NCEPOD: Trauma - Who Cares? - London Health Programmes

CHAPTER 8 - Head injury managementfi rst hour after admission and some patients were not scanneduntil several hours after admission. While this may be lessof a concern for patients with mild head injuries it may wellbe that those with moderate to severe head injuries havedelays to recognition and management of remediable lesions.Unfortunately, as can be seen from Figure 41, delays to CTscanning were present across all categories of head injuryseverity. Thirty-two patients with severe head injuries had to waitmore than two hours for this investigation to be performed.The emergency medicine clinicians’ reasons for any delays toCT head scanning are shown in Table 81.Table 81. Reasons why there was a delay toa CT head scanNumber ofpatients %Patient not stable 22 29.3Awaiting radiology staff 28 37.3Awaiting access to CT 17 22.7Awaiting suitable medical staff 3 4.4Other 5 6.7The majority of cases were delayed because oforganisational factors (awaiting access to CT or awaitingsuitable medical staff). In only 22/75 cases was the delayconsidered to be due to patient instability. Again, theavailability of CT radiography and radiology staff needs to beconsidered.Even patient instability may be considered an organisationalfactor if one considers the grade of medical staff involved inthe early management of these patients. As shown earlier,consultant involvement was variable (especially out ofhours) and junior medical staff may be more reticent thanconsultants to move potentially unstable patients to the CTscanner. Furthermore, the location of the CT scanner maychange the threshold for making the clinical decision thatthe patient is stable enough to scan; it is clearly easier andsafer if the CT scanner is close to the emergency departmentrather than in a remote area.NICE gives guidance on the timing of CT scan after headinjury 17 . The guidance states that in those circumstancesdescribed earlier:Total 75Figure 42. Timeliness of CT scan by Glasgow Coma Score (advisors’ opinion)80Number of patients706050403020100YesNoInsufficient data15 13-14 09-12 04-08 03 Not recordedGlasgow Coma Score100