National Survey Of Current Practice Research Articles

A national survey of current practice on patients with long term and additional needs in paediatric intensive care units.

Patients with long term and additional needs (LEAP) in paediatric intensive care units (PICUs) are a growing and heterogenous cohort that provide unique challenges to clinicians. Currently no standard approach to define and manage this cohort exists. To analyse bed occupancy, examine current practice, and explore ideas to improve PICU care of patients with long term and additional needs. Patients with LEAP were defined as meeting two or more of the following criteria: length of stay >14 days; life limiting condition; ≥2 failed extubations; hospital stay >1 month prior to PICU admission; likely to require long-term ventilation. An electronic survey was then sent to all UK PICUs, via the UK Paediatric Critical Care Society, to collect quantitative and qualitative data relating to bed occupancy, length of stay, multidisciplinary and family involvement, and areas of possible improvement. Data collection were occurred between 8 February 2022 and 14 March 2022. Quantitative data were analysed using Microsoft Excel 365 and SPSS Statistics version 28.0. Raw data and descriptive statistics were reported, including percentages and median with interquartile range for non-parametric data. Qualitative raw data were examined using thematic analysis. Analysis was undertaken independently by two authors and results assessed for concordance. 70.1% (17/24) PICUs responded. 25% (67/259) of PICU beds were occupied by patients with long term and additional needs. 29% (5/17) of responding units have tailored management plans to this cohort of patient. A further 11% (2/17) have guidelines for children with generic chronic illness. 12% (2/16) of responding units had a designated area and 81% (13/16) of responding units had designated professionals. The majority (68% and 62%) of responding units engaged families and community professionals in multidisciplinary meetings. When asked how the care of long term and additional needs patients might be improved five themes were identified: consistent, streamlined care pathways; designated transitional care units; designated funding and hospital-to-home commissioning; development of roles to facilitate collaboration between hospital and community teams; proactive discharge planning and parallel planning. This survey provides a snapshot of UK practice for a cohort of patients that occupies a considerable proportion (29%) of PICU beds. While only a minority of responding PICUs offer specifically tailored management plans, the majority of units have designated professionals. Opportunities exist to improve PICU care in LEAP patients in areas such as: streamlined care pathways, designated clinical areas, designated funding, and development of defined collaborative roles. Next steps may involve working group convention to develop a consensus definition and share good practice examples.

Management of status epilepticus in Malaysia: A national survey of current practice and treatment gap

IntroductionEarly and effective treatment is fundamental in status epilepticus (SE) management. At the initiative of the Epilepsy Council of Malaysia, this study aimed to determine the treatment gap in SE across different healthcare settings in Malaysia. MethodsA web-based survey was sent to clinicians involved in the management of SE, across all states and at all levels of healthcare services. ResultsA total of 158 responses were received from 104 health facilities, including 23 tertiary government hospitals (95.8% of all government tertiary hospitals in Malaysia), 4 (80.0%) universities, 14 (6.7%) private, 15 (11.5%) district hospitals and 21 clinics. Intravenous (IV) diazepam was available in 14 (93.3%) district and 33 (80.5%) tertiary hospitals for prehospital management. Non-IV benzodiazepine (rectal diazepam and intramuscular midazolam) was not widely available in prehospital services (75.8% and 51.5%). Intramuscular midazolam was underutilised (60.0% in district and 65.9% in tertiary hospitals). IV sodium valproate and levetiracetam were only available in 66.7% and 53.3% of the district hospitals, respectively. Electroencephalogram (EEG) services were available in only 26.7% of the district hospitals. Non-pharmacological therapies such as ketogenic diet, electroconvulsive therapy, and therapeutic hypothermia were not available in most district and tertiary hospitals for refractory and super-refractory SE. ConclusionsWe identified several gaps in the current practice of SE management, including limited availability and underutilization of non-IV midazolam in prehospital services, underutilization of non-IV midazolam and other second-line ASMs, and lack of EEG monitoring in district hospitals and limited treatment options for refractory and super-refractory SE in tertiary hospitals.

Towards exploring current challenges and future opportunities relating to the prehospital triage of patients with traumatic brain injury: a mixed-methods study protocol

IntroductionTraumatic brain injury (TBI) is a major global health burden that results in disability and loss of health. Identifying those patients who require specialist neuroscience care can be challenging due...

Pharmacist-Managed Therapeutic Drug Monitoring Programs within Australian Hospital and Health Services-A National Survey of Current Practice.

Pharmacist-managed therapeutic drug monitoring (TDM) services have demonstrated positive outcomes in the literature, including reduced duration of therapy and decreased incidence of the adverse effects of drug therapy. Although the evidence has demonstrated the benefits of these TDM services, this has predominately been within international healthcare systems. The extent to which pharmacist-managed TDM services exist within Australia, and the roles and responsibilities of the pharmacists involved compared to their counterparts in other countries, remains largely unknown. A cross-sectional online survey was conducted evaluating pharmacist-managed TDM programs within Australian hospital and healthcare settings. Pharmacist perceptions were also explored about the strengths, weaknesses, opportunities, and barriers associated with implementing a pharmacist-managed TDM service. A total of 92 surveys were returned, which represents a response rate of 38%. Pharmacist-managed TDM programs were present in 15% of respondents. It is only in the minority of hospitals where there is a pharmacist-managed service, with pharmacists involved in recommending pathology and medication doses. The programs highlighted improved patient outcomes but had difficulty maintaining the educational packages and training. For hospitals without a service, a lack of funding and time were highlighted as barriers. Based on the findings of this survey, there is minimal evidence of pharmacist-managed TDM models within Australian hospital and health services. A standardized national approach to pharmacist-managed TDM services and recognition of this specialist area for pharmacists could be a potential solution to this.

Pubertal staging examinations: a national survey of current practice in consent and chaperone use

Pubertal staging examinations: a national survey of current practice in consent and chaperone use

Management of cardiovascular dysfunction in neonates with hypoxic ischaemic encephalopathy; a national survey of current practice in the UK.

Management of cardiovascular dysfunction in neonates with hypoxic ischaemic encephalopathy; a national survey of current practice in the UK.

Realist evaluation of Autism ServiCe Delivery (RE-ASCeD): which diagnostic pathways work best, for whom and in what context? Findings from a rapid realist review

ObjectivesWaiting times in the UK for an autism diagnostic assessment have increased rapidly in the last 5 years. This review explored research (including ‘grey’ literature) to uncover the current evidence...

Management of code status in the periendoscopic period: a national survey of current practices and beliefs of U.S. gastroenterologists

This study aims to assess current practices and perspectives of gastroenterologists on approaches to code status before inpatient endoscopy. Self-reported data were obtained through a voluntary, anonymous survey of gastroenterologists and gastroenterology trainees in the United States. The survey assessed respondents' approach to, beliefs, and knowledge regarding inpatient periprocedural code status discussions. Four hundred thirty-six gastroenterologists and 83 trainees completed the survey. For patients with an existing do not resuscitate (DNR) order, respondents reversed the code status before endoscopy either all (40.8%, n= 212) or most of the time (18.3%, n= 95). When asked their personal opinion, 32.6% (n=169) supported automatic DNR reversal to full resuscitation attempt during a procedure, 18.5% (n= 96) supported that DNR orders could be sustained, and 48.7% (n= 253) supported offering limited resuscitation. Many gastroenterologists were unaware of institutional (40.7%, n= 211) or national (80.7%, n= 419) policies, and a majority reported that a gastroenterology-specific guideline would be helpful (88.6%, n= 460). Although most of the gastroenterologists reverse DNR orders more than 75% of the time before endoscopy, many also believe patients should be allowed to remain DNR during a procedure and supported a third option for limited resuscitation. Most gastroenterologists were unaware of institutional policies or existing national guidelines. These findings suggest considerable variation in knowledge and current approaches regarding periendoscopic code status reversal.

Attainment grouping in English secondary schools: A national survey of current practices

ABSTRACT Attainment grouping is a prevalent yet controversial practice, used in most English schools and on the rise internationally, despite evidence that it is detrimental to the majority of pupils. In England, no data is routinely recorded regarding these practices, and most research on student outcomes depends on a simplistic dichotomy between pupils grouped and ungrouped by attainment. We present the findings of a survey of attainment grouping practices in English secondary schools, providing an updated picture of the profile of attainment grouping in English and mathematics for students aged 11–16. Grouping in sets is dominant for mathematics and, while variants on mixed attainment grouping are frequently used for students aged 11–14 in English, the frequency of setting increases as students progress through secondary school. Schools with disadvantaged intakes are more likely to group by attainment. We also find that grouping practices are much more complex and dynamic in enactment than is implied by much of the literature and that teachers report that many schools adapt grouping strategies to meet the perceived needs of different cohorts. We provide an updated conceptualisation of grouping practices as a continuum and discuss its implications for current and future research.

Anaesthetic management for robotic-assisted laparoscopic prostatectomy: the first UK national survey of current practice.

Robotic-assisted laparoscopic prostatectomy (RALP) is the most common robotic surgical procedure, but there are little published data to inform anaesthetic practice. We aimed to characterise the range of anaesthetic practice for RALP in the United Kingdom through a national survey. We conducted an online national survey to determine current anaesthetic practice for RALP. The survey was distributed to all NHS hospitals within the UK that perform RALP. Thirty-four (79%) of 43 hospitals responded to the survey. Fourteen (41%) centres routinely provide spinal anaesthesia and 79% of these use diamorphine as their intrathecal opioid of choice. Thirty-one (91%) centres administer intravenous strong opioids intraoperatively, and a wide range of non-opioid analgesic agents are also administered. Five (15%) centres reported that they discharge a minority of patients on the day of surgery. High-volume centres are more likely to have a formalised enhanced recovery after surgery (ERAS) pathway and to provide ambulatory surgery for selected patients. This represents the first UK national survey of anaesthetic practice for RALP. The results of the survey revealed significant variation in anaesthetic practice implying a lack of consensus on best perioperative management.

P132: Optimizing a physician surge protocol to address emergency department wait times during times of increased patient demand

Background: Emergency Department overcrowding remains a significant problem. Interventions have often focused on areas external to the ED, with patient flow in the ED receiving less attention. Efforts to address ED flow are complicated by daily fluctuations in patient volume and acuity. Our local protocol brings in additional physicians when internal metrics indicate patient demand can't be met by current physician resources (a ‘surge’ period). However, anecdotal evidence suggests a lack of satisfaction and efficacy. We therefore undertook a project to improve our local management of these surge periods. Aim Statement: To improve the effectiveness of an ED Physician Surge Protocol to allow for a physician scheduling strategy that is reflective of the needs of the ED. Measures & Design: This project consists of 3 phases. Phase 1 was an analysis of current surge metrics (including frequency, temporal patterns and physician response), with concurrent literature search to identify any best practices or easily addressable protocol changes, with first planned PDSA cycle. Phase 2 is a mixed methods survey of local staff to identify barriers and enablers of our current protocol, concurrent with a national survey of current practices. Phase 3 will be the implementation of a revised protocol, followed by a second mixed methods survey and analysis of metrics of interest. Evaluation/Results: Analysis of surge data (Oct 2018-Oct 2019) demonstrated a high volume of surges per month (78.7 +/- 10.9), highest at Foothills Medical Centre (94.3). Across all sites, afternoon periods had highest frequency of surges (absolute peak 1400 - 1500) with a secondary peak 2200–2300, both peaks occurring most frequently on weekends (Fri-Sun) However, physician response to surge calls was < 10% (5.8-9.1%), with no discernable temporal pattern, even accounting for the significant number of automatic surge calls cancelled by clinicians. Analysis of data, in addition to literature review and engagement with senior administration suggested no immediate protocol changes, therefore project moved to 2nd phase. This phase is currently in progress, with planned analysis using Pareto Chart methodology. Discussion/Impact: Our initial data clearly demonstrates that current procedures are inadequate to address this ongoing issue, with no readily apparent solutions. Analysis of local barriers and enablers is currently underway, in addition to a national survey, with the results expected to inform an extensive redesign of current procedures.

What are emergency ambulance services doing to meet the needs of people who call frequently? A national survey of current practice in the United Kingdom

BackgroundEmergency ambulance services are integral to providing a service for those with unplanned urgent and life-threatening health conditions. However, high use of the service by a small minority of patients is a concern. Our objectives were to describe: service-wide and local policies or pathways for people classified as Frequent Caller; call volume; and results of any audit or evaluation.MethodWe conducted a national survey of current practice in ambulance services in relation to the management of people who call the emergency ambulance service frequently using a structured questionnaire for completion by email and telephone interview. We analysed responses using a descriptive and thematic approach.ResultsTwelve of 13 UK ambulance services responded. Most services used nationally agreed definitions for ‘Frequent Caller’, with 600–900 people meeting this classification each month. Service-wide policies were in place, with local variations. Models of care varied from within-service care where calls are flagged in the call centre; contact made with callers; and their General Practitioner (GP) with an aim of discouraging further calls, to case management through cross-service, multi-disciplinary team meetings aiming to resolve callers’ needs. Although data were available related to volume of calls and number of callers meeting the threshold for definition as Frequent Caller, no formal audits or evaluations were reported.ConclusionsAmbulance services are under pressure to meet challenging response times for high acuity patients. Tensions are apparent in the provision of care to patients who have complex needs and call frequently. Multi-disciplinary case management approaches may help to provide appropriate care, and reduce demand on emergency services. However, there is currently inadequate evidence to inform commissioning, policy or practice development.

National survey of current practice and opinions on rehabilitation for intermittent claudication in the Danish Public Healthcare System

Objective. International guidelines recommend rehabilitation including supervised exercise therapy in patients with Intermittent Claudication (IC), but knowledge of the implementation in clinical practice is limited. This study aims to investigate current practice and opinions on rehabilitation for patients with IC among vascular surgeons and rehabilitation departments in the municipalities and hospitals. Design. Three electronic cross-sectional surveys were distributed nationally to the Danish vascular surgeons (n = 131) and to rehabilitation departments in the municipalities (n = 92) and hospitals (n = 33). Results. The response rates were 70% among the vascular surgeons, 98% among the municipalities and 94% among the hospitals. Vascular surgeons utilize oral advice to exercise by self-administered walking, pharmacological treatment, and revascularization to improve walking distance in patients with IC. Currently, only 12% of the vascular surgeons referred to rehabilitation to improve walking distance, while almost all vascular surgeons (96%) would refer their patients to IC rehabilitation, if it was available. Only 14% of municipalities and none of the hospitals, who treat patients with IC, have a rehabilitation program designed specifically for patients with IC. However, 59% of the rehabilitation departments in the municipalities and 26% in the hospitals included patients with IC in rehabilitation program designed for other patient groups – mostly cardiac patients. There was consensus among the groups of respondents that future IC specific rehabilitation should include an initial conversation, supervised exercise therapy, smoking cessation, and patient education according to guidelines. Conclusion. Vascular surgeons support referral and participation in IC rehabilitation to improve walking distance in patients with IC. Despite some hospitals and municipalities included patients with IC in rehabilitation nearly all services fail to meet current guideline as specific services tailored to patient with IC is almost non-existent in Denmark. Our findings call for action for services to comply with current recommendations of structured, systematic rehabilitation for patients with IC.

Discussing sexuality in the field of plastic and reconstructive surgery: a national survey of current practice in the Netherlands

BackgroundPatient-reported outcomes have become increasingly important to assess the value of surgical procedures. Sexual function is a proven important constituent of quality of life, but is often overlooked by health care professionals. We aim to investigate to what extent plastic surgeons address or discuss issues concerning sexuality with their patients, and if there is a need for improvement.MethodsWe developed a survey to assess whether topics pertaining to sexual function were discussed during plastic surgical consultations. In 2016, all 385 members of the Dutch Association for Plastic Surgery were invited via post mail to participate.ResultsWe received 106 completed surveys (27.5%). The median age of the respondents was 45 (29–66) years. Most participants (78.3%) indicated that they rarely to never discuss sexuality with their patients. Surgeons in the subspecialization gender and genital surgery discussed sexual function most frequently. Two thirds of all respondents indicated that their current knowledge on this topic was insufficient, yet there was generally no interest expressed in receiving additional training (78.6%). However, there was a need for proper patient brochures (43.4%) and an organized referral network (36.5%) regarding sexuality.ConclusionsIn plastic surgery practice, sexuality appears to be a rarely discussed subject, with the gender and genital surgery subspecialties as the exception. Although professionals and patients emphasize the importance of sexuality, plastic surgeons express limited urge to be trained and prefer written patient information and referring patients to other healthcare professionals. The authors stimulate more education on sexuality during (continued) plastic surgery training.Level of Evidence: Not ratable

Suicide Prevention in U.S. Law Enforcement Agencies: a National Survey of Current Practices

Increasing attention is being paid to suicide among law enforcement officers, and how the agencies that employ these officers could prevent such deaths. This study presents the results of a national survey of U.S. law enforcement agencies’ strategies for preventing officer suicide. We invited 177 agencies from across the United States to be interviewed, and 110 agreed to participate in qualitative interviews. Agencies were grouped into one of four categories based on the services they offered. Agencies offered minimal (a municipal employee assistance program), basic (mental health, critical incident response procedures, and training), proactive (in-house mental health care, embedded chaplains, substance misuse programs, peer support, screening, or health and wellness programs), and integrated services (integration of services into day-to-day operations). The results indicate that many U.S. law enforcement agencies are engaged in efforts to promote officer wellness and prevent suicide. Officers’ perceptions of confidentiality may inhibit the use of in-house or contracted mental health services, while a weak or inconclusive evidence-base raises questions about common approaches like peer support or critical incident stress debriefing.

Teaching High-Value Care in Pediatrics: A National Survey of Current Practices and Guide for Future Curriculum Development

Health care expenditures in the United States are increasing at an unsustainable pace. There have been calls to incorporate education on resource stewardship into medical training, yet the perceived need for and current use of high-value care (HVC) curricula in pediatrics residency programs is unknown. We described the current national landscape of HVC curricula in pediatrics residencies, including characterization of current programs, barriers to the practice of HVC, and clarification of preferred curricula types. Using a cross-sectional study design, we conducted a national, anonymous, web-based survey of pediatrics residency program directors and pediatrics chief residents in fall 2014. We received responses from 85 of 199 (43%) pediatrics program directors and 74 of 199 (37%) pediatrics chief residents. Only 10% (8 of 80) of program directors and 12% (8 of 65) of chief residents reported having a formal curriculum on HVC. Respondents identified the largest barriers to HVC as a lack of cost transparency (program directors) and attending physicians having the final say in treatment decisions (chief residents). The majority of respondents (83%, 121 of 146) agreed their program needs a HVC curriculum, and 90% (131 of 145) reported they would use a curriculum if it was available. Respondents significantly preferred a case-based conference discussion format over other approaches. Most pediatrics residency programs responding to a survey lacked formal HVC curricula. There is a desire nationally for HVC education in pediatrics, particularly in a case-based discussion format.

Brain imaging before primary lung cancer resection: a controversial topic.

ObjectiveInternational and national recommendations for brain imaging in patients planned to undergo potentially curative resection of non-small-cell lung cancer (NSCLC) are variably implemented throughout the United Kingdom [Hudson BJ, Crawford MB, and Curtin J et al (2015) Brain imaging in lung cancer patients without symptoms of brain metastases: a national survey of current practice in England Clin Radiol https://doi.org/10.1016/j.crad.2015.02.007]. However, the recommendations are not based on high-quality evidence and do not take into account cost implications and local resources. Our aim was to determine local practice based on historic outcomes in this patient cohort.MethodsThis retrospective study took place in a regional thoracic surgical centre in the United Kingdom. Pathology records for all patients who had undergone lung resection with curative intent during the time period January 2012–December 2014 were analysed in October 2015. Electronic pathology and radiology reports were accessed for each patient and data collected about their histological findings, TNM stage, resection margins, and the presence of brain metastases on either pre-operative or post-operative imaging. From the dates given on imaging, we calculated the number of days post-resection that the brain metastases were detected.Results585 patients were identified who had undergone resection of their lung cancer. Of these, 471 had accessible electronic radiology records to assess for the radiological evidence of brain metastases. When their electronic records were evaluated, 25/471 (5.3%) patients had radiological evidence of brain metastasis. Of these, five patients had been diagnosed with a brain metastasis at initial presentation and had undergone primary resection of the brain metastasis followed by resection of the lung primary. One patient had been diagnosed with both a primary lung and a primary bowel adenocarcinoma; on review of the case, it was felt that the brain metastasis was more likely to have originated from the bowel cancer. One had been clinically diagnosed with a cerebral abscess while the radiology had been reported as showing a metastatic deposit. Of the remaining 18/471 (3.8%) patients who presented with brain metastases after their surgical resection, 12 patients had adenocarcinoma, four patients had squamous cell carcinoma, one had basaloid, and one had large-cell neuroendocrine. The mean number of days post-resection that the brain metastases were identified was 371 days, range 14–1032 days, median 295 days (date of metastases not available for two patients).ConclusionThe rate of brain metastases identified in this study was similar to previous studies. This would suggest that preoperative staging of the central nervous system may change the management pathway in a small group of patients. However, for this group of patients, the change would be significant either sparing them non-curative surgery or allowing aggressive management of oligometastatic disease. Therefore, we would recommend pre-operative brain imaging with MRI for all patients undergoing potentially curative lung resection.

Conservative management of mallet injuries: A national survey of current practice in the UK

Mallet injuries are common and usually treated conservatively. Various systematic reviews have found a lack of evidence regarding the best management, and it is unclear whether this uncertainty is reflected in current UK practice. An online survey was developed to determine the current practice for the conservative treatment of mallet injury among specialist hand clinicians in the UK, including physiotherapists, occupational therapists and surgeons. Clinician's views of study outcome selection were also explored to improve future trials. In total, 336 professionals completed the survey. Inconsistency in overall practice was observed in splint type choice, time to discharge to GP, and assessment of adherence. Greater consistency was observed for recommended duration of continuous immobilisation. Bony injuries were most commonly splinted for 6 weeks (n=228, 78%) and soft tissue injuries for either 8 weeks (n=172, 56%) or 6 weeks (n=119, 39%). Post-immobilisation splinting was frequently recommended, but duration varied between 2 and 10 weeks. The outcome rated as most important by all clinicians was patient satisfaction. There is overall variation in the current UK conservative management of mallet injuries, and the development of a standardised, evidence-based protocol is required. Clinicians' opinions may be used to develop a core set of outcome measures, which will improve standardisation and comparability of future trials.

A national survey of current practices of preparation and management of radical prostate radiotherapy patients during treatment

AimsRadiotherapy is an important radical treatment for prostate cancer patients with services continually evolving. This survey aims to gain an insight in to the variation of radiotherapy practices in the UK, focussing on pre-treatment preparations, on-treatment review and management of radical prostate cancer patients undergoing radiotherapy. To our knowledge this is the first survey reported focussing on prostate radiotherapy practices with responses from a mix of health professionals. Materials and methodsA national survey was designed based on current known practices in supportive care and management of prostate cancer patients. The survey was distributed to lead radiotherapy personnel in radiotherapy services across the UK with a 77% response rate (n = 54). ResultsPre-treatment protocols were mandated in the majority of departments. Use of bladder filling (98%) and bowel emptying (66%) were frequently deployed. Bowel preparation varied between use of laxatives (13%) or enemas (41%) to achieve consistency.On-treatment reviews were carried out by a mix of health professionals; most commonly shared between oncologists and radiographers (20%). Radiographers reviewing patients were independent prescribers in 22% of departments.Toxicity grading tools were not used by almost half of departments (47%) either at baseline and/or on-treatment reviews. Written information about follow-up was given to patients towards the end of their radiotherapy; however, fewer departments included the length of hormone duration (13%). ConclusionThis survey has demonstrated variations in practice exist across the UK. These variations suggest that important questions about the best methods for treatment accuracy and patient management need to be established through further research.

Brain imaging in lung cancer patients without symptoms of brain metastases: a national survey of current practice in England

To determine current practice regarding brain imaging for newly diagnosed lung cancer patients without symptoms of brain metastases. A survey questionnaire was sent by e-mail to all the lung cancer lead clinicians in England currently on the National Cancer Intelligence Network database. The survey asked whether brain imaging was used in new lung cancer patients without symptoms or signs to suggest brain metastases; and if so, which patient subgroups were imaged according to cell type, stage of disease, and intention to treat, and which techniques were used to image these patients. Responses were received between February and May 2014. Fifty-nine of 154 centres replied to the survey (38%). Thirty of the 59 centres (51%) did not image the brain in these patients. Twenty-nine of the 59 (49%) centres imaged the brain in at least certain subgroups. Of those centres that did image the brain 21 (72%) used CT as the first-line imaging technique and six (20%) used MRI. Twenty-five of 59 (42%) centres stated that the 2011 NICE guidelines had led to a change in their practice. There is wide variation in practice regarding brain imaging in this patient group in England, with no brain imaging at all in approximately half of centres and a spectrum of imaging in the other half. When the brain is imaged, CT is the technique most commonly used. The 2011 NICE guidelines have led to some change in practice but not to national uniformity.