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The need for guidelines for head injury
Emergency physicians are already surrounded by guidelines. Surely, you might ask, we don’t need more on head injury to add to those of the US Brain Trauma Foundation, the European Brain Injury Consortium, the SIGN guidelines from Scotland, and recent recommendations from UK neurosurgeons, radiologists, paediatricians, and anaesthetists? Well, yes, I think we do. The guidelines to be published by the National Institute for Clinical Excellence in Spring 2003 will break new ground in a number of ways that will be of particular interest to our specialty.1
The development of the guidelines follows the pattern of best evidence synthesis, resolution of uncertainty by expert consensus, and consultation with a wide spectrum of professional and stakeholder groups that has been used so effectively in the production of National Service Frameworks. The work has been carried out at the recently created National Collaborating Centre for Acute Care, part of NICE, which is located at the Royal College of Surgeons of England.
The parameters of the task were laid down by NICE. Their general philosophy is refreshingly patient centred and will appeal to emergency physicians—the guidelines are intended to help improve both the quality and consistency of clinical care by making available to health professionals and patients well-founded advice based on the best available evidence. . . . not written from the perspective of any individual health care profession. These objectives were reflected in the composition of the Guideline Development Group, which included not only the expected professionals (three from emergency medicine) but also experienced and articulate patient representatives. The real work was undertaken by a project team, which included systematic reviewers, a statistical adviser, an A&E trainee, an information scientist, and a health economist, lead by a graduate project manager. This team spent over 12 months reviewing the extensive literature, determining the level of evidence in each topic area (based on previously accepted definitions), and producing grades of recommendation according to the quality of the evidence. Where the evidence was inadequate the problem was brought to the Guideline Development Group so that expert opinion (and hopefully consensus) could be considered. However, the supremacy of evidence was always acknowledged—albeit with frequent debate about the adequacy of the methodology behind that evidence. Here the professional experience of the project team was critical to success.
While this methodology is widely acclaimed as the best way to approach such a task, a number of problems were encountered. The most difficult were the identification of the boundaries of the guidelines and the paucity of class 1 evidence. Resources and time constraints dictated that the scope be limited to initial assessment, where it was considered that there was the greatest potential health gain. Management was studied up to the point of specialist inpatient team care. It was acknowledged that the longer term care of the many patients with so called mild head injury was often inadequate and that the burden of associated disability demanded attention. However, it was considered to be outside the remit of the group, which limited its comments to a call for research investment in this area.
A period of consultation with international experts, patient groups, and professional bodies was completed in December 2002 and the draft guidelines modified in response to the many constructive comments received. The revised draft was then posted on the NICE web site to encourage dialogue with a wider audience. After any further modification, the documents will then be published by NICE in three forms—a comprehensive report with appendices and extensive bibliography, a short form (running to over 20 pages), and a patient orientated version. However, this will not be the end of the process. There are many areas, particularly in prehospital care and rehabilitation, where the document will, rather lamely, admit that current practice should continue until adequate evidence has been accumulated to more appropriately direct care on an evidence base. It is to be hoped that this unacceptable state of knowledge will act as a prompt to researchers and to funding bodies so that head injury, with its associated youthful mortality and morbidity, can receive the attention it deserves.
Until then, what can we expect to change as a result of the publication of the NICE guidelines? The most challenging will be the strong recommendation that “CT diagnosis” replace “radiological triage” in the investigation of most head injured patients meeting certain prescribed criteria. Concerns about service provision have clouded this issue for too long. Happily, the Guideline Development Group were specifically advised that such issues were outside their terms of reference—and so they should be.
Nevertheless, there will be concern about the service implications of this evidence based recommendation. It is possible that a phased introduction of the guidelines may be deemed sensible to test this and other potential adverse consequences. Certainly it will be necessary to audit guideline use and, hopefully, their effectiveness. It should be possible to adapt North American data to guide us on the level of CT and radiography use we can expect. The use of CT to image the cervical spine in the head injured patient is a more complex issue, but the evidence points to the continued use of radiography in the great majority of cases, with CT reserved for a few specific situations. A literature review indicates that there is stronger evidence of the potential harm from CT in the neck than from CT to the child’s skull.
The full version of the NICE guidelines extends to 90 pages. It provides a snap shot of current evidence and the best synthesis of international expert opinion available. It seeks to meet the aspirations of patients and professionals and has been written from a multidisciplinary perspective. Its objective is to improve the quality and consistency of clinical care. There is an implicit assumption that its impact will be assessed through audit and that the research community will address the extensive evidence free zones in head injury management. One way to promote these developments might be to extend the remit of the National Collaborating Centre for Acute Care to include collaboration with a recently rejuvenated committee in the same building, the College Trauma Committee.
The need for guidelines for head injury
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