Title : Compliance with the liverpool Head Injury Tomography (HIT) score in neurosurgical referral decisions for patients admitted under general surgery: A closed-loop audit
Abstract:
Introduction: The Liverpool Head Injury Tomography (HIT) score is a validated tool that stratifies patients with CT-confirmed traumatic brain injury by their need for neurosurgical intervention, supporting the decision to refer to neurosurgery (HIT >2) or manage locally with neuro-observation (HIT <3). Accurate application reduces both missed referrals of high-risk patients and unnecessary referrals that burden neurosurgical services and delay care. This audit assessed local concordance between HIT score and referral practice in patients admitted under general surgery, and whether low-score patients could be safely managed locally.
Aims: To evaluate whether neurosurgical referral decisions for patients with traumatic intracranial findings on CT were concordant with the HIT score (against a standard of 100% appropriate management), and to assess whether patients with low HIT scores were safely managed locally without complications requiring transfer.
Methods: A retrospective audit was conducted at a single district general hospital over 3 months. Consecutive patients with head injury and acute traumatic findings on CT who were admitted under general surgery for local management were identified. For each patient, the HIT score was calculated from radiological findings, and the resulting recommendation (refer if >2; local management if <3) was compared with the actual referral decision. Outcomes of patients with low HIT scores were reviewed to identify any deterioration or complication requiring subsequent neurosurgical transfer.
Results: Thirty-one patients were included. Fifteen (48%) had a HIT score >2, indicating a need for neurosurgical referral; 14 of these (93%) were appropriately referred. Of the 16 patients with a HIT score <3 suitable for local management, 7 (47%) were referred to neurosurgery despite not meeting the threshold. Overall, 23 of 31 patients (74%) were managed in concordance with the HIT score, the predominant deviation being over-referral of low-risk patients rather than failure to refer high-risk patients. No patient with a low HIT score deteriorated or required transfer to neurosurgery, supporting the safety of local management in this group.
Conclusion: Compliance with referring high-risk patients was good, and low-score patients were safely managed locally, supporting use of the HIT score to guide referral. However, a substantial proportion of low-risk patients were referred unnecessarily, representing avoidable neurosurgical workload. A combined intervention of departmental teaching and an integrated HIT score prompt within the CT reporting and referral pathway was introduced to improve appropriate use of the score. A second cycle is currently underway to assess its impact.
