The implications of NICE guidelines on the management of children presenting with head injury

J Dunning; J P Daly; R Malhotra; P Stratford-Smith; J-P Lomas; F Lecky; J Batchelor; K Mackway-Jones

doi:10.1136/adc.2003.042523

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Acute paediatrics

The implications of NICE guidelines on the management of children presenting with head injury

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The NICE guidelines on the management of head injury - implications for a district general hospital
Sandeep Kapoor
Published on: 9 January 2022

Published on: 9 January 2022

The NICE guidelines on the management of head injury - implications for a district general hospital

Sandeep Kapoor, Consultant Paediatrician
Other Contributors:
- V R Meedimale, Mike Hockey

Dear Editor,

We read with interest the study of Dunning et al [1]. We have done a similar audit in our department and would like to share our results.

Dear Editor,

We read with interest the study of Dunning et al [1]. We have done a similar audit in our department and would like to share our results.

As in the study, our own local guidelines on the management of children presenting with head injury, are based on the guidelines of the Royal College of Surgeons (RCS) of England published in June 1999 [2]. The aim of our audit was to ensure that children with head injury are receiving appropriate management in line with the local protocol and to compare local practice against new recommendations recently published by the National Institute of Clinical Excellence (NICE) [3].

Methods: We retrospectively collected data on all children under 16 years of age, presenting to the Accident and Emergency department of Scunthorpe General Hospital, with a head injury of any severity, during the period 1st July 2003 to 31st October 2003. Our outcome measures were admission criteria, Skull radiograph (SXR), brain computed tomography (CT) and discharge criteria. Actual management was compared against the RCS and NICE guidelines

Results: A total of 361 children presented with a head injury within the 4-month period (Table 1).

a) Admission criteria: 29 out of the 361 children were admitted (8.0%). According to the RCS guidelines, only 25 children should have been admitted (6.9%). However we also admitted 4 children with minor head injury. According to NICE guidelines admission is intrinsically linked to CT results. The admissions will be much lower and we predict we would have admitted 11 (3.0%) children.

b) Skull radiograph: Of the 361 children, SXR was performed in 60 children (16.6%). As per the RCS guidelines SXR should have been performed in 25.2% children. If we had used NICE guidelines only 2 children would have needed SXR (0.6%).

c) CT Scan: A total of 3 CT scans were done (0.8%). In this regard RCS guidelines were followed in 100% cases. If we strictly apply NICE guidelines CT would have been indicated in 20 children (5.2%).

d) Discharge criteria: 26 children had normal observations and were discharged within 24 hours. One child was transferred to a tertiary neuro- surgical centre as he had a depressed skull fracture. He needed a CT scan, requiring Paediatric anaesthesia, which is not available in our institution. One child was kept for more than 24 hours due to concerns about non-accidental injury and another for fractured mandible. 91% of discharged children were given an advice card.

Discussion: If NICE guidelines are strictly followed in a district general hospital like ours the admission rates for head injury are likely to fall from 8.0% to 3.0 %. There will also be fewer skull radiographs (16.6% compared to 0.6%), however the CT scan rate will increase from 0.8% to 5.2%. NICE guidelines state these scans should be performed and reported within one hour. For our hospital this would mean 17 more scans in 4 months or approximately 51 scans per year (in children less than 16) if we have a similar case load throughout the year. A number of these scans would have to be done after 5 p.m. This will have severe unfunded resource implications and currently radiology services are unable to cope with this extra demand.

Small children need to be sedated for CT scan (11 out of the 29 [37.9%] children admitted were less than 5 years old). In the very young ones this means they will need a paediatric anaesthetist. Most district general hospitals do not have paediatric anaesthetists available round the clock. Therefore these patients would have to be transferred to tertiary centres (One of our patients' had to be transferred for this reason). This will increase the load on tertiary centres.

One of the indications for a CT scan in the NICE guidelines is Glasgow coma scale equal to 13 or 14 two hours after the injury. Any crying young child seen 2 hours after injury would score 14 on the Glasgow coma scale and would therefore need a CT scan. This would lead to a lot of probably unnecessary scans in young children.

Our admission rates are higher than those reported by Dunning et al (8.0% Vs 3.7%). However there were 511 children (4.7%) in their study who were observed in the emergency department for more than 3 hours. In our hospital most of these children would have been observed on the Paediatric ward and would have been counted as an admission. Therefore if we add these 511 children, then our admission figures are similar.

In our series SXR was performed in only 16.6% children compared to 25% in the study by Dunning et al. There have been questions about the utility of SXR in children with head injury (4) and this may have been the reason why doctors in our hospital ordered less SXR.

In conclusion, our results are quite similar to the study by Dunning et al and shows the extra burden that would be placed on radiology departments if the NICE guidelines are fully implemented.

References

[1]. Dunning J, Daly JP, Malhotra R, et al. The implications of NICE guidelines on the management of children presenting with head injury. Arch Dis Child 2004;89:763-767.

[2]. Royal College of Surgeons of England. A working party on the management of the head injured patient. Holborn, London: RCS England, Lincoln’s Inn Fields, 1999.

[3]. The National Collaborative Centre for Acute Care. Head injury: triage, assessment, investigation and early management of head injury in infants, children and adults. Clinical Guideline N0234. Published by National Institute of Clinical Excellence, http://www.nice.org.uk 2003.

[4]. Boulis ZF, Dick R, Barnes NR. Head injuries in children—aetiology, symptoms, physical findings and x-ray wastage. Br J Radiol 1978;51:851–4.

Table 1. Management of 362 children with head injury

	Hospital Admission	Skull Radiograph	CT Scan
Actual Management	29 (8%)	60 (16.6%)	3 (0.8%)
RCS Guidelines	25 (6.9%)	91 (25.2%)	3 (0.8%)
NICE Guidelines	11 (3%)	2 (0.6%)	20 (5.2%)

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Conflict of Interest:
None declared.

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