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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