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Abstract
Background Recent guidelines and service developments may have changed the management of isolated minor head injuries in the UK. The authors aimed to review current practice and national statistics, and determine whether methods of service delivery are associated with differences in admission rates.
Methods The authors surveyed management of minor head injuries in all acute hospitals in the UK and then correlated these responses with Hospital Episodes Statistics (HES) emergency department data relating to head injury.
Results Responses relating to children were received from 174/250 hospitals and adults from 181/250. Nearly all hospitals had unrestricted access to CT scanning (adults 96%, children 94.5%). Most hospitals (70.1%) admitted adults under the emergency department staff, usually (61.4%) to an observation ward or clinical decision unit. Children were usually formally admitted to a ward (86.7%) under an inpatient team (78.5%). The median proportion of attendances admitted was higher for adults (18%) than for children (9%). There was no evidence of any association between the proportion admitted and the admission team, location or requirement for senior or specialist approval (all p>0.1).
Conclusion Minor head injury admission, especially for adults, is increasingly the responsibility of the emergency department. Admission policies had no significant effect on the proportion admitted, although improved HES data are required to confirm this.
- Head injury
- survey
- guidelines
- hospital care
- cardiac care
- cardiac systems
- emergency care systems
- emergency departments
- trauma
- head
Statistics from Altmetric.com
- Head injury
- survey
- guidelines
- hospital care
- cardiac care
- cardiac systems
- emergency care systems
- emergency departments
- trauma
- head
Background
Head injury is responsible for around 700 000 emergency department (ED) attendances per year in England and Wales,1 most of which (90%) are minor (GCS 13–15).2 Guidelines for managing head injury were drawn up by the National Institute for Health and Clinical Excellence (NICE) in 2003 and revised in 2007.2 In Scotland, guidance has been published by the Scottish Intercollegiate Guidelines Network (SIGN).3 Recent developments in the management of head injury and the introduction of NICE guidance were expected to lead to substantial changes in the management of patients with isolated minor head injury.4 CT scanning was expected to become more widespread and admission for minor head injury was expected to move from inpatient wards under the care of inpatient teams to ED-based observation or clinical decision units (CDUs). Studies from single centres5–7 and other reports8 9 have identified some changes, and recent national data suggest that head-injury admissions are rising,1 but it is not clear why this has happened or what effect different models of service delivery have upon admission rates.
We aimed to survey current practice in the management of isolated minor head injury and review national statistics relating to head injury, and then correlate these two data sources to determine whether methods of service delivery are associated with differences in admission rates for head injury.
Methods
We sought data from two sources: (1) Postal survey of the lead clinician of all major acute hospital emergency departments in the UK; and (2) Hospital Episode Statistics for England and Wales.
We developed a simple postal questionnaire survey to identify key elements of service provision for isolated minor head injury. We designed it to be completed within 5 min by the lead clinician based entirely upon their working knowledge of the department. We did not ask them to seek out data or estimate any parameters, such as proportions of patients receiving a particular form of care. The aim of this approach was to maximise response rates, data completion and reliability of responses. Two copies were sent to each consultant, one for adults and one for children, except for departments known to only routinely receive adults or children. The two copies only differed in the patient group of interest. The adult questionnaire is outlined in the Appendix. We sent up to two further mailings to non-responders.
Hospital Episode Statistics (HES) is a data warehouse containing details of all admissions to NHS hospitals in England and is openly accessible online (http://www.hesonline.org.uk). Data on all acute hospital episodes from 1998 have been collected, assembled and made available online. Data on ED attendances have recently started to be collected and are available on request. We formally requested HES data from the Health and Social Care Information Centre for all records between 2007 and 2008 containing the ED diagnosis head injury and attendance disposal (eg, admission or discharge) by each provider (eg, hospital or Trust) in the UK.
The questionnaire survey responses were entered onto a Microsoft Excel spreadsheet and a simple descriptive analysis of proportions in each response category undertaken. HES data were received on a Microsoft Excel spreadsheet and were also analysed descriptively. Cases were divided into children (age 0–14) and adults (age >15), and analysed separately. We calculated the proportion of adults and children at each Trust who were admitted or discharged, or had an unknown disposal from the ED, and then calculated the proportion of cases in each category. We excluded Trusts where all patients were admitted, all were discharged or more than 50% were unknown. This was because we suspected that such Trusts were seeing a selected patient group (such as referrals), were unable to admit patients or were providing unreliable data. We then estimated the median proportion of patients admitted and discharged.
Finally, we matched Trusts with analysable HES data to acute hospitals associated with those Trusts that had been sent and returned a questionnaire. We used SPSS for Windows (version 15.0; SPSS, Chicago, Illinois) to compare the median and IQR of the proportion of patients admitted between different types of service delivery, and test the association between proportion admitted and type of service delivery using a Mann–Whitney test.
Results
Adults
Completed questionnaires were returned from 174/250 hospitals (69.6%). Table 1 summarises the questionnaire responses. NICE guidelines were followed by 147/174 hospitals (84.5%), although amendments had been made to 33/147 (22.4%). Nearly all hospitals had unrestricted CT access. The admission location varied between hospitals, but most hospitals admitted adults under the ED staff, and most required approval for admission by a senior or specialist doctor.
Questionnaire responses for adults
HES data relating to adults were available from 121 trusts. We excluded 21 from further analysis because they recorded that all patients were discharged, all were admitted, or had no admission or discharge data for over half the patients. The number of adult cases attending the remaining 100 trusts ranged from 15 to 5630 (median 1050). The proportion discharged ranged from 54 to 95% (median 80%) and the proportion admitted from 1 to 45% (median 18%).
We were able to match 91 of the trusts that supplied usable adult HES data with hospitals that had been sent a questionnaire, 72 of which had returned a completed questionnaire. Table 2 summarises the tests for association between questionnaire data and proportion admitted. There was a slight trend towards a lower proportion being admitted at hospitals requiring formal admission, where admission was under an inpatient team and where admission required senior or specialist approval. However, the differences were small (1–2%), and none of the associations approached statistical significance.
Association between admission policies for adults and proportion admitted
Of the 33 hospitals that had made modifications to formal guidelines for local use, 17 provided further details on the changes undertaken. Although 15 of the hospitals followed the current NICE guidelines for CT scanning in adults, the most prominent characteristic that had been amended for local use was the definition of persistent vomiting required for immediate CT scanning. Additional criteria (not specified in the NICE guidelines) for CT scanning included immediate CT for reduction in Glasgow Coma Score, delayed CT for patients who make assessment difficult while under the influence of alcohol and drugs; considering CT for severe (persistent/prolonged) headache and CT indicated in patients who return to the emergency department within 48 hours.
Children
Completed questionnaires were returned from 181/250 hospitals (72.4%). NICE guidelines were followed by 153/181 hospitals (84.5%), although amendments had been made to 35/153 (22.9%). Nearly all hospitals had unrestricted CT access. Unlike adults, most hospitals formally admitted children under an inpatient team. Most hospitals required approval for admission by a senior or specialist doctor.
Table 3 summarises the questionnaire responses.
Questionnaire responses for children
HES data relating to children were available from 118 trusts. We excluded 32 from further analysis because they recorded that all patients were discharged, all patients were admitted or had no admission or discharge data for over half the patients. The number of child cases ranged from 14 to 3202 (median 753). The proportion discharged ranged from 53 to 97% (median 90%) and the proportion admitted from 3 to 43% (median 9%).
We were able to match 78 of the trusts that supplied usable child HES data with hospitals that had been sent a questionnaire, 64 of which had returned a completed questionnaire. Table 4 summarises the tests for association between questionnaire data and proportion admitted. The trend in children was the opposite of that in adults with slightly more being admitted at hospitals requiring formal admission and/or admission under an inpatient team. However, the differences were again small, and none of the associations approached statistical significance.
Association between admission policies for children and proportion admitted
Of the 35 hospitals that had made modifications to formal guidelines for local use, 20 provided further details on the changes undertaken. Of those hospitals that had modified the NICE guidelines for CT scanning (n=16) in children, amendments were generally around the timing of performing CT that is immediate CT versus delayed CT. The most common features that were amended for local use included delaying or considering CT in patients with (1) amnesia (antegrade or retrograde) lasting >5 min, (2) dangerous mechanism of injury and (3) presence of bruise, swelling or laceration >5 cm on head in children <1 years of age as oppose to immediate CT as indicated in the NICE guidelines. Additional criteria for considering CT scanning included the loss of consciousness or amnesia and coagulopathy or severe (persistent) headache.
Discussion
Most hospitals in the UK follow the NICE or SIGN guidelines for both adults and children, and access to CT scanning is rarely restricted. However, there are variations in admissions policy. Adults are usually admitted under ED staff, although there is variation in the location. Children are usually formally admitted under an inpatient team. The median admission rate for adults, at 18%, is twice as high as that for children, at 9%. There was no significant association between admissions policy and proportion of patients admitted at hospitals that provided both HES data and a response to the survey.
Previous studies evaluating the impact of methods of service delivery upon admission rates following head injury have tended to focus on clinical indicators and decision rules. Conflicting predictions about the NICE guidelines implementation were made following their introduction.1 4–10 Dunning10 performed a hypothetical analysis by applying the NICE criteria to a large cohort of patient data and concluded that they would move patient management ‘from the observation ward to the radiology department.’ This was at odds with a ‘before and after’ study around the guidelines introduction which demonstrated a modest increase in CT and admission rates when compared with previous Royal College of Surgeons ‘Galasko’ guidelines.5 A study by Thomson in the early 1990s11 highlighted the difficulty of implementing new guidelines when no consistent change in management was elicited following introduction of a local management policy.
Little work has been done on specific service delivery effects on admission rates. One study from Scotland in 199412 provided evidence that easy access to hospital beds was a major determinant on admission rates with a rate of 17.7% when an observation ward was used and only 4.9% when formal admission was required. Other work assessing the role of observation/short stay wards or clinical decision units has concentrated on reduction in hospital bed days and average length of stay.13 No work assessing the role of medical seniority in decision-making for admission was identified, but knowledge and application of guidelines would generally be expected to be prevalent in a higher proportion of senior doctors.
This study has a number of limitations that need to be taken into account. We surveyed intended management rather than actual management practices. Thus, although most hospitals reported that they used NICE guidelines, we do not know whether these guidelines were actually followed in practice. The response rate, at almost 70%, is typical for a postal questionnaire survey of this sort, but failure to achieve a response from 30% of hospitals surveyed may have introduced some bias. Emergency department HES data are only just beginning to be assimilated and made available for analysis. Many Trusts do not currently produce usable data, and we were only able to match a minority of hospitals to usable HES data. We had no way of checking the reliability of HES data and had to exclude data from some Trusts because they were clearly inaccurate. Data from other Trusts were included despite doubts about accuracy. These factors mean that the HES data may not be accurate or representative, and findings based on HES data should be interpreted with caution. We used standard tests to determine whether there was a statistically significant association between service organisation and proportion admitted. It could be argued that this was inappropriate, since our sample was not a random sample, but was actually the entire population of hospitals with analysable data. However, the actual differences in admission rate between different methods of service delivery were small (1–2%) and thus not clinically significant. Finally, matching two separate data sources may have led to inaccuracy if the two sources did not match appropriately.
In conclusion, we have shown that most UK hospitals report that they follow NICE or SIGN guidance and have unrestricted access to CT scanning. Observation and admission of patients, especially for adults, are increasingly becoming the responsibility of the emergency department. Admission policies do not appear to have any significant effect upon the proportion of patients admitted, although improved HES data are required to confirm this.
Acknowledgments
We thank The Health and Social Care Information Centre, for providing HES data; J Turner, for clerical support; F Lecky, T Coats, T Pigott and D Hughes, for advice on survey content and layout; and the survey respondents for their responses.
Appendix Questionnaire survey (adults) sent to lead clinician
References
Footnotes
Funding United Kingdom National Institute for Health Research Health Technology Assessment Programme. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Department of Health.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.