Evaluation of the Scandinavian guidelines for head injuries based on a consecutive series with computed tomography from a Norwegian university hospital

Ingrid Haavde Strand,Anne Vik,Kent Gøran Moen,Ole Solheim

doi:10.1186/1757-7241-20-62

Abstract

BackgroundThis study prospectively assesses clinical characteristics and management of consecutive minimal, mild and moderate head injury patients referred for CT scans. Compliance with the Scandinavian head injury guidelines and possible reasons for non-compliance is explored.MethodsFrom January 16th 2006 to January 15th 2007, 1325 computed tomography (CT) examinations due to minimal, mild or moderate head injury according to the Head Injury Severity Scale (HISS) were carried out at our University Hospital. When ordering a CT scan due to head trauma, physicians were asked to fill out a questionnaire.ResultsGuideline compliance was impossible to assess in 49.5% of all cases. This was due to non-assessable or missing key variables necessary in the decision making algorithm. One or more key variables for HISS classification were not assessable in 34.4% as it was unknown whether there had been loss of consciousness (LOC), duration of LOC was unknown or it was impossible to assess amnesia or focal neurologic deficits. Definite compliance with both CT and admittance recommendations in guidelines was seen in only 31.2%. In 54.2% of patients with minimal head injuries who underwent CT scans, imaging was not necessary according to guidelines. 59.1% of all patients were admitted to hospital, however only 23.7% of these were admitted because of the head-injury alone. Age < 4 years, possible medical cause of injuries, severe headache/nausea or vomiting and the presence of non-traumatic CT findings were independently associated with non-assessable compliance with Scandinavian guidelines. Suspicion of influence of alcohol was inversely associated to non-compliance.ConclusionsDespite the prospective study design, guideline compliance was not assessable in nearly half of the patients. Patients with isolated head injuries and available and obtainable complete clinical information necessary for guideline-based decision making are not dominating in a head injury population.

Highlights

This study prospectively assesses clinical characteristics and management of consecutive minimal, mild and moderate head injury patients referred for computed tomography (CT) scans
Patient management can be affected by numerous factors not taken into consideration in the guidelines, including the distance to hospital, patient co-morbidities and other injuries, limitation of radiology services, availability of hospital beds, patient demands, severity of pain, language barriers, the ability to be observed at home and local transportation logistics
Some head injuries are initially managed by the hospital trauma team, when there is suspected or confirmed multi-trauma or high energy trauma, according to the advanced trauma life support (ATLS) guidelines

Summary

Introduction

This study prospectively assesses clinical characteristics and management of consecutive minimal, mild and moderate head injury patients referred for CT scans. Guidelines for the initial management of minimal, mild or moderate head injuries [1,2,3,4,5] were implemented approximately a decade ago. They provide evidence based algorithms for decision making, including indications for CT. A retrospective study from 2003, two years after the implementation of the Scandinavian guidelines, found that overall compliance was only 51%, and that over triage was seen in 69% of patients with minimal injuries. Since many of the important patients’ characteristics were unavailable, reasons for non-compliance could not be explored [10]

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