Head home: a prospective cohort study of a nurse-led paediatric head injury clinical decision tool at a district general hospital

Abstract

ObjectivesTo assess if a nurse-led application of a paediatric head injury clinical decision tool would be safe compared with current practice.MethodsAll paediatric (<17 years) patients with head injuries presenting to Frimley Park Emergency Department (ED), England from 1 May to 31 October 2018 were prospectively screened by a nurse using a mandated electronic 'Head Injury Discharge At Triage' questionnaire (HIDATq). We determined which patients underwent CT of brain and whether there was a clinically important intracranial injury or re-presentation to the ED. The negative predictive value of the screening tool was assessed. We determined what proportion of patients could have been sent home from triage using this tool.ResultsOf the 1739 patients screened, 61 had CTs performed due to head injury (six abnormal) with a CT rate of 3.5% and 2% re-presentations. Of the entire cohort, 1052 screened negative. 1 CT occurred in this group showing no abnormalities. Of those screened negative, 349 (33%)/1052 had ‘no other injuries’ and 543 (52%)/1052 had ‘abrasions or lacerations’. HIDATq's negative predictive value for CT was 99.9% (95% CI 99.4% to 99.9%) and 100% (95% CI 99.0% to 100%) for intracranial injury. The positive predictive value of the tool was low. Five patients screened negative and re-presented within 72 hours but did not require CT imaging.ConclusionA negative HIDATq appears safe in our ED. Potentially 20% (349/1739) of all patients with head injuries presenting to our department could be discharged by nurses at triage with adequate safety netting advice. This increases to 50% (543/1739), if patients with lacerations or abrasions were given advice and discharged at triage. A large multicentre study is required to validate the tool.

Head home: implementation during COVID-19 pandemic

“…We write further to our original paper 1 to report on the implementation of ‘Head Injury Discharge At Triage’ (HIDAT), which went live in March 2020 at our clinical site. The HIDAT tool was designed to identify patients who could be safely discharged soon after triage without medical review.…”

“…Pre-implementation feedback on HIDAT led to the inclusion of an additional question; ‘Have safeguarding concerns been considered and excluded?’ This was to both improve documentation and serve as a reminder to staff to fully consider safeguarding, as children discharged under the policy would not undergo traditional medical review. As noted in our original paper, 1 all children under 1 year are excluded from the tool due to a local policy requiring formal examination by a doctor.…”

“…Seizure (8), injury of limb (upper or lower) (4), collapse (3), headache (2), polytrauma (2), vomiting (2), wound (2), neck pain (1), epistaxis (1), toothache (1). Traumatic brain injury on computed tomography (TBI-CT) defined 1 by the presence of any of the following criteria: diastasis of the skull and/or skull fracture inclusive of orbit, pneumocephalus, intracranial haemorrhage or contusion, sigmoid sinus thrombosis, traumatic infarction, diffuse axonal injury or signs of herniation. Clinically important traumatic brain injury (ciTBI)- defined 1 as death due to TBI, intubation for more than 24 hours, neurosurgery or hospital admission of 2 nights or more due to TBI.…”

“… Traumatic brain injury on computed tomography (TBI-CT) defined 1 by the presence of any of the following criteria: diastasis of the skull and/or skull fracture inclusive of orbit, pneumocephalus, intracranial haemorrhage or contusion, sigmoid sinus thrombosis, traumatic infarction, diffuse axonal injury or signs of herniation. …”

“… Clinically important traumatic brain injury (ciTBI)- defined 1 as death due to TBI, intubation for more than 24 hours, neurosurgery or hospital admission of 2 nights or more due to TBI. …”