Table 1 Key clinical recommendations in the management of mild traumatic brain injury in emergency departments

Post-traumatic amnesia should be prospectively assessed in the emergency department using a validated tool

Post-traumatic amnesia (PTA) is defined as "an interval during which the patient is confused, amnestic for ongoing events and likely to evidence behavioural disturbance" [13]. It may manifest as repetitive questioning or short-term memory deficits [14] and has been shown to have better predictive ability with clinical outcomes compared with Glasgow Coma Scale (GCS) [15–18] (GCS assesses consciousness but not whether the patient is able to lay down new memories). Various validated tools to asses PTA are available such as the Revised Westmead PTA tool, or the Abbreviated Westmead PTA scale (A-WPTAS), the latter being an extended version of the GCS and specifically developed for use in the emergency department (ED). The A-WPTAS standardises some of the questions of the GCS and adds a memory test. Screening for PTA using such a validated tool may reduce the risk of failing to classify mild traumatic brain injury (mTBI) patients and prevents patients from being discharged from hospital while they are suffering from acute cognitive impairment [19, 20].

A retrospective audit in two Australian EDs showed rates of assessment of PTA in adults (for those with an initial GCS of 14 or 15) as 0% (95% CI 0% to 14%; n = 24) in one hospital, and 31% (95% CI 24% to 39%; n = 164) for a second (which had a protocol in place) (Bosch M, McKenzie J, unpublished observations). We are not aware of any published studies reporting rates in adults.

Guideline-developed criteria or clinical decision rules should be used to determine the appropriate use and timing of computed tomography imaging

The aims of using clinical decision rules to determine the need for a computed tomography (CT) scan are to ensure patients at risk of developing intracranial injuries receive a scan, and to decrease unnecessary scanning. Several clinical decision rules have been developed worldwide, some of which have been externally validated, most notably the Canadian Computed Tomography Head Rule (CCTHR) [21] and the New Orleans Criteria [22]. However, both these rules used loss of consciousness or amnesia as entry criteria, which means they could not be reliably used for all patients presenting to the ED with a head injury. Studies show that intracranial complications can also occur without loss of consciousness/PTA, particularly in the presence of other risk factors [23–25]. Therefore, more recent guidance has been developed that is applicable to all patients irrespective of presence or absence of loss of consciousness/PTA [4, 14, 26]. Most evidence-based clinical practice guidelines for the management of patients with mTBI have adapted one or more of these rules. They show considerable concordance [27]. The Institute for Trauma and Injury Management, New South Wales, developed simple recommendations for the identification of high risk patients based on the presence of single criteria that are applicable in the Australian setting [14].

It is difficult to establish target rates for appropriate CT scanning in patients with mTBI (that is, the percentage of mTBI patients who should receive a scan) because this is dependent on the case mix of patients (for example, hospitals that service an older demographic may (appropriately) have higher CT scanning rates for mTBI patients) and the leniency of the rules or guidelines. A study comparing percentages of scans that would be required by applying six different rules found rates between 50% and 71% [28]. A Canadian study using the CCTHR estimated a rate as low as 62.4% was possible and safe [29].

Estimates of how frequently appropriate decisions are made about the need for CT scanning (in populations with slightly variable definitions and using several different rules) range from 66% in the UK [30], 73% in Scandinavia [31], 82.5% in Canada [29], 80% and 92% in indigenous and non-indigenous Australians [32], and 65% to 91% in the US [33].

A study [34] surveying Australian ED physicians (response rate 54.2%, n = 417) showed that 82% had awareness of CCTHR but only 32% used it.

Verbal and written patient information consisting of advice, education and reassurance should be provided upon discharge from the emergency department

Providing patients with information upon discharge serves two purposes: 1) to inform the family/carer about what to observe and what actions to take if the patient’s neurologic condition deteriorates significantly after discharge from the ED [35]; and 2) to provide information regarding post-concussive symptoms, symptom management, and prevention of future head injuries [36–39]. A randomised controlled trial [40] of 202 adults with mTBI in Australia evaluated the impact of patient information (booklet) on outcomes. The booklet outlined common symptoms associated with mTBI, their likely time course and suggested coping strategies. By 3 months, the intervention group had lower scores on most items on a post-concussion checklist, significantly so for anxiety (P < 0.04) and sleeping difficulty (P < 0.01). They also had lower scores on a ‘global severity’ score. There was no statistical difference between the groups on formal neuropsychological assessment.

Studies show that a large proportion of mTBI patients do not receive written information upon discharge from the ED, ranging from 36% [41] and 51% [30] in the UK, to 63% in the US [42].

Studies looking at the quality and content of discharge pamphlets [35, 37, 38, 43] found that the information regarding post-concussive symptoms and reassurance is missing in 41% [37] to 60% [38] of pamphlets reviewed.

One study surveyed nurses (25% response rate) regarding their teaching habits [36], and concluded that in general they were more focused on providing injury-specific information and less on mTBI, symptom management or strategies to prevent future brain damage.