The application of clinical guidelines for skull radiography in the Accident and Emergency department: theory and practice.

Clinical guidelines for the selection of patients with head injuries for skull radiography, based on those formulated by the Royal College of Radiologists, were introduced into the Accident and Emergency department at the Manchester Royal Infirmary. Before the guidelines were implemented 94 skull X-rays were obtained per 1000 new casualty attenders. After implementation the rate of skull radiography initially fell by 40%, but thereafter slowly increased so that 12 months later it had returned to the pre-implementation level. During the first and second 6 months of the study reductions of 37% and 17%, respectively, were achieved. Although the overall annual reduction was only 27% an estimated saving of almost 10,000 pounds was made. Although clinical guidelines for skull radiography can reduce the number of skull radiographs without detriment to the care of the head-injured patient, their constant use is difficult to sustain. The application of clinical guidelines needs regular monitoring. Referring clinicians and radiologists need to be strongly motivated if such guidelines are to find a useful place in clinical management.