Quality statement 1: CT head scans

Quality statement

People attending an emergency department with a head injury have a CT head scan within 1 hour of a risk factor for brain injury being identified.

Rationale

Head injuries can be fatal or cause permanent disability if damage to the brain is not identified and treated quickly. A CT scan within 1 hour will allow rapid treatment and improve outcomes for people with head injuries that have damaged the brain.

Quality measures

Structure

Evidence of local arrangements to ensure that CT head scans can be performed within 1 hour of a risk factor for brain injury being identified in people attending emergency departments with a head injury.

Data source: Local data collection.

Process

Proportion of emergency department attendances of people with a head injury for which a CT head scan is performed within 1 hour of a risk factor for brain injury being identified.

Numerator – the number in the denominator having a CT head scan within 1 hour of a risk factor for brain injury being identified.

Denominator – the number of emergency department attendances of people with a head injury and a risk factor for brain injury indicating the need for a CT head scan.

Data source: Local data collection. The Trauma Audit and Research Network (TARN) collects data for a subset of the population; however, data for the entire process measure are not currently collected. TARN collects data on CT scans performed within 1 hour for people with a head injury and Glasgow Coma Scale (GCS) score of less than 13.

Outcome

Mortality from skull fracture and intracranial injury.

Data source: The Health and Social Care Information Centre's indicator P00103 in the compendium of population health indicators. Directly standardised rate, all ages, 3‑year average.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (emergency departments, hospitals and specialist neurological centres) ensure that a CT head scan can be performed within 1 hour of a risk factor for brain injury being identified in people with a head injury.

Healthcare professionals ensure that CT head scans are performed within 1 hour of a risk factor for brain injury being identified in people with a head injury.

Commissioners (clinical commissioning groups and NHS England) ensure that service providers can perform CT head scans within 1 hour of a risk factor for brain injury being identified in people with a head injury. This may be achieved in a number of ways, which include the use of 1‑hour targets in acute contracts, or enhanced monitoring and audit procedures.

What the quality statement means for patients, service users and carers

People with a head injury who have any sign showing that the injury might have damaged their brain have a CT scan of their head within 1 hour of the sign showing.

Source guidance

  • Head injury (NICE clinical guideline 176), recommendations 1.4.7 and 1.4.9 (key priorities for implementation), and 1.4.10.

Definitions of terms used in this quality statement

Risk factors for brain injury

For adults with head injury, any 1 of the following risk factors indicates the need for a CT head scan within 1 hour of the risk factor being identified:

  • GCS score less than 13 on initial assessment in the emergency department.

  • GCS score less than 15 at 2 hours after the injury on assessment in the emergency department.

  • Suspected open or depressed skull fracture.

  • Any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, and Battle's sign).

  • Post‑traumatic seizure.

  • Focal neurological deficit.

  • More than 1 episode of vomiting.

[NICE clinical guideline 176, recommendation 1.4.7]

For children and young people with head injury, any 1 of the following risk factors indicates the need for a CT head scan within 1 hour of the risk factor being identified:

  • Suspicion of non‑accidental injury.

  • Post‑traumatic seizure but no history of epilepsy.

  • On initial emergency department assessment, GCS score less than 14, or for children under 1 year, GCS (paediatric) score less than 15.

  • At 2 hours after the injury, GCS less than 15.

  • Suspected open or depressed skull fracture or tense fontanelle.

  • Any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign).

  • Focal neurological deficit.

  • For children under 1 year, presence of bruising, swelling or laceration of more than 5 cm on the head.

[NICE clinical guideline 176, recommendation 1.4.9]

In addition, children and young people with head injury and more than 1 of the following risk factors should have a CT head scan within 1 hour of the risk factors being identified:

  • Loss of consciousness lasting more than 5 minutes (witnessed).

  • Abnormal drowsiness.

  • Three or more discrete episodes of vomiting.

  • Dangerous mechanism of injury (high‑speed road traffic accident either as pedestrian, cyclist or vehicle occupant, fall from a height of greater than 3 metres, high‑speed injury from a projectile or other object).

  • Amnesia (antegrade or retrograde) lasting more than 5 minutes.

[NICE clinical guideline 176, recommendation 1.4.10]