Abstract
The National Institute for Health and Care Excellence (NICE) guidelines for management of head injuries on anticoagulation were updated in 2023, to maximise detection of clinically important falls whilst minimising unnecessary scans. They recommend computed tomography (CT) imaging to be considered within 8 hours if clinically appropriate [NG232].[1] The Newcastle upon Tyne Hospitals NHS Foundation Trust (NUTH) current local inpatient falls protocol recommends that all patients who have fallen with suspected head injury, on anticoagulation but in the absence of neurological changes or other underlying risk factors, should undergo CT imaging. This quality improvement project reviewed outcomes in this patient subset, retrospectively analysing patient data during a four-month period.
Between April to August 2024, 550 inpatient adult non-contrast CT head scans were performed at the Freeman Hospital (NUTH). 172 (31.2%, median age 77) of these scans were performed following an inpatient fall. 73 (42.4%) of these scans were performed with active anticoagulation as the solitary indication; in these patients, none (0%) had haemorrhagic pathology and therefore no neurosurgical intervention was required. This data strongly supports a review to rationalise our inpatient fall guidelines to align with the updated NICE recommendations which emphasise clinical judgement and shared decision making. This change should result in a meaningful reduction in valuable CT scanning and reporting time, associated costs and radiation exposure, without compromising patient care and outcomes.
[1] National Institute for Health and Care Excellence (NICE). Head injury: assessment and early management NICE guideline [NG232]. 2023.
Comments
Shared decision making
Thanks for the poster, interesting to read just how low the yield is for this indication!
I was wondering about your thoughts around shared decision making. For older patients in hospital, for whom many of these individuals may have delirium (and hence why they may have fallen), how would shared decision making look? I'm particularly thinking out of hours, where capacity to ring NoK would be limited. How feasible is that recommendation within guidelines for a junior doctor working out of hours?
Shared decision making
Thanks for your question. The common scenario you have described certainly presents challenges applying these recommendations. The NICE guidance describes CT imaging should be performed within 8 hours of the injury - if appropriate, some decisions could be deferred to the day team to facilitate involvement of NoK. In other instances, I think clinical judgment would have to take precedence given potential barriers to shared decision making, although I'm open to suggestions!
Thank you for this, really interesting. I wonder whether the results of this would also be applicable to other patients with head injury on anticoagulants, either in the community, or those presenting to A&E after a fall? In my experience A&E does a lot of CT imaging for this cohort.