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SW Initiative For Traumatic Intracranial Event Evaluation (SWIFTIEE)

An innovative regional pilot, supporting more effective management of minor traumatic brain injury (mTBI) patients with abnormalities on CT Head scans and improving hospital flow.



Background

The number of emergency department attendances has been steadily rising over the last decade. According to NHS Digital, there were 27.4 million attendances in Accident & Emergency (A&E) departments across England in 2024-25. This is an increase of 4 per cent compared with 2023-24 (26.3 million attendances) and an increase of 27.4 per cent compared with 2011-12 (19.8 million attendances).

Head injuries constitute a large proportion of presentations in A&Es. Each year, more than 1 million people present with a head injury in emergency departments across England and Wales (National Institute for Health and Care Excellence [NICE]).

Management of head injuries is based on the NICE NG232 "Head Injury: assessment and early management" guidance. While it is well-established, there are several areas within the document that are subject to local or individual interpretation, namely:

  • Paragraph 1.5.9 - definition of a "dangerous mechanism of injury"

  • Paragraph 1.4.15 - definition of "surgically significant" abnormalities on imaging that warrant a discussion with a neurosurgeon

  • Paragraph 1.9 - definition of "clinically important" abnormalities on imaging that would warrant a hospital admission after a head injury

The SWIFTIEE pilot aims to address these areas of ambiguity and to complement the NICE NG232 guidance by:

  • Introducing a robust framework to support distinction between radiologically visible and clinically significant findings

  • Informing decision-making in the context of abnormal CT Head scans in patients with mTBI

  • Introducing evidence-based standardisation for recommendations regarding hospital admissions



Clinical evidence

The SWIFTIEE pilot's algorithm is based on the Brain Injury Guidelines (BIG) criteria that have been developed and subsequently updated to modified Brain Injury Guidelines (mBIG).

Please refer to the following articles for more information on BIG and mBIG:

  • Joseph, Bellal MD; Friese, Randall S. MD; Sadoun, Moutamn MD; Aziz, Hassan MD; Kulvatunyou, Narong MD; Pandit, Viraj MD; Wynne, Julie MD; Tang, Andrew MD; O’Keeffe, Terence MB, ChB; Rhee, Peter MD. The BIG (brain injury guidelines) project: Defining the management of traumatic brain injury by acute care surgeons. Journal of Trauma and Acute Care Surgery 76(4):p 965-969, April 2014 (Click here to access)

  • Joseph, Bellal MD, FACS; Obaid, Omar MD; Dultz, Linda MD; Black, George MD; Campbell, Marc DO; Berndtson, Allison E. MD; Costantini, Todd MD; Kerwin, Andrew MD; Skarupa, David MD; Burruss, Sigrid MD; Delgado, Lauren NP; Gomez, Mario DO; Mederos, Dalier R. MD; Winfield, Robert MD; Cullinane, Daniel MD; the AAST BIG Multi-institutional Study Group. Validating the Brain Injury Guidelines: Results of an American Association for the Surgery of Trauma prospective multi-institutional trial. Journal of Trauma and Acute Care Surgery 93(2):p 157-165, August 2022 (Click here to access)

  • Khan AD, Elseth AJ, Brosius JA, Moskowitz E, Liebscher SC, Anstadt MJ, Dunn JA, McVicker JH, Schroeppel T, Gonzalez RP. Multicenter assessment of the Brain Injury Guidelines and a proposal of guideline modifications. Trauma Surg Acute Care Open. 2020 May 28 (Click here to access)



The SWIFTIEE pathway

The SWIFTIEE pathway consists of two key elements:

  1. Abnormal CT Head scans are now being classified into three categories based on defined radiological criteria: mBIG1, mBIG2 or mBIG3.

2. The radiological mBIG category is subsequently combined with additional clinical criteria (anticoagulation status and intoxication status) to determine the overall clinical mBIG score: mBIG1, mBIG2 or mBIG3.

If the overall clinical score is:

  • mBIG3: the patient needs to be referred to neurosurgery for a bespoke management plan

  • mBIG2: (A) the patient requires local admission for 48 hours for neuro-observation as per NICE NG232 guidance and (B) the patient needs to be referred to the SWIFTIEE service. The patient will be contacted by the SWIFTIEE Service Lead approximately 5-7 days after the patient has been discharged from the hospital to ensure the patient is recovering well

  • mBIG1: (A) the patient can be discharged home straight from the ED 6 hours after the first observation and (B) the patient needs to be referred to the SWIFTIEE service. The patient will be contacted by the SWIFTIEE Service Lead at two points in time - the next day after the patient has been discharged from the hospital and approximately 5-7 days after the discharge to ensure the patient is recovering well

Please visit the ODN Members Area > SW Neurosurgery ODN resources section to view the SWIFTIEE documentation, including the SWIFTIEE clinical protocol, Radiology poster and ED Workflow poster.



Results to date

The SWIFTIEE pilot went live across the South West region in November 2025. Within the first 5 months, this improvement project has already proven to be a great success:

  • Between November 2025 and March 2026, more than 100 patients have been referred to the SWIFTIEE service

  • More than 60 mBIG1 patients were safely discharged home straight from the ED, avoiding a 48-hour admission

  • The SWIFTIEE service is also contributing to improved patient experience. Our patients highlight that the telephone follow-up calls with the SWIFTIEE Service Lead offer them reassurance, and that they much prefer to be recovering in the comfort of their own home rather than on a hospital ward

If you would like to learn more about the SWIFTIEE pilot, please get in touch through the Contact Us section.