David
A Stewart, Patrick J Finn
Department
of Surgery, Vale of Leven Hospital, Alexandria
Correspondence
to: DavidAlexanderStewart@msn.com
SMJ 2004 49(2): 70
Abstract
Background and Aims. In
September 2000 the Scottish Intercollegiate Guidelines Network published their
recommendations on the optimal early management of head injured patients.
Early identification of significant intracranial pathology through CT
scanning is central to these guidelines. At
our small DGH, head injured patients are received and managed by general
surgeons with no specific training in head trauma.
In addition, there is as yet no arrangement in place for urgent CT
scanning. Because of these factors,
an audit was conducted to determine the extent to which we were able to comply
with these guidelines.
Methods. A 2
month prospective audit of the management of head injured patients was carried
out collecting data on patient demographics, clinical condition on admission,
clinical course, radiological investigations (and difficulty in arranging them)
and outcome.
Results. Over
the 2 month period 52 consecutive patients were studied.
Fifteen patients met criteria for CT scanning, of which 9 were ultimately
scanned. Tellingly, only one of the
fifteen received their scan within the recommended four hour period. In this series, no patient had an adverse clinical event
related to delay in scanning.
Conclusion. Any
hospital admitting head injured patients should have 24 hour access to CT
scanning facilities. If such an
arrangement is not in place then patients with head injuries should not be
admitted to that hospital.
Keywords. Head
Injury, CT Scan, SIGN Guidelines
Introduction
In a small district hospital such as ours, the management
of head injuries falls under the remit of the general surgical team.
At present there is no provision for obtaining a CT scan out with normal
working hours. CT scanning for our hospital is carried out on a non-urgent
basis on two afternoons of the week in a nearby DGH with scanning facilities.
As nationally accepted guidelines recommend that any unit admitting and
managing head injuries should have such an agreement1 we identified
this as a possible problem with the quality of care we were able to provide.
Methods
A 2-month prospective audit was carried out using a
proforma to collect data on patients’ demographic details, condition on
admission including co-morbidity, radiological investigations, subsequent
clinical course and outcome. Time
from admission to CT scanning was recorded if CT was performed and any reasons
for delay were documented, particularly the phone calls necessary to arrange the
scans. Inclusion criteria were any
patients admitted under the general surgical team with a head injury between
10/09/2002 and 16/11/2002.
Results
Mechanism of Injury
52 patients were admitted with a head injury in the period
of the study. Mean age was 55 years
(range 15 – 95). There was a male
predominance (71%).
Chart 1
shows that the majority of our head injuries were as a result of a fall (67%).
Of those who had fallen, 60% were intoxicated at the time.
Of the remainder, 10 patients were assaulted 6 of whom were intoxicated.
Three were involved in a road traffic accident, and 3 in sports related
injuries. One patient’s mechanism
of injury was never determined. In
total, 28 patients (54%) were intoxicated.
Patients
meeting SIGN guidelines for CT Scanning
Table I
shows the breakdown of indications for 15 head injured patients meeting criteria
for scanning. Also shown are the
patients for whom CT scanning was not obtained (n = 6).
Of the 6 patients who were not scanned, 4 did not have a CT scan
requested for reasons outlined in the discussion.
Two patients had scans requested but did not ultimately receive them.
In one case a patient with a severe persistent headache had a CT scan
arranged as an outpatient 9 days after admission and failed to attend.
In the other a patient with a seizure and reduced consciousness had
transfer to the regional neurosurgery unit arranged but then cancelled due to
spontaneous recovery – his problem being ascribed to previously diagnosed
epilepsy rather than the head injury.
Time
from admission to CT scan
Chart 2
shows the range of time intervals between hospital admission and CT scanning for
the 9 patients who were scanned. Median time from admission to CT was 71 hours (range 3 - 192
hours). Only one patient was
scanned within 4 hours.
Table
II represents a case series of all 9 patients who underwent CT scanning in
the audit period, documenting phone calls made, time taken up in phone calls,
and advice given at each stage. For
2 patients the admitting surgical registrar of the day spent a total of 60
minutes on the phone simply organising a scan, on one occasion making four
individual calls over a two-hour period.
Outcome
Twenty-eight patients (54%) were admitted for 24 hours
neurological observation and then discharged with head injury advice.
Two patients (4%) discharged themselves against medical advice.
Two patients were transferred to other hospitals for ongoing care, one to
the regional neurosurgical unit for a severe head injury and one to another DGH
with an orthopaedic service for management of a metacarpal fracture. Of the remaining patients, 8 were kept in hospital for
management of other injuries incurred at time of head injury. Seven patients
were referred to the physicians for investigation of syncope. Social factors precluded early discharge in 3 patients.
Two of the group remained in hospital for three days each while waiting
to get their CT scan.
Skull
X-Rays
All head injured patients had plain skull X-rays performed on admission to hospital. Although a consultant radiologist eventually reported all these films, only 8 patients (15%) had their skull X-rays reported by the time of their discharge.
Discussion
This audit shows that the majority of patients admitted to
our institution are men and alcohol intoxication is involved in a significant
percentage of cases. Over the two
month ‘snapshot’ provided by this audit there were no significant adverse
outcomes related to head injury, and no operable intracranial pathology
detected. In spite of guidelines for
management of head injured patients being available since September 2000, no
strategy exists for timely investigation of this patient group.
This audit clearly shows that a number of patients at high risk of
harbouring an intracranial haematoma2 were not scanned urgently and
in some cases not at all.
Only 1 of 15 patients meeting criteria for urgent scanning received their investigation within four hours. In 6 meeting the criteria, no scan was performed. In 4 of this later group this was because of the very real ‘hassle factor’ incurred when trying to access out of hours CT, in the face of a patient who appeared neurologically stable. Interestingly, 2 of these 4 patients for whom a scan was not requested should, according to SIGN guidelines, have undergone emergency scanning (immediate scan after initial stabilisation) due to a low GCS. However, the patients were also intoxicated, and their low level of consciousness was attributed to this.
Conclusion
Increasingly clinicians are being required to re-evaluate
established methods of care in light of evidence-based guidelines, clinical
governance and risk management. This
audit highlights a major deficiency in care for acutely head injured patients in
our institution. There is an urgent
need to resolve these issues in order to provide a safe environment for care.
Failing the provision of a CT scanner in the hospital, there must be an
agreement for 24-hour access to CT scanning in an appropriate facility if
clinically indicated. If these basic standards cannot be put in place then we
would question the legitimacy of this unit continuing to receive such patients.
Acknowledgements
The authors would like to thank Dr Lorna Hill, Dr Stephen
Lowe, Dr Gary Manson, Dr Kenneth O’Connor and Dr Harriet Stephens, the
surgical pre-registration house officers for help with data collection.
References
Scottish
Intercollegiate Guidelines Network. ‘Early
Management of Head Injury’ 2000.
Teasedale GM, Murray G, Anderson E, Mendelow AD, Macmillan R, Jennet B et al. ‘Risks of acute traumatic intracranial haematoma in children and adults; implications for managing head injuries’ BMJ 1990; 300: 363-7