Survey of the management of patients with minor head injuries in hospitals in Sweden

Management of traumatic brain injury in adult-A cross-sectional national study

Background

Mild traumatic brain injury (mTBI) is a common cause for seeking care. Previous studies have shown considerable variations in TBI management. New guidelines may have influenced management routines.

Methods

This is a descriptive cross-sectional study, collecting data through structured questionnaires. All Swedish emergency hospitals that manage and treat adult patients with mTBI (Reaction Level Scale [RLS] 1-3, Glasgow Coma Scale [GCS] 13-15, age > 18 years) for the initial 24 h after injury were included in this study.

Results

The response rate among hospitals fulfilling the study criteria's was 61/67 (91%). We observed a distinct predominance of nonspecialists being responsible for the initial management of these patients, with general surgeons and ED-physicians being the dominating specialties. A total of 45/61 (74%) of the hospitals use a guideline when managing TBI, with 12 hospitals (20%) stating that no guideline was used.

Conclusion

In general, established guidelines are used for the management of TBI in Sweden. However, some of these are outdated and several hospitals used local guidelines not based upon reliable evidence-based methodology. Most patients with TBI are managed by nonspecialist doctors, stressing the need of a reliable guideline.

A survey of the management of paediatric minor head injury

OBJECTIVES

To investigate present established routines and standards in managing minor head-injured children in Danish hospitals, a survey of present management practice was conducted.

MATERIALS AND METHODS

A cross-sectional mail survey, detailing clinical and radiological examinations, in-hospital observation, discharge criteria and follow-up, was performed on all 46 hospitals treating children with minor head injury in Denmark.

RESULTS

Of the 46 hospitals, 33% report having established written criteria for the referral and management of children with minor head injury. Ten (22%) of the 46 hospitals are so-called injury clinics, where only nurses are employed. All state that they use the Glasgow Coma Scale (GCS) and/or the paediatric GCS to assess the level of consciousness; 15% use the paediatric GCS exclusively. None perform routine radiological examinations. Criteria for early discharge are established in 98% of the hospitals. All hospitals provide written instructions for observations at home before discharge.

CONCLUSION

The management of children with minor head injury varies between hospitals in Denmark. Local management guidelines are either lacking or mainly based on those of adults. Hence, there is a need for the development of minor head injury guidelines specifically designed for the management of children.

Scandinavian guidelines for initial management of minimal, mild and moderate head injuries in adults: an evidence and consensus-based update

BACKGROUND

The management of minimal, mild and moderate head injuries is still controversial. In 2000, the Scandinavian Neurotrauma Committee (SNC) presented evidence-based guidelines for initial management of these injuries. Since then, considerable new evidence has emerged.

METHODS

General methodology according to the Appraisal of Guidelines for Research and Evaluation (AGREE) II framework and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Systematic evidence-based review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology, based upon relevant clinical questions with respect to patient-important outcomes, including Quality Assessment of Diagnostic Accuracy Studies (QUADAS) and Centre of Evidence Based Medicine (CEBM) quality ratings. Based upon the results, GRADE recommendations, guidelines and discharge instructions were drafted. A modified Delphi approach was used for consensus and relevant clinical stakeholders were consulted.

CONCLUSIONS

We present the updated SNC guidelines for initial management of minimal, mild and moderate head injury in adults including criteria for computed tomography (CT) scan selection, admission and discharge with suggestions for monitoring routines and discharge advice for patients. The guidelines are designed to primarily detect neurosurgical intervention with traumatic CT findings as a secondary goal. For elements lacking good evidence, such as in-hospital monitoring, routines were largely based on consensus. We suggest external validation of the guidelines before widespread clinical use is recommended.

Improving the care of people with traumatic brain injury through the Neurotrauma Evidence Translation (NET) program: protocol for a program of research

The Neurotrauma Evidence Translation (NET) program was funded in 2009 to increase the uptake of research evidence in the clinical care of patients who have sustained traumatic brain injury. This paper reports the rationale and plan for this five-year knowledge translation research program. The overarching aims of the program are threefold: to improve outcomes for people with traumatic brain injury; to create a network of neurotrauma clinicians and researchers with expertise in knowledge translation and evidence-based practice; and to contribute knowledge to the field of knowledge translation research. The program comprises a series of interlinked projects spanning varying clinical environments and disciplines relevant to neurotrauma, anchored within four themes representing core knowledge translation activities: reviewing research evidence; understanding practice; developing and testing interventions for practice change; and building capacity for knowledge translation in neurotrauma. The program uses a range of different methods and study designs, including: an evidence fellowship program; conduct of and training in systematic reviews; mixed method study designs to describe and understand factors that influence current practices (e.g., semi-structured interviews and surveys); theory-based methods to develop targeted interventions aiming to change practice; a cluster randomised trial to test the effectiveness of a targeted theory-informed intervention; stakeholder involvement activities; and knowledge translation events such as consensus conferences.

An observational study of compliance with the Scandinavian guidelines for management of minimal, mild and moderate head injury

Background

The Scandinavian guidelines for management of minimal, mild and moderate head injuries were developed to provide safe and cost effective assessment of head injured patients. In a previous study conducted one year after publication and implementation of the guidelines (2003), we showed low compliance, involving over-triage with computed tomography (CT) and hospital admissions. The aim of the present study was to investigate guideline compliance after an educational intervention.

Methods

We evaluated guideline compliance in the management of head injured patients referred to the University Hospital of Stavanger, Norway. The findings from the previous study in 2003 were communicated to the hospitals physicians, and a feed-back loop training program for guideline implementation was conducted. All patients managed during the months January through June in the years 2005, 2007 and 2009 were then identified with an electronic search in the hospitals patient administrative database, and the patient files were reviewed. Patients were classified according to the Head Injury Severity Scale, and the management was classified as compliant or not with the guideline.

Results

The 1 180 patients were 759 (64%) males and 421 (36%) females with a mean age of 31.5 (range 0-97) years. Over all, 738 (63%) patients were managed in accordance with the guidelines and 442 (37%) were not. Compliance was not significantly different between minimal (56%) and mild (59%) injuries, while most moderate (93%) injuries were managed in accordance with the guidelines (p < 0.05). Noncompliance was caused by overtriage in 362 cases (30%) and undertriage in 80 (7%). Guideline compliance was 54% in 2005, 71% in 2007, and 64% in 2009.

Conclusions

This study shows higher guideline compliance after an educational intervention involving feed-back on performance. A substantial number of patients are exposed to over-triage, involving unnecessary radiation from CT examinations, and unnecessary costs from hospital admissions.

Trauma systems and early management of severe injuries in Scandinavia: review of the current state

INTRODUCTION

Scandinavian countries face common challenges in trauma care. It has been suggested that Scandinavian trauma system development is immature compared to that of other regions. We wanted to assess the current status of Scandinavian trauma management and system development.

METHODS

An extensive search of the Medline/Pubmed, EMBASE and SweMed+ databases was conducted. Wide coverage was prioritized over systematic search strategies. Scandinavian publications from the last decade pertaining to trauma epidemiology, trauma systems and early trauma management were included.

RESULTS

The incidence of severe injury ranged from 30 to 52 per 100,000 inhabitants annually, with about 90% due to blunt trauma. Parts of Scandinavia are sparsely populated with long pre-hospital distances. In accordance with other European countries, pre-hospital physicians are widely employed and studies indicate that this practice imparts a survival benefit to trauma patients. More than 200 Scandinavian hospitals receive injured patients, increasingly via multidisciplinary trauma teams. Challenges remain concerning pre-hospital identification of the severely injured. Improved triage allows for a better match between patient needs and the level of resources available. Trauma management is threatened by the increasing sub-specialisation of professions and institutions. Scandinavian research is leading the development of team- and simulation-based trauma training. Several pan-Scandinavian efforts have facilitated research and provided guidelines for clinical management.

CONCLUSION

Scandinavian trauma research is characterised by an active collaboration across countries. The current challenges require a focus on the role of traumatology within an increasingly fragmented health care system. Regional networks of predictable and accountable pre- and in-hospital resources are needed for efficient trauma systems. Successful development requires both novel research and scientific assessment of imported principles of trauma care.

Guideline compliance in management of minimal, mild, and moderate head injury: high frequency of noncompliance among individual physicians despite strong guideline support from clinical leaders

BACKGROUND

The evidence-based Scandinavian Guidelines for the Initial Management of Minimal, Mild, and Moderate Head Injuries were developed to provide safe and cost-effective assessment of patients. A survey based on a questionnaire directed to clinical managers in all Norwegian hospitals indicated that the guidelines had influenced management practice significantly. However, implementation of guidelines and compliance from clinical leaders does not necessarily influence individual physicians decisions making.

METHODS

To evaluate physicians-compliance with the Scandinavian Guidelines in individual patients, we conducted a study (January 2003 to January 2004) that included all patients with minimal, mild, and moderate head injury who presented to the emergency department in a Norwegian university hospital. Guideline compliance was evaluated in the assessment and treatment of 508 patients. The management of each single patient was classified as compliant with the guidelines or not. Classification as compliant required correct use of computed tomography (CT) and hospital admission in accordance with the guideline.

RESULTS

The overall physicians-compliance with the Scandinavian Guidelines was 51%. A substantial overtriage with unnecessary CT examinations and hospital admissions was seen in patients with minimal and mild head injuries. Among patients with minimal head injury, 69% underwent overtriage, 18% with unnecessary hospital admission, 27% with unnecessary CT, and 24% with both. Among patients with mild head injury, 37% were subject to overtriage, all with admission for observation after a negative CT. All patients with moderate head injury were treated in accordance with the guideline.

CONCLUSION

Guidelines for assessment and treatment of minimal and mild head injuries may not have the intended degree of influence on clinical practice. Even in departments where clinical managers report that the practice is evidence based, physicians may not act in accordance with this in their daily practice. This causes significant unnecessary costs, estimated as USD 2,167.000 annually in Norway.

Survey of the management of children with minor head injuries in Sweden

BACKGROUND

This study investigates current management practice of children with MHI in Swedish hospitals to define present need for management guidelines for children.

METHODS

A cross-sectional mail survey including 51 hospitals treating children with MHI outlines management routines concerning clinical and radiological examinations, in-hospital observation, discharge criteria and follow-up.

RESULTS

Twenty-seven per cent of the hospitals have established written criteria for referral and management of children with MHI. Eighty-eight per cent use the Swedish Reaction Level Scale for assessing the level of consciousness. Eight per cent use the paediatric Glasgow Coma Scale. Routine computerised tomography is performed in 18% of the hospitals, 12% perform skull radiography and/or radiography of the cervical spine as routine. Eighty-four per cent have established criteria for early discharge without hospitalisation.

CONCLUSION

The management of children with MHI varies in Swedish hospitals. There is a need for standardised protocols for detection of intracranial complications and guidelines for the management of MHI in children.

Reliability of clinical guidelines in the detection of patients at risk following mild head injury: results of a prospective study

OBJECT

The aims of this study were to analyze the relevance of risk factors in mild head injury (MHI) by studying the possibility of establishing prediction models based on these factors and to evaluate the reliability of the clinical guidelines proposed for the management of MHI.

METHODS

A series of 1101 patients with MHI were prospectively enrolled in this study. In all cases clinical data were collected and a computerized tomography (CT) scan was obtained. The relationship between clinical findings and the presence of intracranial lesions was studied to establish prediction models based on logistic regression and recursive partitioning analysis. Recently proposed guidelines and recommendations for the treatment of MHI were selected, calculating their diagnostic efficiency when applying each of them to our series. The incidence of acute intracranial lesions was 7.5% (83 patients). A Glasgow Coma Scale score of 14, loss of consciousness, vomiting, headache, signs of basilar skull fracture, neurological deficit, coagulopathies, hydrocephalus treated with shunt insertion, associated extracranial lesions, and patient age greater than 65 years were identified as independent risk factors. Prediction models built on clinical variables were able to indicate patients with clinically important lesions, but failed to achieve 100% sensitivity in the detection of all patients with CT scans positive for intracranial lesions within reasonable specificity limits.

CONCLUSIONS

Clinical variables are insufficient to predict all cases of intracranial lesions following MHI, although they can be used to detect patients with relevant injuries. Avoiding systematic CT scan indication implies a rate of misdiagnosis that should be known and assumed when planning treatment in these patients by using guidelines based on clinical parameters.

Mild Head Injuries: Impact of a National Strategy for Implementation of Management Guidelines

BACKGROUND

A national survey in 1996 showed insufficient routines for management of patients with mild head injuries in Norwegian hospitals. Since then, the Scandinavian Guidelines for Management of Mild Head Injuries have been published.

METHODS

A cross-sectional questionnaire survey of management practice was performed in all 59 hospitals in 2002. We compared the results with figures from 1996 and evaluated guideline compliance.

RESULTS

The proportion of noncompliant hospitals was reduced (p = 0.02) from 52% to 31%. The proportion assessing the patient's level of consciousness according to the Glasgow Coma Scale increased (p = 0.001) from 49% to 80%. The proportion requiring a normal computed tomographic scan if a patient with a history of loss of consciousness was to be sent home from the accident and emergency department increased (p < 0.001) from 1 (2%) to 13 (19%).

CONCLUSION

The Scandinavian Guidelines for Management of Mild Head Injuries have had a significant impact on management practice in Norwegian hospitals.

[Minor head injury management in Spain: a multicenter national survey]

INTRODUCTION AND OBJECTIVES

Despite of the high incidence of minor head injury, there is still controversy and disparity of criteria regarding its management. The lack of consensual protocols and clinical guidelines can lead to deficiencies in the attention to these patients and to inadequate use of resources. The objective of this study has been to describe the present situation of the management of this entity in the neurosurgical departments of the Spanish public hospitals, and to compare it with other European countries.

MATERIAL AND METHODS

A 57-item questionnaire regarding different aspects of minor head injury was designed and distributed to the 66 neurosurgical departments of the Spanish National Health System between December 1999 and February 2000.

RESULTS

A 83.3% of responses were obtained. More than 92,000 patients per year are assisted at the Spanish third-level hospitals (general hospitals) after suffering a minor head injury. In-hospital on duty neurosurgeons are not available in 49.1% of the Spanish neurosurgical departments. Only in 7.3% of the centres the neurosurgeon is the first physician that assists these patients. However, in 52.7% of the hospitals neurosurgical evaluation is required if the patient refers transient loss of consciousness. A GCS score of 13 is still included in the group of minor head injuries in 29.1% of the centres. Although 89.1% of the surveyed neurosurgical departments considered as satisfactory the attention they provide to these patients, 85.5% think that it would be convenient to elaborate clinical guidelines. Cranial x-ray is considered a useful diagnostic tool by only 38.2% of the centres, however, 89.1% of them still use it as a routine. CT-scan is systematically indicated in all patients after suffering a mild head trauma only in 5.5% of the centres, although it is completely available in 74.5% of them. The study of economical costs shows that choosing cranial CT as screening tool in these patients would mean a 40.6% reduction in costs compared to a management based on x-ray plus in-hospital observation.

CONCLUSIONS

This study shows the inter-hospital variability of minor head injury management in Spain. Clinical guidelines are considered as positive and necessary. Although the Spanish situation is similar to that in other European countries, following the tendency toward a broader cranial CT utilisation, would improve diagnosis profitability and economical efficiency. The results of this study may contribute to the creation of consensual protocols and clinical guidelines in our country that help in daily practice decision-making optimising assistance quality.