CT head out of hours for head injury: Challenging the NICE guidelines

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1 CT head out of hours for head injury: Challenging the NICE guidelines Poster No.: C-2281 Congress: ECR 2012 Type: Authors: Keywords: DOI: Scientific Exhibit M. Sapundzieski, N. Ali, J. Mather; Bury/UK Emergency, Head and neck, Trauma, CT, Health policy and practice /ecr2012/C-2281 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 17

2 Purpose The National Institute of Clinical Health and Excellence (NICE) published guidelines in the UK in 2003 (revised in 2007) [1] on how to manage head injuries in the emergency department, including when computerised tomography (CT) scans should be requested. Evidence prior to the publishing of these guidelines has suggested that not enough CT scans were being performed for head injuries, and that the traditional skull radiograph was an inadequate form of imaging in many cases [2,3]. Subsequently, the publication of NICE guidelines led to an increased incidence of CT requests [4]. The aim of this study is to determine whether CT scans done out of hours are in accordance with these guidelines, and what the radiological correlation is with positive clinical criteria identified within the guidelines. Methods and Materials A ten month retrospective audit was done in the radiology department in Fairfield General Hospital (Bury,UK). CT scans done out of hours (5pm-9am on weekdays and all day Saturday, Sunday and public holidays) were obtained for all patients who presented to the emergency department between January and October Information from request cards as well as the radiological report was used. The data was separated into trauma and non-trauma based on the clinical history. Traumatic cases were analysed further to assess their compliance with NICE guidelines on when CT scans should be requested (Figures 1-3). The correlation between clinical findings and positive radiological findings was also analysed. Images for this section: Page 2 of 17

3 Fig. 1 Page 3 of 17

4 Page 4 of 17

5 Fig. 2 Fig. 3 Page 5 of 17

6 Results A total of 329 patients who presented to the emergency department out of hours in the 10 month period had CT scans of the head done. Of these, 184 represented patients presenting with trauma to the head. 90.3% of all presentations were acute (less than 24 hours from time of injury). The overall percentage of positive findings in patients presenting with head injury was 21%. 76% of scans contained negative findings in the report and 2% of reports contained equivocal findings (i.e. no firm conclusion reached, often further imaging recommended) (Figure 4). Intracranial bleeds represented the largest proportion (69%) of positive findings, followed by skull fracture (25%), then contre-coup injury (4%) and cerebrovascular accident (2%) (Figure 5). Many reports contained more than one of these findings. The overall rate of compliance with NICE guidelines for performing CT scans out of hours was 76.1%. As compliance was measured using clinical details stated on request cards, perceived non-compliance may have been due to a lack of clinical details provided. (Figure 6). Of the scans with positive reported findings, 80% of requests complied with NICE guidelines, whereas those with negative reports complied with guidelines 75% of the time (Figure 7). Of the scans which were compliant with guidelines, 20% contained positive findings within the report, and of those which were uncompliant with guidelines, 16% of reports contained positive findings. The most common clinical criterion fulfilled for requesting CT scans in adults was more than one episode of vomiting, followed by initial Glasgow Coma Score (GCS) of less than 13, followed by focal neurological deficit (Figure 8). However, the largest correlation between clinical and positive radiological findings based on these criteria was for patients with an initial GCS of <13 (Figure 9-10). 27.3% of patients with a presenting GCS of <13 had positive findings, whereas only 12.5% of patients with more than one episode of vomiting had positive findings on CT. For children, the most frequently fulfilled criterion for requesting CT was 3 or more episodes of vomiting, followed by abnormal drowsiness and dangerous mechanism of injury (Figure 11). The criterion which correlated the most with positive radiological findings was again vomiting 3 or more times (Figure 12). 27.3% of children presenting Page 6 of 17

7 with 3 or more episodes of vomiting had positive findings on CT (Figure 13), whereas 42.9% of patients with abnormal drowsiness had positive findings on CT, perhaps making this a more clinically significant finding. The number of clinical criteria fulfilled according to NICE guidelines varied in terms of actual significance. Often several criteria were met, but with no radiological findings on CT. (Figure 14). Images for this section: Fig. 4: Chart showing the proportion of positive, negative and equivocal findings reported in all CT scans performed out of hours for head injury. Page 7 of 17

8 Fig. 5: Chart showing the proportion of findings in positive reports for CT scans requested out of hours. Note there was often overlap between different findings i.e. some reports contained several findings. Page 8 of 17

9 Fig. 6: Example of positive findings on CT despite non-compliance with NICE guidelines, possibly due to insufficient clinical details. Image shows a left extracranial haematoma, right tempero-partietal lobe contusion (contrecoup injury) and intraventricular blood in the left lateral ventricle. Page 9 of 17

10 Fig. 7: Chart showing the total proportion of scans which were requested in compliance with NICE guidelines, which is compared to the compliance rate of all scans with positive reports and and all those with negative reports. Page 10 of 17

11 Fig. 8: Chart showing the number of times each criterion within the NICE guidelines was fulfilled for every CT scan that was requested for adults out of hours. Fig. 9: Chart showing the clinical correlation with positive radiological findings in adults, based on the criteria from NICE guidelines which were met in CT scans requested. Page 11 of 17

12 Fig. 10: Example of case fulfilling only one criterion for requesting CT scan from the NICE guidelines (initial GCS of 5), with significant findings on imaging, highlighting the importance of GCS in adults in correlating with positive radiological findings. The image shows an acute subdural haematoma in the left fronto-parietal region with mass effect. Page 12 of 17

13 Fig. 11: Chart showing the number of times each criterion within the NICE guidelines was fulfilled for every CT scan that was requested for children. Page 13 of 17

14 Fig. 12: Chart showing the clinical correlation with positive radiological findings in children, based on the criteria from NICE guidelines which were met in CT scans requested. Fig. 13: Example of head injury in a child fulfilling one criterion from NICE guidelines for requesting CT scan (Vomited 7 times) highlighting the importance of vomiting in children. Image 1 shows a depressed skull fracture in the right frontal bone; image 2 shows right frontal lobe haemorrhage with surrounding oedema. Page 14 of 17

15 Fig. 14: Example of case fulfilling 3 criteria for CT head as per NICE guidelines (Vomiting twice post-injury, amnesia and over 65 years, right panda eye) but with no positive findings on CT. Page 15 of 17

16 Conclusion The overall compliance with NICE guidelines for requesting CT scans out of hours for head injuries was 76.1%. There was a slightly higher proportion (5%) of requests that complied with guidelines within the positive findings as compared to scans with negative findings, however the rate of positive findings in scans which complied with guidelines did not far exceed that in scans requested against recommendations (4.5%). The most clinically significant clinical criterion in terms of radiological correlation was a GCS of less than 13 in adults, and vomiting more than 3 times in children, although a high proportion of children presenting with abnormal drowsiness also had positive findings on scanning. These results show that following NICE recommendations on when to request CT scans for head injuries does slightly increase the likelihood of identifying pathology and the study also highlights important clinical criteria within the guideline. However, given the significant percentage of scans which did not comply with the guidelines and with positive findings reported, there is evidence to suggest that the guideline is not foolproof and safe clinical judgement should be employed at the same time. References 1. National Institute Clinical Health and Excellence CG56 Head Injury: NICE guidelines. London: NICE. 2. Stein, S.C. and Ross, S.E The value of computed tomographic scans in patients with low-risk head injuries. Neurosurgery. 26(4): Teasdale, G. M. et al Risks of acute traumatic intracranial haematoma in children and adults: implications for managing head injuries. BMJ. 300: Shravat, B.P. et al NICE guideline for the management of head injury: an audit demonstrating its impact on a district general hospital, with a cost analysis for Englandand Wales. Emergency Medicine Journal. 23(2): Personal Information Dr Milan Sapundzieski (consultant radiologist), Dr Noor Ali (foundation doctor), Dr Judith Mather (consultant radiologist). Page 16 of 17

17 Department of radiology Fairfield General Hospital (Pennine Acute NHS Trust) Bury, UK. Page 17 of 17

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