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Type and Title of Submission


Title:

Impact of the 2007 NICE Guideline for Children's Head Injury

Description:

We designed a retrospective study to assess the impact of the 2007 NICE head injury guideline on rates of CT scanning in children's head injury. We found that the guideline increased scanning rates from 6.0% of patients to 10.5%.

Category:

2010-11 Shared Learning examples

Does the submission relate to the general implementation of all NICE guidance?

No

Does the submission relate to the implementation of a specific piece of NICE guidance?

Yes

Full title of NICE guidance:

CG56 - Head Injury

Category(s) that most closely reflects the nature of the submission:

Is the submission industry-sponsored in any way?

No


Description of submission


Aim

The 2007 NICE head injury guideline gave new criteria for performing CT head scanning in children. Our aim was to evaluate the impact of this guideline in the Emergency Department of a typical rural hospital in the south west of England.

Objectives

We had three objectives: 1. To show how the management of children's head injury would change with the application of the 2007 NICE head injury guideline. 2. To evaluate what this change meant financially to the trust in terms of extra Computed Tomography (CT) scanning and bed occupancy. 3. To evaluate how this change might affect the radiation dose that the children received.

Context

Our starting point was local management of head injury in children. This was done according the NICE 2003 Head Injury guidelines, which extrapolated data from adult head injuries to manage children's head injuries. Using the guideline, a child can be: (a) Determined low risk for an intracranial bleed (using NICE guidance) and sent home with advice to return if symptoms progress. (b) Determined higher risk for an intracranial bleed and undergo a CT head examination If the CT head is normal the child can be sent home or admitted according to the clinician's discretion. If it is abnormal the child will be discussed with the local neurosurgical service. The guideline was updated in 2007 to incorporate the CHALICE rule (Children's Head Injury Algorithm for the prediction of Important Clinical Effects). This rule arose from research to determine the most important clinical variables predicting the risk of death, the need for neurosurgery or CT scan changes. This rule was about to be implemented in our Emergency Department and we wanted to evaluate how this would change our management of head injury. In particular, we wanted to identify the cost implications of the new guideline.

Methods

We conducted a retrospective audit of 464 paediatric patients that had been managed according to the 2003 guidelines. We retrospectively applied the 2007 guideline to each patient to evaluate: 1. How many extra CT head examinations would be done? 2. Why would these examinations be done? (ie, why would the child have been determined higher risk according to the 2007 NICE guideline?). 3. How much would the additional cost or saving be in terms of CT scans and bed days? 4. Would there be extra risk attached to CT head scanning? The project did not incur any extra costs.

Results and evaluation

The headline result was that application of the 2007 guideline would result in an increase in CT scanning from 6.0% to 10.5% of children presenting after head injury. The extra examinations would mainly have been done because of the 'bruise, swelling and lacerations >5cm in patients less than 1 year' rule that mandates a scan. A problem with this study was that actual management did not necessarily follow the 2003 guidelines. Therefore the actual scanning rate was only 1.7% of children in our ED. In terms of pure economics, a CT scan costs about 170 and an overnight stay for 'head injury without intracranial injury' costs 475. About 50% of our patients that were scanned were also admitted. Therefore in our trust: - Adherence to the 2003 guideline would results in 28 scans (4760) and 14 overnight stays (6650) - a total of 11410.00 - Adherence to the 2007 guideline would results in 49 scans (8330) and 24.5 overnight stays (11637.50) - a total of 19967.50 - This represents a cost increase of 8557.50 or 18.44 per paediatric patient with head injury. However as we scan more children the admission rate will probably fall, so this represents the extreme range of the cost increase. - In terms of just CT scans, with admissions not considered, the cost increase attributable to the NICE 2007 guideline is 3570, or 7.69 per patient. The number of CT head scans required to cause one extra death from radiation varies between 1300 and 100000. Even at the most conservative estimates scanning 10% of the 108171 'head injuries' that children present within the UK each year will result in an incidence of fatal brain tumours of 0.12/year (attributable to scanning for head injury). This figure works out as 0.065/year with a 6% scanning rate, ie, with the 2003 guideline. These figures are heavily extrapolated and should be interpreted with caution however. The published paper and references are electronically attached to this submission.

Key learning points

1. Implementing the 2007 NICE head injury guidance for children in a DGH may increase CT scanning rates from 6.0% (before implementation) to 10.6% (after implementation). 2. This is mainly resultant of the new 'bruise, swelling and lacerations >5cm in patients under 1 year' rule that mandates a scan (but amnesia, drowsiness and suspicion of non accidental injury also played a part in the increase). 3. This particular guideline may be particularly prone to decreased clinician compliance because of understandable clinician concern about exposing children to radiation. 4. The rise in scanning rate in our DGH represents a cost increase of 7.69 per child presenting with head injury, or potentially an increase of 18.44 per child if admission rates are taken into consideration. 5. The rise in scanning rate may increase the incidence of fatal brain neoplasia attributable to scanning for head injury from 0.065 per year to 0.12 per year - but these figures are heavily extrapolated and should be interpreted with caution.

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Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.