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United Lincolnshire Hospitals NHS Trust
Head injury audit
Accident and Emergency Department, Grantham and District Hospital
Dr Ivo Dukic, Senior House Officer in Emergency Medicine
Ms Caroline Plant, Staff Nurse in Emergency Medicine
Dr Feroz Rahim, Staff Grade in Emergency Medicine
27th July 2006
Background
• Head injury - 5-7% of attendances
• Majority of head injuries are minor
• NICE Head Injury guidelines 2003
– CT use increase
– Decreased use of Skull x-rays
Aims
1. To ensure appropriate assessment,
management and documentation
2. To avoid discharging potentially serious
head injuries
3. Improve record keeping
4. To assess comparative effectiveness
Guidance
• NICE Guidelines 2003 for Head injury
– Based upon Canadian CT head rules
– Increased use of CT scanning
– Dependant on adequate triage into three
groups of patients
• High risk
• Medium risk
• Low risk
Guidance
• Initial assessment
– All patients triaged within 15 minutes of arrival
– High risk patients seen by clinician within 25
minutes of arrival
– Low risk patients seen by clinician within 75
minutes of arrival
High risk patients
• Criteria (Canadian CT Head Rules, Lancet
2001)
– GCS less than 13 at any point since the injury
– GCS equal to 13 or 14 at 2 hours after the
injury
– Suspected open or depressed skull fracture
– Any sign of basal skull fracture
(haemotympanum, ‘panda’ eyes, CSF
otorrhoea, Battle’s sign)
– Post-traumatic seizure
– Focal neurological deficit
High risk
– More than one episode of vomiting (clinical
judgement)
– Amnesia greater than 30 minutes before
event
– Loss of consciousness or amnesia since
injury and
• Age more than or equal to 65 or
• Coagulopathy (history of bleeding, clotting
disorder, current treatment with warfarin)
• Request CT immediately
• Recommended CT within 1 hour of request
Medium risk patients
• Loss of consciousness or amnesia since injury
and
• Dangerous mechanism of injury
• Or amnesia of greater than 30 minutes before
impact
• Recommended CT with 8 hours of injury and
admission for observation until CT scan is
carried out.
Low risk
• All other presentations with head injury
• Skull X-ray recommendations
– Suspicion of non-accidental injury in infant and young
children.
– Where CT scanning resources are unavailable
• Additional criteria
– No systemic analgesia prior to assessment
– Head injury advice, verbal and written (low risk)
– Suitable adult to supervise low risk patients at home
Admission criteria
• Patients with new, clinically significant
abnormalities on imaging.
• Patients who have not returned to GCS equal to
15 after imaging, regardless of the imaging
results.
• When a patient fulfils the criteria for CT scanning
but this cannot be done within the appropriate
period, either because CT is not available or
because the patient is not sufficiently cooperative to allow scanning.
Admission criteria
• Continuing worrying signs of concern to the
clinician (for example, persistent vomiting,
severe headaches).
• Other sources of concern to the clinician (for
example, drug or alcohol intoxication, other
injuries, shock, suspected non-accidental injury,
meningism, cerebrospinal fluid leak).
Methods
•
•
•
•
Retrospective review of month of March cases
All ages included
Anatomical part ‘head’ used as search criteria
Microsoft Access Database, Excel used for
analysis of collected data
Results
•
•
•
•
Month of March 2006
2384 patients seen in A&E
81 cases of head injury
3.4% of all cases seen in this month
– Usual case load for A&E 5%-7%*
*
Hassan Z, Smith M, Littlewood S et al. Head injuries: a study evaluating the impact of the
NICE head injury guidelines Emerg Med J 2005;22:845–849.
Demographics
Age distribution of head injuries
36%
43%
Paediatric (<16)
Adults (16-65)
Elderly (>65)
21%
• Age range 1-98
• Mean 32
• Males 48% Females 52%
Triage
Triage effectiveness
100
Yes
Percentage
80
No
60
Yes
No
Yes
40
20
0
No
Triaged in 15 mins
Doctor within 25 mins
Doctor within 75 mins
Yes
51
37
88
No
49
63
12
High risk patients
•
•
•
•
10% of all patients
75% triaged within 15 minutes
75% seen by doctor within 25 minutes
1 out of 8 patients had CT scan
– No request made for others (88%)
– 1 patient admitted,
– 88% sent home without CT scan
• No record of HI instructions for 25%
• No record of responsible adult for 25%
• 1 transfer out of hospital for neurosurgery
Medium risk patients
•
•
•
•
•
•
•
•
12% of all patients (10)
60% not seen within 25 minutes
30% not seen within 75 minutes
None admitted
None had CT scans
One had a skull X-ray
All sent home with head injury instructions
No responsible adult recorded in 10%
Low risk patients
• 77% of all patients (63)
• None had CT scans
• One admitted, not relating to head injury
General
• GCS recording
– 98% (80) recorded a GCS
• Systemic analgesia
– 98% (80) not given
• Head injury instructions
– 11% (9) not recorded as given
• Home with responsible adult
– 23% (18) not recorded
History recording – Paeds (<16)
Percentage history not recorded
Dangerous mechanism of injury
3
PMH of clotting or bleeding disorder
60
History
Anticoagulants
69
Drug history
29
Post traumatic seizure
83
Headache
23
Vomiting >1 episode
11
Loss of consciousness > 5 mins
6
Amnesia for >30 mins
88
0
10
20
30
40
50
60
Percentage
70
80
90
100
History recording – Adults (>16)
Percentage of history not recorded
Dangerous mechanism of injury
11
PMH of clotting or bleeding disorder
50
57
Anticoagulants
History
Drug history
11
Post traumatic seizure
83
57
Headache
Vomiting >1 episode
17
Loss of consciousness > 5 mins
15
76
Amnesia for >30 mins
0
10
20
30
40
50
60
Percentage
70
80
90
100
Examination recording - Paeds
Percentage of examination not recorded
Examination
Neurological exam
31
Suspected skull fracture
23
Any sign of basal skull
fracture
43
Pupil status
9
0
10
20
30
40
50
60
Percentage
70
80
90
100
Examination recording - Adults
Percentgage of examination not recorded
41
Examination
Neurological exam
Suspected skull
fracture
35
Any sign of basal skull
fracture
50
Pupil status
15
0
10
20
30
40
50
60
Percentage
70
80
90
100
Management
•
•
•
•
•
•
Discharged: 98% (79)
Admission: 2% (2 – one not for neuro-obs)
CT scans: 1 (1 positive)
1 transfer to neurosurgery
Skull X-ray: 1 (1 negative)
No re-attendances in March
Previous audit - Jan 2006
• Concentrated on observations including
HR and pulse??
• GCS recording improved
• ‘No patients’ with positive indicators for
CT??
• Recommended GCS and pupil recording
at triage
Previous audit - July 2005
• 5% of patients with positive indicators did
not have immediate CT??
• Incomplete data around indicators??
• 79% discharge rate
• Standardised pro-forma to be introduced
including relevant indicators for CT
Relative performance
•
•
*
Better at recording GCS and pupil status
than two DGH audit*
Similar CT scan rate to pre NICE
guideline implementation*
Miller et al., Audit of head injury management in Accident and Emergency
at two hospitals: implications for NICE CT guidelines. BMC Health
Services Research 2004, 4:7 doi:10.1186/1472-6963-4-7
Summary
•
•
•
•
•
•
Time to see a clinician is low
Improved GCS and pupil recording
Inappropriate discharge of majority of
high risk and all medium risk patients
Low level of record keeping of events
Poor compliance with NICE guidance
CT scans are not being requested or
requests not documented
Recommendations
•
•
•
Introduction of a pro-forma for all head
injury patients based upon NICE
guidelines 2003
Teaching of guidance and clear access
to guidance for all new and existing staff
Improved focus on triage within 15
minutes and stratification of high risk and
low risk patients
Recommendations
• Increased use of CT scanning for high risk
and medium risk patients
• Head injury instructions and responsible
adult to be documented
• If patients meet NICE guidance, staff
grade to review need for CT scanning
based on latest evidence for head injury
– Full report and audit resources at
http://www.clinicalaudit.org
Questions?
Thank you
Copyright 2006 www.clinicalaudit.org