The Kimberley Hospital Rule (KHR) for urgent computed tomography of the brain in a resource-limited environment

Abstract

Background. The indications for urgent computed tomography of the brain (CTB) in the acute setting are controversial. While guidelines have been proposed for CTB in well-resourced countries, these are not always  appropriate for resource-limited environments. Furthermore, no unifying guideline exists for trauma-related and non-trauma-related acute  intracranial pathology. Adoption by resource-limited countries of more conservative scanning protocols, with outcomes comparable to  well-resourced countries, would have significant benefit. A multidisciplinary team from Kimberley Hospital in the Northern Cape Province of South Africa adopted the principles defined in the National Institute for Health and Care Excellence (NICE) guideline for the early management of head injury and drafted the Kimberley Hospital Rule (KHR), a proposed unifying guideline for the imaging of acute intracranial pathology in a resource-limited environment.
Objective. To evaluate the sensitivity and specificity of the KHR.
Methods. A prospective cohort study was conducted in the Northern Cape Province between 1 May 2010 and 30 April 2011. All patients older than 16 years presenting to emergency departments with acute intracranial  symptoms were triaged according to the KHR into three groups, as follows: group 1 – immediate scan (within 1 hour); group 2 – urgent scan (within 8 hours); and group 3 – no scan required. Patients in groups 1 and 2 were studied. The primary outcome was CTB findings of clinically significant   intracranial pathology requiring acute change in management.
Results. Seven hundred and three patients were included. The KHR achieved 90.3% sensitivity and 45.5% specificity, while reducing the  number of immediate CTBs by 36.0%.
Conclusion. The KHR is an accurate, unifying clinical guideline that appears to optimise the utilisation of CTB in a resource-limited environment.