2. Head injury audit 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 Accident and Emergency Department, Grantham and District Hospital 27 th July 2006 United Lincolnshire Hospitals NHS Trust

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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.

12. 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

13. 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 co- operative to allow scanning.

14. 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).

15. 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

16. 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.

17. Demographics Age range 1-98 Mean 32 Males 48% Females 52%

18. Triage

19. 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

20. 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%

21. Low risk patients 77% of all patients (63) None had CT scans One admitted, not relating to head injury

22. 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

23. History recording – Paeds (<16)

24. History recording – Adults (>16)

25. Examination recording - Paeds

26. Examination recording - Adults

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. Questions?

35. Thank you Copyright 2006 www.clinicalaudit.org