Guideline compliance in management of minimal, mild, and moderate head injury: high frequency of noncompliance among individual physicians despite strong guideline support from clinical leaders

J Trauma. 2008 Dec;65(6):1309-13. doi: 10.1097/TA.0b013e31815e40cd.


Background: The evidence-based Scandinavian Guidelines for the Initial Management of Minimal, Mild, and Moderate Head Injuries were developed to provide safe and cost-effective assessment of patients. A survey based on a questionnaire directed to clinical managers in all Norwegian hospitals indicated that the guidelines had influenced management practice significantly. However, implementation of guidelines and compliance from clinical leaders does not necessarily influence individual physicians decisions making.

Methods: To evaluate physicians-compliance with the Scandinavian Guidelines in individual patients, we conducted a study (January 2003 to January 2004) that included all patients with minimal, mild, and moderate head injury who presented to the emergency department in a Norwegian university hospital. Guideline compliance was evaluated in the assessment and treatment of 508 patients. The management of each single patient was classified as compliant with the guidelines or not. Classification as compliant required correct use of computed tomography (CT) and hospital admission in accordance with the guideline.

Results: The overall physicians-compliance with the Scandinavian Guidelines was 51%. A substantial overtriage with unnecessary CT examinations and hospital admissions was seen in patients with minimal and mild head injuries. Among patients with minimal head injury, 69% underwent overtriage, 18% with unnecessary hospital admission, 27% with unnecessary CT, and 24% with both. Among patients with mild head injury, 37% were subject to overtriage, all with admission for observation after a negative CT. All patients with moderate head injury were treated in accordance with the guideline.

Conclusion: Guidelines for assessment and treatment of minimal and mild head injuries may not have the intended degree of influence on clinical practice. Even in departments where clinical managers report that the practice is evidence based, physicians may not act in accordance with this in their daily practice. This causes significant unnecessary costs, estimated as USD 2,167.000 annually in Norway.

MeSH terms

  • Algorithms
  • Brain Injuries / classification
  • Brain Injuries / diagnostic imaging*
  • Brain Injuries / therapy
  • Evidence-Based Medicine / statistics & numerical data*
  • Glasgow Coma Scale
  • Guideline Adherence / statistics & numerical data*
  • Hospitals, University
  • Humans
  • Norway
  • Practice Guidelines as Topic
  • Prospective Studies
  • Tomography, X-Ray Computed*
  • Triage