title: 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%.
  
  
  CONCLUSIONS
  The KHR is an accurate, unifying clinical guideline that appears to optimise the utilisation of CTB in a resource-limited environment.
authors.affiliation: Division of Radiodiagnosis, Department of Medical Imaging and Clinical Oncology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa. fouriebez@yahoo.com.
authors.forename: A Fourie
authors.initials: AF
authors.lastname: Bezuidenhout
authors.forename: Delme
authors.initials: D
authors.lastname: Hurter
authors.forename: Arthur T
authors.initials: AT
authors.lastname: Maydell
authors.forename: Francois
authors.initials: F
authors.lastname: van Niekerk
authors.forename: Sonia A B
authors.initials: SA
authors.lastname: de Figueiredo
authors.forename: Justin
authors.initials: J
authors.lastname: Harvey
authors.forename: Adriaan J
authors.initials: AJ
authors.lastname: Vlok
authors.forename: Richard D
authors.initials: RD
authors.lastname: Pitcher
mesh_terms: D000293:Adolescent; D000328:Adult; D001921:Brain / Q000000981:diagnostic imaging*; D002985:Clinical Protocols; D006259:Craniocerebral Trauma / Q000000981:diagnostic imaging*; D003627:Data Interpretation, Statistical; D061345:Early Medical Intervention / Q000191:economics / Q000379:methods / Q000592:standards; D004632:Emergency Medical Services / Q000191:economics / Q000379:methods / Q000592:standards; D005260:Female; D015600:Glasgow Coma Scale; D006295:Health Resources; D006801:Humans; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D013019:South Africa; D014057:Tomography, X-Ray Computed / Q000191:economics / Q000379:methods / Q000592:standards