11.1 Audit

The SIGN guideline development group's deliberations have been given focus by information provided by the Scottish Trauma Audit Group (STAG) on all patients with head injury admitted to participating hospitals who either die or remain in hospital for three or more days. Analysis of the information on these patients was underway at the time of development of the guideline. Preliminary information confirms that problems in assessment, diagnosis, triage and transfer continue to be important potential adverse factors. Audit of these guidelines and their impact on clinical and radiological practice should continue.

11.2 Key indicators of quality of management

1. Has a comprehensive assessment been documented?
   1. Have guidelines been followed in decision-making about investigation?
   2. Have guidelines been followed in decisions about admission or discharge for home observation?
   3. Have guidelines for neurosurgical consultation been appropriately used?
   4. Have decisions about neurosurgical consultation or transfer been carried out appropriately?
2. Have clear and appropriate instructions been given about management?
3. Have appropriate instructions been given to patients discharged?
4. Has progress in hospital been appropriately documented?
5. Is there evidence of untoward incidents in patient management?

The above indicators concentrate on process rather than outcome because death after a head injury is a relatively rare occurrence and information about disability, although common in survivors, is not routinely collected. Nevertheless, patients who die after a head injury are an important and readily identifiable group, and form an appropriate target for a Scotland-wide audit in every instance. STAG is currently developing a robust peer review process for such patients, and this work should be actively encouraged.

Deaths may also be included in the Scottish Audit of Surgical Mortality (SASM), but the focus of the latter has, so far, been on the role of operative and perioperative factors and the value of the data from this source in auditing other aspects of management should be expanded.

11.3 Recommendations for further research

Rigorous, prospective studies are needed to increase the quality of evidence upon which to base future revisions of these guidelines.

Important topics include:

• the merits of the use of skull x-ray or CT scanning in the triage of less severe injuries
• the 'trade-off' between CT scanning in the A&E Department with discharge after normal findings, against routine admission for observation in patients with apparently minor head injury
• the 'trade-off' between early CT scanning in patients admitted to hospital against scanning selected patients after a period of observation
• triage of head injured patients by paramedical crews to select patients for transport to different levels of hospital
• the extent to which recommendations based on data from adults can apply safely to children, and how this is influenced by the age of the child
• the efficacy and effectiveness of different arrangements for follow up.