Quality statement 2: CT head scans for people taking anticoagulants

Quality statement

People attending an emergency department with a head injury have a CT head scan within 8 hours of the injury if they are taking anticoagulants but have no other risk factors for brain injury.

Rationale

Some people who have no other risk factors for brain injury have an increased risk of bleeding after a head injury because they are taking anticoagulants. In these people a CT head scan within 8 hours of the injury will allow appropriate management.

Quality measures

Structure

Evidence of local arrangements to ensure that CT head scans can be performed within 8 hours of head injury in people attending emergency departments who are taking anticoagulants but have no other risk factor for brain injury.

Data source: Local data source.

Process

Proportion of emergency department attendances of people with a head injury who are taking anticoagulants but have no other risk factors for brain injury for which a CT head scan is performed within 8 hours of the injury.

Numerator – the number in the denominator having a CT head scan within 8 hours of the injury.

Denominator – the number of emergency department attendances of people with a head injury who are taking anticoagulants but have no other risk factors for brain injury.

Data source: Local data source.

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, district general hospitals and specialist neurological centres) ensure that CT head scans can be performed within 8 hours of a head injury in people who are taking anticoagulants but have no other risk factor for brain injury.

Healthcare professionals ensure that CT head scans are performed within 8 hours of a head injury in people who are taking anticoagulants but have no other risk factor for brain injury.

Commissioners (clinical commissioning groups and NHS England) ensure that service providers can perform CT head scans within 8 hours of a head injury for all people who are taking anticoagulants but have no other risk factor for brain injury. This may be achieved by increasing awareness of this statement among healthcare professionals in acute settings and seeking evidence of compliance by auditing current practice.

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

People with a head injury have a CT scan of their head within 8 hours of the injury happening if they are taking anticoagulants (drugs that make the blood less likely to clot) and have no sign showing that the injury might have damaged their brain.

Source guidance

  • Head injury (NICE clinical guideline 176), recommendation 1.4.12.

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 guideline176, 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]