Clinical audit regarding adherence to emergency CT imaging pathways in anticoagulated elderly patients with a post-fall head injury.
DOI:
https://doi.org/10.22024/UniKent/03/ajpp.1319Resumo
Background: Anticoagulating patients prone to falls is a complicated decision, given the risk of intracranial haemorrhage (ICH). However, the balance of literature potentially now contradicts the weight of this risk. Several articles were identified demonstrating that anticoagulation is generally weakly associated with ICH, and that other signs such as reduced Glasgow coma scale (GCS) or skull fractures are better predictors. Yet anticoagulation was a key criterion for CT scanning patients who have sustained a head injury (HI) under National Institute for Health and Care Excellence (NICE) guidelines (2014), which state that even in the absence of other risk factors, anticoagulated patients should have a CT head scan within eight hours of HI, or within the hour if presenting more than eight hours from injury. Given the literature findings, it would be reasonable to assume that clinicians may doubt the usefulness of such guidelines, and hence clinical practice may vary. A research question was therefore created- ‘Are emergency department (ED) clinicians appropriately CT scanning anticoagulated elderly patients with a post-fall head injury in accordance with local trust protocol?’
Methods: An audit was designed to answer this question, which involved retrospectively reviewing 50 anticoagulated patients aged 65 or over who had presented to the ED of a single secondary care Trust, over a three-month period due to a post-fall HI, to ascertain whether they had a CT scan in the recommended timeframe.
Results: The audit identified the department’s compliance with guidelines as 78%, though most non-compliance was linked to a subset of patients who required a scan within one hour of attendance as their injury occurred more than eight hours prior, and if this subset was excluded, compliance was 93%. The one-hour scan target was subsequently discussed as being potentially unrealistic given National Health Service (NHS) pressures. Upon further scrutiny, the department’s non-compliance can be divided into scans which were delayed, or not done, though it is important to note that none of these patients came to harm as a result.
Conclusions: This study was limited by the fact that during the course of the project, NICE altered their guidelines, firstly to include antiplatelet medications, and secondly to recommend that in the absence of other risk factors, CT scan need only be considered rather than automatically done. This had significant implications for the audit but enabled the data to be reinspected following the change. While this was a subjective analysis, it appeared that the guidelines had been changed in line with evidence from the literature review and this audit’s findings and highlighted that as clinicians become more familiar with the updated guidelines, significant time and money could be spared for this indication. This project has set a precedent for expanding the scope of this audit and evidenced where further research may be indicated.
Downloads
Publicado
Como Citar
Edição
Seção
Licença
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
AJPP requests that, as the creator(s)/author(s) of the manuscript you are submitting, that you assign certain rights to the manuscript to the AJPP in exchange for undertaking to publish the article in electronic form and, in general, to pursue its dissemination throughout the world. The rights the AJPP requests are:
- The right to publish the article in electronic form or in any other form it may choose that is in keeping with its role as a scholarly journal with the goal of disseminating the work as widely as possible;
- The right to be the sole publisher of the article for a period of 12 months;
- The right to make the article available to the public within a period of not more than 24 months, as determined by relevant journal staff of the AJPP;
- The right to grant republication rights to itself or others in print, electronic, or any other form, with any revenues accrued to be shared equally between the author(s) and the journal;
- The right to administer permission to use portions of the article as requested by others, seeking recompense when the AJPP sees it as warranted;
- The right to seek or take advantage of opportunities to have the article included in a database aimed at increasing awareness of it;
- As the author(s), the AJPP wishes you to retain the right to republish the article, with acknowledgement of the AJPP as the original publisher, in whole or in part, in any other pbulication of your own, including any anthology that you might edit with up to three others;
- As the author(s), the AJPP wishes you to retain the right to place the article on your personal Web page or respository of your university or institution. The AJPP askes that you include this notice: A fully edited, peer-reviewed version of this article was first published by the Advanced Journal of Professional Practice, <Year>, <Volume>, <Issue>, <Page Numbers>.
- You retain the right to unrestricted use of your paper for yourself or for your own teaching purposes.
BY AGREEING TO THE FOREGOING, YOU CONFIRM THAT THE MANUSCRIPT YOU ARE SUBMITTING HAS NOT BEEN PUBLISHED ELSEWHERE IN WHOLE OR IN PART, AND THAT NO AGREEMENT TO PUBLISH IS OUTSTANDING.
SHOULD THE ARTICLE CONTAIN MATERIAL WHICH REQUIRES WRITTEN PERMISSION FOR INCLUSION, YOU AGREE THAT IT IS YOUR OBLIGATION IN LAW TO IDENTIFY SUCH MATERIAL TO THE EDITOR OF THE AJPP AND TO OBTAIN SUCH PERMISSION. THE AJPP WILL NOT PAY ANY PERMISSION FEES. SHOULD THE AJPP BE OF THE OPINION THAT SUCH PERMISSION IS NECESSARY, IT WILL REQUIRE YOU TO PURSUE SUCH PERMISSSION PRIOR TO PUBLICATION.
AS AUTHOR(S), YOU WARRANT THAT THE ARTICLE BEING SUBMITTED IS ORIGINAL TO YOU.
Provided the foregoing terms are satisfactory, and that you are in agreement with them, please indicate your acceptance by checking the appropriate box and proceed with your submission.
