Impact of implementation of the national institute for health and clinical excellence (NICE) head injury guideline in a tertiary care center emergency department: A pre and post-intervention study.

Pratisha Pradhan,Abha Shrestha,Roshana Shrestha,Alok Pradhan,Anmol Purna Shrestha,Ram Chandra Paudel

doi:10.1371/journal.pone.0254754

Abstract

Head injury, a common presentation to the emergency department (ED), is a substantial problem in developing countries like Nepal. The current national institute for health and clinical excellence (NICE) guideline revised in January 2014 focuses on effective clinical assessment and early management of head injuries according to their severity in all age groups. This study assessed the impact of implementing this guideline on the proportions of computed tomography (CT) head scans, guideline adherence, and confidence level of the attending physicians. We consecutively recruited 139 traumatic head injury (THI) patients in this prospective pre-post interventional study conducted in the ED of a tertiary care center. We implemented the NICE guideline into routine practice using multimodal intervention through physicians' education sessions, information sheets and guideline-dissemination. The pre and post-implementation CT head scan rates were compared. The post-implementation guideline adherence was assessed. Online Google form-questionnaires including 12 validated case scenarios were distributed to the attending physicians at the end of both phases to assess their confidence levels. The implementation resulted in a statistically significant decrease in the proportion of CT head scan rates from 92.0% to 70.0% (p-value = 0.005). Following educational interventions, improved guideline adherence of 20.3 percentage points (p-value = 0.001) was observed. Nine ED attending physicians were enrolled in the study who showed statistically significant improvement in their confidence level following the intervention. The NICE guideline showed a sensitivity and specificity of 93.6% and 76.4% with 82.6% accuracy compared to that of clinical judgment (100%, 34.6%, and 58.1% respectively) in detecting intracranial lesions. The implementation was successful in satisfying the aim of the NICE guideline by decreasing the proportion of CT head scans, improving guideline adherence and increasing the confidence of the attending physicians.

Highlights

Head injury, a common presentation to the emergency department (ED), is a substantial problem in developing countries like Nepal
The implementation was successful in satisfying the aim of the national institute for health and clinical excellence (NICE) guideline by decreasing the proportion of computed tomography (CT) head scans, improving guideline adherence and increasing the confidence of the attending physicians
We reviewed the electronic medical records of the samples to determine if the CT had been requested in reference to the NICE guideline

Summary

Introduction

A common presentation to the emergency department (ED), is a substantial problem in developing countries like Nepal. The current national institute for health and clinical excellence (NICE) guideline revised in January 2014 focuses on effective clinical assessment and early management of head injuries according to their severity in all age groups. Patients with THI initially present to the emergency department (ED) and only a few patients require any intervention. The non-contrast computed tomography (NCCT) has become the investigation of choice for THI cases as it has both sensitivities and specificities approaching 100% for detecting any intracranial lesion [6,7,8]. A composed approach is required to ensure the ordering of head CTs when necessary while vindicating the potential disadvantages of over-imaging. Appropriate guidelines can help scrutinize cases [9, 10]

Objectives

Methods

Conclusion