Audit of head injury management in Accident and Emergency at two hospitals: implications for NICE CT guidelines

A retrospective audit of consecutive patients of any age, presenting at A&E with a complaint of head injury during one month in two northern District General Hospitals forming part of a single NHS Trust.419 patients presented with a median age of 15.5 years, and 61% were male. 58% had a Glasgow Coma Score (GCS) recorded and 33 (8%) were admitted. Only four of the ten indicators for a CT scan were routinely assessed, but data were complete for only one (age), and largely absent for another (vomiting). Using just three (incomplete) indicators showed a likely 4 fold increase in the need for a CT scan.The majority of patients who present with a head injury to Accident and Emergency departments are discharged home. Current assessment processes and associated data collection routines do not provide the information necessary to implement NICE guidelines for CT brain scans. The development of such clinical audit systems in a busy A&E department is likely to require considerable investment in technology and/or staff. The resource implications for radiology are likely to be substantial.The National Institute for Clinical Excellence (NICE) has produced guidelines entitled 'Head Injury in Infants, Children and Adults: Triage, Assessment, Investigation and Early Management' [1]. In the document, guidelines are presented which recommend good practice in Accident and Emergency (A&E) assessment and, specifically, what are the indicators for a Computerised Tomography (CT) scan (Figure 1). CT scanning is almost 100% sensitive and specific for the identification of intracranial complications. In comparison, a skull x-ray is 38% sensitive and 95% specific for skull fracture [2]. One reason for this poor sensitivity is the unreliability of the interpretation of the x-ray by under-pressure A&E clinicians.The identification of intracranial complications is important as such problems are not rare. In one study, 47% of patients admitted to hospital with a head injury were found to have a di