Short Stay Head Injuries and the Accident and Emergency Department.

Mr Brodie Paterson, Specialist Registrar, Accident and Emergency Department, Ninewells Hospital, Dundee.

Miss Melissa Ramdarshan, Pre-Registration House Officer, Southern General Hospital, Glasgow.

Dr William Morrison, Consultant, Accident and Emergency Medicine, Ninewells Hospital, Dundee.

Correspondence to; Mr. Brodie Paterson,

An early version of this work was presented at Scottish BAEM in July 2000.

SMJ 2004 49(2): 69

Abstract

Objective: To examine the aetiology and outcome of patients admitted to the Accident and Emergency Short Stay ward with a head injury.

Method: Prospective, observational, hospital based cohort study with 8 week follow up.

This was conducted in the Accident and Emergency Department, Ninewells Hospital, Dundee.

The subjects studied were all patients admitted to the Short Stay ward with a head injury.

Results: 78 patients returned usable replies at 8 weeks, a response rate of 37.3%. Falls (55.1%) and assaults (20.5%) were the main cause of admission. Alcohol was involved in 58.1% of falls and 75% of assaults. Post Concussion Symptoms were more frequently associated with those under forty years old and those who had been assaulted. Post Head Injury scores were highest in those under forty seven years and associated with assault.

Conclusion: The identification of specific groups, who have higher Post Concussion and Post Head Injury scores, allows possible intervention prior to leaving hospital to try and reduce morbidity. A follow up study assessing intervention by a coping strategy is now under way.

Keywords;

Short stay ward, head injury, post concussion syndrome.

Introduction

The care and management of head injured patients is topical following the publication of the recent Royal College of Surgeons of England Report of the Working Party on the Management of Patients with Head Injuries [i] and the Scottish Intercollegiate Guidelines Network (SIGN) publication on the Early Management of Patients with a Head Injury [ii]. Accident and Emergency Medicine (A&E) has until now had a variable role in the ongoing care of the head injured after initial assessment. However, the Royal College of Surgeons of England report proposes the withdrawal of general and orthopaedic surgeons from the in-patient care of the head injured by 2004. The implications of implementing the proposals of this report have been discussed in the British Association for Accident and Emergency Medicine (BAEM) document “Implementing the Galasko Report on Head Injury Care”[iii]. This examines the head injury workload of A&E departments and assesses the impact which inpatient care of the head injured may have in those departments that do not already offer this service.

The Accident and Emergency Department at Ninewells Hospital admits minor and moderate head injuries to a short stay observation ward for a maximum of forty eight hours. We sought to examine the aetiology of the injuries and epidemiology of those admitted, the prevalence of Post Concussion Syndrome in this group and to identify possible areas for intervention.

Methods;

The single A&E department in Dundee has 50,000 new patient attendances per annum. The eight-bedded short stay ward (SSW) is situated within and staffed by the A&E department and is for the observation of head injuries, self-poisoning and other self-limiting conditions. Over a 6 month period from September 1999 we conducted a prospective observational survey of all those patients admitted to the SSW with a diagnosis of head injury, loss of consciousness or post-traumatic amnesia. Exclusion criteria were those patients requiring ventilation, neurosurgery or likely to require more than forty-eight hours observation. 209 patients with a head injury were admitted during this period. Hospital notes were examined for patient demographics, the mechanism of injury and the presence of alcohol. Eight weeks after discharge all patients were sent, to their declared address, a questionnaire, a covering letter and a stamped addressed envelope. The questionnaire incorporated the Rivermead head injury follow up questionnaire[iv] and the Rivermead Post Concussion Symptoms questionnaire[v]. Both these questionnaires have been validated for self assessment  Post head injury patients have a number of physical and psychosocial complaints. The Post Head Injury questionnaire is a ten-question tool that examines the changes before and after head injury in a patients psychosocial functioning. It asks about the ability to perform in social, work and leisure activities, maintain relationships and converse with one or more persons. The Post Concussion questionnaire is a measure of Post Concussion symptoms experienced post head injury. It asks about the change in experience of 16 symptoms including headache, dizziness, irritability and depression.  The questionnaire, with added explanatory comments, is reproduced as table 1. Response rates in previous papers have been low due to poor response rates 41% in Wade (vi) and 37% Skelton (vii). To try to improve our response rate we contacted non-respondents at 12 weeks by telephone. We stopped after two weeks due to concerns about breaching patient confidentiality by disclosing patient details to others at the contact addresses.

Results;

We received seventy eight completed, usable replies, a response rate of 37.3%, which compares to the response rates of other published work in this field[vi]^,[vii]. Eight (3.8%) were returned  by the Royal Mail as not known at that address and four (1.9%) were incomplete. The respondents matched the admitted cohort with regard to sex mix; females 27% of admitted and 28% of respondents and males 73% of the admitted population and 72% of respondents. The results were collated and confidence intervals calculated. The mean age of respondents was 48.0 years, males 46.0 years and females 54.2 years. The recorded cause of the head injury is recorded in table 2.
The Rivermead Questionnaires were examined by symptom scores and by the gender of the respondents. When we examined the Post Head Injury scores, looking at psychosocial function, we found a positive male trend in all categories except “ability to perform domestic activities”. Wide confidence intervals prevent any significance being drawn from these results.

The Post Concussion Syndrome scores had a positive trend  in the reporting, by men, of all symptoms, except dizziness. The wide confidence intervals again prevented any further significance being attached to these results.

We also compared the upper and lower quartiles of the Post Concussion Syndrome and Post Head Injury scores to see if there were difference between those suffering most and least from their head injuries. Table 3 details the age, mechanism of injury and involvement of alcohol in the upper and lower quartiles (95% confidence intervals are shown). There is a significant difference in the age of respondents and the presence of assault as the mode of head injury but no difference in the involvement of alcohol. Those with most Post concussive symptoms are from a younger age group and tend to have been assaulted. Table 4. examines the Post Head Injury scores in the same way as table 3. There is a significant difference (95% confidence intervals) in the age of those reporting symptoms, with a younger group reporting most symptoms, and an increased reporting of assault in the most symptomatic group. Falls and the involvement of alcohol were less represented in the most symptomatic group.

Discussion;

This paper attempted to clarify the aetiology of  head injuries attending A&E and whether there was an undocumented morbidity. It was conducted prospectively over 6 months but was hampered by a low response rate. This has been a feature of previous studies. Our cohort was similar to the Scottish national average in 1985 ^viii for sex, male: female 71.0%: 29.0% and cause, 41%,20% and 13% for falls, assaults and RTAs and similar to recent figures from Glasgow [viii] reporting falls in 43% and assaults in 34% of its head injured.

In 52.6% of our respondents alcohol was involved, this is a similar figure to the 61% in Thornhill’s study in Glasgow ^i[ix]. Alcohol was found to be present in head injured males twice as frequently as females (64.3% vs. 27.3%). There may be scope for in-patient intervention in drinking behaviour.[x]

The Post Concussion Syndrome, despite its listing in the International Classification of Diseases 10 [xi] , still provokes controversy.  There is a body of opinion, which still believes that it is a compensation biased entity. Miller in 1961[xii] suggested that it is “a concomitant of the compensation situation” and this is still frequently quoted. Others accept it as an  ailment^v.

Our population shows a significant prevalence of symptoms in both PCS and PHI scores, with a trend showing men to be particularly affected. This may be due to the association with assault but the wide confidence intervals and poor response prevent any conclusions being drawn. The significant mean age difference between the groups may also affect the results; the reporting of PCS symptoms does reflect the ability to perform one’s expected normal role. It may be that the younger group have more problems coping with their daily lives. When the upper and lower quartiles were compared we can see that PCS and PHI symptoms particularly affect a younger group who have been assaulted. These findings are contrary to those of Binder[xiii] in 1986 who stated that symptomatology was more likely in older patients and Thornhill in 2000 who found a worse outcome in the over 40s. Miller 1961 found no age difference. Our study shows that assault is a significant predictor for PCS and PHI problems; this was a finding in the studies by Thornhill and Wenden[xiv].

Conclusion;

Head injuries admitted to the short stay ward generate a significant amount of morbidity for those involved. We have shown that age under 40 and assault are independent risk factors for the Post Concussion Syndrome. There have been calls[xv]^{, i} for the follow up of all head injured patients, however the value of this is still uncertain ^vi,[xvi].  SIGN recommends further evaluation of follow up and the RCSEng called for further research into the sequelae of minor and moderate head injuries. We felt that this pattern of PCS warranted further research. We have designed a short coping strategy for head injured patients, which, with local ethics committee approval, has recently been tested in a six month randomised single blind study.

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