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Archived Comments for: Audit of head injury management in Accident and Emergency at two hospitals: implications for NICE CT guidelines

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  1. Requirements of NICE guidelines or just good clinical practise

    Joel Dunning, Department of Emergency Medicine , Manchester Royal Infirmary

    10 May 2004

    I was greatly surprised by this article that states that the current assessment process does not record simple and highly important factors on a routine basis such as GCS, vomiting , amnesia , pupillary reaction, and head injury advice cards.

    I was then shocked that there was an assumption that the current state of affairs in these two hospitals was acceptable and that 'in the two hospitals audited, this (i.e. full head injury documentation) would require

    a radical overhaul of existing documentation, which currently contains only a designated

    area for recording GCS and pupil reactivity'.

    This audit exposes a very serious lack of adequate documentation at these two hospitals and I am sure that no matter what guidelines are currently being followed, the standards presented here fall far below those expected of competent physicians.

    It must be remembered that there is at least a 1 in 10-13,000 chance of any 'minor head injury' actually having an undiagnosed intracranial haematoma and thus if this person deteriorates and suffers serious neurological sequelae, the only defence the clinican that sent that person home would have, would be their clinical record including documentation that no high risk symptoms or signs were present at the time of consultation.

    This actual scenario occurred at Sheffield Childrens hospital where a 7 year old child was discharged, but returned subsequently with GCS 3. The case went to court but the SHO was completely cleared of any blame due to their exemplary clinical notes which recorded that every significant high risk clinical correlate was absent.

    In my own cohort study of 23,000 children presenting with a head injury (the CHALICE study) we have records of 10 patients that were sent home but reattended, subsequently needing neurosurgery.

    The Royal College of Surgeons Guidelines of 1999 (the Galasko report) which I assume these hospitals are following, recommend full documentation of all these clinical correlates as minimal competent practise and also recommend the use of a specific proforma to improve the quality of data collection. Of note these guidelines also make decisions on the basis of GCS, vomiting, amnesia, pupillary reaction etc, and thus no matter what guidelines are used, all these factors must be documented.

    In addition, failure to document that head injury advice has been given is unacceptable due to the real risk of deterioration while at home and it is only this head injury advice that might cause the patient to reattend.

    I would suggest that the authors hold an urgent meeting with their Emergency Physicians to rectify this situation before 10,000 patients are seen in their department, as all departments will eventually send home a patient that deteriorates.

    Adequate documentation will have no resource implications of the implementation of the NICE guidelines as they are based on the daily competent assessment of every head injury using no other methods of assessment other than competent clinical skills.

    Competing interests

    Joel Dunning spent 6 months as a full time Systematic reviewer in the construction of the NICE guidelines for the Management and investigation of Head Injuries, and is also Lead researcher for the CHALICE study, a prospective 10 centre study aiming to derive a sensitive rule to diagnose significant intracranial injury in the under 16's