Head injury: triage, assessment, investigation and early ...
Head injury triage, assessment, investigation and early management of head injury in infants,...
-
Upload
jayden-gill -
Category
Documents
-
view
218 -
download
0
Transcript of Head injury triage, assessment, investigation and early management of head injury in infants,...
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