1. Implementing NICE guidance
Head injury
triage, assessment, investigation and early management of head injury in infants, children and adults (update)
ABOUT THIS PRESENTATION:
This is a partial update of NICE clinical guideline 4 (published June 2003). The updated guideline covers the care received from primary care, ambulance and A&E staff who have direct contact with and make decisions concerning the care of patients who present with suspected or confirmed head injury. It recognises the need for care to be integrated between the primary and secondary sectors.
You may want to hand out copies of the quick reference guide at your presentation so that your audience can refer to it. The quick reference guide can be downloaded from or you can order printed copies – for more details please see the NOTES FOR PRESENTERS of the ‘Access the guideline online’ slide at the end of this presentation.
You can add your own organisation’s logo alongside the NICE logo. We have included notes for presenters amplifying the content of the slides: please feel free to adapt, amend or remove these as you see necessary.
At the bottom right-hand corner of some slides in this presentation there is a ‘tools symbol’. Slides with this symbol show suggested actions that may be useful when implementing recommendations. Slides showing the recommendations themselves or other information do not have this symbol.
DISCLAIMER
This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself.
Implementing NICE guidance
December 2007
NICE clinical guideline 56

2. 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
NOTES FOR PRESENTERS:
There was sufficient new evidence to prompt a partial update to be carried out (see section 2 of the full guideline). This guideline is an update of a previous guideline. Some of the recommendations are new and some are amended. This is indicated in the presenter notes.
New and amended recommendations
This presentation will cover the key priorities for implementation as well as highlight other new or amended recommendations that are not key priorities for implementation but are changes form the original guideline due to the availability of new evidence.
NICE clinical guidelines are updated as needed so that recommendations take into account important new information. We check for new evidence 2 and 4 years after publication, to decide whether all or part of the guideline should be updated. If important new evidence is published at other times, we may decide to do a more rapid update of some recommendations.

3. 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
NOTES FOR PRESENTERS:
NICE clinical guidelines aim to ensure that promotion of good health and patient care in the NHS are in line with the best available evidence of clinical effectiveness and cost effectiveness. Guidelines help healthcare professionals in their work, but they do not replace their knowledge and skills.
The Healthcare Commission assesses the performance of NHS organisations in meeting core and developmental standards set by the Department of Health in ‘Standards for better health’ issued in July 2004 and updated in April Core standard C5 states that nationally agreed guidance should be taken into account when NHS organisations are planning and delivering care.

4. What this presentation covers
Background
Key recommendations
Implementation advice
Costs and savings
Resources from NICE
NOTES FOR PRESENTERS:
This presentation covers the background to the updated head injury guideline, the key recommendations and implementation advice to support putting the guideline into practice.
It contains information about the costs and savings that are likely to be incurred in implementing the guideline, and practical tools that are available from NICE to support implementation.

5. 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
NOTES FOR PRESENTERS:
This presentation has been written to raise awareness of the NICE clinical guideline on head jnjury.
It is estimated that head injury admissions represent around 20% of all head injury attenders, which would imply around 280,000 patients per annum attending emergency departments in England and Wales with a head injury.
The guideline offers best practice for the care of all patients who present with a suspected or confirmed traumatic head injury with or without other major trauma.
Separate advice is provided for adults and children (including infants)
It offers advice on the management of patients with a suspected or confirmed head injury who may be unaware that they have had sustained a head injury because of intoxication or other causes.
The guideline does not provide advice on the management of patients with other traumatic injury to the head (for example, superficial injury to the eye or face).
It does not address the rehabilitation or long-term care of patients with a head injury but the guideline does explore possible criteria for the early identification of patients who require rehabilitation.

6. 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
NOTES FOR PRESENTERS:
In this guide, unless otherwise stated:
– infants are under 1 year of age
– children are 1–15 years
– adults are 16 or older
For the purposes of this guideline, ‘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 as outlined on pages 8–11 of the quick reference guide and later in this presentation.

7. 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
NOTES FOR PRESENTERS:
The NICE guideline contains lots of recommendations about how care can be improved, but the experts who wrote the guideline have chosen key recommendations that they think will have the most impact on care and are the most important priorities for implementation. The key recommendations fall into these five areas and you can find them at the front of your quick reference guide. We shall consider each in turn.

8. Initial assessment in the emergency department (ED)
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
NOTES FOR PRESENTERS:
All patients presenting to an emergency department with a head injury should be assessed by a trained member of staff within a maximum of 15 minutes of arrival at hospital.
Part of this assessment should establish whether they are high risk or low risk for clinically important brain injury and/or cervical spine injury, using the guidance on patient selection and urgency for imaging (head and cervical spine).
This is not key recommendation but key information in managing the care of patients who have had a head injury -
NICE guideline Patients who have returned to an emergency department within 48 hours of discharge with any persistent complaint relating to the initial head injury should be seen by or discussed with a senior clinician experienced in head injuries, and considered for a CT scan.

9. Urgency of imaging: head CT
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
NOTES FOR PRESENTERS:
The new guideline contains the amended recommendation that CT imaging of the head should be performed (that is, imaging carried out and results analysed) within 1 hour of the request having been received by the radiology department in those patients where imaging is requested because of any of the risk factors listed in box 7 on page 20 of the NICE guideline. These are:
GCS < 13 on initial assessment in the emergency department
GCS < 15 at 2 hours after the injury
Suspected open or depressed skull fracture. Suspect if mechanism of injury includes sharp object, crushing or high velocity impact. Signs of basal fracture such as (Battles, bleeding from ear, behind eye). Depressed vault fracture suspected on careful palpation of wound with gloved finger.
Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
Two or more episodes of vomiting in adults; three or more in children.
Post-traumatic seizure
Coagulopathy (history of bleeding, clotting disorder, current treatment with warfarin), providing that some loss of consciousness or amnesia has been experienced; patients receiving antiplatelet therapy may be at increased risk of intracranial bleeding, though this is currently unquantified – clinical judgement should be used to assess the need for an urgent scan in these patients
Focal neurological deficit

10. 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
NOTES FOR PRESENTERS:
The updated guideline contains the amended recommendation that patients who have any the following risk factors and none of the risk factors on the previous slide should have CT imaging of the head performed within 8 hours of the injury (imaging should be performed immediately in these patients if they present 8 hours or more after their injury). These risk factors are listed in box 8 on page 21 of the NICE guideline.
Amnesia for greater than 30 minutes of events before impact (the assessment of amnesia will not be possible in pre-verbal children and is 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 (a pedestrian struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or five stairs) providing that some loss of consciousness or amnesia has been experienced.

11. Urgency of imaging: cervical spine CT
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
NOTES FOR PRESENTERS:
The updated guideline contains the new recommendation that 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
It also contains the amended recommendation that imaging of the cervical spine 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 (that is, within 1 hour) has also been received, the cervical spine imaging should be carried out simultaneously

12. Admission
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
NOTES FOR PRESENTERS:
The guideline contains the amended recommendation that, in circumstances where a patient with a head injury requires hospital admission, the patient should only be admitted under the care of a team led by a consultant who has been trained in the management of this condition during his/her higher specialist training.
The consultant and his/her team should have competence (defined by local agreement with the neuroscience unit) in assessment, observation and indications for imaging (see amended recommendations in section 1.7 of the NICE guideline); inpatient management; indications for transfer to a neuroscience unit (see new and amended recommendation in section 1.6 of the NICE guideline); and hospital discharge and follow up (see amended recommendations in section 1.8 of the NICE guideline).
The Implementation advice tool gives advice on training required by staff looking after patients with a suspected or confirmed head injury

13. Admission: Criteria
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)
NOTES FOR PRESENTERS:
This is not a key recommendation. These are key steps in managing the care of patients who have or are suspected of having a head injury.
New, clinically significant abnormalities on imaging
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 co-operative to allow scanning
Continuing worrying signs (for example, persistent vomiting, severe headaches)
Other sources of concern (for example, drug or alcohol intoxication, other injuries, shock, suspected non-accidental injury, meningism, cerebrospinal fluid leak)
Investigation of non-accidental injury in children
A clinician with expertise in non-accidental injuries in children should be involved in any suspected case of non-accidental injury in a child. Consider skull X-ray as part of a skeletal survey; ophthalmoscopic examination for retinal haemorrhage; examine for pallor, anaemia, tense fontanelle and other suggestive features. Imaging such as CT and MRI may be required to define injuries.

14. Admission: When to involve the neurosurgeon
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
NOTES FOR PRESENTERS:
This is not a key recommendation. These are key steps in managing the care of patients who have or are suspected of having a head injury.
Discuss the care of all patients with new, surgically significant abnormalities on imaging with a neurosurgeon (definition of ‘surgically significant’ to be developed by local neurosurgical unit and agreed with referring hospitals)
Regardless of imaging, other reasons for discussing a patient’s care plan with a neurosurgeon include:
- persisting coma (GCS ≤ 8) after initial resuscitation
- unexplained confusion for more than 4 hours
- deterioration in GCS after admission (pay greater attention to motor response deterioration)
- progressive focal neurological signs
- seizure without full recovery
- definite or suspected penetrating injury
- cerebrospinal fluid leak.

15. Organisation of transfer of patients between referring hospital and neuroscience unit
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
NOTES FOR PRESENTERS:
The updated guideline contains the amended recommendation that 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.
For emergency transfers, the patient should be accompanied by a doctor with appropriate training and experience and an adequately trained assistant (see section 1.6 of the NICE guideline for more information)
A child or infant should be accompanied by staff experienced in the transfer of critically ill children
The transfer team should be provided with a means of communicating with their base hospital and the neurosurgical unit during the transfer (a portable phone may be suitable providing it is not used within 1 metre of medical equipment prone to electrical interference, such as infusion pumps)
In the multiply injured patient: consider the possibility of occult extracranial injuries, and do not transfer to a service unable to deal with other aspects of trauma
Medical care during transfer
In all circumstances: complete initial resuscitation and stabilisation of the patient and establish comprehensive monitoring before transfer to avoid complications during the journey.
In patients who are persistently hypotensive despite resuscitation: do not transport until the cause of hypotension has been identified and the patient stabilised.

16. 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
NOTES FOR PRESENTERS:
The updated guidelines contains the amended recommendation that all patients and their carers should be made aware of the possibility of long-term symptoms and disabilities following head injury and should be made aware of the existence of services that they could contact should they experience long-term problems
Details of support services should be included on patient discharge advice cards (see bespoke implementation support tools)

17. 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
NOTES FOR PRESENTERS:
These are not key recommendations but are key steps in managing the care of patients who have or are suspected of having a head injury.
It is recommended that GPs, nurse practitioners, dentists and ambulance crews should receive training, as necessary, to ensure that they are capable of assessing the presence or absence of the risk factors listed in section of the NICE guideline (Amended).
Telephone advice services (for example, NHS Direct, emergency department helplines) should refer people who have sustained a head injury to the emergency ambulance services (that is, 999) for emergency transport to the emergency department if they have experienced any of the risk factors in box 1 on page 12 of the NICE guideline (Amended).
Community health services (general practice, ambulance crews, NHS walk-in centres, dental practitioners) and NHS minor injury clinics should refer patients who have sustained a head injury to a hospital emergency department, using the ambulance service if deemed necessary (see section of NICE guideline), if any of the risk factors listed in box 3 in the NICE guideline are present (Amended).

18. 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
NOTES FOR PRESENTERS:
These are not key recommendations but are key steps in managing the care of patients who have or are suspected of having a head injury
Some patients may require an extended period in a recovery setting because of the use of general anaesthesia during CT imaging (Amended).
Plain X-rays (skull) should not be used, without prior discussion with a neurosciences unit, except as part of a skeletal survey in children suspected of a Non Accidental Injury” (New).
If CT imaging is unavailable because of equipment failure, patients with GCS 15 may be admitted for observation. Arrangements should be in place for urgent transfer to a centre with CT scanning available should there be a clinical deterioration that indicates immediate CT scanning is necessary (New). Patients with a GCS lower than 15 are to be transferred to a unit where scanning is available.

19. 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
NOTES FOR PRESENTERS:
For most guidelines that are developed by NICE an implementation advice tool is produced. This includes suggested actions to help people put it into practice. The implementation advice is compiled in collaboration with the guideline developers and with professional and patient groups. The suggested actions fall into these 4 areas. We shall consider each in turn.

20. Training and competencies of staff
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
NOTES FOR PRESENTERS:
The implementation advice lists courses that provide staff with the skills to assess and manage the care they provide according to clear principles and standard practice required to care for patients with a suspected or confirmed head injury.
The advice on training is split into the following categories: clinicians caring for children, ambulance crews, emergency department staff, imaging staff, community staff and training in observations to reflect the skills needed when following a care pathway for a patient with a suspected or confirmed head injury.
Observations
Medical, nursing and other staff caring for head-injured patients admitted for observation should be capable of performing the observations listed in the following section
Dedicated training should be available to relevant staff to enable them to acquire and maintain observation and recording skills – specific training is required for the observation of infants and young children
Observations of infants and young children under 5 should only be performed by units with staff experienced in the observation of infants and young children with a head injury (this may be in normal paediatric observation settings, provided staff have the appropriate experience)
Perform and record observations on a half-hourly basis until GCS = 15
When GCS = 15, the minimum frequency of observations is:
– half-hourly for 2 hours
– then 1-hourly for 4 hours
– then 2 hourly thereafter
(starting after the initial assessment in emergency department)

21. 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
Family Involvement Ensure that when caring for a patient with a head injury that the family are kept informed and included in the patients progress (section NICE guideline)
Need for neurosurgeon Imaging staff should ensure that all patients with new surgically significant abnormalities or complications identified in imaging are discussed with a neurosurgeon (section NICE guideline).
Discharge
All patients should receive verbal advice and a written head injury advice card before discharge from emergency department or ward (an example is available from
Discuss details of the advice card before discharge – this should include instructions on contacting community services in the event of delayed complications
Alert patients and carers of the possibility that some patients may make a quick recovery, but go on to experience delayed complications
Make all patients and carers aware of the possibility of long-term symptoms and disabilities and of the existence of services that they could contact should they experience long-term problems (details of support services should be included on patient discharge advice cards)
If necessary, use other formats to communicate discharge advice (for example, tapes)
If there is a need, facilitate communication in languages other than English
Give information and advice on alcohol or drug misuse to patients who presented to the emergency department with drug or alcohol intoxication if they are now fit for discharge
Communication with community services Patients who attended emergency department with head injury: send letter or to GP within 1 week of end of hospital episode – include details of the clinical history and examination, and ensure patient or carer has access (letter/ is open or patient given a copy). School-aged child who received head or cervical spine imaging: send letter or to GP and school nurse within 1 week of end of hospital episode – include details of the clinical history and examination. Pre-school-aged child who received head or cervical spine imaging: send letter or to GP and health visitor within 1 week of end of hospital episode – include details of the clinical history and examination
Outpatient appointments Every patient who has undergone imaging of their head and/or been admitted to hospital: refer to GP for follow-up within 1 week after discharge. If problems persist there should be an opportunity for referral from primary care to an outpatient appointment with a professional trained in assessment and management of brain injury sequelae.

22. Configuration of services
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
NOTES FOR PRESENTERS:
Services should be organised so that the algorithms identified within the head injury quick reference guide can be followed. These algorithms should be displayed in the relevant areas:
Assessment in the emergency department
Investigations for clinically important brain injury (investigations for CT scanning of the head for adults and children)
Investigation for injuries to the cervical spine (adults and children)
Provision should be made to enable the urgency imaging recommendations to be put into practice within 1 hour of the request having been received by the radiology department. To ensure that these services are maintained out of hours you may wish to consider training radiographers to perform and report basic CT, making provision for an on-call radiologist (on site) or, if local skills are unavailable to report images in the time frame required, distance reporting via teleradiology may be another option (see the implementation advice for national support resources).
NB. Provision of these services needs to be considered in conjunction with other NICE guidance e.g. stroke guidance, in order to consider the needs of the service as a whole taking into account all NICE guidance not each piece of guidance in isolation.

23. Local care pathways
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
NOTES FOR PRESENTERS:
NHS Direct and emergency department help lines should up date systems in line with this NICE guideline on head injury
Ensure that local guidelines are written for the transfer of patients with a head injury between referring hospitals, neuroscience units and ambulance services, according to NICE guideline on head injury (sections [adults] and [children])
Ensure that when transferring patients with head injuries between services that efficient verbal and written/computer handovers are given and are, where possible, standardised.
NICE guideline There should be a designated consultant in the referring hospital with responsibility for establishing arrangements for the transfer of patients with head injuries to a neuroscience unit and another consultant at the neuroscience unit with responsibility for establishing arrangements for communication with referring hospitals and for receipt of patients transferred.
Pathways between secondary and primary care should be established to ensure effective communication with community services for patients with head injury and ensure effective written and verbal communication (section NICE guideline). See bespoke tools
Suggested written discharge advice
Sample referral letter to neurosurgeon
Patients initially deemed to be at high risk for clinically important brain injury (see page 17 of the quick reference guide) should be routinely referred to their GP for follow up within 1 week of discharge.

24. Costs per 100,000 population
Recommendations with significant resource impact
Annual 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
NOTES FOR PRESENTERS:
ADAPTING THIS SLIDE FOR LOCAL USE: We are aware that local factors such as incidence and baseline can vary considerably when compared with the national average. NICE has provided a costing template for you to calculate the financial impact this guideline will have locally. We encourage you to calculate the local impact of this guideline by amending the local variations in the template such as incidence, baseline and uptake. You can then remove the figures from the table and replace them with your local figures to present to your colleagues.
NICE has worked closely with the guideline developers and other people in the NHS to look at the major costs and savings related to implementing this guideline. The estimated annual changes in costs and savings arising from implementing the head injury guideline are £12,100. It is recognised that implementation of the recommendations may take place over a number of years.
NICE has also provided a costing template to calculate the local costs associated with implementing this guideline. The costs are summarised in the table.
For further information please refer to the costing template and costing report for this guideline on the NICE website.

25. 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
NOTES FOR PRESENTERS:
NICE has worked closely with the guideline developers and other people in the NHS to look at the major costs and savings related to implementing this guideline and found that it is unlikely to result in any significant changes based on national assumptions. However, different areas may vary from the national average and it is important to scrutinise the recommendations likely to have the most significant resource impact locally to make sure that practice matches the national average.

26. Resources from NICE www.nice.org.uk/CG056 Implementation advice
Costing tools
costing report
costing template
Audit criteria
Bespoke tools
NOTES FOR PRESENTERS:
NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website.
The implementation advice gives details of how to put the guideline into practice and national initiatives that support this locally.
Costing tools – a costing report gives the background to the national savings and costs associated with implementation, and a costing template allows you to estimate the local costs and savings involved.
• Audit criteria assist NHS trusts to determine whether the service is implementing, and is in compliance with, the NICE clinical guideline.
Bespoke tools:
- discharge advice card for people over 12 years
- discharge advice card for carers of children
- discharge advice card for carers of adults
- adult observation proforma
- paediatric observation proforma (below 5 years)
- paediatric observation proforma (above 5 years)
- letter of referral to neurosurgical department
- adult version of the Glasgow Coma Scale
- paediatric version of the Glasgow Coma Scale.

27. 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
NOTES FOR PRESENTERS:
The guideline is available in a number of formats. You can download them from the NICE website or order printed copies of the quick reference guide or ‘Understanding NICE guidance’ by calling the NHS Response Line on Please refer to the implementation advice for information on key policy developments that support this guideline and links to useful resources.