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New management guideline for MHI will be a headache for UK hospitals

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Two studies, probably the first in Britain, have suggested that new guidelines for managing minor head injury (MHI) adopted by the National Institute of Clinical Excellence (NICE) may raise costs, not reduce them as in North America. They predict that there may be major consequences for hospitals without ready access to computed tomography (CT).

Both were studies at Addenbrooke’s Hospital, Cambridge, England, a tertiary referral centre for neurosurgery. One was a retrospective case note study of MHI in adults during seven months in the emergency department to compare the number of requests for CT to exclude injury within the skull predicted under the Canadian CT head rule against the actual number and against the number predicted under national guidelines then in force. It concluded that the overall extra cost was 68%, even allowing for cost savings on skull x ray examinations. Under the Canadian rule nearly 78% more requests over actual requests would have resulted and 45% more than under British guidelines, with little clear patient benefit.

The other study was a before and after study of seven months in 2001 and nine months in 2002 to asses the effect of introducing a new protocol based on the Canadian rule, but modified to conserve resources by scrapping night time CT for patients at medium risk in favour of overnight admission for observation and scan if necessary. Essentially, for 12 hours during daytime it conformed to NICE guidelines released in 2003 based on the Canadian rule.

CT scans rose, from 14% to 20%, a significant but modest rise, and admissions for observation rose too, from 34% to 45%, though most patients were discharged without needing CT. Skull x ray examinations fell drastically, from 33% to 1.6%. The ensuing cost increase was not balanced by reduced costs for x ray examinations. Furthermore, the extra expense was conservative, as night time scans had been avoided. This strategy, the study showed, would be a feasible option for hospitals with limited CT resources and is probably low risk, though a larger study would be needed to be sure of safety. Costs were kept within the hospital’s resources, but the department intends to continue using its local protocol.

The results were based on 363 useable sets of data in the case note study and 330 and 267 patients with MHI according to the Canadian rule in the before and after stages of the second study, respectively.

MHI accounts for most—up to one million—of those attending hospital with head injuries in the UK a year. The definitive examination for medium or severe head injury is CT, but management of MHI varies enormously around the world.

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