criteria

Discuss the care of all patients with new, surgically significant abnormalities on imaging with a neurosurgeon

Regardless of imaging, other reasons for discussing a patient’s care plan include:

•persisting coma (GCS ≤ 8) after initial resuscitation

•unexplained confusion for more than 4 hours

•deterioration in GCS after admission

•progressive focal neurological signs

•seizure without full recovery

•definite or suspected penetrating injury

•cerebrospinal fluid leak

Admission: When to involve the neurosurgeon

Local guidelines on the transfer of patients with head injuries should be drawn up between the referring hospital trusts, the neuroscience unit and the local ambulance service, and should recognise that:

•transfer would benefit all patients with serious head injuries (GCS ≤ 8), irrespective of the need for neurosurgery

•if transfer of those who do not require neurosurgery is not possible, ongoing liaison with the neuroscience

unit over clinical management is essential

Organisation of transfer of patients between referring hospital

and neuroscience unit

Advice about long-term problems and support services

All patients and their carers should be made aware of the possibility of long-term symptoms and disabilities following head injury and the existence of support services for long-term problems

Details of support services should be included on patient discharge advice cards

Other new or amended recommendations: presentation

and referral

GPs, nurse practitioners, dentists and ambulance crews should receive training to ensure that they are

capable of assessing the presence or absence of risk factors

Telephone advice services should refer people with a head injury who meet the risk criteria to

ambulance services for transportation to an emergency department (ED)

Community health services and NHS minor injury clinics should refer patients with a head injury who meet

the risk criteria to an ED, using the ambulance service if deemed necessary

Other new or amended recommendations: imaging

Patients may require an extended period in a recovery setting due to general anaesthesia during CT imaging

Plain X-rays (skull) should not be used to diagnose significant brain injury

If CT is unavailable, patients with GCS 15 may be admitted for observation before urgent transfer to a centre with CT in case there is a clinical deterioration

Implementation advice

Feedback to NICE suggests that there are likely to be four key areas for successful implementation:

• Training and competencies of staff

• Communication

• Configuration of services

• Local care pathways

The advice document gives information on the training required for staff responsible for looking after patients with a confirmed or suspected head injury

Training is categorised into general training requirements and training for:

• Clinicians caring for children• ambulance crews• emergency department staff• imaging staff• community staff and • training in observations

Training and competencies of staff

Communication :

Ensure that families are kept involved in the patients progress

Imaging staff should ensure that all patients with new surgically significant abnormalities or complications identified in imaging are discussed with a neurosurgeon

Patients should receive detailed written information on discharge e.g. information cards

Ensure effective communication between hospital and community services e.g. details of hospital treatment and follow up appointments such as out patient appointments

Services should be organised so that the algorithms identified in the head injury quick reference guide can be followed

Provision for out of hours imaging

Configuration of services

Ensure that services such as NHS direct and emergency department helpline are updated

Ensure that local guidelines are written for transferring patients between referring hospitals, neuroscience units and ambulance services with efficient, standardised handovers

Ensure that effective pathways between secondary and primary care are established

Local care pathways

Costs per 100,000 population

Recommendations with significant resource impactAnnual cost

£000

imaging of head in children under 16 years 1.7

imaging of cervical spine in adults and children over 10 years 9.8

transfers to neuroscience units 0.6

increased costs in tertiary care 30.6

opportunity for savings in secondary care −30.6

Total net cost of implementing the guideline 12.1

Costs and savings

The updated guideline on head injury results in additional resources and a movement of resources from secondary to tertiary care

The transfer of patients with a GCS less than 8 to a neuroscience unit will result in a transfer of resources for these admissions

It will also result in additional costs for intensive therapy units in tertiary care and a corresponding opportunity for saving in secondary care

Resources from NICE

Implementation advice

Costing tools

•costing report•costing template

Audit criteria

Bespoke tools

www.nice.org.uk/CG056

Access the guideline online

Quick reference guide – a summary

NICE guideline – all of the recommendations

Full guideline – all of the evidence and rationale

‘Understanding NICE guidance’ – a version for patients and carers

www.nice.org.uk/CG056