Application of NICE or SNC guidelines may reduce the need for computerized tomographies in patients with mild traumatic brain injury: a retrospective chart review and theoretical application of five guidelines

Abstract

BackgroundTraumatic brain injuries continue to be a significant cause of mortality and morbidity worldwide. Most traumatic brain injuries are classified as mild, with a low but not negligible risk of intracranial hemorrhage. To help physicians decide which patients might benefit from a computerized tomography (CT) of the head to rule out intracranial hemorrhage, several clinical decision rules have been developed and proven effective in reducing the amount of negative CTs, but they have not been compared against one another in the same cohort as to which one demonstrates the best performance.MethodsThis study involved a retrospective review of the medical records of patients seeking care between January 1 and December 31, 2017 at Helsingborg Hospital, Sweden after head trauma. The Canadian CT Head Rule (CCHR), the New Orleans Criteria (NOC), the National Emergency X-Radiography Utilization Study II (NEXUS II), the National Institute of Health and Care Excellence (NICE) guideline and the Scandinavian Neurotrauma Committee (SNC) guideline were analyzed. A theoretical model for each guideline was constructed and applied to the cohort to yield a theoretical CT-rate for each guideline. Performance parameters were calculated and compared.ResultsOne thousand three hundred fifty-three patients were included; 825 (61%) CTs were performed, and 70 (5.2%) cases of intracranial hemorrhage were found. The CCHR and the NOC were applicable to a minority of the patients, while the NEXUS II, the NICE, and the SNC guidelines were applicable to the entire cohort. A theoretical application of the NICE and the SNC guidelines would have reduced the number of CT scans by 17 and 9% (P = < 0.0001), respectively, without missing patients with intracranial hemorrhages requiring neurosurgical intervention.ConclusionA broad application of either NICE or the SNC guidelines could potentially reduce the number of CT scans in patients suffering from mTBI in a Scandinavian setting, while the other guidelines seemed to increase the CT frequency. The sensitivity for intracranial hemorrhage was lower than in previous studies for all guidelines, but no fatality or need for neurosurgical intervention was missed by any guideline when they were applicable.

Microwave scan and brain biomarkers to rule out intracranial hemorrhage: study protocol of a planned prospective study (MBI01)

“…This is time-consuming, expensive and exposes the patient to potentially harmful radiation [ 14 , 15 ]. The annual ED influx of head-trauma patients is substantial [ 7 , 21 , 25 ]. Even small improvements in the clinical management that lead to decreased processing time, decreased use of radiation and/or decreased cost due to the use of brain biomarkers and other diagnostic tools, such as microwave machines, would benefit the health care system and patients alike [ 7 , 21 , 25 ].…”

“…Previous research has shown that patients with trauma to the head who are Glasgow Coma Scale (GCS) 13-15 do not have an increased risk of cervical spine injury [26]. A previous study by Vedin et al [7,21,25] at Helsingborg General Hospital on a very similar patient cohort has shown that approximately 99% of the patients are GCS 13-15. Hence, the theoretical risk of aggravating a pre-existing cervical spine injury is very low with this study design.…”

“…Of these scans, 92.5% were negative [13]. In spite of this, a reduction in CT-scans has been seen when applying the SNC Guideline in both North American and Scandinavian settings [7,13]. Apart from the cost of at least $200/CT scan and prolonged ED stay, there is also the small but significant risk of radiation-induced cancer to take into account [14][15][16].…”

“…Intracranial hemorrhages can be difficult to detect by clinical examination. Even if the physician follows a clinical practice guideline, it can be difficult to know from signs, symptoms and patient history which patient will have an intracranial hemorrhage [ 7 , 8 ]. It can also be difficult to predict what patients will need neurosurgical intervention [ 8 ].…”

Ways to improve guideline adherence in the emergency department: an interview study on the management of traumatic brain injuries

“…Several guidelines have been developed and shown good validity in identifying patients at risk of significant intracranial injury, but have often been wrongfully applied [7][8][9][10]. A study conducted by our group indicated that computerised tomographies (CT) following TBIs could be reduced with strict guideline adherence [11]. Another study that we conducted regarding perceived and actual adherence to guidelines for managing patients with TBI in the emergency department (ED) showed low levels of adherence and frequent guideline misinterpretation.…”