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

27th July 2006

United Lincolnshire Hospitals NHS Trust

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 co-operative 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 range 1-98• Mean 32• Males 48% Females 52%

Age distribution of head injuries

43%

21%

36%

Paediatric (<16)

Adults (16-65)

Elderly (>65)

TriageTriage effectiveness

Yes

Yes

Yes

No

No

No

0

20

40

60

80

100

Per

cen

tag

e

Yes 51 37 88

No 49 63 12

Triaged in 15 mins Doctor within 25 mins Doctor within 75 mins

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

88

6

11

23

83

29

69

60

3

0 10 20 30 40 50 60 70 80 90 100

Amnesia for >30 mins

Loss of consciousness > 5 mins

Vomiting >1 episode

Headache

Post traumatic seizure

Drug history

Anticoagulants

PMH of clotting or bleeding disorder

Dangerous mechanism of injury

His

tory

Percentage

History recording – Adults (>16)Percentage of history not recorded

76

15

17

57

83

11

57

50

11

0 10 20 30 40 50 60 70 80 90 100

Amnesia for >30 mins

Loss of consciousness > 5 mins

Vomiting >1 episode

Headache

Post traumatic seizure

Drug history

Anticoagulants

PMH of clotting or bleeding disorder

Dangerous mechanism of injury

His

tory

Percentage

Examination recording - PaedsPercentage of examination not recorded

9

43

23

31

0 10 20 30 40 50 60 70 80 90 100

Pupil status

Any sign of basal skullfracture

Suspected skull fracture

Neurological exam

Ex

am

ina

tio

n

Percentage

Examination recording - Adults

Percentgage of examination not recorded

15

50

35

41

0 10 20 30 40 50 60 70 80 90 100

Pupil status

Any sign of basal skullfracture

Suspected skullfracture

Neurological exam

Exa

min

atio

n

Percentage

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