Department of General Practice and Emergency Medicine, Kathmandu University School of Medical Sciences, Dhulikhel, Kavrepalanchok, Bagmati Province, Nepal.
Department of Community Medicine, Kathmandu University School of Medical Sciences, Dhulikhel, Kavrepalanchok, Bagmati Province, Nepal.
PLoS One. 2021 Jul 15;16(7):e0254754. doi: 10.1371/journal.pone.0254754. eCollection 2021.
Head injury, a common presentation to the emergency department (ED), is a substantial problem in developing countries like Nepal. The current national institute for health and clinical excellence (NICE) guideline revised in January 2014 focuses on effective clinical assessment and early management of head injuries according to their severity in all age groups. This study assessed the impact of implementing this guideline on the proportions of computed tomography (CT) head scans, guideline adherence, and confidence level of the attending physicians.
We consecutively recruited 139 traumatic head injury (THI) patients in this prospective pre-post interventional study conducted in the ED of a tertiary care center. We implemented the NICE guideline into routine practice using multimodal intervention through physicians' education sessions, information sheets and guideline-dissemination. The pre and post-implementation CT head scan rates were compared. The post-implementation guideline adherence was assessed. Online Google form-questionnaires including 12 validated case scenarios were distributed to the attending physicians at the end of both phases to assess their confidence levels.
The implementation resulted in a statistically significant decrease in the proportion of CT head scan rates from 92.0% to 70.0% (p-value = 0.005). Following educational interventions, improved guideline adherence of 20.3 percentage points (p-value = 0.001) was observed. Nine ED attending physicians were enrolled in the study who showed statistically significant improvement in their confidence level following the intervention. The NICE guideline showed a sensitivity and specificity of 93.6% and 76.4% with 82.6% accuracy compared to that of clinical judgment (100%, 34.6%, and 58.1% respectively) in detecting intracranial lesions.
The implementation was successful in satisfying the aim of the NICE guideline by decreasing the proportion of CT head scans, improving guideline adherence and increasing the confidence of the attending physicians.
头部损伤是急诊科（ED）常见的就诊原因，在尼泊尔等发展中国家是一个严重的问题。目前，国家卫生与临床卓越研究所（NICE）于 2014 年 1 月修订的指南侧重于根据所有年龄段的严重程度对头部损伤进行有效的临床评估和早期管理。本研究评估了实施该指南对计算机断层扫描（CT）头部扫描比例、指南遵循率和主治医生信心水平的影响。
我们在一家三级护理中心的急诊科进行了这项前瞻性的前后干预研究，连续招募了 139 名创伤性头部损伤（THI）患者。我们通过医生教育课程、信息表和指南传播等多种方式实施 NICE 指南，将其纳入常规实践。比较了实施前后的 CT 头部扫描率。评估了实施后的指南遵循情况。在两个阶段结束时，我们向主治医生分发了包括 12 个经过验证的案例场景的在线 Google 表单问卷，以评估他们的信心水平。
实施后，CT 头部扫描率从 92.0%降至 70.0%（p 值=0.005），具有统计学意义。经过教育干预，我们观察到指南遵循率提高了 20.3 个百分点（p 值=0.001）。有 9 名急诊科主治医生参与了这项研究，他们的信心水平在干预后有了统计学上的显著提高。与临床判断（分别为 100%、34.6%和 58.1%）相比，NICE 指南在检测颅内病变方面的灵敏度和特异性分别为 93.6%和 76.4%，准确率为 82.6%。
通过降低 CT 头部扫描的比例、提高指南遵循率和提高主治医生的信心，实施取得了成功，满足了 NICE 指南的目标。
