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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 and the NICE guidelines have just reiterated this
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.
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.
4.af Geijerstam JL, Britton M. Mild head injury: reliability of early
computed tomographic findings in triage for admission. Emerg Med J.