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Re: NICE head injury guidelines – the need for further studies before we judge them

Dear Editor,

There have been a series of articles recently published regarding the impact of NICE head injury guidelines and the rising cost implications.[1,2,3] One gets the impression that all NICE guidelines have done so far in the UK is to increase the number of CT scans but with no comment whether it has added positively to the high quality of service we intend to provide to head injury patients.

The studies published so far have extrapolated the guidelines onto patient data and produced figures for the extra number of patients that would have been scanned if the NICE guidelines were rigidly followed and stressed the importance of clinical judgement.[1,2,3] However we do not know for certain that the ones that were discharged out of these patients, who should theoretically have had a scan but did not, have any cerebral trauma because they were not followed up. Clinical judgements may vary a lot depending on the experience of the evaluating physician. In such circumstances who should make these decisions not to scan when they would have warranted one as per the NICE guidelines? Surely with these guidelines available to the general public and rising patient awareness, one would find it increasingly difficult in a court of law to defend such a decision if something actually went wrong.

The NICE guidelines intend to use CT as a screening test instead of skull x-rays and as with all screening tests it would be acceptable to have high sensitivities with a compromised specificity. Current literature does not give an idea of these figures in relation to the NICE guidelines and there have been no reports on the efficacy of the NICE guidelines as such. We know for sure that CT scan is a reliable and safe way of triaging head injury patients[4] and the NICE guidelines have just reiterated this fact.

While I entirely agree that there is no substitute to an experienced clinician’s judgement in the actual management of head injuries I am not convinced we are right in criticizing these guidelines on the basis of the studies currently available.

References:

1.Macgregor DM, McKie L. CT or not CT--that is the question. Whether 'tis better to evaluate clinically and x ray than to undertake a CT head scan! Emerg Med J. 2005 ;22:541-3.

2.Shravat BP, Hynes KA. The impact of NICE guidelines for the management of head injury on the workload of the radiology department. Emerg Med J. 2004 ;21:521-2.

3.Boyle A, Santarius L, Maimaris C. Evaluation of the impact of the Canadian CT head rule on British practice. Emerg Med J. 2004;21:426-8.