A Pickering

Clinical decision rules for children with minor head injury: a systematic review

Introduction Clinical decision rules aid clinicians with the management of head injured patients. This study aimed to identify clinical decision rules for children with minor head injury and compare their diagnostic accuracy for detection of intracranial injury (ICI) and injury requiring neurosurgical intervention (NSI). Methods Relevant studies were identified by an electronic search of key databases. Papers in English were included with a cohort of at least 20 children suffering minor head injury (GCS 13–15). Studies of a decision rule derived to identify patients at risk of ICI or NSI had to include a proportion of the cohort undergoing imaging. Study quality was assessed using the QUADAS checklist. Results 16 publications, representing 14 cohorts, with 79 740 patients were included. Only four rules were tested in more than one cohort. Of the validated rules the paediatric emergency care applied research network (PECARN) rule was most consistent (sensitivity 98%; specificity 58%). For neurosurgical injury all had high sensitivity (98–100%) but the childrens head injury algorithm for the prediction of important clinical events (CHALICE) rule had the highest specificity (86%) in its derivation cohort. Conclusion Of the current decision rules for minor head injury the PECARN rule appears the best for children and infants, with the largest cohort, highest sensitivity and acceptable specificity for clinically significant ICI. Application of this rule in the UK would probably result in an unacceptably high rate of CT scans per injury, and continued use of the CHALICE-based NICE guidelines represents an appropriate alternative.

Clinical Decision Rules for Adults With Minor Head Injury: A Systematic Review

BACKGROUND There are many clinical decision rules for adults with minor head injury, but it is unclear how they compare in terms of diagnostic accuracy. This study aimed to systematically identify clinical decision rules for adults with minor head injury and compare the estimated diagnostic accuracies for any intracranial injury and injury requiring neurosurgical intervention. METHODS Several electronic bibliographic databases covering biomedical, scientific, and gray literature were searched from inception to March 2010. At least two independent reviewers determined the eligibility of cohort studies that described a clinical decision rule to identify adults with minor head injury (Glasgow Coma Scale score, 13-15) at risk of intracranial injury or injury requiring neurosurgical intervention. RESULTS Twenty-two relevant studies were identified. Differences existed in patient selection, outcome definition, and reference standards used. Nine rules stratified patients into high- and moderate-risk categories (to identify neurosurgical or nonsurgical intracranial lesions). The Canadian Computed Tomography Head Rule (CCHR) high-risk criteria have sensitivity of 99% to 100% with specificity of 48% to 77% for injury requiring neurosurgical intervention. Other rules such as New Orleans criteria, National Emergency X-Radiography Utilization Study II, Neurotraumatology Committee of the World Federation of Neurosurgical Societies, Scandinavian, and Scottish Intercollegiate Guidelines Network produce similar sensitivities for injury requiring neurosurgical intervention but with lower and more variable specificity values. DISCUSSION The most widely researched decision rule is the CCHR, which has consistently shown high sensitivity for identifying injury requiring neurosurgical intervention with an acceptable specificity to allow considered use of cranial computed tomography. No other decision rule has been as widely validated or demonstrated as acceptable results, but its exclusion criteria make it difficult to apply universally.

The cost-effectiveness of diagnostic management strategies for adults with minor head injury

STUDY OBJECTIVE To estimate the cost-effectiveness of diagnostic management strategies for adults with minor head injury. METHODS A mathematical model was constructed to evaluate the incremental costs and effectiveness (Quality Adjusted Life years Gained, QALYs) of ten diagnostic management strategies for adults with minor head injuries. Secondary analyses were undertaken to determine the cost-effectiveness of hospital admission compared to discharge home and to explore the cost-effectiveness of strategies when no responsible adult was available to observe the patient after discharge. RESULTS The apparent optimal strategy was based on the high and medium risk Canadian CT Head Rule (CCHRhm), although the costs and outcomes associated with each strategy were broadly similar. Hospital admission for patients with non-neurosurgical injury on CT dominated discharge home, whilst hospital admission for clinically normal patients with a normal CT was not cost-effective compared to discharge home with or without a responsible adult at £39 and £2.5 million per QALY, respectively. A selective CT strategy with discharge home if the CT scan was normal remained optimal compared to not investigating or CT scanning all patients when there was no responsible adult available to observe them after discharge. CONCLUSION Our economic analysis confirms that the recent extension of access to CT scanning for minor head injury is appropriate. Liberal use of CT scanning based on a high sensitivity decision rule is not only effective but also cost-saving. The cost of CT scanning is very small compared to the estimated cost of caring for patients with brain injury worsened by delayed treatment. It is recommended therefore that all hospitals receiving patients with minor head injury should have unrestricted access to CT scanning for use in conjunction with evidence based guidelines. Provisionally the CCHRhm decision rule appears to be the best strategy although there is considerable uncertainty around the optimal decision rule. However, the CCHRhm rule appears to be the most widely validated and it therefore seems appropriate to conclude that the CCHRhm rule has the best evidence to support its use.

Impact of prehospital transfer strategies in major trauma and head injury: systematic review, meta-analysis, and recommendations for study design.

BACKGROUND It is unclear whether trauma patients should be transferred initially to a trauma center or local hospital. METHODS A systematic review and meta-analysis assessed the evidence for direct transport to specialist centers (SCs) versus initial stabilization at non-SCs (NSCs) for major trauma or moderate-to-severe head injury. Nine databases were searched from 1988 to 2012. Limitations in the study design informed recommendations for future studies. RESULTS Of 19 major trauma studies, five (n = 19,910) included patients not transferred to SCs and adjusted for case mix. Meta-analysis showed no difference in mortality for initial triage to NSCs versus SCs (odds ratio [OR] 1.03; 95% confidence interval [CI], 0.85–1.23). Within studies excluding patients not transferred to SCs, unadjusted analyses of mortality nonsignificantly favored transfer via NSCs (16 studies; n = 37,079; OR, 0.83; 95% CI, 0.68–1.01), whereas adjusted analysis nonsignificantly favored direct triage to SCs (9 studies; n = 34,266; OR, 1.18; 95% CI, 0.96–1.44). Of 11 head injury studies, all excluded patients not transferred to SCs and half were in remote locations. There was no significant mortality difference between initial triage to NSCs versus SCs within adjusted analyses (3 studies; n = 1,507; OR, 0.74; 95% CI, 0.31–1.79) or unadjusted analyses (10 studies; n = 3,671; OR, 0.87; 95% CI, 0.62–1.23). CONCLUSION This systematic review demonstrated no difference in outcomes for direct transport to a trauma center versus initial triage to a local hospital. Many studies had significant limitations in the design, and heterogeneity was high. Recommendations for future studies include the following: (i) inclusion of patients not transferred to SCs and those dying during transport; (ii) clear description of centers plus transport distances/times; (iii) adjustments for case mix; and (iv) assessment of morbidity and mortality. LEVEL OF EVIDENCE Systematic review, level IV.

A cohort study of outcomes following head injury among children and young adults in full-time education

Objective To estimate the prevalence of post-concussive symptoms (PCS) following head injury among adolescents in full-time education and to identify prognostic factors at presentation to the emergency department (ED) that may predict the development of PCS. Methods An observational cohort study of all head injured patients aged 13–21 and in full-time education presenting to an inner city ED was performed. Subjects were followed up at 1 and 6 months after injury by structured telephone interview to assess for the presence of symptoms or ongoing disability. Presentation data of those identified as having PCS underwent regression analysis to isolate potential prognostic indicators for such problems. Results Of the 188 patients recruited, 5.9% (95% CI 3.3% to 10.2%) still had some symptoms after 6 months, with half of these claiming that such symptoms were affecting everyday living. Of these patients, 82% were assaulted as the cause of their injury and nearly 40% had no conventional indicators of head injury severity at presentation. After 1 month, 46/188 (24.5%, 95% CI 18.9% to 31.1%) patients had some degree of symptoms, most of whom were discharged directly from the ED. Potential prognostic indicators identified were a reduced Glasgow Coma Score (GCS) (<15) at presentation and being assaulted as the cause of injury. Conclusion The prevalence of PCS 6 months following head injury for the selected sub-group was 5.9%, and 10.6% if assaulted. Most patients who developed PCS were discharged directly from the ED.

The cost-effectiveness of diagnostic management strategies for children with minor head injury

Aim To estimate the cost-effectiveness of diagnostic management strategies for children with minor head injury and identify an optimal strategy. Methods A probabilistic decision analysis model was developed to estimate the costs and quality-adjusted life years (QALYs) accrued by each of six potential management strategies for minor head injury, including a theoretical ‘zero option’ strategy of discharging all patients home without investigation. The model took a lifetime horizon and the perspective of the National Health Service. Results The optimal strategy was based on the Childrens Head injury Algorithm for the prediction of Important Clinical Events (CHALICE) rule, although the costs and outcomes associated with each strategy were broadly similar. Conclusions Liberal use of CT scanning based on a high sensitivity decision rule is not only effective but also cost saving, with the CHALICE rule being the optimal strategy, although there is some uncertainty in the results. Incremental changes in the costs and QALYs are very small when all selective CT strategies are compared. The estimated cost of caring for patients with brain injury worsened by delayed treatment is very high compared with the cost of CT scanning. This analysis suggests that all hospitals receiving children with minor head injury should have unrestricted access to CT scanning for use in conjunction with evidence-based guidelines.

Diagnostic Accuracy of Clinical Characteristics for Identifying CT Abnormality after Minor Brain Injury: A Systematic Review and Meta-Analysis

Clinical features can be used to identify which patients with minor brain injury need CT scanning. A systematic review and meta-analysis was undertaken to estimate the value of these characteristics for diagnosing intracranial injury (including the need for neurosurgery) in adults, children, and infants. Potentially relevant studies were identified through electronic searches of several key databases, including MEDLINE, from inception to March 2010. Cohort studies of patients with minor brain injury (Glasgow Coma Score [GCS], 13-15) were selected if they reported data on the diagnostic accuracy of individual clinical characteristics for intracranial or neurosurgical injury. Where applicable, meta-analysis was used to estimate pooled sensitivity, specificity and likelihood ratios. Data were extracted from 71 studies (with cohort sizes ranging from 39 to 31,694 patients). Depressed or basal skull fracture were the most useful clinical characteristics for the prediction of intracranial injury in both adults and children (positive likelihood ratio [PLR], >10). Other useful characteristics included focal neurological deficit, post-traumatic seizure (PLR >5), persistent vomiting, and coagulopathy (PLR 2 to 5). Characteristics that had limited diagnostic value included loss of consciousness and headache in adults and scalp hematoma and scalp laceration in children. Limited studies were undertaken in children and only a few studies reported data for neurosurgical injuries. In conclusion, this review identifies clinical characteristics that indicate increased risk of intracranial injury and the need for CT scanning. Other characteristics, such as headache in adults and scalp laceration of hematoma in children, do not reliably indicate increased risk.

Management of isolated minor head injury in the UK

Background Recent guidelines and service developments may have changed the management of isolated minor head injuries in the UK. The authors aimed to review current practice and national statistics, and determine whether methods of service delivery are associated with differences in admission rates. Methods The authors surveyed management of minor head injuries in all acute hospitals in the UK and then correlated these responses with Hospital Episodes Statistics (HES) emergency department data relating to head injury. Results Responses relating to children were received from 174/250 hospitals and adults from 181/250. Nearly all hospitals had unrestricted access to CT scanning (adults 96%, children 94.5%). Most hospitals (70.1%) admitted adults under the emergency department staff, usually (61.4%) to an observation ward or clinical decision unit. Children were usually formally admitted to a ward (86.7%) under an inpatient team (78.5%). The median proportion of attendances admitted was higher for adults (18%) than for children (9%). There was no evidence of any association between the proportion admitted and the admission team, location or requirement for senior or specialist approval (all p>0.1). Conclusion Minor head injury admission, especially for adults, is increasingly the responsibility of the emergency department. Admission policies had no significant effect on the proportion admitted, although improved HES data are required to confirm this.

Acute ischaemic stroke patients – direct admission to a specialist centre or initial treatment in a local hospital? A systematic review

Objectives To assess the clinical effectiveness, in acute ischaemic stroke patients, of bypassing non-specialist centres in preference for a specialist stroke centre to receive the time-critical intervention of thrombolysis. Methods Systematic review and meta-analysis using: MEDLINE; MEDLINE In-Process; EMBASE; CINAHL; Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane CENTRAL Controlled Trials Register, DARE, NHS EED and HTA databases. Studies were included if they compared acute ischaemic stroke patients directly triaged to a specialist centre versus those initially triaged to a non-specialist centre with some or all later transferred to a specialist centre. Studies were excluded if they compared patients ever treated in a specialist centre versus those never treated in such a centre, since the aim was to assess the optimum initial triage route rather than the optimum location for overall management. The assumption being, based on previous research, that management in a specialist centre leads to better patient outcomes. Results Fourteen studies investigating 2790 patients were identified. Studies comparing commencement of thrombolysis in non-specialist centres versus the specialist centres (n=1394) showed no significant difference in unadjusted mortality (OR = 0.89; 95% CI = 0.61–1.30) or morbidity (favourable modified Rankin Score, n = 899) (OR = 1.16; 95% CI = 0.85–1.59) among thrombolysed patients. In studies where thrombolysis could only be administered in a specialist centre, data for patients arriving within the therapeutic window (n = 140) revealed significantly higher mortality for those initially admitted to a non-specialist centre compared to directly admitted to a specialist centre (OR = 6.62; 95% CI = 2.60–16.82); morbidity data also favoured direct admission to a specialist centre, although not consistently. Conclusions For ischaemic stroke patients, the location of initial thrombolysis treatment does not affect outcomes. However, if thrombolysis is only available at a specialist centre, outcomes are considerably better for those patients admitted directly. However, these conclusions are based on poor quality data with small sample populations, significant heterogeneity and subject to confounding.

002 Special delivery: where best to take a head injured patient?

Objectives and Backgrounds The current focus on development of specialist centres in the UK to improve outcomes is based on evidence from overseas care models. While care in a specialist neurosurgical centre will improve outcomes for head injured patients, does transferring them directly have any clinical benefit compared with delivery to a local hospital for initial stabilisation and subsequent transfer to the specialist centre? We performed a systematic review to identify the clinical effectiveness of bypassing local hospital care in moderate or severely head injured patients. Methods Relevant studies were identified by an electronic search of key databases. Papers in English were included if they compared the outcomes of moderate or severely head injured patients (GCS<13, AIS≥3) directly transferred and treated at a specialist centre (SC) vs those who received their initial resuscitation at a local hospital (LH) with some or all patients later transferred to a SC. Outcomes were assessed using available mortality and morbidity data. Results We identified 6 studies involving 2580 patients. One further study was found that did not report the number of subjects. Most studies used SC registry data and adjusted their outcomes for age, pupil dilatation and injury severity. No studies included results for, or adjusted for, patients not transferred after delivery to the LH. For mortality, the adjusted OR was taken from three studies. For those taken to their LH first the OR of death was higher than for the direct transfer group (SC). The level of significance was marginal and undergoing formal meta-analysis at the time of submission. The adjustment of data tended to favour direct transfer over local hospital delivery. No significant difference was reported for morbidity outcomes (Glasgow Outcome Scale) in the three studies that looked at these. Conclusions The reviewed literature comparing direct transfer of head injured patients to specialist neurosurgical centres vs initial local hospital delivery is sparse. What evidence there is supports direct transfer to improve mortality although, at present, this is only marginally significant.