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Pandor A, Goodacre S, Harnan S, et al. Diagnostic Management Strategies for Adults and Children with Minor Head Injury: A Systematic Review and an Economic Evaluation. Southampton (UK): NIHR Journals Library; 2011 Aug. (Health Technology Assessment, No. 15.27.)

6Survey of current NHS practice

We aimed to evaluate current NHS practice in the management of isolated MHI, review national statistics relating to head injury and then correlate these two data sources to determine whether or not methods of service delivery are associated with differences in admission rates for head injury.

Methods of the survey

Data sources

Data were sought from two sources: (1) postal survey of the lead clinician of all major acute hospital EDs in the UK and (2) HES for England and Wales.

Questionnaire specification

A simple postal questionnaire survey was developed to identify key elements of service provision for isolated MHI. The survey was designed to be completed within 5 minutes by the lead clinician, based entirely upon his/her working knowledge of the department. The clinician was not asked to seek out data or estimate any parameters, such as proportions of patients receiving a particular form of care. The aim of this approach was to maximise response rates, data completion and reliability of responses. Two copies of the questionnaire were sent to each consultant, one for adults and one for children, except for departments known to only routinely receive adults or children. The two copies differed only in the patient group of interest. An example of the adult questionnaire is outlined in Appendix 12. Two further reminders, sent at 3-week intervals, were sent to non-responders.

Hospital Episode Statistics data requests

The HES is a data warehouse containing details of all admissions to NHS hospitals in England and is openly accessible online (www.hesonline.org.uk). Data on all acute hospital episodes from 1998 have been collected, assembled and made available online. Data on ED attendances have recently started to be collected and are available on request. HES data were formally requested from the Health and Social Care Information Centre for all records between 2007 and 2008 containing the ED diagnosis ‘head injury’ and attendance disposal (e.g. admission or discharge) by each provider (e.g. hospital or trust) in the UK.

Data analysis

The questionnaire survey responses were entered onto a Microsoft Excel 2007 (Microsoft Corporation, Redmond, WA, USA) spreadsheet and simple descriptive analysis of proportions in each response category were undertaken. The HES data were received on a Microsoft excel spreadsheet and were also analysed descriptively. Cases were divided into children (age 0–14 years) and adults (age > 14 years) and analysed separately. The proportions of adults and children at each trust who were admitted, discharged or had an unknown disposal from the ED were calculated, and then the proportion of cases in each category was determined. The following were excluded: trusts through which all patients were admitted, all were discharged or > 50% were unknown. This was because it was suspected that such trusts were seeing a selected patient group (such as referrals), were unable to admit patients or were providing unreliable data. The median proportion of patients admitted and discharged was then estimated.

Finally, each trust with analysable HES data was matched to an acute hospital associated with those trusts that had been sent and returned a questionnaire. Data were analysed using spss for Windows version 15.0 (SPSS Inc., Chicago, IL, USA). The median and IQR of the proportion of patients admitted between different types of service delivery were compared, and the Mann–Whitney U-test was used to assess the association between the proportions admitted and the type of service delivery. Data were presented separately for adults and children.

Results of the survey

Adults

Completed questionnaires were returned from 174/250 hospitals (69.6%). Table 63 summarises the questionnaire responses. Nearly all hospitals had unrestricted CT access. NICE guidelines were followed by 147/174 hospitals (84.5%), although amendments had been made to 33/147 (22.4%). Of the 33 hospitals that had made modifications to formal guidelines for local use, 17 provided further details on the changes undertaken. These typically took the form of additional criteria (not specified in the NICE guidelines) for CT scanning, including immediate CT for any reduction in GCS at presentation, delayed CT for patients that make assessment difficult while under the influence of alcohol and drugs, considering CT for severe (persistent/prolonged) headache and CT indicated in patients who return to the ED within 48 hours. The admission location varied between hospitals, but most hospitals admitted adults under the ED staff, and most required approval for admission by a senior or specialist doctor.

TABLE 63. Questionnaire responses for adults.

TABLE 63

Questionnaire responses for adults.

Hospital Episode Statistics data relating to adults were available from 121 trusts. We excluded 21 from further analysis because they either recorded that all patients were discharged, all were admitted, or had no admission or discharge data for over one-half of the patients. The number of adult cases attending the remaining 100 trusts ranged from 15 to 5630 (median 1050). The proportion discharged ranged from 54% to 95% (median 80%) and the proportion admitted from 1% to 45% (median 18%).

A total of 91 trusts that supplied usable adult HES data were matched with hospitals that had been sent a questionnaire, 72 of which had returned a completed questionnaire. Table 64 summarises the tests for association between questionnaire data and proportion admitted. There was a slight trend towards a lower proportion being admitted at hospitals requiring formal admission, where admission was under an inpatient team and where admission required senior or specialist approval. However, the differences were small (1–2%) and none of the associations approached statistical significance.

TABLE 64. Association between admission policies for adults and proportion admitted.

TABLE 64

Association between admission policies for adults and proportion admitted.

Children

Completed questionnaires were returned from 181/250 hospitals (72.4%). Table 65 summarises the questionnaire responses. Nearly all hospitals had unrestricted CT access. NICE guidelines were followed by 153/181 hospitals (84.5%), although amendments had been made to 35/153 (22.9%). Of the 35 hospitals that had made modifications to formal guidelines for local use, 20 provided further details on the changes undertaken. Of those hospitals that had modified the NICE guidelines for CT scanning (n = 16) in children, amendments were generally around the timing of performing CT, i.e. immediate CT versus delayed CT. The most common features that were amended for local use included delaying CT in patients with amnesia (anterograde or retrograde) lasting > 5 minutes, and dangerous mechanism of injury or presence of bruise, swelling or laceration > 5 cm on head in children < 1 year of age, as opposed to immediate CT as indicated in the NICE guidelines. Additional criteria for considering CT scanning included LOC or amnesia and coagulopathy or severe (persistent) headache. Unlike adults, most hospitals formally admitted children under an inpatient team. Most hospitals required approval for admission by a senior or specialist doctor.

TABLE 65. Questionnaire responses for children.

TABLE 65

Questionnaire responses for children.

The HES data relating to children were available from 118 trusts. Data from 32 were excluded from further analysis because they recorded either that all patients were discharged or that all patients were admitted or because they had no admission or discharge data for over half the patients. The number of child cases ranged from 14 to 3202 (median 753). The proportion discharged ranged from 53% to 97% (median 90%) and the proportion admitted from 3% to 43% (median 9%).

A total of 78 trusts that supplied useable child HES data were matched with hospitals that had been sent a questionnaire, 64 of which had returned a completed questionnaire. Table 66 summarises the tests for association between questionnaire data and proportion admitted. The trend in children was the opposite of that in adults, with slightly more being admitted at hospitals requiring formal admission and/or admission under an inpatient team. However, the differences were again small and none of the associations approached statistical significance.

TABLE 66. Association between admission policies for children and proportion admitted.

TABLE 66

Association between admission policies for children and proportion admitted.

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Cover of Diagnostic Management Strategies for Adults and Children with Minor Head Injury: A Systematic Review and an Economic Evaluation
Diagnostic Management Strategies for Adults and Children with Minor Head Injury: A Systematic Review and an Economic Evaluation.
Health Technology Assessment, No. 15.27.
Pandor A, Goodacre S, Harnan S, et al.
Southampton (UK): NIHR Journals Library; 2011 Aug.

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