• R Thomson, J Gray, R Madhok, A Mordue, and A D Mendelow.
• Medical School, University of Newcastle upon Tyne.
• Qual Health Care. 1994 Jun 1;3(2):86-91.

ObjectiveTo compare record keeping and decision making in accident and emergency departments before and after distribution of guidelines on head injury management as indices of implementation.DesignBefore (1987) and after (1990) study of accident and emergency medical records.SettingTwo accident and emergency departments in England.Patients1144 adult patients with head injury in department 1 (533 in 1987, 613 in 1990) and 734 in department 2 (370, 364 respectively).Main MeasuresRecording of relevant symptoms and signs as determined in the guidelines; presence of, indications for, and rates and appropriateness of skull x ray examination and admission.ResultsThe median number of guidelines variables recorded for all study periods ranged from 7 to 9 out of a possible maximum of 27. For key decision making variables the presence or absence of penetrating injury was least likely to be recorded (< or = 1%) and that of loss of consciousness most likely (> or = 75%). Altogether, the proportion of patients receiving skull x ray examination or admitted varied from 25%-60% and 7%-23% respectively; overall, 69% (1280/1856) and 64% (1177/1851) of patients were managed appropriately. However, no consistent change occurred in the departments between the study periods. For instance, in department 1 the proportion of appropriate x ray examinations rose significantly after distribution of the guidelines (from 61% (202/330) to 73% (305/417)) and appropriate decisions on whether to x ray or not also rose (from 65% (340/522) to 72% (435/608)). There was no significant change in department 2, although the proportion of appropriate admissions fell (from 33% (55/166) to 15% (19/130)).ConclusionsRecording practice and decision making were variable and had not consistently improved after dissemination of the guidelines. Strategies are required to ensure effective implementation of guidelines.

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