# paper.pdf ## Metadata - PDFFormatVersion=1.4 - IsLinearized=false - IsAcroFormPresent=false - IsXFAPresent=false - IsCollectionPresent=false - IsSignaturesPresent=false - Producer=GPL Ghostscript 9.55.0 - CreationDate=D:20260320165120Z00'00' - ModDate=D:20260320165120Z00'00' - Creator=Adobe InDesign CC 2015 (Macintosh) - xmp:modifydate=2026-03-20T16:51:20Z - xmp:createdate=2026-03-20T16:51:20Z - xmp:creatortool=Adobe InDesign CC 2015 (Macintosh) - dc:title=Untitled ## Contents ### Page 1 September 2015Traumatic head injury in children and young people: a national overviewA review of 6 months data from 2009-2010, collected from England, Wales, Northern Ireland, Channel Islands and the Isle of Man ### Page 2 2 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewReport prepared by:Professor Alison M Kemp, Professor of Child Health, Cardiff University, Dr Laszlo Trefan, Research Associate and Statistician, Cardiff University Ms Amanda Summers, Research Administrator, Cardiff UniversityIndependent Advisory Group (IAG):Dr Ian Maconochie: Chair of (IAG), Imperial College NHS Healthcare Trust, London Ms Rosie Houston: Research fellow CMACE (at the time of the project). Dr Gale Pearson: Director of CMACE (at the time of the project) University of Birmingham Dr Phillip Hyde: Paediatric Intensivist, Southampton Children’s Hospital Dr Richard Edwards: Neurosurgeon Bristol Hospital for Children, Dr Roger Parslow: Senior Lecturer in Epidemiology, University of Leeds, Dr Jacqueline Cornish: National Clinical Director for Children, Young People and Transition, NHS England Ms Heather Livingston: Northern Ireland, Department of Health Dr Heather Payne: Senior Medical Officer for Maternal and Child Health, Wales Assembly Government Ms Jenny Mooney, Healthcare Quality Improvement Partnership HQIPAdditional Members of original CMACE External advisory group Head Injury project:Professor Robert Tasker, Paediatrics , University of Cambridge, Dr Rosemary Arthur Consultant Paediatric Radiologist Leeds (British Society Paediatric Radiology), Dr Fiona Lecky: Research Director TARN, Senior Lecturer, Honorary Consultant Emergency Medicine Manchester, Dr Fiona Moore: Medical Director London Ambulance Service, Dr Kevin Morris: Director PICU Birmingham Children’s Hospital Lisa Turan : Chief Executive Child Brain Injury Trust, Girkamal Virdi: Assistant Head of Clinical and Audit Research London Ambulance Service, Mark Woolcock: Emergency Medical Practitioner and Emergency Specialist Service South Western Ambulance Service NHS Foundation Trust, UK The Child Head Injury Project was commissioned by The Healthcare Quality Improvement Partnership (HQIP) on behalf of NHS England, DHSSPS Northern Ireland, and the Health Department of the Welsh Government. The Healthcare Quality Improvement Partnership (HQIP) is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices. HQIP is a not for profit limited company established in April 2008 to promote quality in healthcare, and in particular to increase the impact that clinical audit has on healthcare quality in England and Wales. The work programme, which also encompasses confidential enquiries, is designed to help assess the quality of healthcare, and stimulate improvement in safety and effectiveness by systematically enabling clinicians, managers and policy makers to learn from audit data and patient safety adverse events. More details can be found at: www.hqip.org.uk ### Page 3 3 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewContentsExecutive Summary page 4 Recommendations page 4 Introduction page 13 Methodology of data collection and analysis page 14 Epidemiology of children and young people with THI page 15 The causes of traumatic head injuries page 19 The early management of THI: pre-hospital setting page 26 The early management of THI: Hospital management page 34 CT scanning and compliance with NICE head injury guidance page 43 The recognition and investigation of children with suspected maltreatment page 47 and abusive head trauma Bibliography page 52 List of abbreviations page 54 Appendices page 55 ### Page 4 4 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewExecutive SummaryThis report is an analysis of data on 5700 children with mild, moderate and severe traumatic head injury (THI) from 2009 to 2010. The inclusion criterion for entry into the study was that the child had been in receipt of treatment or observation in an inpatient area for at least 4 hours. Therefore it is important to note that this dataset includes many children with minor head injury who would have been sent home shortly after this time and relatively few children with severe traumatic head injury. In addition there have been significant changes in trauma care management in England (and parts of Wales) since the date of this data collection and analysis which came into being in April 2012.1 This included the development of structured networks of care, based on a hub and spoke model, the spokes being Trauma Units (TU) and the hub being the Regional Major Trauma Centre (MTC). Other aspects of clinical practice have also changed since the time that the study was conducted, for example, NICE 2007 guidelines on the management of head injury in children and young people were revised in 2014, and new guidance on imaging produced by the Royal College of Radiology in 2014 have come into play. The importance of the data in this report is that it acts as a comprehensive benchmark of service delivery prior to the re- organisation services and introduction of new guidance. Six specific areas were considered in the analysis of this data: • The epidemiological features of traumatic head injury in children and young people. • The causes of traumatic head injury. • The assessment and management of traumatic head injury in prehospital and in hospital settings. • The use of CT head scanning and compliance with NICE head injury guidance (2007). • How children with suspected maltreatment and abusive head trauma were investigated and managed. Importantly, the data have also been incorporated into a series of forthcoming peer-reviewed publications, which benchmark activity prior to the advent of the trauma system in operation in England and parts of Wales. Based on the detailed analysis of this dataset, together with the clinical and academic input and consensus of the Independent Advisory Group for this project a number of recommendations have been produced which are summarised below. Where the recommendation has been met due to changes in service provision since this data collection or where guidance exists this has been noted in bold beneath the recommendation. Full details of the analysis that led to these conclusions and recommendations follow in the subsequent report chapters.1. Three of the London MTCs began treating patients from April 2010 with the fourth London MTC starting in April 2011Recommendation 1There is currently no system for the collection of data on all forms of head injury in children.* A future standardised data gathering exercise is recommended to fully understand the ongoing determinants of childhood head injury and to evaluate the benefits of the changes to the national trauma system and national head injury guidelines that have been introduced since the data collection time period for this study. These data could be used as baseline figures to inform such an evaluation. *The Trauma Audit Research Network (TARN) is a national dataset and collects data on severely injured children who stay in hospital longer than 72 hours. However the data collection will only cover a small proportion of hospital admissions for traumatic head injury in children. ### Page 5 5 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewRecommendation 2These data would support the organisation of services such that health care professionals with the skills to assess and manage very young children with traumatic head injury are available at the peak times that they present to health care services, namely afternoon and early evening. Since these data were collected, standards for staff training and competencies have been set by a. the Intercollegiate Committee for Standards for Children and Young People in Emergency Care Settings (2012), and b. The Royal College of Paediatrics and Child Health, Facing the future (2010 updated 2015). ‘A consultant paediatrician or equivalent staff, associate specialist or specialty doctor who is trained and assessed as competent to work on the paediatric consultant rota is present and readily available in the hospital during periods of peak activity, seven days a week’a. Click here to go to Royal College of Paediatrics and Child Health PDF b. Click here to go to Facing the Future PDFRecommendation 3Falls must be a clear priority in accident prevention interventions for infants and toddlers. These could be delivered by Health Visitors, Family Nurses in Children Centres, Flying Start programmes and through other mediums that have the capacity to reach parents of young children. A focus on falls from a parent or carer’s arms, particularly when they are being carried upstairs can be justified. In June 2014 Public Health England launched a program of work to reduce unintentional injuries in and around the home among children under five years. Falls were identified as one of five priority areas.Click here to go to Reducing unintentional injuries in and around the home PDFRecommendation 4Preventative interventions that rely upon safe sports surfaces, cycle-helmets, in-car safety and road traffic calming must be maintained. The study was not powered sufficiently to be able to comment on the effect of wearing a cycle helmet but further evaluation of the efficacy and benefits of helmet wearing would be valuable. In June 2014 Public Health England launched a program of work to decrease unintentional injuries on the roads among children and young people under 12 years.Click here to go to Reducing unintentional injuries on the roads PDF ### Page 6 6 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewRecommendation 5Clinicians who evaluate children with traumatic head injury must avoid a simplistic interpretation of falls and take a detailed history using a standardised proforma at the time of presentation to determine the likely risk of serious head injury and ensure that the explanation provided is plausible to exclude concerns about physical abuse or neglect. The history must include items such as the item fallen from, the time of the injury and chronology of signs and symptoms. Other items not covered in this data set would include the estimated height of the fall, the position and activity of the child before they fell, nature of surface of impact, point of impact to the head. These recommendations are partially incorporated in Children Protection Companion 2nd edition RCPCH 2013 and NICE Head Injury Guidelines CG176 published 2014: Triage, assessment, investigation and early management of head injury in children, young people and adults.Click here to go to RCPCH Child Protection Publications Click here to go to NICE Head Injury GuidanceRecommendation 6It is essential that all ambulance crews and clinicians who first see a child with a traumatic head injury are trained to recognise children who have potentially serious head injury early to ensure that they are managed in centres that can provide the appropriate level of care to optimise outcome. In 2015: All Major Trauma Networks have triage and by pass criteria to enable rapid and safe transfer of children to the most appropriate hospital.Click here to go to NHS Major Trauma PDFStandards of practice are set out Joint Royal Colleges Ambulance Liaison Committee.Click here to go to JRCALC Guidelinesand NICE Head Injury Guidelines CG176 published 2014: Triage, assessment, investigation and early management of head injury in children, young people and adults.Click here to go to NICE Head Injury Guidance ### Page 7 7 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewRecommendation 7All ambulance staff should be trained and ambulances fully equipped with age appropriate equipment to assess and manage young children with traumatic head injury. This would include age specific blood pressure, oxygen saturation monitoring equipment and face-masks to administer oxygen to small children.Recommendation 8Ambulance teams require further training in the importance of administering oxygen to children with traumatic head injury and impaired levels of consciousness.Click here to go to JRCALC Guidelines‘Oxygen should be administered routinely whatever the oxygen saturation in patients (children) sustaining major trauma’.Recommendation 9All children with traumatic head injury and impaired consciousness should be transported to hospital quickly and by ambulance to optimise their early management. Members of the public, especially parents and youth workers should be alerted to the signs of serious head injury and the importance of calling an ambulance. This requires targeted explicit education to avoid flooding the system with unnecessary calls. Effective triage of emergency calls to identify serious head injury should be reinforced. NICE Head Injury Guidelines CG176 published 2014: Triage, assessment, investigation and early management of head injury in children, young people and adults.Click here to go to NICE Head Injury Guidance (Section 1.1)Recommendation 10Ambulances transporting children with serious head injury must adhere to triage and by-pass criteria that are now in place for all Major Trauma Networks. Children should be transported to the appropriate Children’s Major Trauma Centre or nearest Trauma Unit (accounting for the geography of the ‘Network’) to optimise prompt health care and reduce the time taken for children to reach appropriate services. This recommendation has been reinforced by the changes to the organisation of trauma services in England and North Wales. The announcement of the major trauma centres by the government, 6th April 2012.Click here to go to NHS Major Trauma PDF ### Page 8 8 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewRecommendation 11Retrieval teams for children with traumatic head injury should be established to ensure children get to the appropriate hospital for their level of need according to the severity of their head injury. Specific provision must be made for rapid transfer in rural areas where the time to get the child to a specialist unit would exceed an hour. This is likely to involve air ambulance retrieval. This recommendation is reinforced in the changes to the organisation of trauma services in England and North Wales.Click here to go to NHS Major Trauma PDFRecommendation 12All children with a traumatic head injury should be assessed by a health care professional who has been trained in the assessment and management of childhood trauma. Many of these children are very young and the assessment of neurological impairment differs considerably from that in adults. NICE Head Injury Guidelines CG176 published 2014: Triage, assessment, investigation and early management of head injury in children, young people and adults.Click here to go to NICE Head Injury GuidanceRecommendation 13When hospital transfer to a Major Trauma Centre is required, the proportion of Inter-hospital transfers undertaken by PICU retrieval teams should be improved.Click here to go to UK PICS Standards (2010)Recommendation 14Children with impaired levels of consciousness should be safely transferred to Children’s Major Trauma Centre by appropriately trained staff utilising the Network transfer criteria and transport system. This recommendation is embedded in changes to the organization of trauma services in England and N Wales.Click here to go to NHS Major Trauma PDF ### Page 9 9 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewRecommendation 15A small proportion of children re-attended hospital post following traumatic head injury. This reiterates the need for all parents to receive information about the risk factors that mean patients need to return to the emergency department. Guidance on information to be provided to parents is available in NICE Head Injury Guidelines CG176 published 2014: Triage, assessment, investigation and early management of head injury in children, young people and adults.Click here to go to NICE Head Injury Guidance (Section 1.9.11)Recommendation 16Clinical pathways and clinical training needs to ensure that the following standards are improved in ED for children with traumatic head injury with all levels of neurological impairment. • Quicker time taken to assess children in ED with head injury. • Recording of Glasgow Coma Score (GCS) with details of component scores in all cases. • Early intubation of children with GCS ≤ 8. This recommendation is reiterated by the changes to the organization of trauma services in England and N Wales, in managing injured patients.Click here to go to NHS Major Trauma PDFThese standards are set within the NICE Head Injury Guidelines CG176 published 2014: Triage, assessment, investigation and early management of head injury in children, young people and adults.Click here to go to NICE Head injury Guidance (Sections 1.2, 1.3, 1.7.13)Recommendation 17In patients with a GCS less than or equal to 8, there should be early involvement of an anaesthetist or critical care physician to ensure that early, appropriate intubation and ventilation or oxygen are instigated when appropriate. This recommendation is embedded in the NICE Head Injury Guidelines CG176 published 2014: Triage, assessment, investigation and early management of head injury in children, young people and adults.Click here to go to NICE Head Injury Guidance (Section 1.3.5) ### Page 10 10 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewRecommendation 18All children with impaired consciousness should have an early assessment by a consultant grade doctor, a consultant with paediatric training should be involved in their care and there should be access to a neurosurgical team. This recommendation is embedded in the changes to the organization of trauma services in England and North Wales. Trained trauma teams are now based in the major trauma centres.Click here to go to NHS Major Trauma PDFRecommendation 19It is increasingly recognised that children with minor traumatic brain injury can suffer from post-concussion syndrome and long term behavioural and emotional consequences. Provision for this must be made within the ongoing management of the majority of children who present with head injury. This is referred to in the NICE Head Injury Guidelines CG176 published 2014: Triage, assessment, investigation and early management of head injury in children, young people and adults.Click here to go to NICE Head Injury Guidance (Section 1.9.12)Recommendation 20In view of the low percentage of children with indicators for CT who actually have a CT, there should be a national review of the facilitators and barriers to CT scanning, (especially for the infants and toddler age group) and an on-going national audit of the implementation of NICE head injury guidelines in General hospitals.Recommendation 21The practice of admitting young children for observation versus early CT scanning should be evaluated according to short and long term clinical outcome. The potential benefits of low-dose CT scanning should be considered to reduce the risks of irradiation against the benefits of early detection of traumatic brain injury. ### Page 11 11 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewRecommendation 22A large scale prospective evaluation of the indicators for CT head scan within NICE head injury guidelines is needed to determine their accuracy and efficacy in practice.Recommendation 23ED staff and hospital paediatricians must receive appropriate levels of safeguarding training that includes guidance on the recognition of abusive head trauma (AHT). For frontline staff who are assessing young children with head injury, training must be provided in a manner that accounts for the rapid turnover of staff in ED, many of whom are adult specialists or locums.The Royal College of Emergency Medicine, clinical standards document (click here to access the document) published in August 2014 recommends that ‘All ED medical and nursing staff should, as a minimum, have level 2 Child Protection training. All senior Emergency Medicine doctors (ST4 or equivalent and above) should have level 3 Child Protection training’. Safeguarding children and young people: roles and competences for health care staff published 2014.Click here to go to RCPCH Safeguarding Children and Young People PDFRecommendation 24Paediatricians must improve their adherence to national guidance when physical abuse is suspected in young children with head injury. Recommended investigations: CT scan, skeletal survey (RCR/RCPCH radiology guidelines 2008), ophthalmology (RCOPH/ RCPCH guidelines) examination should be conducted for all infants and children who have a head injury where physical abuse is suspected. All children must be assessed on an individual basis and if recommended investigations are not performed the reasons why must be clearly documented. Children Protection Companion 2nd edition RCPCH 2013Click here to go to RCPCH Child Protection PublicationsRecommendation 25NICE head injury guidelines 2007 and 2014 recommend that head CT scan should be performed if non-accidental head injury is suspected, yet they give no explanation as to when this suspicion should be raised. This should be considered in the next revision of the guidelines. There are several detailed evidence based publications around this topic (www.core-info.cf.ac.uk). All health care professionals involved with these children must be made aware that AHT is a condition that is prevalent in infants and toddlers and be familiar with the guidelines where AHT is suspected. ### Page 12 12 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewPaediatric traumatic brain injury is one of major causes of death and long- term disability in the UK. The injury’s impact is not only to the child and the loss of that individual’s potential development, in terms of their physical, educational, psychologically, and social outcomes, but there are often significant effects on their carers and family. Families of children and young people who suffer chronic disability often experience economic hardship and there are effects on immediate relatives, e.g. the educational performance of siblings may be disturbed and have long-term detrimental effects. To reduce the morbidity and mortality associated with injury, public health strategies traditionally run in three different streams of care: primary, secondary and tertiary prevention schemes. The first two for traumatic head injury (THI) include public health awareness campaigns, legislation, altering the environmental factors (e.g. safe play surfaces), changing behaviour where needed, and promoting effective educational schemes. Combinations of these risk reduction strategies may have played a part in the decline in the trauma mortality over the last 30 years, but nonetheless paediatric THI still occurs. Tertiary prevention strategies then come into play once injury has occurred. These act to reduce mortality and morbidity by minimising the consequent effects of the injury, putting in place resources, expertise and remodelling old systems of care. Currently, this is by means of a network of trauma care, modelled on a hub and spoke basis, with the Major Trauma Centres (MTC) dealing with the most severely injured patients. This trauma system came into place in England and N Wales in April 2012, after the period of data collection by Centre for Maternal and Child Enquiries (CMACE). Within this system, starting in the pre-hospital environment and continued into secondary and tertiary settings, there is co-ordinated access to expert care so that life and limb saving procedures can be undertaken safely and in a timely fashion. Examples of these procedures include emergency intubation, CT head scanning to determine the extent of THI and inform the management of any intracranial pathology, and the use of intensive care facilities to support the patient and decrease the likelihood of any complications. The CMACE dataset comprises information on 5700 children and young people with head injury, admitted to hospital for four hours or longer over 6 months, from September 2009 to February 2010. The National Confidential enquiry collected data on discrete points of care that are presented in this report. The clinical management of head injuries at the time of CMACE data collection was subject to the NICE head injury clinical guidelines 2007 and those of the Joint Royal Colleges Ambulance Liaison Committee (JRCALC). Since the data collection, both have been updated (NICE GUIDELINES 2014, JRCALC 2013) and, as mentioned previously, the care pathway for trauma patients was revised when the Major Trauma Networks were introduced across England and N Wales.Commissioning of the reportThe Centre for Maternal and Child Enquiries (CMACE) was commissioned by the Department of Health and the funding bodies of Wales, Northern Ireland, the Channel Islands and the Isle of Man to review morbidity and mortality in childhood as part of the Child Health Confidential Enquiry programme. The Confidential Enquiry into Head Injury in Childhood was the principal project within the CMACE national child health enquiry from 2009. The enquiry was timetabled to run from 2009-2012. In March 2011, Department of Health funding to CMACE ended further to a tender process for the Child Health Confidential Enquiry programmes, where CMACE were unsuccessful in their bid. Following an independent review of the project and data collection, Child Health specialists at Cardiff University were commissioned by HQIP on behalf of NHS England to continue the task of data analysis. The results of the data collected by CMACE and its subsequent analysis by Cardiff University are presented here. Input from the external advisory group to CMACE head injury project contributed significantly to the initial design of the study. The data have been used to explore key components of trauma management and a series of peer-reviewed publications have arisen from this body of work.Introduction ### Page 13 13 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewAims of the reportThe aims are to: • Describe the epidemiological features of 5700 children and young people admitted to hospital with THI. • Delineate the causes of THI and make recommendations for prevention. • Consider the early pre-hospital management of THI. • To describe the care delivered in hospital settings and explore the potential to improve health outcomes. • Determine the use of CT head scanning and compliance with NICE head injury guidance (2007). • Investigate extent of recognition and subsequent investigation of children with suspected maltreatment and abusive head injury (AHT).MethodsCollection and analysis of dataInclusion criteria: Data on all children (up to 15 years old) with an isolated head injury (or a head injury as part of a pattern of injuries) and were admitted to hospital were collected prospectively between September 2009 and February 2010 from 90% of hospitals in England, Wales, Northern Ireland and the Channel Islands (Appendix 1). An admission was defined as occurring when the patient was in receipt of treatment or observation in an inpatient area for at least four hours. Cases of suspected physical abuse were included.Exclusion criteria: Data from children admitted with superficial or facial injuries that were unlikely to be associated with a head +/or brain injury (e.g. isolated or trivial facial, scalp or auricular injuries) were not included.Data collection: A local head injury enquiry coordinator in each hospital was responsible for the collecting the data and returning it to CMACE at the end of each study month. The data collection forms (Appendix 2-4) were developed following a review of the literature which included peer reviewed journals, surveys, standards and guidelines, and discussions with experienced professionals. They were designed to follow children’s and young people’s pathway of care. Questions were designed to elicit objective/factual responses routinely available from the clinical records or from hospital electronic systems. The forms were piloted and reviewed by the external advisory group, prior to national distribution. The forms consisted of seven sections covering: demographic information; incident events; transfer to hospital details; pre-hospital care information; assessment in the emergency department; imaging; admission, and outcome at 72 hours post arrival at the first hospital. CMACE obtained Section 251 approval to gather patient information without consent. Research and Development or clinical governance forms were obtained from all participating hospitals. Ethical approval and section 251 approvals were renewed when the project was transferred to Cardiff University for analysis by the Central Manchester Research Ethics Committee and updated in July 2012 (Ref 09/H1008/74).Data analysis: On return to CMACE, data from completed forms were entered onto a secure database and placed in SPSS Statistics 19 for analysis. These datasets were transferred to research team at Cardiff University in early 2013 for analysis. Statistical analysis used ¯2 tests of categorical data. The Kolmogorov-Smirnoff test was used for comparative analysis where data were not normally distributed. For all tests, p<0.05 was used to denote the cut off level for statistical significance. All the children entered into this CMACE dataset were admitted to hospital (for four hours or longer) with a head injury, of varying degrees of severity, so reflecting a broad range of patient data. The dataset does not include those children and young people who were discharged from the emergency department (ED) but nonetheless, CMACE data provide useful insights into the epidemiological profile of a significant disease, THI in the UK.Recommendations: Recommendations were drawn up by consensus agreement of the Independent Advisory Group, based upon the key findings from the data analysis.Methodology of data collection and analysis ### Page 14 14 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewEpidemiology of Children and Young People with THIKey findings• One third of admissions to hospital with head injury were to children younger than two years of age. • The majority of children were admitted to hospital in the early afternoon or evening. • Ninety percent of these injuries are minor and fifty six percent of children were admitted for one night or less. • More children from socially deprived families were admitted to hospital with head injury than for families with no social deprivation. • 9.4% of children had an abnormality on CT scan (skull fracture and/or intracranial injury). • The mortality rate from childhood head injury was 0.4%.Recommendation 1There is currently no system for the collection of data on all forms of head injury in children.* A future standardised data gathering exercise is recommended to fully understand the ongoing determinants of childhood head injury and to evaluate the benefits of the changes to the national trauma system and national head injury guidelines that have been introduced since the data collection time period for this study. These data could be used as baseline figures to inform such an evaluation. *The Trauma Audit Research Network (TARN) is a national dataset and collects data on severely injured children who stay in hospital longer than 72 hours. However the data collection will only cover a small proportion of hospital admissions for traumatic head injury in children.Recommendation 2These data would support the organisation of services such that health care professionals with the skills to assess and manage very young children with traumatic head injury are available at the peak times that they present to health care services, namely afternoon and early evening. Since these data were collected, standards for staff training and competencies have been set by a. the Intercollegiate Committee for Standards for Children and Young People in Emergency Care Settings (2012), and b. The Royal College of Paediatrics and Child Health, Facing the future (2010 updated 2015) ‘A consultant paediatrician or equivalent staff, associate specialist or specialty doctor who is trained and assessed as competent to work on the paediatric consultant rota is present and readily available in the hospital during periods of peak activity, seven days a week’a. Click here to go to Royal College of Paediatrics and Child Health PDF b. Click here to go to Facing the Future PDF ### Page 15 15 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewHead injury is a leading cause of hospital attendance at emergency departments for children; paediatric head injuries comprise between 33 to 50% of all head injuries seen. However, there are relatively few publications that describe the causes of head injury in children and young people across the UK, the age groups involved or document their clinical outcomes. This section provides the demographic details of the dataset . It is noteworthy that there is no national collection of data on minor or moderate head injury in the UK.ResultsThere were 5700 children admitted to hospital with a head injury during the six month study period (September 2009 - February 2010), 90% attended a hospital in England, 3% in Northern Ireland and 7% in Wales. The data collection occurred over the autumn and winter months, the number of admissions decreased over the study period (Figure 1).0 200 400 600 800 1000 1200 1400 1600 Number of children and young peopleSeptember 2009 October 2009 November 2009 December 2009 January 2010 February 2010Figure 1 Number of children and young people with THI admitted by month The decrease in trauma admissions in the late autumn and winter is a common feature as there is a tendency for older children and young adults to be indoors during this time and so less likely to take part in activities associated with traumatic injury. Data collected in Spring or Summer months usually reflect increasing numbers of admissions from March onwards. ### Page 16 16 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewNumber of cases Time of arrival in emergency department 0 50 100 150 2002500:00:00 1:00:00 2:00:00 3:00:00 4:00:00 5:00:00 6:00:00 7:00:00 8:00:00 9:00:00 10:00:00 11:00:00 12:00:00 13:00:00 14:00:00 15:00:00 16:00:00 17:00:00 18:00:00 20:00:00 19:00:00 21:00:00 22:00:00 23:00:00 0:00:000 200 400 600 800 1000 1200 Number of children & young people Age (yrs) Male 0 1 2 3 4 5 7 8 9 10 11 12 13 146 FemaleFigure 2 Time of arrival of children and young people to the emergency department Figure 3 Age and gender of the children and young people with THIThe majority of incidents leading to THI took place in the afternoon. The peak time of arrival at hospital was between 16:00-20:00 (Figure 2). This was the same for weekdays and for weekends. ### Page 17 17 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewChildren younger than 3 years old accounted for 34% of admissions. There was a male predominance (61.4%). As age increased, so did the M:F ratio (Figure 3).70 60 50 40 30 20 10 0 Risk of head injury/100,000 population IMD deprivation quintiles 2 3 4 Highest deprivation (5) Lowest deprivation (1)Figure 4 Index of Multiple Deprivation for children and young people with THI living in England and risk of head injury per 100,000 population.The impact of socioeconomic status was recorded as the index of multiple deprivation (IMD) scores which were available for 95.1% (4882) of children and young people in England. The risk of head injury increased with social deprivation (Figure 4). There were significantly fewer children with head injury in the least deprived quintile than in the rest of the population. Whilst the majority of children and young people in CMACE data were admitted to hospital with minor head injuries, 9.4% had skull fractures or intracranial injury identified on neuroimaging. Using the length of hospital stay as a marker of severity, the majority of children and young people, 56.0%, were admitted for one night or less, and at 72 hours, only 241 (4.2%) were still inpatients. Twenty four children and young people died, giving a mortality rate of 0.4% for this dataset. Of those deaths, five died at the scene of injury or on route to hospital, six in ED and thirteen during hospital admission. The status of 85 (1.5%) children and young people were unknown. ### Page 18 18 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewThe causes of traumatic head injuries (THI)Key findings• Falls in the home were the most common cause of head injury amongst pre-school children. • Infants who fall or are dropped from parent’s or carer’s arms are seven times as likely to sustain skull fracture or intra cranial injury than a child who falls from standing. • Head injuries from sports, recreational activities or MVA were prevalent in older children of young persons. • Child abuse was suspected in 4.5% of cases overall.Recommendation 3Falls must be a clear priority in accident prevention interventions for infants and toddlers. These could be delivered by Health Visitors, Family Nurses in Children Centres, Flying Start programmes and through other mediums that have the capacity to reach parents of young children. A focus on falls from a parent or carer’s arms, particularly when they are being carried upstairs can be justified. In June 2014 Public Health England launched a program of work to reduce unintentional injuries in and around the home among children under five years. Falls were identified as one of five priority areas.Click here to go to Reducing unintentional injuries in and around the home PDFRecommendation 4Preventative interventions that rely upon safe sports surfaces, cycle-helmets, in-car safety and road traffic calming must be maintained. The study was not powered sufficiently to be able to comment on the effect of wearing a cycle helmet but further evaluation of the efficacy and benefits of helmet wearing would be valuable. In June 2014 Public Health England launched a program of work to decrease unintentional injuries on the roads among children and young people under 12 years.Click here to go to Reducing unintentional injuries on the roads PDF ### Page 19 19 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewRecommendation 5Clinicians who evaluate children with traumatic head injury must avoid a simplistic interpretation of falls and take a detailed history using a standardised proforma at the time of presentation to determine the likely risk of serious head injury and ensure that the explanation provided is plausible to exclude concerns about physical abuse or neglect. The history must include items such as the item fallen from, the time of the injury and chronology of signs and symptoms. Other items not covered in this data set would include the estimated height of the fall, the position and activity of the child before they fell, nature of surface of impact, point of impact to the head. These recommendations are partially incorporated in Children Protection Companion 2nd edition RCPCH 2013 and NICE Head Injury Guidelines CG176 published 2014: Triage, assessment, investigation and early management of head injury in children, young people and adults.Click here to go to RCPCH Child Protection Publications Click here to go to NICE Head Injury GuidanceUnderstanding the causes of THI is key to develop effective public health policies, aimed at reducing the burden of the disease entity. The following factors were examined in THI cases, as they could be amenable to primary prevention strategies: location, age of the children /young people, mechanism of injury and extent of cranial and intra cranial injury.ResultsThe greatest proportion of head injuries, 50.6%, happened at home or at a private address, 15.3% in school/nursery and 13.7% on road/street/motorway. Other locations e.g. park, swimming pool, supermarket, church etc. accounted for 11.3% of THI whilst 9.1% of the data were missing. The causes of head injury varied by age (Figure 5). Falls were the frequent cause of THI, mostly in younger children whereas head injuries from sports and recreation activities and motor vehicle accidents (MVA) were seen more frequently in older children and young people (Table 1). The common causes of the 361 sports-related THI were: • Rugby (39.6%) • Football (31.9%) • Horse riding (17.2%) • Hockey (13.1%) • Trampolining (7.8%) ### Page 20 20 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewCause of injury Number of cases (% of total cases) Male: female ratio Mean age (range) in years Percentage of each cause where physical abuse suspected (number affected) Percentage of each cause with abnormal CT head scans (number affected)Fall from heightFall from <1m or <5 stairs 1830 32.1% 1.3:1 3.6 (0-14.9) 4.20% (77/1830) 6.20% (114/1830) Fall from >1m or >5 stairs 1004 17.6% 1.2:1 3.9 (0-14.8) 2.70% (27/1004) 10% (100/1004) Fall, height unknown 703 12.3% 1.5:1 5.4 (0-14.9) 3.00% (21/703) 7.80% (55/703)Motor vehicle accident (MVA)MVA (child was not a pedestrian) 89 1.6% 1.5:1 7.2 (0-14.9) 1.10% (1/89) 21.40% (19/89) Struck by car (child was a cyclist) 35 0.6% 3.4:1 11 (1-14.9) 0% (0/35) 28.60% (10/35) Struck by car (child was a pedestrian) 277 4.9% 1.6:1 9.8 (0-14.9) 0% (0/277) 25.60% (71/277)Sport and recreationalCycling 268 4.7% 4.6:1 10.5 (0.8-14.8) 0% (0/268) 12.30% (33/268) Sport 361 6.3% 6.4:1 11.4 (0-14.9) 0% (0/361) 7.80% (28/361) Other recreational 154 2.7% 2:1 8.3 (0.4-14.9) 0% (0/154) 13.60% (21/154) Assault 119 2.1% 3:1 11 (0-14.9) 41.20% (49/119) 13.50% (16/119) Other impact 703 12.3% 1.6:1 5.1 (0-14.9) 4.80% (34/703) 6% (42/703) Missing 51 0.9% 1.4:1 6.39 (0-14.8) 0% (0/51) 2% (1/51) Not known 106 1.9% 2.6:1 3.17 (0-14.7) 45.30% (48/106) 24.50% (26/106)Total 5700 100% 1.6:1 5.6 (0-14.9) 4.50% (257/5700) 9.40% (536/5700)Table 1 Causes of children & young people’s THI, numbers, male: female ratio, ages with ranges in years, percentage of suspected non-accidental injury compared with the total number and the percentage of abnormal head CT scansPhysical abuse was suspected in 257(4.5%) cases (with a mean age 35.5 months). They accounted for 41.2% of cases in the assault category, 45.3% of cases where the cause of injury was unknown and in 3.5% of THI that were said to have resulted from falls (Table 1). ### Page 21 21 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overview10-14 5-9 1-4 <1 0% Assault Fall MVA Not Known Other Sport/cycling/recreational 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%Figure 5 Mechanisms for THI in children and young people at different agesFalls in preschool childrenFalls were the most common cause of THI occurring more often in the younger children. Of 3423 children less than six years old, 76.9% sustained THI from a fall, 54.7% were boys. A detailed analysis of 1775 of these children where information about the cause and outcome were available is in Table 2 and 3.Children Age No. Children who had CT scan Minor HI Isolated skull fracture ICI with/without skull fracture Abnormal CT scan no results/ Total<1 yr. 100/603 545 36 20 2 603 16.4% 90.4% 6.0% 3.3% 0.3% 100.0% 1 yr. 69/429 409 14 5 1 429 16.1% 95.3% 3.3% 1.2% 0.2% 100.0% 2 yrs. 42/250 239 3 7 1 250 16.8% 95.6% 1.2% 2.8% 0.4% 100.0% 3 yrs. 50/199 192 2 5 0 199 25.1% 96.5% 1.0% 2.5% 0.0% 100.0% 4 yrs. 41/152 145 3 3 1 152 27.0% 95.4% 2.0% 2.0% 0.7% 100.0% 5 yrs. 40/142 135 0 7 0 142 28.2% 95.1% 0.0% 4.9% 0.0% 100.0%Total 342/1775 1665 58 47 5 1775 19.3% 93.8% 3.3% 2.6% 0.3% 100.0%Table 2 : Number and proportion of 1775 children (< 6 years) who had a CT scan and CT findings by age (ICI: intracranial injury) ### Page 22 22 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewThe majority 1316 (74.1%) of falls occurred at home and were recorded in infants and toddlers younger than two years (Table 2). A total of 94% of falls resulted in non-severe head injuries. Infants were at greatest risk of sustaining a skull fracture or intracranial injury (Table 2). There was a relationship between the age of the children and the circumstances of their fall. Older children tended to fall from building components such as windows and attics whereas those who fell from a person’s arms were the younger children, being largely under 2 years of age (Table 3). Mechanism of the fall Mean age (SD) in years Minor head injury (CT normal or deemed unnecessary) (%) Skull fracture (% of total) ICI with / without skull fracture (% of total) Abnormal CT head scan (results not available) (% of total) Total Odds ratio of skull fracture or ICI compared to falls from standing or sitting p-value Building, building component, or related fitting 3.2 (1.6) 43 (84.3) 2 (3.9) 5 (9.8) 1 (2) 51 6.84 (2.65- 17.6)<0.001 Furniture 1.8 (1.4) 388 (95.8) 8 (2) 7 (1.7) 2 (0.5) 405 1.61 (0.76- 3.41) 0.214 Infant or child product 1.8 (1.8) 334 (93) 17 (4.7) 8 (2.2) 0 359 2.75 (1.36- 5.56) 0.005 Other e.g. shopping trolley, tree etc. 3.3 (1.6) 52 (92.9) 2 (3.6) 1 (1.8) 1 (1.8) 56 2.83 (0.89- 9.09) 0.081 From a person’s arms 1.0 (1.4) 196 (84.1) 21 (9) 15 (6.4) 1 (0.4) 233 6.94 (3.54- 13.6)<0.001 Stairs 1.9 (1.2) 211 (96.8) 2 (0.9) 5 (2.3) 0 218 1.22 (0.47- 3.14) 0.682 Standing/ sitting 2.7 (1.6) 441 (97.4) 6 (1.3) 6 (1.3) 0 453 1 -Total 1665 (93.8) 58 (3.3) 47 (2.6) 5 (0.3) 1775Table 3 CT head scan outcome by circumstances of the fall in children younger than six years and the odds ratio OR (95% Confidence Interval) of sustaining a skull fracture or ICI from each mechanism compared to a fall from sitting or standing ### Page 23 23 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewThe three mechanisms with the largest proportions of abnormal CT were falls from: 1. A person’s arms 2. A building or building component e.g. wall, window, stairs 3. An infant or child product such as from a changing mat, bugy, pushchair. A child who was dropped or fell from a person’s arms had a seven times greater risk of sustaining a skull fracture or ICI than a child who fell from standing. The proportion of children who sustained skull fracture or ICI was even greater if the child was dropped from a person’s arms when being carried on the stairs 23.3% (95% 13.2-37.8%) (10/43) vs. 14.2% (95%CI 10-20%) (27/190). Falls from parents arms, particularly when they are being carried upstairs are complex injuries. The infant head may impact the floor at an angle exerting rotational forces on the head and subsequently result in a skull fracture or intra cranial injury. These are important factors for preventative advice that can be given by health visitors and other healthcare workers.Bike, scooter, skateboard Childs arms/ground Changing tale/mat on table Worktop300 250 200 150 100 50 0 Number of head injuriesVehicle Table Shopping trolley Bouncy chair High/booster chair Collided with furniture Carers arms/stairs Baby pram/pushchair/buggy Wall/window/attic/other Playground equipment Collided with building Other Cot/mosses basket/carry chair/car seat Bed Carers arms/ground Chair/bench/sofa Stairs Ground Total Abnormal CTFigure 6 The objects from which children and young people fell (noting abnormal head CT scan results) ### Page 24 24 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewFalls downstairs were responsible for a significant number of hospital admissions, (Figure 6) however, these patients were no more likely to have a skull fracture or ICI than if they fell from standing (Table 3). These factors can be useful as an educational tool in preventative schemes aimed at reducing injury in children and young people, as the relative risk of different situations can be considered.Motor Vehicle AccidentsThe proportion of children who suffered MVA was lower than previous studies; pedestrian related injuries continue to predominate. Whilst these figures would fit with the general reduction in MVAs (Arbogast 2013) caution is needed when interpreting them due to the study taking place during autumn and winter months. MVAs continue to have the greatest associated morbidity. Of the children with abnormal CT scans 18.6% had suffered an MVA. ### Page 25 25 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewThe early management of THI: pre-hospital settingKey findings• Nearly a third of children with head injury were transported to hospital by ambulance. A small proportion (2.7%) were taken by air ambulance. • 73.4% of children taken to hospital by ambulance had an apparent non-serious head injury (GCS 15 or Alert on AVPU). • 39% of children with impaired levels of consciousness did not arrive at hospital by ambulance (e.g. travelled by private car) and have the potential to deteriorate on the journey without early care by ambulance staff or paramedics. • Half of the children taken to hospital by ambulance were younger than five years of age.Ambulance call out and transfer times• Ambulance arrival times at the scene fell well below national targets. For the most seriously injured children (GCS≤12) less than half of the ambulances arrived at the scene within eight minutes. Overall 89% arrived within 19 minutes. • The overall median time from ambulance call to arrival at hospital ED for road ambulance was 48 minutes and for air ambulance was 67 minutes. This time exceeded an hour for one in four cases. Children with lower GCS scores were transported from the scene of injury more quickly than those with a GCS of 15. • Whilst travel time by air ambulance was significantly longer than by road ambulance, the children transported by air were more likely to be taken to a neurotrauma centre or children’s hospital.Facilities in admitting Hospitals• Overall one in five of the children taken to hospital by ambulance were managed in a neurotrauma centre. • Of children with impaired consciousness (GCS≤12), 34% were taken to, and managed in a general hospital with no PICU. 29% were taken to a neurotrauma centre and 36.5% reached the neurotrauma centre after a hospital transfer.Admission times for hospital transfers• The median time between admission to the first hospital and arrival at a second hospital; (most frequently a neurotrauma centre) was 7.9 hours. • Inter-hospital transfers were undertaken by specialist PICU teams in a minority of cases which would not comply with current standards.Clinical monitoring:• Whilst GCS, airway status, respiratory rate, heart rate and capillary reaction were recorded in more than 75% of cases during ambulance journeys, equipment dependent measures of blood pressure and oxygen saturation were recorded in fewer than 40%. • Oxygen was not administered to all children with impaired levels of consciousness (78.4% if GCS ≤8, 61.8% GCS (9-12), 34.5% GCS (13-14)). • Four of 55 children with GCS ≤ 12 who were intubated when they reached the hospital had been intubated by ambulance staff. ### Page 26 26 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewRecommendation 6It is essential that ALL ambulance crews and clinicians who first see a child with a traumatic head injury are trained to recognise children who have potentially serious head injury early to ensure that they are managed in centres that can provide the appropriate level of care to optimise outcome. In 2015: All Major Trauma Networks have triage and by pass criteria to enable rapid and safe transfer of children to the most appropriate hospital.Click here to go to NHS Major Trauma PDF Click here to go to JRCALC Guidelinesand NICE Head Injury Guidelines CG176 published 2014: Triage, assessment, investigation and early management of head injury in children, young people and adults.Click here to go to NICE Head Injury GuidanceRecommendation 7All ambulance staff should be trained and ambulances fully equipped with age appropriate equipment to assess and manage young children with traumatic head injury. This would include age specific blood pressure, oxygen saturation monitoring equipment and face-masks to administer oxygen to small children.Recommendation 8Ambulance teams require further training in the importance of administering oxygen to children with traumatic head injury and impaired levels of consciousness.Click here to go to JRCALC Guidelines‘Oxygen should be administered routinely whatever the oxygen saturation in patients (children) sustaining major trauma’. ### Page 27 27 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewRecommendation 9All children with traumatic head injury and impaired consciousness should be transported to hospital quickly and by ambulance to optimise their early management. Members of the public, especially parents and youth workers should be alerted to the signs of serious head injury and the importance of calling an ambulance. This requires targeted explicit education to avoid flooding the system with unnecessary calls. Effective triage of emergency calls to identify serious head injury should be reinforced. NICE Head Injury Guidelines CG176 published 2014: Triage, assessment, investigation and early management of head injury in children, young people and adults.Click here to go to NICE Head Injury Guidance (Section 1.1)Recommendation 10Ambulances transporting children with serious head injury must adhere to triage and by-pass criteria that are now in place for all Major Trauma Networks. Children should be transported to the appropriate Children’s Major Trauma Centre or nearest Trauma Unit (accounting for the geography of the ‘Network’) to optimise prompt health care and reduce the time taken for children to reach appropriate services. This recommendation has been reinforced by the changes to the organisation of trauma services in England and North Wales. The announcement of the major trauma centres by the government, 6th April 2012Click here to go to NHS Major Trauma PDFRecommendation 11Retrieval teams for children with traumatic head injury must be established to ensure children get to the appropriate hospital for their level of need according to the severity of their head injury. Specific provision must be made for rapid transfer in rural areas where the time to get the child to a specialist unit would exceed an hour. This is likely to involve air ambulance retrieval. This recommendation is reinforced in the changes to the organisation of trauma services in England and North Wales.Click here to go to NHS Major Trauma PDF ### Page 28 28 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewFor tertiary prevention to be most effective, optimum care must start in the pre-hospital phase. This means that children or young people with head injury receive the most appropriate to ensure , maintenance of satisfactory tissue oxygenation and perfusion to minimise any subsequent effects of the traumatic episode. The accurate assessment of the severity of their injury will determine how seriously affected they are and where the best place for their ongoing management should be. These are important processes that are useful in determining the quality of the service delivered and can serve as benchmarks against which current practice can be assessed.ResultsOf the 5700 children admitted to hospital, 31.6% (1801), were transported to hospital by ambulance. Air ambulance accounted for 2.7% (49) of these cases. Of the 93 children with a GCS of ≤ 8 recorded in the ED, 81.7% were taken to hospital by ambulance versus 60.5% of the 507 children with GCS=9-14 and 29.5% of the 3582 children with GCS=15. A greater proportion of air ambulance cases had GCS<15, 43.9% (21/49), vs. 23% (406/1752) of road ambulance cases. Of the 1801 children, 43.7% were recovered from the home and 28% from the roadside or a motorway. The age profile of ambulance cases followed that of the overall study population, where a significant proportion, (47%), of the children and young people were less than five years of age; 63.2% were boys. Transportation: Most emergency calls to the Ambulance service were made in the afternoon and early evening, the peak time being at 16.00 hours. There was no relationship between the timing of the emergency call with the age of the child, the day of the week or the GCS at initial assessment (i.e. at the scene)First professional on the scene and time of arrival of AmbulanceThe first professionals on the scene were described in 654 cases: • 34.5%, ambulance crewed by paramedics. • 25.8% paramedic and emergency medical technician ambulance crew. • 11.7%, emergency medical technician ambulance crew. • 1.2%, healthcare professional. • 8.6% rapid response vehicle with paramedic. • 0.5%. St John’s Ambulance responder. “The standards required that all Ambulance Services would be expected to reach 75% of immediately life-threatening calls within 8 minutes irrespective of location and that all incidents that require a fully equipped Ambulance vehicle (car or Ambulances) must have a vehicle, able to transport the PATIENT in a clinically safe manner (Emergency Ambulance), arrive within 19 minutes of the TRANSPORT REQUEST being made in 95% of cases)” (Ambulance service dataset) With respect to the most serious head injuries, GCS≤ 8 as subsequently assessed at scene, 44.4% of ambulances arrived within 8 minutes. A GCS score of less than 8 would trigger concerns about the patient being able to protect his or her own airway. This figure was 48.6%, if GCS was 9-12. The median time for road ambulances to arrive at the scene was 9 minutes (range 0-70) whilst for air ambulance services, this was 11 minutes (range 4-31). Overall, 88.7% of ambulances arrived at the scene within 19 minutes of the call being received by the dispatcher. Ambulance arrival times at the scene fell well below national targets. These findings are consistent with the trend of decreasing matching of targets for emergency vehicles to reach their destination with the standard 8 minute period. Reported by Health Foundation/Nuffield Trust Foundation, for the period April 2011-June 2014. (Quality watch) ‘There has been a steady decline in the number of Category A calls attended within eight minutes over the past three years. In particular, there has been a substantial decrease in performance since March of this year, although most of this change has been driven by London Ambulance Service. The national target of reaching 75% of Category A calls within eight minutes has been breached in six out of seven months this year.’ At the same time the number of ambulance calls had increased significantly There are multiple factors involved in the failure of the timely arrival of an emergency response vehicle but what precisely they are is unclear (Quality watch: Ambulance response times). ### Page 29 29 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewGlasgow coma score and its influence on the mode of transportThe GCS was recorded at the scene for 89.6% of the 1801 cases. The majority of children (73.4%) taken to hospital by ambulance had a potentially non-severe head injury (i.e. with GCS of 15). The detailed data collection proforma C (Appendix) was completed for 798 (44%) of the ambulance transfers and a detailed analysis of the data is provided (Table 4). n Time to arrive Mean (SD) Median n Time at the scene Mean (SD) Median n Time to ED Mean (SD) Median n Overall time Mean (SD) MedianGCS ≤ 8 36 10.42 (7.6) 8 36 19.83 (13.5) 16 35 18.51 (9.0) 16 33 48.36 (20.9) 44 GCS 9-12 37 8.51 (3.9) 8 35 17.49 (9.5) 15 34 17.29 (9.04) 17.5 37 43.59 (14.5) 43 GCS 13-14 83 10.07 (7.7) 9 85 18.72 (10.2) 17 91 27.69 (37.3) 23 86 56.45 (40.9) 48.5 GCS 15 458 11.01 (8.8) 9 496 18.17 (12.1) 15 468 23.29 (13.6) 21 448 52.26 (20.3) 49Health RegionsMidlands and East England 127 9.28 (7.77) 7 127 22.55 (12.9) 21 126 26.0 (32.5) 23 124 58.29 (35.3) 52 Wales 49 13.86 (10.92) 10 88 15.02 (9.7) 12.5 82 23.37 (18.8) 20 48 54.69 (26.34) 47.5 London 162 12.4 (8.26) 10 155 21.74 (13.5) 18 146 21.66 (10.9) 19.5 153 54.92 (19.34) 53 North England 274 10.21(8.4) 8 151 14.15 (8.4) 12 148 22.57 (12.2) 21 153 47.56 (20) 44 South England 37 10.68 (6.92) 9 37 22.14 (14.0) 21 32 24.66 (15.1) 21.5 37 52 (21.76) 53 N Ireland 28 9.86 (7.39) 9.5 26 15.08 (7.98) 13.5 25 24.96 (13.8) 21 26 49.38 (18.18) 43Ambulance servicesWelsh 57 13.89 (11.3) 11 92 14.89 (9.3) 12 88 25.86 (19.3) 21.5 56 57.59 (26.18) 51 South East Coast (NHS) 23 11.2 (7.3) 10 22 24.5 (16.1) 22.5 17 22 (15) 18 23 50.39 (21.24) 51 Yorkshire (NHS) 58 10.64 (7.7) 9 60 15.03 (7.1) 15 60 22 (9.2) 22 60 47.4 (14.56) 46 North West (NHS Trust) 134 10.4 (9.4) 8 132 12.94 (7.7) 11 129 22.76 (12.5) 21 136 46.21 (19.58) 41 East Midlands (NHS Trust) 15 10.7 (7.1) 10 24 13.83 (9.3) 11.5 23 24.26 (11.3) 22 14 44.7 (18.43) 41 N Ireland (NHS Trust) 28 9.86 (7.4) 9.5 26 15.08 (8) 13.5 25 24.96 (13.8) 21 26 49.38 (18.18) 43 West Midlands 101 7.92 (5.7) 6 96 22.98 (13.2) 21 93 21.47 (10.7) 22 99 52.79 (17.9) 51 South Central (NHS Trust) 8 7.88 (5.0) 5.5 9 17.2 (11.6) 17 9 21.67 (18.2) 19 8 43.25 (21.93) 41 North East 47 7.77 (6.4) 6 51 15.69 (10.1) 12 52 19.56 (13.2) 17 48 44 (17.46) 42.5 Lancashire 1 7 1 22 1 5 1 34 London NHS ambulance 151 12.43(8.1) 10 142 21.63 (13.55) 17.5 134 21.8 (10.8) 19.5 143 55 (18.7) 54 East of England 4 24.25 (16.9) 21 7 14.86 (6.2) 13 6 38.83 (17.6) 35 4 82.5 (33.59) 82,5 Great North air 1 23 1 43 1 21 1 87Table 4 The times of; arrival, duration of remaining on scene, transportation to the ED and overall time spent with NHS prehospital services for children and young people with head injury according to GCS, regional ambulance service and Health Region. ### Page 30 30 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewThe median time spent at the scene for road ambulance was 15 minutes (range 0-91 minutes), and for air ambulance, it was 28 minutes (5-63 minutes). These times did not vary significantly with respect to GCS severity, but the length of time spent at the scene was longer (median 19 minutes) if the children or young people had associated major injuries over and above the head injury. The median time between air or road ambulance leaving the scene and arriving in ED was 21.0 minutes. The time to get to ED from the scene was shorter for children and young people with serious THI with GCS≤12 than for those with GCS> 12 (Table 4, Figure 8). The overall median time from ambulance call to arrival in ED at hospital for road ambulance was 48 minutes and air ambulance was 67 minutes (28-121 minutes). The overall times of each leg of the ambulance transfer varied between ambulance authorities (Table 4). However, the numbers were small for some regions, and it was not possible to account for distances travelled. In 27.7% (185/668) of cases, the time from ambulance call to arrival in ED time exceeded 60 minutes. There may be a variety of reasons for this, e.g. if children or young people are trapped in a vehicle, it may take time to extract them so that they can be safely removed. Throughout this time, the children and young people should be receiving care from pre-hospital healthcare staff. There may have been other causes such as delay in dispatch, ambulances not being able to approach the scene because of hazards or that access was difficult as a consequence of the emergency.To what type of hospital were the 798 children and young people taken to?‘Isolated severely head injured patients (GCS 8 or less) should ideally be transferred to a neurosciences centre to receive treatment irrespective of any need for neurosurgical operation instead of receiving treatment at an acute care centre for initial assessment’ (NICE 2007) Proportionately more children and young people , 67.5% (95%CI 53.4-78.8), (33/49) were taken to a neurosurgical centre or designated children’s hospitals by air ambulance than those conveyed by road ambulance, 29% (95%CI 26.9- 31.2), (508/1752). The standard operating procedure for most air ambulance services was to co-ordinate with these major hospitals and many therefore took patients there based on the initial pre-hospital assessment and discussion with local services.Subsequent management of 798 of children and young people• 91.5% (730) remained in the first hospital to which they were admitted. • 66% (530) were taken to, and were completely managed in a general hospital. • 21.3% (170) children were ultimately managed at a hospital with paediatric neurosurgery facilities, 34% (58) of these reached the neurosurgical centre after an inter hospital transfer. • 6.9% (55) were managed at a hospital which had adult neurosurgery services. • Of 85 children with GCS ≤ 12 assessed by the ambulance team, 34.1% (29) were taken to and managed in a general hospital without PICU or neurosurgery facilities, the 56 remaining cases were ultimately managed in a neurosurgical centre. 36.5% (95%CI 27-47) 31/85 of these children experienced a hospital transfer compared to 5.5% (95%CI 4-7) of those with GCS>12. ### Page 31 31 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewHospital Transfer798 68 Hospital A Hospital B85% PNT 8.8% GH/ICU 4.4% ANT 1 n/k 14% PNT 75% GH/ICU 6.5% ANT 2.4% GH/no ICU 1.5% CH/PICU 6 diedFigure 7: Health care facilities at hospitals where children and young people (transported by ambulance) were admitted. General hospital with intensive care unit facilities (GH/ICU), General hospital without ICU (GH/no ICU, Hospital with adult neurotrauma (ANT), hospital with paediatric neurotrauma facilities (PNT), Children Hospital or Unit with PICU (CH/PICU). Hospital were classified according to the children’s, neurosurgery or intensive care facilities available.Inter-hospital transfersThe median time for the 68 children between leaving the first hospital and arriving at the specialist centre in another hospital was 70 minutes (range 0.25-4.75 hours). The median time between the original call for emergency ambulance services and arrival at the second hospital for definitive care was 7.9 hours (range 3.26-31 hours).Hospital TransferGCS≤12 N=85Median 44 minsGCS≤12 N=31 GCS>12 N=713Median 49 minsGCS>12 N=37 Hospital A Hospital B Median time to 2nd hospital 7.9hrsFigure 8 Median times of arrival to the first hospital by ambulance and time taken for transfer to the second hospital according to GCS of greater or lesser than 12 ### Page 32 32 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewInter-hospital transfers were undertaken by a specialist PICU team in 16 (23.5%) cases, by paramedics with road ambulance for 32 children and young people (47%), and 14 (20.6%) by local ambulance crew or non-paramedic. The details of who accompanied the children and young people were not stated in 6 cases. Figure 8 shows that children and young people with a lower GCS did arrive at hospital by ambulance more quickly than those with a higher GCS (GCS> 12), 36.5% of children with GCS≤12 were involved in a secondary transfer.Clinical monitoring and management in the pre-hospital settingThe frequency of the following clinical measures were recorded in children and young people with THI: • Glasgow Coma Score 90% • Airway status, respiratory rate, heart rate and pupillary reaction 75% • Capillary refill time 62% • Blood pressure and peripheral oxygen saturation 42% ‘High concentration oxygen should be administered routinely whatever the oxygen saturation in patients (children) sustaining major trauma’ (guidance produced by the JRCALC at the time). Oxygen administration was recorded in 86% (686/798) of all children and young people with THI. According to the GCS, oxygen was given to: • GCS ≤8 78.4% (29/37) • GCS (9-12) 61.8% (21/34) • GCS (13-14) 34.5% (29/84) • GCS=15 12.6% (59/469) Four children and young people with GCS ≤ 12 were intubated by ambulance staff and 55 children and young people were intubated when they reached the hospital, 32 of whom were transferred to a second hospital; 15 by PICU specialist team, eight by paramedic transfer and eight by local team (in one case this information was not recorded). ### Page 33 33 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewThe early management of THI: Hospital managementKey findings• All children were assessed at the first hospital they were taken to and 6.8% were transferred to a second hospital. • 4.6% of children re-attended hospital after discharge with ongoing concern about the head injury, the majority within a day of first attendance. • The majority (84%) of children were admitted to a general hospital. • Overall 13.4% were admitted to hospitals with paediatric neurotrauma facilities. One third of these children were admitted to the neurotrauma centre after a hospital transfer. • 50% of children with GCS≤8 required hospital transfer to reach a specialist centre, 22.6% of children with GCS≤8 were managed in a general hospital. • The majority (73.5%) of children were first assessed by a member of ED staff. • The median time between arrival in ED and the child’s first clinical assessment was 43 minutes (IQR 18-78 minutes). • The median time for first assessment of children with GCS< 14 was 15.0 minutes (range 0-219 minutes). • 75% of clinicians who first saw the child were trainee doctors 7.7% were consultants. • The proportion of children seen by consultant increased with increasing level of impaired consciousness, 52% of children with GCS ≤ 8 were first assessed by consultant. • The designated lead team was General paediatrician in 71.5%, an adult clinician in 11.4% and specialty paediatric, emergency, surgery or intensive care teams in 9.3%. • In ED at the first hospital attended GCS was recorded for 73.4% of the cases. (Individual component GCS scores were not recorded for 26% of these cases). • GCS and AVPU for 30.5% • AVPU only for 17.3% • No formal recording of conscious level in 9% • In ED at the first hospital attended GCS was recorded for 4182 (73.4%) of the cases. • 87.5% (3582) had a GCS=15, • 9.4% (393) had a GCS=13-14, • 2.7% (114) a GCS=9-12 • 2.2% (93) had GCS≤ 8. • 60% of children with GCS ≤ 8 were intubated, half of whom were intubated post hospital transfer. • Hospital transfers: 35% of transfers were by non- paramedic, 40% by paramedic ambulances and 13.2 % by specialist PICU retrieval teams. Only 27% of children with impaired levels of consciousness (GCS<15) were transferred by specialist retrieval teams. ### Page 34 34 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewRecommendation 12All children with a traumatic head injury should be assessed by a health care professional who has been trained in the assessment and management of childhood trauma. Many of these children are very young and the assessment of neurological impairment differs considerably from that in adults. NICE Head Injury Guidelines CG176 published 2014: Triage, assessment, investigation and early management of head injury in children, young people and adults.Click here to go to NICE Head Injury GuidanceRecommendation 13When hospital transfer to a Major Trauma Centre is required, the proportion of Inter-hospital transfers undertaken by PICU retrieval teams should be improved.Click here to go to UK PICS Standards (2010)Recommendation 14Children with impaired levels of consciousness should be safely transferred to Children’s Major Trauma Centre by appropriately trained staff utilising the Network transfer criteria and transport system. This recommendation is embedded in changes to the organization of trauma services in England and N Wales.Click here to go to NHS Major Trauma PDFRecommendation 15A small proportion of children re-attended hospital post following traumatic head injury. This reiterates the need for all parents to receive information about the risk factors that mean patients need to return to the emergency department. Guidance on information to be provided to parents is available in NICE Head Injury Guidelines CG176 published 2014: Triage, assessment, investigation and early management of head injury in children, young people and adults.Click here to go to NICE Head injury Guidance (Section 1.9.11) ### Page 35 35 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewRecommendation 16Clinical pathways and clinical training needs to ensure that the following standards are improved in ED for children with traumatic head injury with all levels of neurological impairment. • Quicker time taken to assess children in ED with head injury. • Recording of Glasgow Coma Score (GCS) with details of component scores in all cases. • Early intubation of children with GCS ≤ 8. This recommendation is reiterated by the changes to the organization of trauma services in England and N Wales, in managing injured patients.Click here to go to NHS Major Trauma PDFThese standards are set within the NICE Head Injury Guidelines CG176 published 2014: Triage, assessment, investigation and early management of head injury in children, young people and adults.Click here to go to NICE Guidance (Sections 1.2, 1.3, 1.7.13)Recommendation 17In patients with a GCS less than or equal to 8, there should be early involvement of an anaesthetist or critical care physician to ensure that early, appropriate intubation and ventilation or oxygen is instigated when appropriate. This recommendation is embedded in the NICE Head Injury Guidelines CG176 published 2014: Triage, assessment, investigation and early management of head injury in children, young people and adults.Recommendation 18All children with impaired consciousness should have an early assessment by a consultant grade doctor, a consultant with paediatric training should be involved in their care and there should be access to a neurosurgical team. This recommendation is embedded in the changes to the organization of trauma services in England and North Wales. Trained trauma teams are now based in the major trauma centres.Click here to go to NHS Major Trauma PDF ### Page 36 36 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewRecommendation 19It is increasingly recognised that children with minor traumatic brain injury can suffer from post-concussion syndrome and long term behavioural and emotional consequences. Provision for this must be made within the ongoing management of the majority of children who present with head injury. This is referred to in the NICE Head Injury Guidelines CG176 published 2014: Triage, assessment, investigation and early management of head injury in children, young people and adults.Click here to go NICE Head Injury Guidance (Section 1.9.12)NICE guidelines in 2007 set several standards for the management of children with head injury once admitted to hospital. Where possible this report describes the extent to which these standards were met.Hospital facilities where the children were admitted“Patients who have sustained a head injury should be transported directly to a facility that has been identified as having the resources necessary to expeditiously assess and intervene to optimise outcome. It is expected that all acute hospitals accepting patients who have sustained a head injury should have these resources, and that these resources should be appropriate for the patient’s age” (NICE 2007) The majority of the 5700 children and young people were admitted to the first hospital that they were taken to for one night or less, 84% were general hospitals, whilst 6.8% of children and young people were transferred to a second hospital to access specialist neurosurgery services. (Figure 9) The majority of interhospital transfers, 80% (308/385), were made directly from the ED. The remaining transfers were 42 children and young people transferred within 24 hours whilst 35 who were transferred more than 24 hours later.253 Re-attend 1st Transfer 2nd Transfer5700 385 (6.8%) Hospital A Hospital B 2 2484% GH 9% PNT 3.3% ANT 3.3% CH/PICU 59.5% PNT 31.1% GH 4.7% ANT 4.4% CH/PICU N/K 12 Re-attendFigure 9 Hospital type (according to facilities available) where children were admitted Hospital A (first hospital) hospital B second hospital transfersGeneral hospital (GH), Paediatric neurotrama facilities (PNT), Adult neurotrauma (ANT), Children hospital with paediatric intensive care (CH/PICU) ### Page 37 37 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewOverall, 20.6% (1176) children and young people were treated in a specialist centre (paediatric or adult neurosurgical centre, or hospital with PICU). • Paediatric neurosurgical centre 13.4% (766) (Over a third, 34% (229), of whom were patients transferred in from their first hospital of admission). • Hospitals with PICU 9.8% (206) • Hospitals with adult neurosurgical centres 5.6% (204). Of 93 children and young people with GCS≤8, 26.9% (25) were treated in a specialist neurosurgical centre or hospital with PICU where they were first taken, 50% (47) were transferred to a second hospital, with 22.6% (21) being managed in a general hospital. A small (4.6%), but significant, proportion of children and young people re-attended hospital after discharge owing to concern about the head injury. The majority re-attended within a day of first attendance.Assessment and management of children and young peopleHow quickly were children and young persons assessed?“All patients presenting to A&E with a head injury should be assessed by triage by a trained member of staff within a maximum of 15 minutes of arrival at hospital.” (NICE 2007) The median time between arrival in ED and the child’s first clinical assessment was 43 minutes (IQR 18-78 minutes) (Figure 10). Only 18.5% of the cases (n=2988) fulfilled the standard whereby children should be assessed within 15 minutes. For children and young people with GCS of 15, it was 46.0 minutes (range: 0-12 hours). “Patients presenting to A&E with impaired consciousness (GCS less than 15) should be assessed immediately by a trained member of staff (for example, triage nurse).” (NICE 2007) The median time for first assessment of those with GCS<14 was 15.0 minutes (range 0-219 minutes). Thus few were seen immediately.Clinician who first saw the child or young person with THIThe designation of the clinician who first saw the patient with THI was available for 75% of reported cases. The clinician grade first seeing the children and young people was a consultant in 7.7% of cases and 49.6% were seen by foundation or trainee doctors. The majority (73.5%) were assessed by a member of the ED staff (Table 5). In a few cases, anaesthetists or critical care physicians were listed as the first attending clinician. The proportion of children and young people seen by a consultant for the first assessment increased as the degree of neurological impairment worsened. However, the first assessment was not undertaken by a consultant for 48% of the children and young people with a GCS≤8 in the ED. Following the first assessment, 1846 (32.4%) of all patients were referred to a more senior member of medical team and 3845 (67.5%) to another speciality. ### Page 38 38 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewClinician grade performing the first assessment Number of children and young people Percentage of the total number of children and young people with THIClinical Fellow/Associate specialist 227 4.0 Consultant 439 7.7 Foundation training 1049 18.4 GP 45 .8 Locum 7 .1 Nurse (other) 50 .9 Nurse practitioner 123 2.2 Speciality training/ specialist registrar 1781 31.2 Staff grade 527 9.2 Missing 1452 25.5 Total 5700 100.0 Clinician Specialty Anaesthetics 8 .1 Critical care medicine 2 .0 Paediatric intensive care 6 .1 Emergency medicine 4191 73.5 General medicine 104 1.8 Paediatrics 690 12.1 Other medical specialty 16 .3 Surgical specialties 54 1.0 Neurosurgery 3 .1 ENT 3 .1 Missing 626 11.0 Total 5700 100.0Table 5 Designation and specialty of the first clinician to see the children and young people with THI ### Page 39 39 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewAssessment 0 50 100 150 200 250 300 350 400 Time in minutes AdmissionFigure 10: Tukey box plot showing median, interquartile range and 1.5 IQR for the time to assessment and time to admission for children and young children Figure 11 Designations of clinicians involved in the care of children and young with THI (when recorded) together with GCS: (First assessment undertaken by consultant, paediatrician or neurosurgeon involved in overall care)Paediatrician involved Neurosurgeon involvedFirst Dr Consultant GCS≤ 8 0 10 20 30 40 50 60 70 80 90 GCS 9-12 GCS 13-14 GCS 15 ### Page 40 40 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewPaediatricians were involved in 51.7% (1978/3828) of cases and the neurosurgery team in 10% (401/3985) (Figure 11). The designated lead team was recorded in 5308 cases. In most of the cases, 3795 (71.5%), this was the general paediatric team. For 11.4% (608), adult clinicians were the nominated lead clinicians; specialty paediatric, emergency, surgery or intensive care teams were the leads in 9.3% (488) of cases. Multiple teams were listed in 6.2% (330).Admission to the ward from EDThe median time between arrival in ED and admission to a ward was 165 minutes (IQR range 110-224 minutes) (Figure 10). The majority of children were admitted to a general children’s ward (Table 6).AssessmentNICE guidelines 2007 recommended that all children and young people with head injury have a GCS score with its constituent values recorded on arrival at the ED. Methods of recording the levels of consciousness varied in the ED at the first hospital attended: GCS was recorded for 4182 (73.4%) of the cases. • 87.5% (3582) had GCS=15. • 9.4% (393) had GCS=13-14. • 2.7% (114) had GCS=9-12. • 2.2% (93) had GCS≤ 8. Individual component scores were not recorded for 26% (1096) of these cases. In ED, 47.8% (2725) children and young people had an AVPU recorded whilst 30.5% (1739) had both GCS and AVPU scores. • 94.3% (2569) were Alert. • 3.3% (90) responded to Voice. • 1.1% (29) responded to Pain. • 1.4% (37) were Unconscious. When GCS was not recorded 986 (17.3%) but an AVPU assessment was, the results were as follows: • Alert 940 (95.3%) • Verbal 28 (2.8%) • Pain response 9 (0.9%) • Unconscious 9 (0.9%) There was no formal level of consciousness recorded in the notes for 9% (532) of children and young people.Intubation and ventilation“Intubate and ventilate all patients with GCS≤ 8 requiring transfer to neuroscience unit.” (NICE 2007) Maintenance of the airway is essential as at this level of impaired consciousness, the protective airway reflexes are lost and aspiration into the lungs can occur. General Children’s ward 4391 (77%) Specialist children’s ward 179 (3.1%) PICU/ paediatric HDU 77 (1.4%) Paediatric neurosurgical 101 (1.8%) Observation or Short stay 628 (11%) General adult ICU/HDU or neurosurgery unit 15 Theatre 13Table 6 Locations to which children and young people with THI were admitted. ### Page 41 41 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewOf the children and young people with GCS≤ 8, 60% (56/93) were intubated. Twelve were intubated at the scene of injury, 17 in ED and 27 when transferred to second hospital. The intubation status of 14 children was not recorded and 23 were not intubated.Length of stay in the first hospitalThe majority, 89.1% (4725), of the children and young people spent up to one night in the first hospital, 420 (7.9%) between 2 to 4 nights and 73 (1.4%) stayed more than five nights. For 86 (1.6%) children and young people, the number of nights spent in hospital is unknown.Interhospital transfers and admission to the second hospitalThere were 385 interhospital transfers, 79.5%, were by ambulance, and 13.2% by specialist PICU retrieval teams (Table 7). There were 119 children and young people with GCS < 15. Specialist retrieval teams transferred 26.9% (32/119) cases and 34.4% (41) were carried by paramedic ambulances. These 385 children and young people transferred to a second hospital were generally more serious cases with a large proportion having impaired levels of consciousness (Table 7). • 51.4% (198) had GCS=15 (n=157) or Alert on AVPU (n=41). • 5.1% (37) had GCS=13-14. • 7.8% (30) had GCS=9-12 (n=27) or had AVPU responding to voice (n= 3). • 13.5% (52) had GCS=<8 (n=47) or had AVPU responding to pain or who were unconscious (n=5).Number of children and young people (%)Ambulance (non-paramedic) 97 (35.2%) Air ambulance (paramedic/medic) 3 (0.8%) Other land-hospital car 1 (0.3%) Paramedic ambulance 153 (39.7%) Private/public transport 28 (7.3%) Specialist PICU transport 52 (13.5%) Not known/not recorded 51 (13.2%) Total 385Table 7 Mode of transport to second hospital ### Page 42 42 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewCT scanning and compliance with NICE head injury guidanceKey findings• One third (30.4%) of the 5700 children had a head CT scan. • A greater proportion of older children had a CT scan than younger age groups. • The CT scans were performed at a median time of 1.5 hours (range 0-35.8hrs). The time to CT scan was shorter in those with GCS<15 but the median still exceeded one hour. • The rate of abnormal CT scan was greater in infants than older children. • Of 2437 children with a recognised indicator for CT (NICE 2007) only 40% of children received a CT scan. • Children younger than three years old, with indications for a CT were less likely to have CT than older children. • Children admitted to general hospitals with indications for CT were less likely to have a CT than those admitted to hospitals with specialist paediatric units or neurotrauma centres. • For the children admitted to a general hospital, there was variation of CT scanning rates across Commissioning Boards and health regions.Recommendation 20In view of the low percentage of children with indicators for CT who actually have a CT, there should be a national review of the facilitators and barriers to CT scanning, (especially for the infants and toddler age group) and an on-going national audit of the implementation of NICE head injury guidelines in General hospitals.Recommendation 21The practice of admitting young children for observation versus early CT scanning should be evaluated according to short and long term clinical outcome. The potential benefits of low-dose CT scanning should be considered to reduce the risks of irradiation against the benefits of early detection of traumatic brain injury.Recommendation 22A large scale prospective evaluation of the indicators for CT head scan within NICE head injury guidelines is needed to determine their accuracy and efficacy in practice. ### Page 43 43 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewNICE head injury guidelines for CT imagingThe criteria for CT scanning according to NICE guidelines in 2007 are given in figure 12 for children and young people less than 16 years old. In 2009-10 children and young people with THI were subject to these recommendations. The study data were matched against these criteria to see the degree of compliance with the guideline.Compliance with NICE guidelines 2007 for neuroimaging in children & young people with THIOverall, 30% (1734) children and young people admitted with THI had head CT scan performed at a median time of 1.5 hours (range 0-35.8hrs) after their arrival at the ED. Cervical spine CT was also performed in 292 (5.1%). Proportionately more of the older children had head CT scan than younger age groups, 22% (95% CI 20.6-23.5) of children<5 year vs. 41% (95% CI 38.8-42.6) for those aged 5-14 years old. There were more abnormal CT head scans in those less than five years 37% (95% CI 33.4-40.6) than children and young persons aged 5-14 years, 26.8% (95% CI 24-29.6). Head CT scan should be undertaken within an hour of admission, according to NICE 2007. In this study, head CT scans were performed at a median time of 1.5 hours (range 0-35.8hrs), 33% (297) of which occurred within an hour. The time to head CT scan was shorter in those with GCS<15, (median time: GCS 15 = 100 minutes, GCS 13-14= 69 minutes, GCS 9-12=72 minutes, GCS 5 minutes Amnesia (antegrade or retrograde) lasting >5 minutes Abnormal drowsiness 3 or more discrete episodes of vomiting Clinical suspicion of non-accidental injury Post-traumatic seizure but no history of epilepsy Age > 1 year: GCS<14 on assessment in the ED Age < 1 year: GCS (paediatric) <15 on assessment in the ED Suspicion of open or depressed skull injury or tense fontanelle Any sign of basal skull fracture Focal neurological deficit Age < 1year: presence of bruise, swelling or laceration >5cm on head Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist or vehicle occupant, fall from > 3m, high-speed injury from a projectile or an object)Figure 12: NICE head injury guideline 2007 with clinical indicators for head CT scan in children and young people with THI ### Page 44 44 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewAge (years) numberof children (%) Total number of children (% of total no. of patients)<1 1-Apr 5-Sep Oct-14 Missing ageGCS 1 year 15/ ‘Alert’ <15:V/P/U GCS/AVPU not recorded 14-15: ‘Alert’ <14:V/P/U GCS/AVPU not recorded TotalNormal 78 (43·1%) 7 (20%) 14 (35·9%) 844 (72·1%) 113 (50·2%) 52 (64·2) 1108 (+1*) (64%)Ici and/or depressed #37 (20·4%) 19 (54·3%) 14 (35·9%) 124 (10·6%) 64 (28·4%) 10 (12·4%) 268 (+1*) (15·5%)Simple # 40 (22·1%) 2 (5·7%) 8 (20·5%) 67 (5·7%) 21 (9·3%) 9 (11·1%) 147 (+1*) (8·5%)Other 9 (5%) 1 (2·9%) 0 33 (2·8%) 4 (1·8%) 1 48 (2·8%)Abnormality but not described10 (5·5%) 3 (8·6%) 1 40 (3·4%) 17 (7·6%) 1 72 (4·2%)Result not recorded7 (3·9%) 3 (8·6%) 2 62 (5·3%) 6 (2·7%) 8 (10%) 88 (5·1%)Total 181 35 39 1170 225 81 1731 (3*)Table 8 The numbers and proportion of head CT scans in children and young people according to their GCS/AVPU assessment in the ED and their age Table 9 Comparison of the CT outcome according to GCS/AVPU for < 1 year olds where CT recommended if GCS < 15 and older children where CT recommended if GCS < 14.An abnormality was identified on head CT scan in (Table 9) • 52.5% of infants with a GCS of 15/Alert. • 71.4% of infants with GCS < 15 (AVPU=V,P/U). • 28% of children (older than a year) with a GCS of 14-15/Alert. • 46.9% of children with GCS 14 (AVPU-V,P/U).*The age of three children was not recorded ### Page 45 45 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewLoss of ConsciousnessLoss of consciousness at the time of the incident was reported in 17.7% (1010 /5700) children. However, the duration of loss of consciousness was not recorded. 46.9% (474/1010) of these children had head CT scan, 33% of whom sustained ICI or a depressed fracture, 20% a simple fracture, and 25% other findings such as structural anomalies.Multiple indicators as per NICE head injury imaging guidance2437 children had at least one of the following indicators for head CT scan. • GCS <15 for a child <1yr or <14 for an older child • Loss of consciousness • A dangerous mechanism of injury • A suspicion of non-accidental injury Overall only 40% (984) of these children had head CT scan. Children and young people admitted to a general hospital, or who were less than three years old, were less likely to have a head CT scan despite NICE 2007 indicators being present. There appears to be a leaning towards the admission of young children to general hospitals for observation rather than doing head CT scan. This may be due to a reluctance to sedate these children or to expose them to irradiation. A lack of anaesthetic facilities or the facilities to report head CT scans out of hours may have contributed to this problem. There was considerable regional variation in the number of children who had a head CT scan. Children and young people who had normal head CT scan spent an average of 24 hours in hospital, those who were discharged without a scan were there for a mean time of 15 hours. Children and young people with ICI or depressed skull fracture spent a mean period of 89 hours, those with a simple fracture, 45 hours. ### Page 46 46 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewThe recognition and investigation of children with suspected maltreatment and abusive head traumaKey findings• For children younger than two years with head injury, physical abuse was suspected at the point of admission in 9.3% children and for a further 4.3% during hospital admission. • Only a third of children with suspected physical abuse and head injury received the full extent of recommended investigations to exclude AHT. Investigation rates were better for infants although still poor. • A paediatrician with level 3 training was involved in the assessment of children with suspected child abuse. • At discharge 11.5% of children (< 2 years old) were referred to social services with child protection concerns, 4.7% fulfilled the criteria for Abusive head trauma with skull fracture and or intra cranial injury identified on CT imaging. • Features that distinguished suspected physical abuse from accidental head injury included children with unexplained head trauma, closed head injury and subdural haemorrhages that were more likely to be interhemispheric or multiple.Recommendation 23ED staff and hospital paediatricians must receive appropriate levels of safeguarding training that includes guidance on the recognition of abusive head trauma (AHT). For frontline staff who are assessing young children with head injury, training must be provided in a manner that accounts for the rapid turnover of staff in ED, many of whom are adult specialists or locums.The Royal College of Emergency Medicine, clinical standards document (click here to access the document) published in August 2014 recommends that ‘All ED medical and nursing staff should, as a minimum, have level 2 Child Protection training. All senior Emergency Medicine doctors (ST4 or equivalent and above) should have level 3 Child Protection training’. Safeguarding children and young people: roles and competences for health care staff published 2014Click here to go to RCPCH Safeguarding Children and Young People PDF ### Page 47 47 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewAbusive head trauma (AHT) is seen mostly in children younger than two years of age with a peak at 5-6 months of age. It is defined as ‘an injury to the skull or intracranial contents of an infant or young child (< 5 years of age) due to inflicted blunt impact and/or violent shaking’ (American Association Paediatrics). The Companion for Child Protection was first published in 2006 by the Royal College of Paediatrics and Child Health and revised in 2013 (Companion Child Protection RCPCH 2006, 2013). It set out the standard criteria for the investigation of children with suspected physical abuse. These investigations are used to identify or exclude the diagnosis and to delineate the full extent of any injuries sustained by these children. The standards include: • An examination by a clinician with level 3 child protection training. • A skeletal survey in children younger than two years old. • A head CT scan in children younger than a year or if AHI is suspected. • An ophthalmology examination. In addition, NICE head injury guidelines 2007 stated that head CT scan should be performed in children where AHT is a possibility.How many children with suspected physical abuse were investigated?Physical abuse was suspected in 16.4% (320) of 1953 children younger than two years during the hospital admission. Only a quarter of children younger than two years with suspected physical abuse received all of the recommended investigations to identify or exclude AHT (Figure 13). At discharge 11.5% (225) of children were referred to social services with child safeguarding concerns, whilst 4.7% fulfilled the criteria for AHT with skull fracture and/or intracranial injury on head CT scanning. A paediatrician with level 3 training was involved in the assessment of 79% of these children.Recommendation 25NICE head injury guidelines 2007 and 2014 recommend that head CT scan should be performed if non-accidental head injury is suspected, yet they give no explanation as to when this suspicion should be raised. This should be considered in the next revision of the guidelines. There are several detailed evidence based publications around this topic (www.core- info.cf.ac.uk). All health care professionals involved with these children must be made aware that AHT is a condition that is prevalent in infants and toddlers and be familiar with the guidelines where AHT is suspected.Recommendation 24Paediatricians must improve their adherence to national guidance when physical abuse is suspected in young children with head injury. Recommended investigations: CT scan, skeletal survey (RCR/RCPCH radiology guidelines 2008), ophthalmology (RCOPH/ RCPCH guidelines) examination should be conducted for all infants and children who have a head injury where physical abuse is suspected. All children must be assessed on an individual basis and if recommended investigations are not performed the reasons why must be clearly documented. Children Protection Companion 2nd edition RCPCH 2013Click here to go to RCPCH Child Protection Publications ### Page 48 48 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewFigure 13 Flow chart of the investigations taken in the 1953 children less than two years old. This flow chart shows the range of investigations performed including those to exclude AHT.351 seen by paediatrician with Level 3 training 142 seen by paediatrician with CP training1953 children <2 years with HI seen in ED 181 admitted with suspected child aduse 16 known to SS 20 subject to CP plan 1772 No suspicion of child abuse on admission 33 known SS 21 Subject to CP plan Skeletal survey + ophthalmology 23 Skeletal survey + ophthalmology 74 Neither Investigation 1715 CT Scan 16 CT Scan 5 CT Scan 10 CT Scan 281 CT Scan 62 CT Scan 14 CT Scan 3 CT Scan 19 Ophthalmology 18 Neither Investigation 82 Skeletal survey 20 Skeletal survey 16 Ophthalmology 5How many children were referred to social services at hospital discharge with safeguarding concerns?Overall, 225 (11.5%) of children (< 2 years old) were referred to social services for child abuse concerns, 16% of infants and 6% of children aged one –two years. The extent of investigation of these children discharged with suspected child abuse varied. Infants were more likely to receive all three recommended investigations that those aged one year, nonetheless the recommended investigations were only completed in 44% of cases (Table 10). Eighty eight children had an abnormal CT scan and fulfilled a diagnosis of suspected AHT, equivalent to 4.5% (88/1953) of all the <2 year olds with THI. Of note however the prevalence of suspected AHT was 48% (88/183) amongst children < two years old who had an abnormal CT scan. ### Page 49 49 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewAge 12 months or less (n=174)Number of children (% of total population) Head CT scan Skeletal survey Ophthalmology review 77 (44.3%) • • •10 (5.7%) • • -8 (4.6%) - • •4 (2.3%) • - •17 (2.9%) • - -5 (2.9%) - • -4 (2.3%) - - •49 (28.2%) - - -Age 13-23 months (n=51)Number of children (% of total population) Head CT scan Skeletal survey Ophthalmology 9 (17.6%) • • •1 (2%) • • -2 (4%) - • •3 (6%) • - •9 (17.6%) • - -4 (8%) - • -0 - - •23 (45%) - - -130 116 107Table 10 The degree of completion of the recommended investigations for non-accidental injury for infants and children aged up to 2 years of age with THI who were referred on to social services at hospital discharge.Characteristics of AHTComparing 88 children (< two years old) with abnormal head CT scans and a discharge diagnosis of suspected AHT, and 95 children with abnormal head CT scan and a diagnosis of accidental head injury confirmed the following findings: • Significantly more children with accidental head injury had a history of a fall from a height whilst significantly more of those with AHT had no history of trauma or one of assault. • Subdural haemorrhage that were more likely to be inter- hemispheric or multiple was significantly more common in AHT than accidental injury. • Isolated skull fractures were significantly more common in accidental injury. • Closed head injury was significantly more common in AHT than accidental head injury. ### Page 50 50 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewAccidental THI (n=95) Suspected AHT (n=88)n (%: 95% CI) n (% : 95%CI) History at presentation Fall from a height 68 (71.6%: 61.8-79.7)* 37 (42%: 32.3-52.5) Fall (height unknown) 0 7 (7.9% : 3.9-15) Fall from standing 8 (8.4% : 4.3-15.7) 2 (2.3%: 0.6-7.9) Motor Vehicle Accident 3 (3.2%: 1.1-8.9%) 0 No trauma explanation 12 (12.6%: 7.4-20.8) 36 (40.9% 31.2-51.4)** Assault 0 3 (3.4%: 1.2-9.5%) Impact with object/person 4 (4.2%: 1.6-10.3) 3 (3.4%: 1.2-9.5%) Characteristics of head injury ICI and skull fracture 21 (22.1%: 14.9-31.5) 25 (28.4% :38.6) Closed head injury (ICI) 13 (13.7% :8.2-22.0) 26 (29.5% :21.0-39.8)* Isolated fracture 55 (57.9% 47.8-67.3 )** 31 (35.2% 26.1-45.6)* Contusion 4 (4.2%: 1.6-10.3) 0 Abnormal CT details unspecified 2 6 (6.8%: 3.2-14.1)* p< 0.05, ** p< 0.01, ICI ( defined as extra axial haemorrhage and or intracerebral injury)Table 11 Comparison of the stated mechanism of injury and abnormalities seen in 95 children with accidental head injury and 88 children with suspected AHT ### Page 51 51 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewBibliographyAnderson T, Heitger M, Macleod AD. Concussion and mild head injury. Practical Neurology 2006;6(6):342-57 Ambulance Service Dataset : available from http://www.datadictionary.nhs.uk/data_dictionary/messages/central_ return_data_sets/data_sets/ambulance_services_data_set_(ka34)_fr.asp?shownav=1Arbogast KB, Durbin DR. Epidemiology of child motor vehicle crash injuries and fatalities. Pediatric Injury Biomechanics. 2013.33-86.Burrows P, Trefan L, Houston R, Hughes J, Pearson G, Edwards RJ, Hyde P, Maconochie I, Parslow RC, Kemp AMHead injury from falls in children younger than six years of age. http://adc.bmj.com/content/early/2015/08/21/ archdischild-2014-307119.fullCentre for disease Control and prevention: CDC (http://www.cdc.gov/violenceprevention/pdf/pedheadtrauma-a.pdf )College of Emergency Medicine http://www.rcem.ac.uk/ShopFloor/Service%20Design%20&%20Delivery/System%20 integration%20and%20service%20configuration/Children%20and%20Young%20People%20in%20Emergency%20 Care%20SettingsCompanion to Child Protection - Children Protection Companion 2nd edition RCPCH 2013www.rcpch.ac.uk/child-protection-publicationsCore Info: www.core-info.cardiff.ac.ukFacing the Future: www.rcpch.ac.uk/facingthefuture #Facing the Future: Standards for Paediatric Services Hospital Episode Statistics: available from www.hscic.gov.uk/hesJoint Royal Colleges Ambulance Liaison Committee guidelines available from http://www.jrcalc.org.uk/guidelines.htmlKemp A, Nickerson L, Trefan L, Houston R, Hyde P Pearson G, Edwards R, Maconochie I, Parslow RC.The selection of children for head Computerised Tomography following head injury (In Press)Kirkwood MW, Yeates KO, Taylor HG, et al. Management of pediatric mild traumatic brain injury: A neuropsychological review from injury through recovery. The Clinical Neuropsychologist 2008;22(5):769-800. NHS STANDARD CONTRACT FOR MAJOR TRAUMA SERVICE (ALL AGES)http://www.england.nhs.uk/wp-content/uploads/2014/04/d15-major-trauma-0414.pdfNICE Head Injury guidelines 2007, 2014 available from http://www.nice.org.uk/guidance/cg176Public Health England Report 2014:https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/322210/Reducing_unintentional_ injuries_in_and_around_the_home_among_children_under_five_years.pdf ### Page 52 52 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewPublic Health England Report 2014:https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/322212/Reducing_unintentional_ injuries_on_the_roads_among_children_and_young_people_under_25_years.pdfQuality watch : Ambulance response times available from http://www.qualitywatch.org.uk/indicator/ambulance- response-timesRCPCH safeguarding competencies available from. http://www.rcpch.ac.uk/system/files/protected/page/ Safeguarding%20children%20and%20young%20people%20-%20%20roles%20and%20competencies%20for%20 health%20care%20staff%20-%20Intercollegiate%20document%20March%202014.pdfRoyal College of Paediatrics and Child Health and The Royal College of Ophthalmologists. Abusive Head Trauma and the Eye in Infancy June 2013 Royal College of Radiology /RCPCH: Radiology guidelines for investigation of children with suspected NAIhttps://www.rcr.ac.uk/docs/radiology/pdf/RCPCH_RCR_final.pdfTrauma Audit Research Network available from https://www.tarn.ac.ukTrefan L, Houston R, Pearson G, Edwards R, McChonachie I, Parslow R, Kemp A.Epidemiology of children with head injury: a national overview. In PressYeates KO, Taylor HG. Neurobehavioural outcomes of mild head injury in children and adolescents. Pediatric rehabilitation 2005;8(1):5. ### Page 53 53 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewList of AbbreviationsAbbreviation MeaningAHT Abusive Head Trauma ANT Adult Neurotrauma Centre AVPU (Coma Score) Alert, Voice, Pain, Unconscious CDC Centre for Disease Control and Prevention CI Confidence Interval CMACE Centre for Maternal and Child Enquiries CT Computerised Tomography ED Emergency Department EM Emergency Medicine GCS Glasgow Coma Score GH General Hospital HDU High Dependency Unit HQIP Healthcare Quality Improvement Partnership IAG Independent Advisory Group ICI Inter Cranial Injury ICU Intensive Care Unit IMD Index of Multiple Deprivation IQR Inter Quartile Range JRCALC Joint Royal Colleges Ambulance Liaison Committee MTC Major Trauma Centre MVA Motor Vehicle Accident NAI Non Accidental Injury NCD National Clinical Director NHS National Health Service NICE National Institute of Clinical Excellence OR Odds Ratio PICU Paediatric Intensive Care Unit PNT Paediatric Neurotrauma Centre RCR Royal College of Radiology RCOPH Royal College of Ophthalmology RCPCH Royal College of Paediatrics and Child Health R&D Research and Development SD Standard Deviation SPSS Statistical Packages for Social Sciences SS Social Services TARN The Trauma Audit & Research Unit THI Traumatic Head Injury ### Page 54 54 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overview© CMACE 2009 Please note: All rights are reserved. Please do not reproduce, distribute, modify, display or communicate the contents of this document without specific authorisation.HEAD INJURY IN CHILDREN NOTIFICATION FORM (A)Please complete this form for a child or young person up to 15 years old (14 yrs + 365 days) who as a result of a head injury* or a head injury as part of a pattern of injuries meets ONE of the following criteria between 1st SEPTEMBER 2009 and 28th FEBRUARY 2010 inclusive:Please tick type of case: (Select one option only)Seen in your Emergency Department and admitted* to your hospital for secondary or tertiary care ORSeen in your Emergency Department but transferred for admission* to secondary or tertiary care at another hospital (within or out of your trust) ORSeen in your Emergency Department but died before admission* or transfer* to secondary care ORDied at the scene or died between the scene and attendance at the first hospital.Instructions for completing and returning the notification form1. Certain sections may not be applicable to all children. Please read the guidance manual before completing.2. Please complete the form using the information available in the child’s notes. Complete all dates in the formatDD/MM/YY and times using the 24hr clock e.g. 18:50.3. Please keep a copy of this form for your records. Return hardcopies of completed forms to your local CMACE regional office. See back of form for local contact details.4. If you have any queries about completing or returning this form please contact your CMACE regional office.Date form completed: Date form returned:DETAILS OF PERSON COMPLETING FORMName: Trust: Job title/Role: Telephone: Unit: Email: Hospital:* Head injury: Examples of head injuries to include or exclude can be found on the back of this form. * Admission: Hospital admission is defined as occurring when the patient is in receipt of treatment or observation in an inpatient area. This includes short term assessment units associated with wards or emergency departments, short stay units, general or specialist wards, PICUs, Neurosurgical unit, or other inpatient unit. This may only be for a matter of hours beyond the first four hours from arrival at hospital. * Transfer: Refers to the transport of a patient by ambulance (land or air) from one hospital to another hospital facility. Also referred to as an ‘inter-hospital transfer’ between two hospitals either within or out of the same trust.Centre for Maternal and Child EnquiriesImproving the health of mothers, babies and children ### Page 55 55 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewIs this the first hospital the child attended following the incident? Yes No→ If no, hospital child transferred fromSECTION 1: DETAILS OF CHILD (Affix patient label if preferred)1.1 Hospital Number1.2 NHS Number/Healthcare Number / /1.3 Surname/family name1.4 First name1.5 Sex Male Female Not known1.6 Date of birth and/or estimated ageIf no full date of birth is known enter month and year. If no full or short DOB, enter their estimated age. Not knownyears months1.7 Address of patient’s normal residenceNot knownPostcode of patient’s normal residence /1.8 Ethnic group Not knownWhiteEnglishOther BritishIrishAny other white backgroundMixed:White & Black CaribbeanWhite & Black AfricanWhite & AsianAny other Mixed backgroundAsian or Asian BritishIndianPakistaniBangladeshiChineseAny other Asian backgroundBlack or Black British:CaribbeanAfricanOther Black backgroundOther ethnic groups:ArabGypsy/ Romany/ Irish TravellerOther ethnic groupIf other, please specify1.9 Child known to Social Services Yes No Not knownIf answering this question is not indicated as part of the admission process and you are unaware of whether the child is or is not known toSocial Services, tick ‘Not known’. i.e. you are not required to call Social Services to answer this question.1.10 Child subject of existing child protection plan Yes No Not knownSECTION 2: DETAILS OF INCIDENT2.1 Date of incident Not recorded2.2 Time of incident (24 hr clock) Not recorded2.3 Postcode of incident location / Not knownIf postcode is not known indicate area/first line of address Not known2.4 Place of incidentHome/private address Road/ School/ Street/Motorway NurseryOther, specify Not known2.5 Cause of injuryStruck by car (i.e. child was pedestrian)Motor vehicle accident (not pedestrian)CyclingFall from > 1m or > 5 stairsFall < 1m or < 5 stairsFall, height unknownSport, please specifyOther recreational (e.g. skateboard) specifyAssaultOther, please specifyNot known2.6 Additional incident details, if known (e.g. Fall from trampoline, speed, not in age appropriate car seat, etc)Please use the additional space provided on page 7 if there is not enough room to complete your answer2.7 Suspicion of Non Accidental Injury (NAI) Yes No Not known2.8 Seatbelt worn Yes No Not known N/A2.9 Helmet worn Yes No Not known N/A ### Page 56 56 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewSECTION 2: DETAILS OF INCIDENT continued2.10 Did the child sustain any other injury to other area(s) of their body? (e.g. bruises, fractures) Yes → Go to 2.11 No→ Go to 2.12 Not known → Go to 2.122.11 If yes, please indicate whether the child sustained any other injuries to the following areas(If an injury is ‘Not recorded’ then tick ‘Minor/None’)Major - requiring hospital admission itself Minor/None Not Knowna. Headb. Facec. Neckd. Cheste. Abdomen (including pelvic contents)f. Spineg. Limbs (excluding pelvic girdle)h. Bone pelvisi. Body surface (penetrating)j. Body surface (blunt)k. Burnsl. Other, specifyPlease use the additional space on page 7 to provide additional details on these other injuries, if information available2.12 Child experienced a period of loss of consciousness(at any time)Yes No Not known2.13 Route of referral to this Emergency Department999 Ambulance ServiceMinor Injury Unit, (specify)Other hospital, (specify)Self/Parental referral GP surgeryTelephone advice – NHS Direct Not knownGP assessment unit Other (specify)2.14 Mode of arrival to the first hospitalRoad ambulance Air ambulance→ Go to Section 3 → Go to Section 3Private/public transport Other, specify→ Go to Section 4→ Go to Section 4SECTION 3: PRE HOSPITAL – AT SCENE/EN ROUTEPlease complete the following details as fully as possible from the child’s notes. This will help us to be able to obtainrecords from the ambulance services. Referring to the guidance manual will help you.3.1 Name of Ambulance Service involved Not recorded3.2 Ambulance notes in the child’s hospital records Yes No3.3 Patient Report Form number Not known3.4 Incident number/CAD number (or equivalent) Not known3.5 On arrival of emergency services at the scene child was found to be:Alive → Continue completing this sectionDead → Go to Section 63.6 Child’s neurological status at sceneDocument the worst score before intubation/intervention. If no intubation/intervention occurred, document the worst score.3.6.1 Glasgow Coma Scale Score Not recordedEye opening Verbal response Motor response TOTAL (out of 15)Time GCS recorded: 3.6.2 AVPU Score Not recordedAlert Respond to Voice Respond to PainUnresponsiveTime AVPU recorded:(24 hr clock) Not recorded (24 hr clock) Not recorded3.7 Child intubated at scene/en-route Yes No Not known3.8 Other mechanical airway/breathing assistance employed at scene/en-route (e.g. Bagging/BVM)Yes No Not knownNot recorded ### Page 57 57 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewSECTION 4: EMERGENCY DEPARTMENT4.1 Name of Hospital4.2 Date of arrival at the Emergency Department Not recorded4.3 Time of arrival at the Emergency Department (24 hr clock) Not recordedPrevious attendance/s4.4 Was this current visit a re-attendance in relation to a previous injury?(that occurred within 72 hours of this attendance)Yes → Go to 4.4.1 No → Go to 4.5 Not known → Go to 4.54.4.1 Name of hospital first attended Not known4.4.2 Date attended that hospital Not recorded4.4.3 Time of review at previous attendance (24 hr clock) Not recorded4.4.4 Grade of clinician who discharged child(see codes on page 7) Not known4.4.5 Head CT scan at previous attendance Yes No Not knownThis attendance4.5 Details of first clinical assessment for this attendance (please refer to codes on page 7)This refers to the first clinical assessment (i.e. not included assessment by the triage nurse)4.5.1 Grade of clinician (see codes on page 7) Not recorded4.5.2 Speciality of clinician (see codes on page 7) Not recorded4.5.3 Time of first clinical assessment(i.e. not assessment by the triage nurse) (24 hr clock) Not recorded4.6 Following first clinical assessment (i.e. not assessment by triage nurse) was the child referred for consideration by:4.6.1 A more senior member of medical team Yes No Not known4.6.2 Another speciality Yes No Not known4.7 Child’s neurological status in the Emergency DepartmentDocument the worst score before intubation/intervention in the Emergency Department. If no intubation/intervention occurred in the Emergency Department, document the worst score.4.7.1 Glasgow Coma Scale Score Not recordedEye opening Verbal response Motor response TOTAL (out of 15)Time GCS recorded: 4.7.2 AVPU Score Not recordedAlert Respond to Voice Respond to PainUnresponsiveTime AVPU recorded:(24 hr clock) Not recorded (24 hr clock) Not recorded4.8 Child intubated in the Emergency Department Yes No Not knownIMAGING (At any time following attendance)4.8 Head CT scan performed Yes → Go to 4.8.1 No → Go to 4.8.4 Not known → Go to 4.94.8.1 Date first head CT scan performed Not recorded4.8.2 Time first head CT scan performed (24 hr clock) Not recorded4.8.3 Was the first head CT scan reported as normal on provisional report?Yes → Go to 4.9 No → Specify Not known → Go toabnormality: 4.94.8.4 If no head CT performed, please indicate reason/reasons why: (tick all that apply)CT scan already done at first hospitalNot considered to be clinically indicatedChild not stableNo CT availableOther, please specifyNot known ### Page 58 58 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewIMAGING continued (At any time following attendance)4.9 Complete cervical spine CT performed Yes → Go to 4.9.1. No→ Go to 4.9.2 Not known → Go to 4.104.9.1 Was the first spine CT scan reported as normal on provisional report?Yes → Go to 4.10 No → Specify Not known → Go toabnormality: 4.104.9.2 If no spine CT scan performed please indicate reason/reasons why: (tick all that apply)CT scan already done at first hospitalNot considered to be clinically indicatedChild not stableNo CT availableOther, please specifyNot known4.10 Was the child ‘admitted’ to your hospital?(see cover for definition of admission) Yes → Go to 5.1 No → Go to 4.10.14.10.1 If no, where did child go following discharge from the Emergency DepartmentTransferred to another hospital → Go to 6.2Deceased → Go to 6.4Other, please specify → Go to 6.1SECTION 5: ADMISSION5.1 Area child first admitted to:General children’s wardPaediatric Intensive Care Unit (PICU)Paediatric Neurosurgical unitPaediatric High Dependency Unit (PHDU)Specialist children’s ward, specifyGeneral/Adult ICUAdult Neurosurgical unitAdult High Dependency Unit (HDU)Other, specifyTheatreShort stay UnitObservation unitNot known5.2 Date admitted to area Not recorded5.3 Time admitted to area (24 hr clock) Not recorded5.4 Designated lead team for this admission (If joint care tick all that apply)General PaediatricsPaediatric Emergency MedicinePaediatric Intensive CarePaediatric NeurosurgeryPaediatric SurgeryGeneral/Adult Emergency MedicineGeneral/Adult Intensive CareAdult NeurosurgeryGeneral/Adult SurgeryOrthopaedic SurgeryNot knownOther, specify5.5 Indication for admission (Please tick all that apply)Severity of the head injury Recovery from GA or sedation used for CT scanSeverity of other injuriesSeverity of mechanism of injuryChild fulfils criteria for CT scanning but this cannot be done within the appropriate periodContinuing worrying signs in relation to head injury Not sufficiently cooperative to allow scanningAbnormality identified on CT scan Admitted for GA to have a CT scanBase of skull fracture ShockMeningism Suspected Non Accidental Injury (NAI)CSF leakDrug or Alcohol intoxicationOther, please specify (e.g. not related to head injury, gastroenteritis)5.6 Consultant paediatrician involved in care of child(i.e. Discussed with at time of care delivered) Yes No Not known5.7 Neurosurgeon involved in care of child(This includes liaison over telephone, or other means) Yes No Not known5.8 Specialist in Child Protection with level 3 training or above involved (i.e. Discussed with at time of care delivered) Yes No Not known5.9 Child Protection referral made to external body(e.g. Social Services or Police) Yes No Not known5.10 Skeletal survey undertaken(i.e. as part of a child protection assessment) Yes No Not known5.11 Review by ophthalmology undertaken(i.e. as part of a child protection assessment) Yes No Not known ### Page 59 59 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewSECTION 5: ADMISSION continued5.12 IN ADDITION to the first area of admission, was the child at any time during the first 72 hours post injury admitted to any of the following areas?Area Yes No Date admitted Time admitted(24 hr clock) Date discharged Time discharged(24 hr clock)a. PICUb. PHDUc. General ICUd. General HDUe. Neurosurgical unitf. Wardg. Theatreh. Other, specifySECTION 6: CHILD’S OUTCOME - Complete at whichever occurs first: at transfer, at death in hospital, or at the end of the first 72 hours post injury.6.1 Please indicate the status or location of the child at whichever occurs first(i.e. at transfer, at death in hospital, or at the end of the first 72 hours post injury)Transferred → Go to 6.2Discharged → Go to 6.3Deceased → Go to 6.4General children’s wardSpecialist children’s ward, specifyPaediatric Intensive Care Unit (PICU)Paediatric High Dependency Unit (PHDU)Paediatric Neurosurgical unitGeneral/Adult ICUAdult Neurosurgical unitAdult/General HDUNot knownOther, specify6.2 Transferred6.2.1 Was this a transfer or retrieval? Transfer Retrieval Not known6.2.2 Name of hospital and trust child transferred to (Hospital) (Trust)6.2.3 Date and time first referral made for transfer Not recorded(24 hr clock)6.2.4 First referral request for transfer accepted Yes No6.2.5 Date and time departure for transfer Not recorded(24 hr clock)6.2.6 Reason for transferNo paediatric facilitiesNo ICU facilities in hospitalNo PICU bed available in hospitalNo general ICU bed available in hospital(please tick all that apply)Access to paediatric neuroscience facilitiesPaediatric surgeryReceiving hospital close to child’s homeOther, please specifyNot recordedNot known6.2.7 Means of transferSpecialist PICU transport teamLocal teamParamedic AmbulanceAmbulance (Non paramedic)Private/public transportOther land, please specify Helicopter (Paramedic/medic)Other airborne, please specify Not recordedNot known6.2.8 Additional transfer information (e.g. reason for delay )Please use the additional sheet provided on page 7 if there is not enough room to complete your answer ### Page 60 60 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewSECTION 6: CHILD’S OUTCOME continued6.3 Discharged6.3.1 Place child discharged to Home Rehab centreOther, specify Not known6.3.2 Date of discharge Not recorded6.3.3 Time of discharge (24 hr clock) Not recorded6.3.4 Diagnosis on discharge6.4 Death (if a diagnosis of brain stem death is made then the date and time of this diagnosis equals the date and time of death)6.4.1 Date of death Not recorded6.4.2 Time of death (24 hr clock) Not recorded6.4.3 Place of deathGeneral children’s wardPaediatric Intensive Care Unit (PICU)Paediatric Neurosurgical unitPaediatric High Dependency Unit (PHDU)Specialist children’s ward, specifyGeneral/Adult ICUAdult Neurosurgical unitAdult High Dependency Unit (HDU)Emergency DepartmentOther, specifyTheatreShort stay UnitObservation unitHomeNot known6.4.4 Death certificate issued Yes No Not known6.4.5 Coroner’s referral made Yes No Not known6.4.6 Cause of death (as stated on death certificate. If no certificate issued state cause of death as in notes)For children who died <28 days old For deaths of a child (> 28 days old) 1 1a.2a. 1b.2b. 1c.2c. 2.2d.Additional space for further information (please indicate question number you are referring to)PLEASE PHOTOCOPY THIS FORM AND KEEP A COPY FOR YOUR RECORDS BEFORE RETURNING TO YOUR CMACE REGIONAL OFFICESpeciality & Clinician CodesCODE SPECIALITY CODE SPECIALITY CODE CLINICIAN 100 General Surgery 302 Endocrinology CONS Consultant110 Trauma & Orthopaediacs 303 Clinical Haematology SG Staff Grade120 Ear Nose Throat (ENT) 400 Neurology CF Clinical Fellow145 Oral & Maxillo Facial Surgery 401 Clinical Neuro-Physiology AS Associate Specialist150 Neurosurgery 420 Paediatrics ST + 1-8 Single Training e.g. ST4170 Cardiothoracic Surgery 421 Paediatric Neurology SpR + year Specialist Registrar e.g. SpR2171 Paediatric Surgery 450 Dental Medicine Specialities FY + year Foundation year e.g. if year 1, enter FY1180 Emergency Medicine 460 Medical Opthamology ENP Emergency Nurse Practitioner190 Anaesthetics 600 General Medical Practice APNP Advanced Paediatric Nurse Practitioner192 Critical Care Medicine 601 General Dental Practice ATNC Nurse - Advance Trauma Cert193 Paediatric Intensive Care 810 Radiology RSCN Nurse - RSCN300 General Medicine 823 Haematology NURS Nurse - General301 Gastroenterology 000 Other (Surgical or Medical) GP General Practitioner ### Page 61 61 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewInclusion & exclusion criteriaPlease include: Children up to 15 years old (14 years and 364 days) who between 00:00 on the 1st September 09 and 23:59 on the 28th February 2010 have a brain or skull injury (trauma to the head) as a result of blunt or penetrating trauma or acceleration or deceleration force (e.g. road traffic accident, fall, shaking) OR who have experienced a head injury as part of a pattern of injuries or multi traumaAND fulfill the following length of stay criteria: Admitted to an area of inpatient care (regardless of length of stay) OR Died in the hospital, including the Emergency Department OR Transferred to other hospital for specialist care or for an ICU/HDU bed OR Died at the scene or en route to the receiving hospital OR Transferred in to your hospital (regardless of length of stay)Please exclude: Children who have experienced primarily superficial or facial injuries which are unlikely to be associated with a brain injury (e.g. isolated or trivial facial (nose, ear, lip etc), scalp or auricular injuries) Children who do not meet the above inclusion criteria (i.e. children who do not die that are not admitted; children who have reached their 15thbirthday at the time of injury).S02 Fracture of skull and facial bones, e.g. S00 Superficial Injuries, e.g.Fracture of vault of skull Superficial injury of scalp Fracture of base of skull Contusion of eyelid and periocular area Multiple fractures involving skull and facial bones Other superficial injuries of eyelid and periocular area Fractures of other skull and facial bones Superficial injury of nose, ear, lip, or oral cavityS04 Injury of cranial nerves, e.g. S01 Open wound of head, e.g.Injury of optic nerve and pathways Injury of oculomotor nerveS06 Intracranial injury, e.g. S02 Fracture of skull and facial bones, e.g.Concussion Traumatic cerebral oedema Diffuse brain injury S03 Dislocation, sprain & strain of joints & ligaments of head,Focal brain injury Dislocation of jaw, septal cartilage of nose, septal cartilage of EDH (Extra Dural Haematoma) nose, or tooth. Sprain and strain of jaw. Traumatic subdural/subarachnoid haemorrhage S04 Injury of cranial nerves, e.g.Intracranial injury with prolonged coma Injury of trochlear nerve, trigeminal nerve, abducent nerve, facial nerve Other intracranial injuries S05 Injury of eye and orbit, e.g.Intracranial injuries - unspecified Injury of conjunctiva and corneal abrasionS07 Crushing injury of head, e.g. Contusion of eyeball and orbital tissues Crushing injury of the face Ocular laceration and rupture with prolapse Crushing injury of the skull Penetrating wound of orbit, or eyeballS08 Traumatic amputation of part of head, e.g. Avulsion of eye Traumatic amputations S08 Traumatic amputation of part of head, e.g.Multiple injuries of head Avulsion of scalp Traumatic amputation of earExamples of types of head injuries to be INCLUDED Examples of types of head injuries to be EXCLUDEDScalp, eyelid and periocular area, nose, ear, cheek & temporomandibular area, lip & oral cavity. Fracture of tooth, mandible, nasal bones, orbital floor, malar & maxillary bones.If you have any queries regarding the inclusion/exclusion criteria, please contact your CMACE regional office.CMACE East of England OfficeCarol Hay, Regional Manager Box 111, Room 414, Clinical School Addenbrooke's Hospital, Hills Road Cambridge, CB2 0SPT: 01223 330 356 or 351 E: carol.hay@cmace.org.ukCMACE Northern Ireland OfficeTerry Falconer, Project Manager The Health Promotion Agency 18 Ormeau Avenue, Belfast BT2 8HST: 028 9027 9397 E: terry.falconer@cmace.org.ukCMACE East Midlands and Yorkshire and The Humber OfficeDaniel Beever, Administrative Assistant Heeley Suite, Blades Enterprise Centre John Street, Sheffield S2 4SWT: 0114 292 2492 E: daniel.beever@cmace.org.ukCMACE North West, West Midlands & Wales OfficePamela Norris, Project Midwife Research Floor (5th Floor), St Mary's Hospital Oxford Road, Manchester M13 9WLT: 0161 7016915 E: pamela.norris@cmace.org.ukCMACE London and South East OfficeDave Kimani, Administrative Assistant Lower ground floor, Chiltern Court 188 Baker Street, London NW1 5SDT: 020 7467 3224 E: dave.kimani@cmace.org.ukCMACE South West and Wessex OfficeJo Coffee, Regional CMACE Assistant Institute of Child Life & Health, Level D St Michaels Hospital, Southwell Street Bristol, BS2 8EGT: 0117 928 5141 or 5143 E: jo.coffee@cmace.org.ukCMACE North East Office (FAO Marjorie Renwick)C/O CMACE Central Office Lower ground floor, Chiltern Court 188 Baker Street, London NW1 5SDT: 020 7467 3224 E: headinjury@cmace.org.ukCMACE Central OfficeRachael Davey, Projects Research Assistant Lower ground floor, Chiltern Court 188 Baker Street, London NW1 5SDT: 020 7467 3224 E: rachael.davey@cmace.org.ukDefinition of ‘admission’ can be found on the front of this form ### Page 62 62 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overview© CMACE 2009 Please note: All rights are reserved. Please do not reproduce, distribute, modify, display or communicate the contents of this document without specific authorisation.HEAD INJURY IN CHILDREN TRANSFER INFORMATION FORM (B)Please complete this form for a child or young person up to 15 years old (14 yrs + 365 days) who as a result of a head injury* or a head injury as part of a pattern of injuries was transferred* to your hospital within the first 72 hours post injury for secondary or tertiary care between 1st SEPTEMBER 2009 and 28thFEBRUARY 2010 inclusive:Please tick type of case: (Select one option only)Child arrives in your Emergency Department following transfer* from another hospital and admitted* for secondary or tertiary care in the same hospital ORChild admitted directly to a unit in your hospital for secondary or tertiary care following transfer or retrieval from another hospital (e.g. direct to PICU)Instructions for completing and returning the notification form1. This form should be completed by the hospital receiving the child. 2. Certain sections may not be applicable to all children. Please read the guidance manual before completing.3. One form should be completed per child, per transfer.4. Please complete the form using the information available in the child’s notes. Complete all dates in the formatDD/MM/YY and times using the 24hr clock e.g. 18:50.5. Please keep a copy of this form for your records. Return hardcopies of completed forms to your local CMACE regional office. See back of form for local contact details.6. If you have any queries about completing or returning this form please contact your CMACE regional office.Date form completed: Date form returned:DETAILS OF PERSON COMPLETING FORMName: Trust:Job title/Role: Telephone:Unit: Email:Hospital:* Head injury: Examples of head injuries to include or exclude can be found on the back of this form. * Admission: Hospital admission is defined as occurring when the patient is in receipt of treatment or observation in an inpatient area. This includes short term assessment units associated with wards or emergency departments, short stay units, general or specialist wards, PICUs, Neurosurgical unit, or other inpatient unit. This may only be for a matter of hours beyond the first four hours from arrival at hospital. * Transfer: Refers to the transport of a patient by ambulance (land or air) from one hospital to another hospital facility. Also referred to as an ‘inter-hospital transfer’ between two hospitals either within or out of the same trust.Centre for Maternal and Child EnquiriesImproving the health of mothers, babies and children ### Page 63 63 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewSECTION 1: DETAILS OF CHILD (Affix patient label if preferred)1.1 Hospital Number1.2 NHS Number/Healthcare Number / /1.3 Surname/family name1.4 First name1.5 Sex Male Female Not known1.6 Date of birth and/or estimated ageIf no full date of birth is known enter month and year. If no full or short DOB, enter their estimated age. Not knownyears months1.7 Postcode of patient’s normal residence / Not knownSECTION 2: DETAILS OF TRANSFER TO SECONDARY/TERTIARY CARE2.1 Was this a transfer or retrieval? Transfer Retrieval Not known2.2 Name of hospital and trust child transferred FROM (Hospital) (Trust)2.3 Name of hospital and trust child transferred TO (Hospital) (Trust)2.4 Date and time first referral made for transfer Not recorded(24 hr clock)2.5 First referral request for transfer accepted Yes No Not recorded2.6 Date and time departure for transfer Not recorded(24 hr clock)2.7 Date and time arrival at secondary/tertiary care Not recorded(24 hr clock)2.8 Reason for transfer (please tick all that apply)No paediatric facilitiesNo ICU facilities in hospitalNo PICU bed available in hospitalNo general ICU bed available in hospitalAccess to paediatric neuroscience facilitiesPaediatric surgeryReceiving hospital close to child’s homeOther, please specifyNot recordedNot known2.9 Means of transferSpecialist PICU transport teamLocal teamParamedic AmbulanceAmbulance (Non paramedic)Private/public transportOther land, please specify Helicopter (Paramedic/medic)Other airborne, please specify Not recordedNot known2.10 Additional transfer information (e.g. reason for delay)2.11 Was the child ‘admitted’ to receiving hospital for secondaryor tertiary care (see cover for definition of admission) Yes → Go to 3.1 No → Go to 2.11.12.11.1 If no, where did child go:Transferred to another hospital → Go to 4.2Deceased → Go to 4.4Other, please specify → Go to 4.1 ### Page 64 64 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewSECTION 3: ADMISSION AT SECONDARY/TERTIARY CARE3.1 Date admitted to area Not recorded3.2 Time admitted to area (24 hr clock) Not recorded3.3 Area child first admitted to:General children’s wardPaediatric Intensive Care Unit (PICU)Paediatric Neurosurgical unitPaediatric High Dependency Unit (PHDU)Specialist children’s ward, specifyGeneral/Adult ICUAdult Neurosurgical unitAdult High Dependency Unit (HDU)Other, specifyTheatreShort stay UnitObservation unitNot known3.4 Designated lead team for this admission (If joint care tick all that apply)General PaediatricsPaediatric Emergency MedicinePaediatric Intensive CarePaediatric NeurosurgeryPaediatric SurgeryGeneral/Adult Emergency MedicineGeneral/Adult Intensive CareAdult NeurosurgeryGeneral/Adult SurgeryOrthopaedic SurgeryNot knownOther, specify3.5 Indication for admission (Please tick all that apply)Severity of the head injury Recovery from GA or sedation used for CT scanSeverity of other injuriesSeverity of mechanism of injuryChild fulfils criteria for CT scanning but this cannot be done within the appropriate periodContinuing worrying signs in relation to head injury Not sufficiently cooperative to allow scanningAbnormality identified on CT scan Admitted for GA to have a CT scanBase of skull fracture ShockMeningism Suspected Non Accidental Injury (NAI)CSF leakDrug or Alcohol intoxicationOther, please specify (e.g. not related to head injury, gastroenteritis)3.6 Child’s neurological status at admission to secondary/tertiary careDocument the worst score before intubation/intervention on arrival. If no intubation/intervention occurred, document the worst score.3.6.1 Glasgow Coma Scale Score Not recordedEye openingVerbal responseMotor responseTOTAL (out of 15)Time GCS recorded: 3.6.2 AVPU Score Not recordedAlertRespond to VoiceRespond to PainUnresponsiveTime AVPU recorded:(24 hr clock) Not recorded (24 hr clock) Not recorded3.7 Child intubated following arrival at centre Yes No Not known3.8 Consultant paediatrician involved in care of child(i.e. Discussed with at time of care delivered) Yes No Not known3.9 Neurosurgeon involved in care of child(This includes liaison over telephone, or other means) Yes No Not known3.10 Specialist in Child Protection with level 3 training or above involved (i.e. Discussed with at time of care delivered) Yes No Not known3.11 Child Protection referral made to external body(e.g. Social Services or Police) Yes No Not known3.12 Skeletal survey undertaken(i.e. as part of a child protection assessment) Yes No Not known3.13 Review by ophthalmology undertaken(i.e. as part of a child protection assessment) Yes No Not known ### Page 65 65 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewSECTION 3: ADMISSION AT SECONDARY/TERTIARY CARE continued3.14 IN ADDITION to the first area of admission was the child at any time during the first 72 hours post injury admitted to any of the following areas?Area Yes No Date admitted Time admitted(24 hr clock) Date discharged Time discharged(24 hr clock)a. PICUb. PHDUc. General ICUd. General HDUe. Neurosurgical unitf. Wardg. Theatreh. Other, specifyIMAGING (At any time following transfer)3.15 Head CT scan performed Yes → Go to 3.15.1 No → Go to 3.15.4 Not known → Go to 3.163.15.1 Date first head CT scan performed Not recorded3.15.2 Time first head CT scan performed (24 hr clock) Not recorded3.15.3 Was the first head CT scan reported as normal on provisional report?Yes → Go to 3.16 No → Specify Not known → Go toabnormality: 3.163.15.4 If no head CT performed, please indicate reason/reasons why: (tick all that apply)CT scan already done at first hospitalNot considered to be clinically indicatedChild not stableNo CT availableOther, please specifyNot known3.16 Complete cervical spine CT performed Yes → Go to 3.16.1 No→ Go to 3.16.2 Not known → Go to 3.173.16.1 Was the first spine CT scan reported as normal on provisional report?Yes → Go to 3.17 No → Specify Not known → Go toabnormality: 3.173.16.2 If no spine CT scan performed please indicate reason/reasons why: (tick all that apply)CT scan already done at first hospitalNot considered to be clinically indicatedChild not stableNo CT availableOther, please specifyNot known3.17 Additional CT information (e.g. reason for delay)SECTION 4: CHILD’S OUTCOME - Complete at whichever occurs first: at transfer, at death in hospital, or at the end of the first 72 hours post injury.4.1 Please indicate the status or location of the child at whichever occurs first(i.e. at transfer, at death in hospital, or at the end of the first 72 hours post injury)Transferred → Go to 4.2Discharged → Go to 4.3Deceased → Go to 4.4General children’s wardSpecialist children’s ward, specifyPaediatric Intensive Care Unit (PICU)Paediatric High Dependency Unit (PHDU)Paediatric Neurosurgical unitGeneral/Adult ICUAdult Neurosurgical unitAdult/General HDUNot knownOther, specify ### Page 66 66 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewSECTION 4: CHILD’S OUTCOME continued4.2 Transferred .4.2.1 Was this a transfer or retrieval? Transfer Retrieval Not known4.2.2 Name of hospital and trust child transferred to (Hospital) (Trust)4.2.3 Date and time first referral made for transfer Not recorded(24 hr clock)4.2.4 First referral request for transfer accepted Yes No4.2.5 Date and time departure for transfer Not recorded(24 hr clock)4.2.6 Reason for transferNo paediatric facilitiesNo ICU facilities in hospitalNo PICU bed available in hospitalNo general ICU bed available in hospital(please tick all that apply)Access to paediatric neuroscience facilitiesPaediatric surgeryReceiving hospital close to child’s homeOther, please specifyNot recordedNot known4.2.7 Means of transferSpecialist PICU transport teamLocal teamParamedic AmbulanceAmbulance (Non paramedic)Private/public transportOther land, please specify Helicopter (Paramedic/medic)Other airborne, please specify Not recordedNot known4.2.8 Additional transfer information (e.g. reason for delay)4.3 Discharged4.3.1 Place child discharged to Home Rehab centreOther, specify Not known4.3.2 Date of discharge Not recorded4.3.3 Time of discharge (24 hr clock) Not recorded4.3.4 Diagnosis on discharge4.4 Death (if a diagnosis of brain stem death is made then the date and time of this diagnosis equals the date and time of death)4.4.1 Date of death Not recorded4.4.2 Time of death (24 hr clock) Not recorded4.4.3 Place of deathGeneral children’s wardPaediatric Intensive Care Unit (PICU)Paediatric Neurosurgical unitPaediatric High Dependency Unit (PHDU)Specialist children’s ward, specifyGeneral/Adult ICUAdult Neurosurgical unitAdult High Dependency Unit (HDU)Emergency DepartmentOther, specifyTheatreShort stay UnitObservation unitHomeNot known4.4.4 Death certificate issued Yes No Not known4.4.5 Coroner’s referral made Yes No Not known4.4.6 Cause of death (as stated on death certificate. If no certificate issued state cause of death as in notes)For children who died <28 days old For deaths of a child (> 28 days old) 1 1a.2a. 1b.2b. 1c.2c. 2.2d. ### Page 67 67 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewInclusion & exclusion criteriaPlease include: Children up to 15 years old (14 years and 364 days) who between 00:00 on the 1st September 09 and 23:59 on the 28th February 2010 have a brain or skull injury (trauma to the head) as a result of blunt or penetrating trauma or acceleration or deceleration force (e.g. road traffic accident, fall, shaking) OR who have experienced a head injury as part of a pattern of injuries or multi traumaAND fulfill the following length of stay criteria: Admitted to an area of inpatient care (regardless of length of stay) OR Died in the hospital, including the Emergency Department OR Transferred to other hospital for specialist care or for an ICU/HDU bed OR Died at the scene or en route to the receiving hospital OR Transferred in to your hospital (regardless of length of stay)Please exclude: Children who have experienced primarily superficial or facial injuries which are unlikely to be associated with a brain injury (e.g. isolated or trivial facial (nose, ear, lip etc), scalp or auricular injuries) Children who do not meet the above inclusion criteria (i.e. children who do not die that are not admitted; children who have reached their 15thbirthday at the time of injury).S02 Fracture of skull and facial bones, e.g. S00 Superficial Injuries, e.g.Fracture of vault of skull Superficial injury of scalp Fracture of base of skull Contusion of eyelid and periocular area Multiple fractures involving skull and facial bones Other superficial injuries of eyelid and periocular area Fractures of other skull and facial bones Superficial injury of nose, ear, lip, or oral cavityS04 Injury of cranial nerves, e.g. S01 Open wound of head, e.g.Injury of optic nerve and pathways Injury of oculomotor nerveS06 Intracranial injury, e.g. S02 Fracture of skull and facial bones, e.g.Concussion Traumatic cerebral oedema Diffuse brain injury S03 Dislocation, sprain & strain of joints & ligaments of head,Focal brain injury Dislocation of jaw, septal cartilage of nose, septal cartilage of EDH (Extra Dural Haematoma) nose, or tooth. Sprain and strain of jaw. Traumatic subdural/subarachnoid haemorrhage S04 Injury of cranial nerves, e.g.Intracranial injury with prolonged coma Injury of trochlear nerve, trigeminal nerve, abducent nerve, facial nerve Other intracranial injuries S05 Injury of eye and orbit, e.g.Intracranial injuries - unspecified Injury of conjunctiva and corneal abrasionS07 Crushing injury of head, e.g. Contusion of eyeball and orbital tissues Crushing injury of the face Ocular laceration and rupture with prolapse Crushing injury of the skull Penetrating wound of orbit, or eyeballS08 Traumatic amputation of part of head, e.g. Avulsion of eye Traumatic amputations S08 Traumatic amputation of part of head, e.g.Multiple injuries of head Avulsion of scalp Traumatic amputation of earExamples of types of head injuries to be INCLUDED Examples of types of head injuries to be EXCLUDEDScalp, eyelid and periocular area, nose, ear, cheek & temporomandibular area, lip & oral cavity. Fracture of tooth, mandible, nasal bones, orbital floor, malar & maxillary bones.If you have any queries regarding the inclusion/exclusion criteria, please contact your CMACE regional office.CMACE East of England OfficeCarol Hay, Regional Manager Box 111, Room 414, Clinical School Addenbrooke's Hospital, Hills Road Cambridge, CB2 0SPT: 01223 330 356 or 351 E: carol.hay@cmace.org.ukCMACE Northern Ireland OfficeTerry Falconer, Project Manager The Health Promotion Agency 18 Ormeau Avenue, Belfast BT2 8HST: 028 9027 9397 E: terry.falconer@cmace.org.ukCMACE East Midlands and Yorkshire and The Humber OfficeDaniel Beever, Administrative Assistant Heeley Suite, Blades Enterprise Centre John Street, Sheffield S2 4SWT: 0114 292 2492 E: daniel.beever@cmace.org.ukCMACE North West, West Midlands & Wales OfficePamela Norris, Project Midwife Research Floor (5th Floor), St Mary's Hospital Oxford Road, Manchester M13 9WLT: 0161 7016915 E: pamela.norris@cmace.org.ukCMACE London and South East OfficeDave Kimani, Administrative Assistant Lower ground floor, Chiltern Court 188 Baker Street, London NW1 5SDT: 020 7467 3224 E: dave.kimani@cmace.org.ukCMACE South West and Wessex OfficeJo Coffee, Regional CMACE Assistant Institute of Child Life & Health, Level D St Michaels Hospital, Southwell Street Bristol, BS2 8EGT: 0117 928 5141 or 5143 E: jo.coffee@cmace.org.ukCMACE North East Office (FAO Marjorie Renwick)C/O CMACE Central Office Lower ground floor, Chiltern Court 188 Baker Street, London NW1 5SDT: 020 7467 3224 E: headinjury@cmace.org.ukCMACE Central OfficeRachael Davey, Projects Research Assistant Lower ground floor, Chiltern Court 188 Baker Street, London NW1 5SDT: 020 7467 3224 E: rachael.davey@cmace.org.ukDefinition of ‘admission’ can be found on the front of this form ### Page 68 68 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overview© CMACE 2009 Please note: All rights are reserved. Please do not reproduce, distribute, modify, display or communicate the contents of this document without specific authorisation.HEAD INJURY IN CHILDREN PREHOSPITAL CARE (C)Instructions for completing and returning the form1. This form should be completed by the ambulance service who responded to the child. 2. Certain sections may not be applicable to all children.3. One form should be completed per child, per response made.4. Please complete all dates in the format DD/MM/YY and times using the 24hr clock e.g. 18:50.5. Please keep a copy of this form for your records. Return hardcopies of completed forms to your local CMACE regional office. See back of form for local contact details.6. If you have any queries about completing or returning this form please contact your CMACE regional office.Date form completed: Date form returned:DETAILS OF PERSON COMPLETING FORMName: Telephone:Job title/Role: Email:1. DETAILS PROVIDED BY CMACE (for matching)1.1 Ambulance Service 1.2 Surname/family name1.3 Sex Male Female Not known1.4 Date of birth and/or estimated ageIf no full date of birth is known enter month and year. If no full or short DOB, enter their estimated age. Not knownyears months1.5 Patient Report Form (or equivalent) number Not known1.6 Incident number/CAD number (or equivalent) Not known1.7 Date and time of incident Not recorded(24 hr clock)1.8 Name of hospital and trust child transported to(Hospital) (Trust)1.9 Date and time of arrival at this hospitalNot recorded(24 hr clock)Centre for Maternal and Child EnquiriesImproving the health of mothers, babies and children ### Page 69 69 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewSECTION 2: EMERGENCY RESPONSE DETAILS2.1 Blue call time(A pre alert call placed to receiving hospital) Not recorded(24 hr clock)2.2 Date and time of call to emergency services Not recorded(24 hr clock)2.3 Data and time ambulance service arrived at scene Not recorded(24 hr clock)2.4 Date and time ambulance service left scene Not recorded(24 hr clock)2.5 Were pre arrival instructions given (e.g. resuscitation) Yes No Not known2.6 Attendant Grade (e.g. paramedic/technician etc)(see codes on back of form) Not known2.7 Driver Grade (e.g. paramedic/technician etc)(see codes on back of form) Not known2.8 Who from a health related service was first to attend the site of injury?Paramedic crewed land ambulanceParamedic + EMT crewed land ambulance EMT crewed land ambulanceAir ambulanceDoctor, BASICSDoctor, other, specifyLone responderOther, specify2.9 Other emergency services or crew present at the scene: (please tick all that apply)ParamedicEmergency Medical Technician (EMT) Doctor, BASICSDoctor, other, specifyPoliceFireAir ambulanceOther, specifyNot known2.10 On arrival of emergency services at the scene child was found to be:Alive DeadSECTION 3: INCIDENT DETAILS3.1 Presenting complaint Not known3.2 Postcode of incident location (first part only) Not knownOnly the first part of the postcode is required If postcode is not known indicate area/first line of addressNot known3.3 Place of incidentHome/private address Road/ School/ Street/Motorway NurseryOther, specify Not known3.4 Cause of injuryMotor vehicle accident/road traffic accidentCyclingFall from > 1m or > 5 stairsFall < 1m or < 5 stairsFall, height unknownSport, please specifyOther recreational (e.g. skateboard) specifyAssaultOther, please specifyNot known3.5 If motor vehicle accident or road traffic accident (RTA) N/A → Go to 3.6Vehicle occupant – DriverVehicle occupant – Passenger (front)Vehicle occupant – Passenger (rear)Vehicle occupant – Position unknownCyclingMotorcyclistPedestrianNot knownOther, specify3.5.1 Helmet worn Yes No Not known N/A3.5.2 Seatbelt worn Yes No Not known N/A3.5.3 Child restraint Yes No Not known N/A3.5.4 Airbag Yes No Not known N/A3.5.5 Child ejected Yes No Not known N/A3.5.6 Fatality in the same vehicle Yes No Not known N/A3.5.7 Child trapped Yes No Not known N/A3.6 Additional incident details, if known (e.g. Fall from trampoline, speed, not in age appropriate car seat, etc) ### Page 70 70 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewSECTION 4: PRIMARY SURVEY AND OBSERVATIONS4.1 Airway compromised Yes – partially obstructed Yes – obstructedNo, it was clear Not recorded4.2 C-spine Normal Suspect Not recorded4.3 Breathing Present and normal ApnoeasPresent but noisy/laboured AbsentNot known4.4 Respiratory rate breaths per min Not recorded4.5 Pulse status Present Absent Not recordedRegular Irregular Not recordedStrong Weak Not recorded4.6 Pulse rate bpm Not recorded4.7 Capillary refill Normal >2 seconds Not recorded4.8 Assisted Oxygen Saturations % Not recorded4.9 Unassisted Oxygen Saturations % Not recorded4.10 Blood pressure mm/Hg Not recorded4.11 Pupillary reaction Equal and reactive One unreactiveBoth unreactive Not known4.12 Neurological status at sceneDocument the worst score before intubation/intervention. If no intubation/intervention occurred, document the worst score.4.12.1 Glasgow Coma Scale Score Not recordedEye openingVerbal responseMotor responseTOTAL (out of 15)Time GCS recorded: 4.12.2 AVPU Score Not recordedAlertRespond to VoiceRespond to PainUnresponsiveTime AVPU recorded:(24 hr clock) Not recorded (24 hr clock) Not recordedSECTION 5: MANAGEMENT5.1 Head tilt/chin lift Yes No Not recorded5.2 Jaw thrust Yes No Not recorded5.3 Manual clearance Yes No Not recorded5.4 Suction Yes No Not recorded5.5 Nasopharyngeal Airway (NPA) Yes No Not recorded5.6 Laryngeal Mask Airway (LMA) Yes No Not recorded5.7 Oropharyangeal Airway (OPA) Yes No Not recorded5.8 Pocket and mask Yes No Not recorded5.9 Intubated prior to arrival at the first hospital Yes No Not recordedIf yes, 6.9.1 Who was the attempt made by(see codes on back of form) Not recorded5.10 Needle thoracocentesis (Nth) Yes No Not recordedIf yes, 6.10.1 Was this successful 6.10.2 Who was the attempt made by(see codes on back of form)Yes No Not recordedNot recorded5.11 Needle cricothyroidotomy (NCr) Yes No Not recordedIf yes, 5.11.1 Was this successful 5.11.2 Who was the attempt made byYes No Not recordedNot recorded5.12 O2 therapy administered Yes No Not recorded ### Page 71 71 © Copyright HQIP 2015Traumatic head injury in children and young people: a national overviewSECTION 5: MANAGEMENT Continued5.13 Intravenous (IV) cannulation attempted Yes No Not recordedIf yes, 5.13.1 Was this successful 5.13.2 Who was the attempt made byYes No Not recordedNot recorded5.14 Intraosseous cannulation attempted Yes No Not recordedIf yes, 5.14.1 Was this successful 5.14.2 Who was the attempt made byYes No Not recordedNot recorded5.15 Fluid therapy given Yes No Not recorded5.16 Cervical spine and/or whole spine immobilised Yes No Not recorded5.17 Drugs administered Yes No Not recorded5.18 C-Collar Yes No Not recorded5.19 Resuscitation (CPR) required prehospital Yes No Not recordedCODESCODE SPECIALITY CODE SPECIALITY PAR Paramedic DRB BASICS DoctorEMT Emergency Medical Technician DRO Doctor - otherECA Emergency Care Assistant OTH OtherECP Emergency Care PractitionerCCP Critical Care PractitionerCMACE REGIONAL OFFICE CONTACT DETAILSCMACE East of England OfficeCarol Hay, Regional Manager Box 111, Room 414, Clinical School Addenbrooke's Hospital, Hills Road Cambridge, CB2 0SP T: 01223 330 356 or 351 E: carol.hay@cmace.org.ukCMACE Northern Ireland OfficeTerry Falconer, Project Manager The Health Promotion Agency 18 Ormeau Avenue, Belfast BT2 8HS T: 028 9027 9397 E: terry.falconer@cmace.org.ukCMACE East Midlands and Yorkshire and The Humber OfficeDaniel Beever, Administrative Assistant Heeley Suite, Blades Enterprise Centre John Street, Sheffield S2 4SW T: 0114 292 2492 E: daniel.beever@cmace.org.ukCMACE North West, West Midlands & Wales OfficePamela Norris, Project Midwife Research Floor (5th Floor), St Mary's Hospital Oxford Road, Manchester M13 9WL T: 0161 7016915 E: pamela.norris@cmace.org.ukCMACE London and South East OfficeDave Kimani, Administrative Assistant Lower ground floor, Chiltern Court 188 Baker Street, London NW1 5SD T: 020 7467 3224 E: dave.kimani@cmace.org.ukCMACE South West and Wessex OfficeJo Coffee, Regional CMACE Assistant Institute of Child Life & Health, Level D St Michaels Hospital, Southwell Street Bristol, BS2 8EG T: 0117 928 5141 or 5143 E: jo.coffee@cmace.org.ukCMACE North East Office (FAO Dr Claire Bradford)C/O CMACE Central Office Lower ground floor, Chiltern Court 188 Baker Street, London NW1 5SD T: 020 7467 3224 E: headinjury@cmace.org.ukCMACE Central OfficeRachael Davey, Projects Research Assistant Lower ground floor, Chiltern Court 188 Baker Street, London NW1 5SD T: 020 7467 3224 E: rachael.davey@cmace.org.ukINCLUSION and EXCLUSION CRITERIAInclusions: Children up to 15 years old (14 years and 364 days) who between 00:00 on the 1st September 09 and 23:59 on the 28th February 2010 have a brain or skull injury (trauma to the head) as a result of blunt or penetrating trauma or acceleration or deceleration force (e.g. road traffic accident, fall, shaking) OR who have experienced a head injury as part of a pattern of injuries or multi traumaAND fulfill the following length of stay criteria: Admitted to an area of inpatient care (regardless of length of stay) OR Died in the hospital, including the Emergency Department OR Transferred to other hospital for specialist care or for an ICU/HDU bed OR Died at the scene or en route to the receiving hospital OR Transferred in to a hospital (regardless of length of stay)Exclusions: Children who have experienced primarily superficial or facial injuries which are unlikely to be associated with a brain injury (e.g. isolated or trivial facial (nose, ear, lip etc), scalp or auricular injuries) Children who do not meet the above inclusion criteria (i.e. children who do not die that are not admitted; children who have reached their 15thbirthday at the time of injury).Definition of ‘admission’ can be found on the front of this form ### Page 72 Further information is available at: www.hqip.org.uk ISBN NO 978-1-907561-06-1September 20156th Floor, 45 Moorfields, London, EC2Y 9AET 0207 997 7370 F 0207 997 7398E communications@hqip.org.ukwww.hqip.org.ukRegistered Office: 70 Wimpole Street, London W1G 8AX Registration No. 6498947 Registered Charity Number: 1127049 © 2015 Healthcare Quality Improvement Partnership Ltd. (HQIP) All rights reserved