Heskestad Ben, Baardsen Roald, Helseth Eirik, Ingebrigtsen Tor
Department of Neurosurgery, Ulleval University Hospital, Oslo, Norway.
J Trauma. 2008 Dec;65(6):1309-13. doi: 10.1097/TA.0b013e31815e40cd.
The evidence-based Scandinavian Guidelines for the Initial Management of Minimal, Mild, and Moderate Head Injuries were developed to provide safe and cost-effective assessment of patients. A survey based on a questionnaire directed to clinical managers in all Norwegian hospitals indicated that the guidelines had influenced management practice significantly. However, implementation of guidelines and compliance from clinical leaders does not necessarily influence individual physicians decisions making.
To evaluate physicians-compliance with the Scandinavian Guidelines in individual patients, we conducted a study (January 2003 to January 2004) that included all patients with minimal, mild, and moderate head injury who presented to the emergency department in a Norwegian university hospital. Guideline compliance was evaluated in the assessment and treatment of 508 patients. The management of each single patient was classified as compliant with the guidelines or not. Classification as compliant required correct use of computed tomography (CT) and hospital admission in accordance with the guideline.
The overall physicians-compliance with the Scandinavian Guidelines was 51%. A substantial overtriage with unnecessary CT examinations and hospital admissions was seen in patients with minimal and mild head injuries. Among patients with minimal head injury, 69% underwent overtriage, 18% with unnecessary hospital admission, 27% with unnecessary CT, and 24% with both. Among patients with mild head injury, 37% were subject to overtriage, all with admission for observation after a negative CT. All patients with moderate head injury were treated in accordance with the guideline.
Guidelines for assessment and treatment of minimal and mild head injuries may not have the intended degree of influence on clinical practice. Even in departments where clinical managers report that the practice is evidence based, physicians may not act in accordance with this in their daily practice. This causes significant unnecessary costs, estimated as USD 2,167.000 annually in Norway.
基于循证医学制定的斯堪的纳维亚半岛轻微、轻度和中度头部损伤初始管理指南，旨在为患者提供安全且具成本效益的评估。一项针对挪威所有医院临床管理人员的问卷调查显示，该指南对管理实践产生了重大影响。然而，指南的实施以及临床负责人的依从性并不一定会影响个别医生的决策。
为评估医生对个别患者遵循斯堪的纳维亚半岛指南的情况，我们开展了一项研究（2003年1月至2004年1月），纳入了挪威一家大学医院急诊科收治的所有轻微、轻度和中度头部损伤患者。对508例患者的评估和治疗过程进行了指南依从性评估。将每位患者的管理情况分类为是否符合指南。符合指南的分类要求根据指南正确使用计算机断层扫描（CT）并安排住院治疗。
医生对斯堪的纳维亚半岛指南的总体依从率为51%。在轻微和轻度头部损伤患者中，存在大量过度检查，包括不必要的CT检查和住院治疗。在轻微头部损伤患者中，69%接受了过度检查，18%存在不必要的住院治疗，27%接受了不必要的CT检查，24%两者均有。在轻度头部损伤患者中，37%接受了过度检查，所有患者在CT检查结果为阴性后均住院观察。所有中度头部损伤患者均按照指南进行治疗。
轻微和轻度头部损伤的评估和治疗指南可能未对临床实践产生预期程度的影响。即使在临床管理人员报告实践基于循证医学的科室，医生在日常实践中也可能未按此行事。这导致了大量不必要的费用，据估计在挪威每年达216.7万美元。
