Management of minor head injuries according to NICE guidelines and changes in the number of patients requiring computerised tomography imaging in a district general hospital: a retrospective study

The objective of this study was to investigate how many patients with minor head injury would have required computerised tomography (CT) imaging if they were to be managed according to the National Institute of Clinical Excellence (NICE) guidelines (June 2003) and the difference in workload for patients presenting out of hours at Calderdale Royal Hospital, Halifax. The study was a retrospective cohort analysis of patient's notes presenting with head injury at Calderdale Royal Hospital, Halifax. The data set comprised case notes of 844 patients with head injuries, 400 adults and 444 children attending the Accident and Emergency department from January to June 2003. The case notes were evaluated according to the NICE guidelines for the indications for CT imaging for the time that they presented to the Accident and Emergency department, and how many of them actually underwent CT imaging. The number of patients who required CT imaging and how many of them presented out of hours (between 17:00 and 21:00 hours on weekdays and at any time on weekends). Ten patients underwent CT imaging for minor head injuries from January to June 2003. Eighty-eight patients required CT imaging if they were to be managed according to the NICE guidelines. Sixty-three per cent of these patients presented out of hours when a radiologist was not available in the hospital. Adhering to the NICE guidelines would significantly increase the number of patients requiring CT imaging. A significant proportion of these patients would present out of hours.     

Health care-associated infections in primary and community care

The National Institute for Clinical Excellence recently published guidelines for preventing health care-associated infections (HAIs) in primary and community care (NICE, 2003). These were commissioned by the Department of Health and NICE to complement previously published guidelines for preventing HAIs in hospitals (Pratt et al, 2001). The new guidelines aim to facilitate a seamless approach to using the best evidence for infection prevention practices as patients transfer between primary and secondary health care services. This article discusses the need for the guidelines and describes the methods used to develop them.     

Managing bladder symptoms in people with multiple sclerosis

Multiple sclerosis is a chronic disease of the central nervous system (brain and spinal cord). The cause is still unknown but there is evidence that suggests there is an autoimmune component to the disease that causes damage to the myelin sheath, a complex material that surrounds the axon of myelinated nerves (Fig 1). It affects 100-120 people per 100,000 population, approximately 75 per cent of whom will develop urinary symptoms (NICE, 2003). Bladder problems usually occur when the disease involves the spinal cord (Fig 2) and these can get worse as the disease progresses and the patient becomes less mobile. Bladder symptoms affect many aspects of daily life and their management is extremely important. As the disease progresses and symptoms worsen, a well-planned strategy can offer patients the most effective pathway to manage their bladder problems.     

Guidelines for the prevention and treatment of pressure ulcers

An 'all-in-one' guideline on pressure ulcer prevention and management in primary and secondary care was published last year by the National Institute for Health and Clinical Excellence (NICE 2005a). The guideline is published in two parts. The first part is The Management of Pressure Ulcers in Primary and Secondary Care (Royal College of Nursing (RCN) and NICE 2005). The second part concerns pressure ulcer risk assessment and prevention, including the use of pressure-relieving devices (NICE 2003). A quick reference guide (NICE 2005b) summarises the recommendations made in both parts and is the focus of this article.     

An audit of the management of acute asthma in accident and emergency

It is estimated that 3.4 million people suffer from asthma in the UK, with 640,000 having the condition in a severe or very severe form (Action on Smoking and Health, 2002). Asthma also accounts for 1,250 deaths annually (De Keyser, 2002). Between 1980 and 1990 the prevalence of asthma in males increased by 114 per cent and in females by 165 per cent (Respiratory Alliance, 2003).     

Early warning systems in the UK: variation in content and implementation strategy has implications for a NHS early warning system

The Royal College of Physicians report Acute medical care: the right person, in the right setting--first time advocates the introduction of a standardised NHS Early Warning Score (NEWS). Recommendations for the optimum scoring system have been released by NHS Quality Improvement Scotland (NHS QIS) and the National Institute for Health and Clinical Excellence (NICE). This study reviewed clinical practice in London and Scotland against national guidelines. All hospitals responsible for acute medical admissions completed a telephone survey (n = 25 London; n = 23 Scotland). All used an early warning system at point of entry to care. Eleven different systems were used in London and five in Scotland. Forty per cent of London hospitals and 70% of Scottish hospitals incorporated the minimum data set recommended by NICE. Overall, Scotland was closer to achieving standardisation. If NEWS is implemented, consideration of the NHS QIS approach may support a more consistent response.     

NICE guideline for the management of head injury: an audit demonstrating its impact on a district general hospital, with a cost analysis for England and Wales

Objectives

To answer concerns related to implementation of the National Institute for Clinical Excellence (NICE) guideline on the management of head injury by determining the impact on the workload of a district general hospital. Increased computed tomography (CT) was of particular concern (cost, radiation risk, and delivery constraints).

Method

Retrospective audit of all patients attending the hospital''s emergency department with a head injury over a three month period. Any reattendees for the same head injury episode were excluded but the need for CT was recorded. Case notes and electronic records were reviewed to determine whether the CT head or skull radiograph (SXR) was indicated in line with the NICE guideline. The workload was compared with an identical audit performed before the implementation of the NICE guideline.

Results

Of 17 472 patients attending the ED in 2004, 472 had a head injury. CT scan was indicated in 36, a significant increase from 2003 (p<0.001). No SXR was indicated but two were performed, a significant decrease (p<0.001). The admission rate was unaltered. The positive predictive value of NICE was 17.1% compared with 25% (p = not significant) for the authors'' pre‐NICE departmental guideline.

Conclusions

This department has seen an increase in CT head requests since the implementation of the NICE guideline. This costs an extra £15 000 per 100 head injuries annually for this department, with an estimated £51.7 million burden for England and Wales. Further evaluation is required as there were only nine brain injuries in this audit population.     

Catheter specimens of urine: an audit of practice

Catheterisation is an established procedure and is usually performed by nurses (Bissett, 2005). According to Crow et al (1988) 10-12 per cent of hospital patients have an indwelling urinary catheter for short- to medium-term use (up to 28 days). Up to 80 per cent of urine infections (bacteriuria) are associated with the use of indwelling urinary catheters (Pinkerman, 1994; DoH, 2003).     

Assessment of the side effects of antipsychotic medication

BACKGROUND: Antipsychotic medication is the first-line treatment for people with psychosis in the State Hospital, Carstairs: Scotland's only high-security forensic hospital. The Clinical Standards for Schizophrenia (Clinical Standards Board for Scotland 2001) require clinicians to use standardised rating scales to monitor the side effects associated with medication. Liverpool University Neuroleptic Side Effect Rating Scale (LUNSERS) (Day et al 1995) was implemented in the hospital in December 2003. A baseline audit was carried out following its implementation to establish the incidence of side effects. Of those patients audited (n=152), 87 (57 per cent) reported either low or medium (n=51, 34 per cent) LUNSERS scores, indicating an acceptable level of medication tolerance. CONCLUSION: It is expected that clinicians will continue to use LUNSERS as part of their routine clinical practice to help inform patients and meet national standards.     

Antimicrobial resistance in non-typhoidal Salmonella from human sources, Spain, 2001-2003

OBJECTIVES: To determine the current state of antimicrobial resistance among non-typhoidal Salmonella strains isolated from humans in Spain. METHODS: All strains of Salmonella from human sources received in the reference laboratory from 2001 to 2003 were serotyped and phage types were determined in the most common serovars. A systematic sampling procedure was carried out in order to obtain a random sample for susceptibility testing. The selected strains were tested for susceptibility to 12 different antimicrobial agents by a disc diffusion method using Mueller-Hinton agar. Results were scored as susceptible, moderately susceptible or resistant, according to CLSI criteria. RESULTS: From 2001 to 2003, 5777 strains of Salmonella were tested for susceptibility. Fifty per cent of strains of Salmonella Enteritidis were resistant to nalidixic acid. This was the most frequent resistance pattern of this serovar and it was characteristic of PT1, the most frequent phage type of Salmonella Enteritidis in Spain. Seventy-four per cent of Salmonella Typhimurium strains were resistant to four antibiotics or more. Resistance to ampicillin, chloramphenicol, streptomycin, sulphonamide and tetracycline was the most frequent resistance pattern of Salmonella Typhimurium and it was characteristic of DT104, the most frequent phage type in Spain. Sixty-nine per cent of Salmonella Hadar strains were resistant to at least four antibiotics. CONCLUSIONS: The results of our study showed both a worrying percentage of strains of Salmonella Enteritidis resistant to nalidixic acid and of strains of Salmonella Typhimurium with a pattern of resistance to four antibiotics or more. Surveillance of antimicrobial resistance should carry on and improve in order to be able to evaluate the control measures carried out for decreasing resistance in Salmonella, specifically that addressed to the prudent use of antimicrobial agents by farmers and veterinarians.     

A service to address the sexual health needs of the homeless population

Between 1991 and 2001, the clinical workload of genitourinary medicine services increased by 155 per cent, and diagnoses of sexually transmitted infections (STIs) increased by 61 per cent in England, Wales and Northern Ireland (Public Health Laboratory Service et al, 2002). However there is a paucity of data regarding the rate of sexually transmitted infections in the homeless population.     

The challenge of teenage smoking

Smoking cessation services for adults are now well established in England and have proven to be effective and successful. From April to June 2003, a total of 64,700 people set a stop date and at four weeks 33,900 (52 per cent) had successfully given up smoking (Department of Health, 2003a).     

Head injuries: a study evaluating the impact of the NICE head injury guidelines

Background: The NICE head injury guidelines recommend a different approach in the management of head injury patients. It suggests that CT head scan should replace skull x ray (SXR) and observation/admission as the first investigation. We wished to determine the impact of NICE on SXR, CT scan, and admission on all patients with head injury presenting to the ED setting and estimate the cost effectiveness of these guidelines, which has not been quantified to date. Design: Study of head injury patients presenting to two EDs before and after implementation of NICE guidelines Methods: The rate of SXR, CT scan, and admission were determined six months before and one month after NICE implementation in both centres. The before study also looked at predicted rates had NICE been applied. This enabled predicted and actual cost effectiveness to be determined. Result: 1130 patients with head injury were studied in four 1 month periods (two in each centre). At the teaching hospital, the CT head scan rate more than doubled (3% to 7%), the SXR declined (37% to 4%), while the admission rate more than halved (9% to 4%). This represented a saving of £3381 per 100 head injury patients: greater than predicted with no adverse events. At the District General Hospital, the CT head scan rate more than quadrupled (1.4% to 9%), the SXR dropped (19 to 0.57%), while the admission rate declined (7% to 5%). This represented a saving of £290 per 100 head injury patients: less than predicted. Conclusion: The implementation of the NICE guidelines led to a two to fivefold increase in the CT head scan rate depending on the cases and baseline departmental practice. However, the reduction in SXR and admission appears to more than offset these costs without compromising patient outcomes.     

Audit of a pathway for childhood idiopathic constipation

Constipation is a common condition in developed and industrialised nations. Although its exact prevalence is unknown it is estimated that between five and thirty per cent of the U.K. population suffer with it, depending on the criteria used for diagnosis (Candelli, 2001). Constipation that cannot be explained by any underlying abnormalities is known as idiopathic constipation.     

Change in career aspirations and job values from study time to working life

AIM: The main aim of this paper is to uncover whether the actual career choices and job values of newly qualified nurses are in accordance with the predictions they made at the commencement of their nursing education. BACKGROUND: A cohort of Norwegian nurse students was followed from the beginning of their education in 1998 through nursing school and 2,years after graduating. METHODS: Questionnaire data from 221 nursing students at three points in time: 1998, 2001 and 2003 were analysed with frequency distributions and paired samples t-tests. For 140 respondents data from all three points were available. RESULTS: Initially motives like human contact, helping others, job security were important, and 92% had a wish for further education. Career preferences were often midwifery, public heath and nursing practice in high tech areas. Towards the end of the bachelor course (2001), there was more ambiguity in the helping motives. On one hand, the students wanted to be altruistic but on the other hand, they wanted gratitude in return when giving help to patients. Seventy five per cent of the students had plans for further education within a period of about 2 years after graduation. Midwifery, public health work and high tech practice were still preferred. Findings from 2003 indicated only 16% had started or finished further education 2 years after graduation. When appraising future job challenges in 2001 and 2003, there is a decrease in emphasis on the values human contact and part-time work and an increase in emphasis on high salary and job security. CONCLUSIONS: During the student period, the bachelor programme was regarded as a basis for further education, but 2 years after graduation only 16% had realized further education. Preferences related to job values regarding a prospective job reveal a decrease in the importance of human contact and an increase in the importance of a high salary and job security from 2001 to 2003.     

Recognising the signs of skin cancer

Skin cancer is the most common cancer in the UK, with about 100,000 cases reported each year (UK Skin Cancer Working Party, 2001). There are three main types of skin cancer, which can be divided into two categories: non-melanoma (basal cell carcinoma and squamous cell carcinoma) and melanoma skin cancer. Basal cell carcinoma is the most common and accounts for about 80 per cent of all skin cancers. Malignant melanoma is the least common type of skin cancer, accounting for about five per cent of all skin cancers. However, it has a high mortality rate because of its aggressive nature (Krige et al, 1991).     

Reducing the risk of catheter-related urinary tract infection

It is estimated that 10-12 per cent of hospital patients and four per cent of patients in the community have a urinary catheter at any one time (Stamm, 1998). Urinary tract infections (UTIs) account for almost half of all health care-associated infection (HAI), and a significant number of these infections are related to the insertion of urinary catheters (Pratt et al, 2001). Recent research has estimated that a patient who has a catheter for 20 days is almost certain to develop a catheter-related UTI and that the cost of treatment of UTI is estimated as being 1,327 pounds sterling per patient (Roadhouse and Wellsted, 2004). Plowman et al (1999) have estimated that a UTI can extend the length of a patient's stay in hospital by six days.