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This observational study aimed to determine the cost implication for a typical size district general hospital (DGH) adopting the recently published NICE head injury (HI) management guidelines.1 The author reviewed the records of all patients (4688) attending York District Hospital emergency department (60 000 new patients/year) in April 2003 to identify those patients who had suffered a head injury (393). April was chosen because it represented an average month both for attendances and skull radiograph and CT head scan requests. Data were collected from a combination of the triage nurse assessment and the doctor’s notes, followed by retrospective application of the NICE HI guidelines.
Adherence to the guidelines would have resulted in requests for 61 adult and 18 child CT head scans compared with the six actually conducted for trauma during this period. This is probably a conservative estimate. That patients were only placed in the “need CT head” group if a specific indication for a scan was recorded may account for why 20.1% HI patients would have been scanned compared with the NICE estimate of 29.3%.
NICE estimates that about 58% of HI patients in the UK have skull radiographs taken. The figure was 22.6% in this study. Local guidelines2 were not followed in every case but it seems that projected savings from a reduction in skull radiographs may be less than NICE predicts. Similarly, only 2.3% of HI patients were admitted for observation compared with the NICE estimate of 14%. Persisting symptoms, intoxication, or lack of supervision would have prohibited discharge of any of the admitted cases after a “normal” CT scan. Of the patients meeting NICE CT head criteria, 75% attended out of hours, implying that on-call radiologists would be interpreting scans after midnight on most nights.
The Canadian CT head rule that the guidelines are adopted from excluded children.3 However, NICE recommends application of guidelines to both adults and children the same, including scanning all patients who vomit more than once. It surprised the author that only 7 of 149 (3.5%) children vomited more than once after HI, most fulfilling CT head criteria on a dangerous mechanism of injury and witnessed loss of consciousness (table 1).
The commonest mode of injury was a fall (47.8%), followed by assault (23.7%), “accident” (20.4%), and road traffic accident (5.6%). This is generally representative of previous UK HI studies,4 except that there were marginally fewer road traffic accidents in this cohort. This subgroup accounts for a greater proportion of moderate to severe HIs and may partly explain the comparatively low number of CT scans requested. It is the aetiological differences between the UK and Canadian populations2 (11% assault, 43% road traffic accident) that have raised questions about the validity of applying the Canadian CT head rule guidelines to the UK population.
Based on NICE pricing1 (skull radiograph £26, CT head £160), this study suggests that a typical DGH adopting NICE HI guidelines would have net increased imaging costs alone of over £9000/month and £110 000/year. Admission costs may not change significantly. Allied to radiology shortages, this will probably prove prohibitive to full implementation of the guidelines in many areas.
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