Explainer: The South West Initiative for Traumatic Intracranial Event Evaluation (SWIFTIEE)

Executive Summary

This document outlines the South West Initiative for Traumatic Intracranial Event Evaluation (SWIFTIEE), a new regional protocol for managing adult patients with minor traumatic brain injuries (MTBI) who have abnormalities on CT head imaging. The initiative aims to standardise care, improve hospital flow, and enhance patient safety by addressing ambiguities in current NICE NG232 guidance regarding the definition of 'surgically significant' and 'clinically important' radiological findings.

The core of the SWIFTIEE protocol is the implementation of the Modified Brain Injury Guidelines (mBIG), an evidence-based framework that stratifies patients into three categories (mBIG1, mBIG2, mBIG3) based on specific CT head findings. This stratification directs clinicians to clear, standardised management pathways:

mBIG1: Safe discharge from the Emergency Department (ED) with structured telephone follow-up.
mBIG2: Local admission for a 48-hour observation period.
mBIG3: Immediate referral to neurosurgery.

By implementing this protocol, the South West region aims to avoid an estimated 1,098 unnecessary admissions and save over 2,000 bed days annually, resulting in a projected cost saving of £2.26 million per year. The protocol introduces a new safety-netting process involving specialist-led telephone reviews and long-term electronic patient-reported outcome measures (ePROMS), improving post-discharge care and reducing the burden on primary care. The service is scheduled to go live on Monday 10th November 2025.

Definition and Classification

A Minor Traumatic Brain Injury (MTBI) is caused by the rapid acceleration and deceleration of the brain within the skull, which can occur from blunt force or a sudden change of direction, even without a direct blow to the head or loss of consciousness. This movement can cause bruising and a temporary disruption to brain function. While a head injury does not always lead to a brain injury, approximately 50% of individuals with an MTBI will experience some subsequent symptoms.

The SWIFTIEE protocol introduces a standardised classification system based on the validated Modified Brain Injury Guidelines (mBIG) to risk-stratify patients with abnormal CT head scans, thereby guiding management decisions.

Epidemiology & Aetiology

Incidence: In England and Wales, approximately 1.4 million people attend Emergency Departments annually with a recent head injury. Of these, 90% are classified as minor head injuries (1).
Aetiology: Common causes include falls, assaults, sports injuries, and road traffic accidents. The underlying mechanism is the rapid acceleration and deceleration of the brain within the skull.
Pathology: The injury can cause bruising and temporary disruption to cerebral function. Macroscopic pathological findings visible on CT imaging form the basis of the mBIG risk stratification.
Risk Stratification: The SWIFTIEE protocol uses the mBIG criteria to stratify patients based on CT head findings into three management groups. The original mBIG criteria have been slightly altered for this protocol by removing the depth criteria for Subarachnoid Haemorrhage (SAH), based on communication with the lead author of the validation paper (2).

mBIG Category	Radiological Findings
mBIG1	Subdural Haematoma (SDH) ≤4mm Intraparenchymal Haemorrhage (IPH) ≤4mm Subarachnoid Haemorrhage (SAH) in ≤3 sulci
mBIG2	Non-displaced skull fracture SDH 4–7.9mm IPH 4–7.9mm SAH in 1 hemisphere, affecting >3 sulci
mBIG3	Extradural Haematoma (EDH) Intraventricular Haemorrhage (IVH) Displaced skull fracture SDH ≥8mm in depth IPH ≥8mm or multiple IPH Bi-hemispheric SAH

Prognosis: Most patients with an MTBI are expected to fully recover within two to three months. Recovery is aided by adequate rest and a gradual resumption of normal activities.

Clinically Relevant Anatomy

The mBIG classification system is based on the anatomical location and size of traumatic intracranial pathology. Key structures involved include:

Meningeal Spaces: Extradural, subdural, and subarachnoid spaces, where haematomas or haemorrhages can occur.
Cerebral Parenchyma: The brain tissue itself, which can sustain intraparenchymal haemorrhages or contusions.
Ventricular System: The ventricles of the brain, where intraventricular haemorrhage may occur.
Cranium: The skull, which can sustain non-displaced or displaced fractures.

Clinical Assessment

Patients presenting with a head injury will undergo standard assessment in the ED as per Head injury & Assessment NICE NG232 guidance.

History

Key historical points include the mechanism of injury, presence of intoxicants (drugs or alcohol), and current use of any anticoagulant or antiplatelet medications (including aspirin and clopidogrel), as these are critical modifiers of the management pathway.

Physical Examination (ABCDE Approach)

Airway, Breathing, Circulation: Standard resuscitation and assessment apply.
Disability: This is a critical component of the assessment.
- Glasgow Coma Scale (GCS): Patients must present with a GCS of 13-15 (or their normal baseline) and must have returned to GCS 15 (or their normal baseline) before discharge can be considered.
- Pupils: Assess for and document any pupillary abnormalities.
- Focal Neurology: A thorough neurological examination is required to identify any focal deficits. The presence of focal neurologic findings is a contraindication to early discharge.
Exposure: A full secondary survey should be conducted to identify any other injuries or pathologies that may necessitate hospital admission independent of the head injury.

Signs and Symptoms

It is crucial to differentiate between "red flag" symptoms indicating potential deterioration and common, expected symptoms during recovery.

Red Flag Symptoms Requiring Immediate Return to ED or 999 Call

Loss of consciousness
Drowsiness when normally awake or being un-wakeable
New deafness in one or both ears
Clear fluid from the nose or ears (or a salty taste at the back of the throat)
Bleeding from one or both ears
Weakness, numbness, or problems with co-ordination/dizziness
Vomiting
Increasing disorientation, confusion, or problems with speech/understanding
Persistent blurred or double vision
Severe headaches persisting despite simple analgesia
Neck stiffness
Fits or seizures

Common Symptoms During Recovery from MTBI

Mild headache
Dizziness and nausea (without vomiting)
Sensitivity to light and noise
Sleep disturbance, fatigue, and needing more sleep
Irritability, restlessness, impulsivity, or self-control problems
Feeling depressed, tearful, or anxious
Difficulties with concentration, memory, planning, and problem-solving

Investigations

CT Head Scan: The primary investigation for patients with suspected TBI meeting NICE NG232 criteria. Teleradiology providers (Everlight, Medica, TMC) have agreed to include the mBIG score in their reports to streamline the ED workflow.
Biomarkers: As part of the protocol's research arm, point-of-care biomarker testing for GFAP & UCH-L1 will be introduced at Bristol and Plymouth to investigate their potential to refine CT imaging decision-making in the future.

Management and Treatment

Management is dictated by the mBIG classification from the CT head report, in conjunction with the patient's clinical status.

mBIG1 Pathway

This pathway is for patients with minimal radiological findings who are clinically stable.

Action: Discharge from ED and refer to the SWIFTIEE service via the Referapatient platform.
Key Inclusion Criteria for Discharge:
- GCS returned to 15 or normal baseline.
- No focal neurologic or pupillary abnormalities.
- No other injuries, pathology, or social factors requiring admission.
- A responsible adult is available to observe the patient for the first 24 hours.
Exclusions / Cautions:
- Anticoagulants or Antiplatelets: These patients are excluded from immediate discharge and should be admitted locally for 48 hours.
- Intoxication: These patients require a 6-hour observation period post-scan. Discharge can proceed if they meet all other criteria and a senior clinical review at 6 hours is satisfactory.
Follow-up: Patients receive a telephone call from the SWIFTIEE clinical team on the day after discharge and again between days 5 and 7 post-injury.

mBIG2 Pathway

This pathway is for patients with moderate radiological findings.

Action: Admit to local hospital for a 48-hour observation period and refer to the SWIFTIEE service via Referapatient.
Inpatient Management: Low molecular weight heparin (LMWH) for VTE prophylaxis should be withheld for the first 48 hours.
Follow-up: These patients receive the same telephone and ePROMS follow-up as the mBIG1 group upon discharge.

mBIG3 Pathway

This pathway is for patients with significant radiological findings.

Action: Follow normal standard of care. Refer to Neurosurgery via the Referapatient platform for a bespoke management plan.

General Discharge Advice for Patients

Patients discharged from the ED should be provided with the Patient Information Leaflet and advised:

DO: Rest, stay hydrated, use simple analgesia (e.g., paracetamol), and gradually resume activities.
DO NOT: Drive, operate machinery, consume alcohol or illicit drugs, or play contact sports for at least 3 weeks. Avoid taking sleeping pills or sedatives unless prescribed by a doctor.
Crucial Safety Netting: The patient must not be alone for the first 48 hours and must remain within easy reach of a telephone and medical help.

Complications

Condition-Related Complications

Immediate/Early: Neurological deterioration is the primary concern. The "Red Flag" symptoms listed previously are indicators of potential deterioration and mandate immediate medical review.
Delayed: Post-concussive symptoms (headache, dizziness, fatigue, cognitive difficulties) are common and can persist. If symptoms do not resolve after two weeks, the patient should be advised to contact their GP. The SWIFTIEE follow-up service is designed to identify and support patients with persistent symptoms.

Management-Related Complications

The SWIFTIEE protocol aims to mitigate complications associated with unnecessary hospital admission, particularly for older people and those living with frailty. These risks include deconditioning, delirium, and hospital-acquired infections.

References

NICE. Head injury: assessment and early management. National Institute for Health and Care Excellence. 2023.
Khan AD, Elseth AJ, Brosius JA, et al. Multicentre assessment of the Brain Injury Guidelines and modifications. Trauma Surg Acute Care Open. 2020.
Joseph B, Obaid O, Dultz L, et al. Validating the Brain Injury Guidelines. J Trauma Acute Care Surg. 2022.
Kay AB et al. First steps towards a BIG change: A pilot study to implement the Brain Injury Guidelines across a 24-Hospital System. American Journal of Surgery. 2023.
Sweeney JF et al. Utilization of the Modified Brain Injury Guidelines by Neurosurgeons to Improve Traumatic Brain Injury Patient Throughput at a Level 1 trauma Center: A Retrospective Observational Study. World Neurosurgery. 2024.
Khan AD, Lee J, Galicia K, Billings JD, Dobaria V, Patel PP, McIntyre RC, Gonzalez RP, Schroeppel TJ. A multicenter validation of the modified brain injury guidelines: Are they safe and effective? J Trauma Acute Care Surg. 2022 Jul 1;93(1):106-112.
Marincowitz C, Lecky FE, Townend W, et al. Clinical decision rules for early discharge of minor TBI patients. Journal of Neurotrauma. 2020.
Southerland LT, Alnemer A, Laufenberg C, Nimjee SM, Bischof JJ. The Brain Injury Guidelines (BIG) and emergency department observation and admission rates: A retrospective cohort study. The American Journal of Emergency Medicine. 2024;82:37-41.

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Appendix: Example EPIC EHR Documentation Template

This patient presented with a minor traumatic brain injury. The CT head demonstrates findings consistent with mBIG1 criteria. The patient meets all criteria for safe discharge from the Emergency Department as per the SWIFTIEE regional protocol.

Discharge Checklist (mBIG1 Patients Only):
• [ ] CT confirmed mBIG1.
• [ ] Patient is NOT on anticoagulants or antiplatelets.
• [ ] Patient is NOT clinically intoxicated
• [ ] GCS has returned to 15 or normal baseline.
• [ ] No focal neurologic or pupillary abnormalities on examination.
• [ ] No other injuries, pathology, or social factors identified that require admission.
• [ ] A responsible adult is present to observe the patient for the next 24-48 hours.
• [ ] Has been observed for 6 hours post injury
• [ ] Senior clinical review satisfactory and agrees with discharge plan.

Discharge & Follow-Up Plan
• Disposition: Discharged home with a responsible adult.

Referrals:
◦ [ ] SWIFTIEE Service referral completed via Referapatient.

- [ ] Contact details confirmed.

Patient Education:
◦ [ ] Patient Information Leaflet provided and key points discussed.
◦ [ ] Emphasised red flag symptoms and when to call 999 or return to ED.
◦ [ ] Advised that the SWIFTIEE clinical team will telephone them tomorrow and again in 5-7 days.
◦ [ ] Provided with advice regarding gradual return to activity, avoiding alcohol, driving, and contact sports.

**(Cut and paste the following into the discharge summary)**

The patient and their accompanying responsible adult have been counselled on the diagnosis (minor traumatic brain injury), expected recovery, and the SWIFTIEE follow-up process.

They have verbalised understanding of all safety netting advice, including red flag symptoms requiring immediate return to the ED.

A physical or electronic copy of the patient information leaflet has been provided which also explains these points and additional copies of this information can be obtained from this website:
Link to Patient Information Leaflet:

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Link to the SWIFTEE Website SWIFTIEE

Especially of relevance is the ED Workflow Poster