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Head injury overview

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Head injury

About

What is covered

This pathway covers the triage, assessment, investigation and early management of head injury in infants, children and adults.
Head injury is the commonest cause of death and disability in people aged 1–40 years in the UK. Each year, 1.4 million people attend emergency departments in England and Wales with a recent head injury. Between 33% and 50% of these are children aged under 15 years. Annually, about 200,000 people are admitted to hospital with head injury. Of these, one-fifth have features suggesting skull fracture or have evidence of brain damage. Most patients recover without specific or specialist intervention, but others experience long-term disability or even die from the effects of complications that could potentially be minimised or avoided with early detection and appropriate treatment.
The incidence of death from head injury is low, with as few as 0.2% of all patients attending emergency departments with a head injury dying as a result of this injury. Ninety five per cent of people who have sustained a head injury present with a normal or minimally impaired conscious level (Glasgow Coma Scale [GCS] score greater than 12) but the majority of fatal outcomes are in the moderate (GCS 9–12) or severe (GCS 8 or less) head injury groups, which account for only 5% of attenders. Therefore, emergency departments see a large number of patients with minor or mild head injuries and need to identify the very small number who will go on to have serious acute intracranial complications.
For the purposes of this pathway, head injury is defined as any trauma to the head other than superficial injuries to the face. Children are defined as patients aged under 16 years and infants as those aged under 1 year of age at the time of presentation to hospital with head injury.

Updates

Updates to this pathway

18 February 2015 Minor maintenance updates.
22 October 2014 Head injury (NICE quality standard 74) added to this pathway.
22 August 2014 Minor maintenance updates.

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Patient-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Triage, assessment, investigation and early management of head injury in infants, children and adults

What is covered

This pathway covers the triage, assessment, investigation and early management of head injury in infants, children and adults.
Head injury is the commonest cause of death and disability in people aged 1–40 years in the UK. Each year, 1.4 million people attend emergency departments in England and Wales with a recent head injury. Between 33% and 50% of these are children aged under 15 years. Annually, about 200,000 people are admitted to hospital with head injury. Of these, one-fifth have features suggesting skull fracture or have evidence of brain damage. Most patients recover without specific or specialist intervention, but others experience long-term disability or even die from the effects of complications that could potentially be minimised or avoided with early detection and appropriate treatment.
The incidence of death from head injury is low, with as few as 0.2% of all patients attending emergency departments with a head injury dying as a result of this injury. Ninety five per cent of people who have sustained a head injury present with a normal or minimally impaired conscious level (Glasgow Coma Scale [GCS] score greater than 12) but the majority of fatal outcomes are in the moderate (GCS 9–12) or severe (GCS 8 or less) head injury groups, which account for only 5% of attenders. Therefore, emergency departments see a large number of patients with minor or mild head injuries and need to identify the very small number who will go on to have serious acute intracranial complications.
For the purposes of this pathway, head injury is defined as any trauma to the head other than superficial injuries to the face. Children are defined as patients aged under 16 years and infants as those aged under 1 year of age at the time of presentation to hospital with head injury.

Updates

Updates to this pathway

18 February 2015 Minor maintenance updates.
22 October 2014 Head injury (NICE quality standard 74) added to this pathway.
22 August 2014 Minor maintenance updates.

Sources

NICE guidance and other sources used to create this pathway.
Head injury (2014) NICE guideline CG176
Head injury (2014) NICE quality standard 74

Quality standards

Quality statements

CT head scans

This quality statement is taken from the head injury quality standard. The quality standard defines clinical best practice in head injury care and should be read in full.

Quality statement

People attending an emergency department with a head injury have a CT head scan within 1 hour of a risk factor for brain injury being identified.

Rationale

Head injuries can be fatal or cause permanent disability if damage to the brain is not identified and treated quickly. A CT scan within 1 hour will allow rapid treatment and improve outcomes for people with head injuries that have damaged the brain.

Quality measures

Structure
Evidence of local arrangements to ensure that CT head scans can be performed within 1 hour of a risk factor for brain injury being identified in people attending emergency departments with a head injury.
Data source: Local data collection.
Process
Proportion of emergency department attendances of people with a head injury for which a CT head scan is performed within 1 hour of a risk factor for brain injury being identified.
Numerator – the number in the denominator having a CT head scan within 1 hour of a risk factor for brain injury being identified.
Denominator – the number of emergency department attendances of people with a head injury and a risk factor for brain injury indicating the need for a CT head scan.
Data source: Local data collection. The Trauma Audit and Research Network (TARN) collects data for a subset of the population; however, data for the entire process measure are not currently collected. TARN collects data on CT scans performed within 1 hour for people with a head injury and Glasgow Coma Scale (GCS) score of less than 13.
Outcome
Mortality from skull fracture and intracranial injury.
Data source: The Health and Social Care Information Centre’s indicator P00103 in the compendium of population health indicators. Directly standardised rate, all ages, 3 year average.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (emergency departments, hospitals and specialist neurological centres) ensure that a CT head scan can be performed within 1 hour of a risk factor for brain injury being identified in people with a head injury.
Healthcare professionals ensure that CT head scans are performed within 1 hour of a risk factor for brain injury being identified in people with a head injury.
Commissioners (clinical commissioning groups and NHS England) ensure that service providers can perform CT head scans within 1 hour of a risk factor for brain injury being identified in people with a head injury. This may be achieved in a number of ways, which include the use of 1 hour targets in acute contracts, or enhanced monitoring and audit procedures.

What the quality statement means for patients, service users and carers

People with a head injury who have any sign showing that the injury might have damaged their brain have a CT scan of their head within 1 hour of the sign showing.

Source guidance

  • Head injury (NICE clinical guideline 176), recommendations 1.4.7 and 1.4.9 (key priorities for implementation), and 1.4.10.

Definitions of terms used in this quality statement

Risk factors for brain injury
For adults with head injury, any 1 of the following risk factors indicates the need for a CT head scan within 1 hour of the risk factor being identified:
  • GCS score less than 13 on initial assessment in the emergency department.
  • GCS score less than 15 at 2 hours after the injury on assessment in the emergency department.
  • Suspected open or depressed skull fracture.
  • Any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, and Battle's sign).
  • Post traumatic seizure.
  • Focal neurological deficit.
  • More than 1 episode of vomiting.
[NICE clinical guideline 176, recommendation 1.4.7]
For children and young people with head injury, any 1 of the following risk factors indicates the need for a CT head scan within 1 hour of the risk factor being identified:
  • Suspicion of non-accidental injury.
  • Post traumatic seizure but no history of epilepsy.
  • On initial emergency department assessment, GCS score less than 14, or for children under 1 year, GCS (paediatric) score less than 15.
  • At 2 hours after the injury, GCS less than 15.
  • Suspected open or depressed skull fracture or tense fontanelle.
  • Any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign).
  • Focal neurological deficit.
  • For children under 1 year, presence of bruising, swelling or laceration of more than 5 cm on the head.
[NICE clinical guideline 176, recommendation 1.4.9]
In addition, children and young people with head injury and more than 1 of the following risk factors should have a CT head scan within 1 hour of the risk factors being identified:
  • Loss of consciousness lasting more than 5 minutes (witnessed).
  • Abnormal drowsiness.
  • Three or more discrete episodes of vomiting.
  • Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist or vehicle occupant, fall from a height of greater than 3 metres, high-speed injury from a projectile or other object).
  • Amnesia (antegrade or retrograde) lasting more than 5 minutes.
[NICE clinical guideline 176, recommendation 1.4.10]

CT head scans for people taking anticoagulants

This quality statement is taken from the head injury quality standard. The quality standard defines clinical best practice in head injury care and should be read in full.

Quality statement

People attending an emergency department with a head injury have a CT head scan within 8 hours of the injury if they are taking anticoagulants but have no other risk factors for brain injury.

Rationale

Some people who have no other risk factors for brain injury have an increased risk of bleeding after a head injury because they are taking anticoagulants. In these people a CT head scan within 8 hours of the injury will allow appropriate management.

Quality measures

Structure
Evidence of local arrangements to ensure that CT head scans can be performed within 8 hours of head injury in people attending emergency departments who are taking anticoagulants but have no other risk factor for brain injury.
Data source: Local data source.
Process
Proportion of emergency department attendances of people with a head injury who are taking anticoagulants but have no other risk factors for brain injury for which a CT head scan is performed within 8 hours of the injury.
Numerator – the number in the denominator having a CT head scan within 8 hours of the injury.
Denominator – the number of emergency department attendances of people with a head injury who are taking anticoagulants but have no other risk factors for brain injury.
Data source: Local data source.
Outcome
Mortality from skull fracture and intracranial injury:
Data source: The Health and Social Care Information Centre’s indicator P00103 in the compendium of population health indicators. Directly standardised rate, all ages, 3-year average.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (emergency departments, district general hospitals and specialist neurological centres) ensure that CT head scans can be performed within 8 hours of a head injury in people who are taking anticoagulants but have no other risk factor for brain injury.
Healthcare professionals ensure that CT head scans are performed within 8 hours of a head injury in people who are taking anticoagulants but have no other risk factor for brain injury.
Commissioners (clinical commissioning groups and NHS England) ensure that service providers can perform CT head scans within 8 hours of a head injury for all people who are taking anticoagulants but have no other risk factor for brain injury. This may be achieved by increasing awareness of this statement among healthcare professionals in acute settings and seeking evidence of compliance by auditing current practice.

What the quality statement means for patients, service users and carers

People with a head injury have a CT scan of their head within 8 hours of the injury happening if they are taking anticoagulants (drugs that make the blood less likely to clot) and have no sign showing that the injury might have damaged their brain.

Source guidance

  • Head injury (NICE clinical guideline 176), recommendation 1.4.12.

Definitions of terms used in this quality statement

Risk factors for brain injury
For adults with head injury, any 1 of the following risk factors indicates the need for a CT head scan within 1 hour of the risk factor being identified:
  • GCS score less than 13 on initial assessment in the emergency department.
  • GCS score less than 15 at 2 hours after the injury on assessment in the emergency department.
  • Suspected open or depressed skull fracture.
  • Any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, and Battle's sign).
  • Post traumatic seizure.
  • Focal neurological deficit.
  • More than 1 episode of vomiting.
[NICE clinical guideline 176, recommendation 1.4.7]
For children and young people with head injury, any 1 of the following risk factors indicates the need for a CT head scan within 1 hour of the risk factor being identified:
  • Suspicion of non accidental injury.
  • Post-traumatic seizure but no history of epilepsy.
  • On initial emergency department assessment, GCS score less than 14, or for children under 1 year, GCS (paediatric) score less than 15.
  • At 2 hours after the injury, GCS less than 15.
  • Suspected open or depressed skull fracture or tense fontanelle.
  • Any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign).
  • Focal neurological deficit.
  • For children under 1 year, presence of bruising, swelling or laceration of more than 5 cm on the head.
[NICE clinical guideline176, recommendation 1.4.9]
In addition, children and young people with head injury and more than 1 of the following risk factors should have a CT head scan within 1 hour of the risk factors being identified:
  • Loss of consciousness lasting more than 5 minutes (witnessed).
  • Abnormal drowsiness.
  • Three or more discrete episodes of vomiting.
  • Dangerous mechanism of injury (high speed road traffic accident either as pedestrian, cyclist or vehicle occupant, fall from a height of greater than 3 metres, high speed injury from a projectile or other object).
  • Amnesia (antegrade or retrograde) lasting more than 5 minutes.
[NICE clinical guideline 176, recommendation 1.4.10]

CT cervical spine scans

This quality statement is taken from the head injury quality standard. The quality standard defines clinical best practice in head injury care and should be read in full.

Quality statement

People attending an emergency department with a head injury have a CT cervical spine scan within 1 hour of a risk factor for spinal injury being identified.

Rationale

Head injuries can be fatal or cause disability if there is damage to the cervical spine that is not identified and treated quickly. A CT cervical spine scan within 1 hour will allow rapid treatment and improve outcomes for people with head injuries that have damaged the cervical spine.

Quality measures

Structure
Evidence of local arrangements to ensure that CT cervical spine scans can be performed within 1 hour of a risk factor for spinal injury being identified in people attending emergency departments with head injury.
Data source: Local data collection
Process
a) Proportion of emergency department attendances of people with a head injury for which a CT cervical spine scan is performed within 1 hour of a risk factor for spinal injury being identified.
Numerator – the number in the denominator having a CT cervical spine scan within 1 hour of a risk factor for spinal injury being identified.
Denominator – the number of emergency department attendances of people with a head injury and a risk factor for spinal injury indicating the need for a cervical spine scan.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (emergency departments, hospitals and specialist neurological centres) ensure that a CT cervical spine scan can be performed within 1 hour of a risk factor for spinal injury being identified in people with a head injury.
Healthcare professionals ensure that CT cervical spine scans are performed within 1 hour of a risk factor for spinal injury being identified in people with a head injury.
Commissioners (clinical commissioning groups and NHS England) ensure that service providers can perform CT cervical spine scans within 1 hour of a risk factor for spinal injury being identified in people with a head injury. This may be achieved in a number of ways including the use of 1-hour targets in acute contracts or enhanced monitoring and audit procedures.

What the quality statement means for patients, service users and carers

People with a head injury who have any sign showing that the injury might have damaged their neck have a CT scan of their neck within 1 hour of the sign showing.

Source guidance

  • Head injury (NICE clinical guideline 176), recommendations 1.5.8 and 1.5.11 (key priorities for implementation).

Definitions of terms used in this quality statement

Risk factors for spinal injury
For adults with head injury, any 1 of the following risk factors indicates the need for a CT cervical spine scan within 1 hour of the risk factor being identified:
  • Glasgow Coma Scale (GCS) score less than 13 on initial assessment.
  • The patient has been intubated.
  • Plain X-rays are technically inadequate (for example, the desired view is unavailable).
  • Plain X-rays are suspicious or definitely abnormal.
  • A definitive diagnosis of cervical spine injury is needed urgently (for example, before surgery).
  • The patient is having other body areas scanned for head injury or multi-region trauma.
  • The patient is alert and stable, there is clinical suspicion of cervical spine injury and any of the following apply:
    • age 65 years or older
    • dangerous mechanism of injury (fall from a height of greater than 1 metre or 5 stairs; axial load to the head, for example, diving; high speed motor vehicle collision; rollover motor accident; ejection from a motor vehicle; accident involving motorised recreational vehicles; bicycle collision)
    • focal peripheral neurological deficit
    • paraesthesia in the upper or lower limbs.
[NICE clinical guideline 176, recommendation 1.5.8].
For children and young people with a head injury, a CT cervical spine scan should be performed only if any of the following apply (because of the increased risk to the thyroid gland from ionising radiation and the generally lower risk of significant spinal injury):
  • GCS score less than 13 on initial assessment.
  • The patient has been intubated.
  • Focal peripheral neurological signs.
  • Paraesthesia in the upper or lower limbs.
  • A definitive diagnosis of cervical spine injury is needed urgently (for example, before surgery).
  • The patient is having other body areas scanned for head injury or multiregion trauma.
  • There is strong clinical suspicion of injury despite normal X-rays.
  • Plain X-rays are technically difficult or inadequate.
  • Plain X-rays identify a significant bony injury.
[NICE clinical guideline 176, recommendation 1.5.11].

Provisional radiology reports

This quality statement is taken from the head injury quality standard. The quality standard defines clinical best practice in head injury care and should be read in full.

Quality statement

People attending an emergency department with a head injury have a provisional written radiology report within 1 hour if a CT head or cervical spine scan is performed.

Rationale

Head injuries can be fatal or cause permanent disability if damage to the brain is not identified and treated quickly. Having the provisional results of a CT scan available within an hour will allow rapid treatment and improve outcomes for people with head injuries that have damaged the brain.

Quality measures

Structure
Evidence of local arrangements to ensure provisional written radiology reports are available within 1 hour of CT head and cervical spine scans.
Data source: Local data collection.
Process
Proportion of emergency department attendances for head injury for which a provisional written radiology report is available within 1 hour of any CT head or cervical spine scan.
Numerator – the number in the denominator with a provisional written radiology report available within 1 hour.
Denominator – the number of emergency department attendances for head injury having a CT head or cervical spine scan.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (emergency departments, hospitals and specialist neurological centres) ensure that provisional written radiology reports are available within 1 hour of CT head or cervical spine scans for head injury.
Healthcare professionals ensure that a provisional written radiology report is available within 1 hour of the CT head or cervical spine scans for head injury.
Commissioners (clinical commissioning groups and NHS England) ensure that service providers can deliver a provisional written radiology report within 1 hour of the scan. This may be achieved in a number of ways, including the use of 1-hour targets in acute contracts or enhanced monitoring and audit procedures.

What the quality statement means for patients, service users and carers

People with a head injury who have a CT scan have a written report of the scan results available within 1 hour.

Source guidance

  • Head injury (NICE clinical guideline 176), recommendations 1.4.7 and 1.4.9 (key priorities for implementation), and 1.4.10.

Access to neuroscience units

This quality statement is taken from the head injury quality standard. The quality standard defines clinical best practice in head injury care and should be read in full.

Quality statement

People with a head injury who have a Glasgow Coma Scale (GCS) score of 8 or lower at any time have access to specialist treatment from a neuroscience unit.

Rationale

A GCS score of 8 or lower indicates a severe traumatic brain injury. People with GCS scores of 8 or lower will benefit from specialised clinical management provided by a neuroscience unit.

Quality measures

Structure
Evidence of locally agreed transfer protocols between the ambulance service, emergency department, district general hospital and designated neuroscience unit.
Data source: Local data collection.
Process
Proportion of emergency department attendances of people with a head injury and a GCS score of 8 or lower at any time for which there is a documented record of ongoing liaison with or transfer to a neuroscience unit.
Numerator – the number in the denominator for which there is a documented record of ongoing liaison with or transfer to a neuroscience unit.
Denominator – the number of emergency department attendances of people with a head injury and GCS score of 8 or lower at any time.
Data source: Local data collection.
Outcome
Mortality from skull fracture and intracranial injury: directly standardised rate, all ages, 3 year average.
Data source: The Health and Social Care Information Centre’s indicator P00103 in the compendium of population health indicators.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (emergency departments, ambulance services, district general hospitals and specialist neurological centres) ensure that there are agreed protocols for ongoing liaison about the management of head injury in people with a GCS score of 8 or lower, and when to transfer to a neuroscience unit.
Healthcare professionals ensure that people with a head injury and a GCS score of 8 or lower have access to specialist treatment through ongoing liaison with or transfer to a neuroscience unit.
Commissioners (clinical commissioning groups and NHS England) ensure that appropriate pathways and protocols are in place for specialist treatment of head injury in people with a GCS score of 8 or lower through ongoing liaison with and transfer to a neuroscience unit.

What the quality statement means for patients, service users and carers

People with a head injury who show signs of severe brain injury are cared for with advice from specialists in brain injury, or have their care transferred to a clinic that specialises in treating brain injury.

Source guidance

  • Head injury (NICE clinical guideline 176), recommendation 1.7.1.

Definitions of terms used in this quality statement

Glasgow Coma Scale (GCS)
A standardised system used to assess the degree of brain impairment and to identify the seriousness of injury in relation to outcome. The system involves 3 determinants: eye opening, verbal responses and motor response, all of which are evaluated independently according to a numerical value that indicates the level of consciousness and degree of dysfunction. [NICE full clinical guideline 176]
Neuroscience unit
A neuroscience unit is a specialist centre or a unit that has facilities for neurosurgery and neurointensive care. [NICE full clinical guideline 176]

Quality statement 6: Inpatient rehabilitation for people with traumatic brain injury

This quality statement is taken from the head injury quality standard. The quality standard defines clinical best practice in head injury care and should be read in full.

Quality statement

People who are in hospital with new cognitive, communicative, emotional, behavioural or physical difficulties that continue 72 hours after a traumatic brain injury have an assessment for inpatient rehabilitation.

Rationale

Rehabilitation enables people with traumatic brain injuries to reach and maintain optimal functioning levels in areas such as intellect, sensory, physical and social behaviour. Traumatic brain injuries can affect many aspects of a person’s life; therefore, it is important to assess the benefits of inpatient rehabilitation.

Quality measures

Structure
Evidence of local arrangements to ensure that inpatient rehabilitation assessments can be carried out for people who are in hospital with new cognitive, communicative, emotional, behavioural or physical difficulties continuing 72 hours after a traumatic brain injury have an assessment of inpatient rehabilitation needs.
Data source: Local data collection.
Process
Proportion of people in hospital with new cognitive, communicative, emotional, behavioural or physical difficulties continuing 72 hours after a traumatic brain injury who have an assessment for inpatient rehabilitation.
Numerator – the number in the denominator who have an assessment for inpatient rehabilitation.
Denominator – the number of people who are in hospital with new cognitive, communicative, emotional, behavioural or physical difficulties continuing 72 hours after a traumatic brain injury.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (district general hospitals and specialist neurological centres) ensure that systems are in place for people who are in hospital with new cognitive, communicative, emotional, behavioural or physical difficulties continuing 72 hours after a traumatic brain injury to have an assessment of their need for inpatient rehabilitation.
Healthcare professionals ensure that they assess the inpatient rehabilitation needs of people who are in hospital with new cognitive, communicative, emotional, behavioural or physical difficulties continuing 72 hours after a traumatic brain injury.
Commissioners (clinical commissioning groups and NHS England) ensure that service providers assess the inpatient rehabilitation needs of people who are in hospital with new cognitive, communicative, emotional, behavioural or physical difficulties continuing 72 hours after a traumatic brain injury. This may be achieved by asking services to audit current practice to show evidence of compliance.

What the quality statement means for patients, service users and carers

People who are in hospital after a head injury that has damaged their brain and caused problems lasting 3 days or more with their memory, concentration or communication, or emotional or physical difficulties, have an assessment to find out whether a programme of rehabilitation while they are in hospital would help them to recover.

Source guidance

Definitions of terms used in this quality statement

Traumatic brain injury
Traumatic brain injury is defined as a traumatically induced structural injury and/or physiological disruption of brain function as a result of an external force that is indicated by new or worsening of at least 1 of the following clinical signs, immediately after the event:
  • Any period of loss of or a decreased level of consciousness.
  • Any loss of memory for events immediately before or after the injury.
  • Any alteration in mental state at the time of the injury (such as confusion, disorientation or slowed thinking).
  • Neurological deficits (such as weakness, loss of balance, change in vision, praxis, paresis or plegia, sensory loss or aphasia) that may or may not be transient.
  • Intracranial lesion.

Community rehabilitation services for people (aged 16 and over) with traumatic brain injury

This quality statement is taken from the head injury quality standard. The quality standard defines clinical best practice in head injury care and should be read in full.

Quality statement

Community-based neuro-rehabilitation services provide a range of interventions to help support people (aged 16 and over) with continuing cognitive, communicative, emotional, behavioural or physical difficulties as a result of a traumatic brain injury.

Rationale

Community-based neuro-rehabilitation services can be important in helping people (aged 16 and over) who have had a traumatic brain injury to regain independence and return to their normal daily lives (for example, going back to work or continuing their education).

Quality measures

Structure
Evidence of local arrangements to provide community-based neuro-rehabilitation services supplying a range of interventions to support people (aged 16 and over) with continuing cognitive, communicative, emotional, behavioural or physical difficulties as a result of a traumatic brain injury.
Data source: Local data source.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (primary care and community rehabilitation services) ensure that systems are in place to offer community-based neuro-rehabilitation services providing a range of interventions to people (aged 16 and over) with continuing cognitive, communicative, emotional, behavioural or physical difficulties after a traumatic brain injury.
Healthcare professionals ensure that they offer community-based neuro-rehabilitation services providing a range of interventions to people (aged 16 and over) with continuing cognitive, communicative, emotional, behavioural or physical difficulties after a traumatic brain injury.
Commissioners (clinical commissioning groups, NHS England and local authorities) ensure that there is sufficient capacity for community-based neuro-rehabilitation services to provide a range of interventions to help support people (aged 16 and over) with continuing cognitive, communicative, emotional, behavioural or physical difficulties after a traumatic brain injury.

What the quality statement means for patients, service users and carers

People aged 16 and over who have had a head injury that has left them with problems with their memory, concentration or communication, or with emotional or physical difficulties, are offered a programme of rehabilitation after they leave hospital to help them recover their independence and return to their normal daily lives.

Source guidance

Definitions of terms used in this quality statement

Traumatic brain injury
Traumatic brain injury is defined as a traumatically induced structural injury and/or physiological disruption of brain function as a result of an external force that is indicated by new or worsening of at least 1 of the following clinical signs, immediately after the event:
  • Any period of loss of or a decreased level of consciousness.
  • Any loss of memory for events immediately before or after the injury.
  • Any alteration in mental state at the time of the injury (such as confusion, disorientation or slowed thinking).
  • Neurological deficits (such as weakness, loss of balance, change in vision, praxis, paresis or plegia, sensory loss or aphasia) that may or may not be transient.
  • Intracranial lesion.
Range of interventions
Interventions to provide rehabilitation after a traumatic brain injury can include neuropsychological therapy, cognitive behavioural therapy, occupational therapy, physiotherapy, speech and language therapy, family interventions and vocational interventions.

Equality and diversity considerations

Provision should be made to ensure access to services for people (aged 16 and over) who find it difficult to travel long distances because of disability, financial barriers or other factors.

Post-acute phase rehabilitation for children and young people: placeholder statement

What is a placeholder statement?

A placeholder statement is an area of care that has been prioritised by the Quality Standards Advisory Committee but for which no source guidance is currently available. A placeholder statement indicates the need for evidence-based guidance to be developed in this area.

Rationale

Rehabilitation services in the post-acute phase can be important in helping children and young people (aged under 16) who have had a traumatic brain injury to regain independence and return to their normal daily lives (for example, continuing their education). The services can also provide information and advice to families and carers.

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Implementation

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Pathway information

Professional responsibilities

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. Applying the recommendations in this pathway is at the discretion of health and care professionals and their individual patients or service users and does not override the responsibility of health and care professionals to make decisions appropriate to the circumstances of the individual, in consultation with them and/or their carer or guardian.
Commissioners and/or providers have a responsibility to enable the recommendations to be applied (and to provide funding required for technology appraisal guidance) when individual health and care professionals and their patients or service users wish to use them. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Patient-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Glasgow coma score

Base monitoring and exchange of information about individual patients on the three separate responses on the GCS (for example, a patient scoring 13 based on scores of 4 on eye-opening, 4 on verbal response and 5 on motor response should be communicated as E4, V4, M5).
If a total score is recorded or communicated, base it on a sum of 15, and to avoid confusion specify this denominator (for example, 13/15).
Describe the individual components of the GCS in all communications and every note and ensure that they always accompany the total score.
In the paediatric version of the GCS, include a 'grimace' alternative to the verbal score to facilitate scoring in preverbal children.
In some patients (for example, patients with dementia, underlying chronic neurological disorders or learning disabilities) the pre-injury baseline GCS may be less than 15. Establish this where possible, and take it into account during assessment.

Glossary

Problems restricted to a particular part of the body or a particular activity, for example, difficulties with understanding, speaking, reading or writing; decreased sensation; loss of balance; general weakness; visual changes; abnormal reflexes; and problems walking.
For example, pedestrian struck by motor vehicle, occupant ejected from motor vehicle, fall from a height of greater than 1 metre or more than 5 stairs, diving accident, high-speed motor vehicle collision, rollover motor accident, accident involving motorised recreational vehicles, bicycle collision, or any other potentially high-energy mechanism.
Signs include clear fluid running from the ears or nose, black eye with no associated damage around the eyes, bleeding from one or both ears, bruising behind one or both ears, penetrating injury signs, visible trauma to the scalp or skull of concern to the professional.

Paths in this pathway

Pathway created: January 2014 Last updated: December 2015

© NICE 2016

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