Material and method
The University Hospital of North Norway, Tromsø is a local hospital for 167 202 inhabitants in Troms county (2018). The majority of head injuries are assessed by general practitioners on call at a local emergency room, with patients referred to hospital if the severity of their injury – as assessed using the Scandinavian guidelines – is greater than minimal
(1). The emergency medical dispatch centre can also arrange direct transport to the hospital if a serious head injury is suspected.
Triage in the Accident and Emergency department is performed by a nurse. Patients with a score > 13 on the Glasgow Coma Scale (GCS) without focal neurological deficits are examined by a specialty registrar in general surgery, while patients with a GCS score ≤ 13 and/or focal neurological deficits are examined by a specialty registrar in neurosurgery. The hospital performs CT scans as well as analysis of the brain injury marker S100B, which is released into the bloodstream upon damage to glial cells. The Scandinavian Neurotrauma Committee guidelines recommends the test as an alternative to a CT scan for mild, low-risk head injuries (Figure 1).
Figure 1 Flowchart for the initial management of minimal, mild or moderate head injuries in adults ( 1).
We conducted a study of all adult patients with minimal, mild or moderate head injuries assessed in Acute Admissions in the period 1 September 2018–31 August 2019. A search in the patient administration system identified 448 patients with an ICD-10 diagnosis code for head injury. We included 150 patients aged ≥ 18 years who were assessed within 24 hours of injury. A total of 298 patients were excluded because they either had a serious head injury (GCS score < 9), had inadequate medical records such that their GCS score could not be calculated (n = 8), did not have a head injury (miscoded), or because they arrived at the hospital following a trauma alert in accordance with the national trauma system criteria (such cases are managed using other guidelines).
A retrospective review of the medical records was performed and the following information recorded: age and sex, relevant previous illnesses, use of anticoagulants and antiplatelet agents, history of the injury (loss of consciousness, nausea/vomiting and seizures after the injury) and findings upon clinical examination (GCS score, focal neurological deficits and clinical signs of skull fracture).
In 42 patients for whom GCS scores were not recorded, we were able to calculate the scores using information in the medical records on eye opening as well as motor and verbal responses. We also recorded whether a CT scan and/or S100B analysis had been performed, plus any results, and whether the patient had been admitted for observation. Management was categorised as either compliant or non-compliant with the Scandinavian guidelines (Figure 1). We defined non-compliance as overtesting (unnecessary CT scan and/or hospital admission) or undertesting (omission of necessary CT scan and/or hospital admission).
The study was approved by the Data Protection Officer as a quality assurance project (no. 02344).