Head injury

1. Head injury triage, assessment, investigation and early management of head injury in infants, children and adults (update) 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

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

4. What this presentation covers Background Key recommendations Implementation advice Costs and savings Resources from NICE

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

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

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

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

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

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

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

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

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)

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

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

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

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

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

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

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

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

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

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

24. Costs per 100,000 population

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

26. Resources from NICE Implementation advice Costing tools • costing report • costing template Audit criteria Bespoke tools • www.nice.org.uk/CG056

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 • www.nice.org.uk/CG056