Who should be admitted to hospital for observation and who can be discharged home from A&E?

6.1 Indications for Admission to Hospital

Surveys show that only some 20% of the patients who attend hospital with a head injury are admitted.⁵⁴, ¹¹⁹ The reasons for admission include evidence that the patient has not recovered from the effects of the injury and/or any brain damage already sustained or that there are features that indicate the risk that further complications are likely. Some patients have a head injury that in itself would not require admission but this is necessary because they have serious injuries elsewhere, medical problems, or social factors that indicate that discharge is inappropriate.¹²⁰ Evidence level III

If a patient has persisting impaired consciousness, there is a clear need for continuing observation and care. Debate, about where and how care should be provided, can arise if it is suspected that the patient's condition is not due to a head injury but to another factor such as the effects of the intake of alcohol or drugs.¹²¹ If there is doubt, the appropriate course usually is to regard the patient's condition as due to a head injury.¹²², ¹²¹ Evidence level III

If a patient has apparently recovered from the effects of a head injury, so that concern is only about the possibility of a delayed complication, the benefits of admission to hospital are less clear.⁹³, ¹⁰¹, ¹²³ The potential advantage lies in the possibility of carrying out repeated observation by trained staff, so that neurological deterioration due to delayed complication could be detected and appropriate action taken promptly. Against this has to be set the reality that this event is rare (frequency of development of an intracranial haematoma in a patient with a Glasgow Coma Score of 15 has been estimated as 1 in 3,61541 (see section 5.2.1). In addition to the cost, in terms of resources, being disproportionately high,¹²³ it has been argued that observation in hospital is more likely to be effective if it is focused on patients selected to be at higher risk, whereas well conducted home observation can be appropriate in low risk cases.¹²⁴, ¹²⁵, ¹²⁶ Evidence level III and IV

In a patient who is fully conscious after an injury, the guideline development group consider that clear indications for admission include persistence of symptoms or signs that develop as a consequence of the injury or the finding of abnormalities on a skull x-ray or CT scan.

The necessity to admit a patient who has recovered, but who has a clear history of having lost consciousness or who has amnesia for the circumstances of the injury, remains controversial. There is evidence that such patients are at very low risk of an intracranial complication but also a view that extended periods of unconsciousness or amnesia in themselves may merit admission. The precise duration of amnesia or unconsciousness that enables the distinction to be made has not been established, the guideline development group's view was that a period of more than five minutes should be considered an indication for admission. The concept that admission for 24 hours of those with a brief period of amnesia might reduce the occurrence of post-concussional syndrome has not been confirmed. ¹²⁷

A patient should be admitted to hospital if: the level of consciousness is impaired (GCS (15/15) the patient is fully conscious (GCS 15/15) but any of the following risk factors are present: continuing amnesia (for at least five minutes after injury) continuing nausea and/or vomiting a seizure at any time after injury focal neurological signs irritability or abnormal behaviour clinical or radiological evidence of a recent skull fracture or suspected penetrating injury an abnormal CT scan severe headache or other neurological symptoms the patient has significant medical problems, e.g. anticoagulant use the patient has social problems or cannot be supervised by a responsible adult

Children should be admitted if any of the following risk factors apply: history of loss of consciousness neurological abnormality or persisting headache or vomiting clinical or radiological evidence of skull fracture or penetrating injury difficulty in making a full assessment suspicion of non-accidental injury other significant medical problem not accompanied by responsible adult or social circumstances considered unsatisfactory

In injured children, especially the very young, the possibility of non-accidental injury must be considered when findings are not consistent with the explanation given, if the history changes, or if the family is known to be on the "At Risk" register. In such a case a medical practitioner with experience in the care of children should be involved and should contact the duty social worker to allow early investigation. Locally agreed guidelines and protocols should be followed.

6.2 Indications for Discharge from A&E

It is neither feasible nor desirable to admit to hospital the majority of patients attending A&E with a head injury who have recovered and who are at low risk of an intracranial complication. The circumstances in which discharge home is appropriate are therefore the converse of the criteria for admission.

Observation at home is especially appropriate for most patients who are fully conscious and orientated and who have recovered from any brief period of post traumatic amnesia.¹²⁵, ¹²⁷ Any adverse social factors should be taken into account. Evidence level Ib and III

A patient can be discharged from A&E for observation at home if fully conscious (GCS 15/15) with none of the additional risk factors noted in section 6.1 above or other relevant adverse medical and social factors.

The following social criteria must be met prior to discharge: a responsible adult is available and willing to observe the patient for at least 24 hours verbal and written instructions about observations to be made and action to be taken are given to and discussed with that adult there is easy access to a telephone the home is within reasonable distance of medical advice transport home is available.

Children can be discharged from A&E if none of the risk factors noted in section 6.1 apply.

6.3 Information and Instruction on Discharge from A&E

If a patient is to be observed at home, compliance with observations and awakening advice is best if the verbal and written instructions are given directly to a responsible adult who can understand them.¹²⁵, ¹²⁸ Several different versions of instruction sheets have been described and many hospitals have locally devised versions.¹²⁸ The development of a standard uniform approach has been advocated.¹²⁶ Example advice sheets for the person taking responsibility for the patient and for the patient are provided as Annexes 3 and 4.

Patients and carers should be given verbal and written advice and encouraged to seek prompt advice from their general practitioner or hospital emergency department by phone about any worrying symptoms or other concerns.

Clear written head injury observation instructions should be given to and discussed with parents or carers before a child is discharged (see Annex 5).