Aims. Background. The aims of this report are to:

Transcription

1 COMMENTARY Aims The aims of this report are to: establish current practice in the provision of services for the management of patients with head injuries in the United Kingdom and the Republic of Ireland; identify any deficiencies in the provision of these services; assess the magnitude of the problem and resulting morbidity; make recommendations to correct these deficiencies and to monitor outcome; and update the guidelines on The Provision of Surgical Services to Patients with Head Injuries (published by The Royal College of Surgeons of England in 1986). Background There are approximately one million patients in the United Kingdom who present to hospitals each year with head injuries. Almost half are under 16 years old. Many patients are left with significant behavioural, cognitive, emotional and physical damage, resulting in severe social and economic effects including marital breakdown, loss of employment and dependence on social services, at significant cost to the community at large. Some 63% of adult patients who sustain moderate head injuries and 85% of patients who sustain severe head injuries remain disabled one year after their accident. Even patients with minor head injuries have problems. Three months after sustaining minor head injuries, 79% have persistent headaches, 59% have memory problems and 34% are still unemployed. Only 45% of patients who have sustained a minor head injury have made a good recovery one year after admission.* The resources available, in terms of manpower, facilities and beds, for treating these patients and for the training of the medical staff who care for them are inadequate. On reviewing the current treatment of head-injured patients, it would seem that only two groups of doctors are being trained in the immediate/early management of such cases, those working in accident and emergency (A&E) medicine and the * The British Society of Rehabilitation Medicine. Rehabilitation after Traumatic Brain Injury. London; This document defines the scale of head injuries as follows: Mild=Glasgow Coma Score (GCS) 13-15; Moderate=GCS 9-12; Severe=GCS less than 9. 1

2 neurosciences. It would therefore seem reasonable that these specialties should be responsible for the care of the head-injured patient in the future. Organisation of Care The overall care of patients with head injuries should be within the remit of regional or sub-regional neuroscience departments, but no single specialty is able to treat all aspects of a patient with a head injury. However, each department of neurosciences (which must include neurosurgeons, neuroanaesthetists, neuroradiologists, neurologists, neuropsychologists and rehabilitationists) should take responsibility for and oversee the organisation and management of all patients with head injuries within their region or subregion. This will require additional resources. ACCIDENT AND EMERGENCY DEPARTMENTS All patients with head injuries report initially to the A&E department. Consultants in A&E medicine have the responsibility for initial patient assessment and specialist registrars are being trained to assess these patients competently as part of their training programme. It is the responsibility of the A&E department to determine: which patients can go home without admission to hospital; which patients with a relatively minor injury require admission to a hospital for a short period, ie not more than 48 hours; which patients require transfer to a neurosurgical unit and may require neurosurgery; after discussion with neurosurgeons, which severely head-injured patients do not require neurosurgical intervention but do require admission to an intensive care unit; which other severely head-injured patients require admission to a neuroscience unit; and which accompanying injuries require the involvement of other specialties. Because A&E departments must take responsibility for these initial decisions as part of their routine work, experience in the management of head injuries is now a recommended part of the training of doctors in A&E medicine. It is reasonable and appropriate for A&E departments to admit and supervise headinjured patients for up to the first 48 hours, provided satisfactory facilities and suitably trained staff are available on-site. 2

3 Patients with minor head injuries who require admission to hospital for up to 48 hours should be admitted under the care of the A&E department to an observation/ short-stay ward. A survey of A&E departments showed that most are inadequately resourced (para 4.1.1). A&E departments that receive head-injured patients must have an observation ward which must: be within or adjacent to the A&E department; be given adequate resources and beds; be appropriately staffed (both medical and nursing); and have a time limit of 48 hours, after which local arrangements must be made for the onward referral of patients not fit for discharge. Our survey also showed that most hospitals that receive head-injured patients are inadequately resourced (para 4.1.3), with only 79% of them being able to perform on-site CT head scanning 24 hours a day. All hospitals which admit and observe head-injured patients must have CT scanning facilities available 24 hours a day, seven days a week. Hospitals should not be allowed to receive patients with head injuries unless these facilities are available 24 hours a day. CARE OF PATIENTS REQUIRING A PERIOD OF OBSERVATION Our survey showed that only a minority of practising general and orthopaedic surgeons responsible for the in-patient care of patients with head injuries not requiring transfer to a neurosurgical unit have been trained in the management of head injuries. With the introduction of the new specialist registrar training programmes, general surgeons and orthopaedic surgeons will not be trained in the management of head injuries in future. It is our recommendation that patients should no longer be admitted under their care. Instead, those patients who need admission for up to 48 hours would be managed better under the care of A&E consultants and those who require continuing care should be the responsibility of the neurosciences department. Additional resources will be needed by both A&E departments and neurosciences units, if they are to be able to manage these patients. The morbidity and costs associated with head injuries are such that we would expect the resources to be made available within five years. The quality framework as described in A First Class Service: Quality in the New NHS demands that patients with head injuries are appropriately cared for and the requisite facilities are made available. NEUROSCIENCE UNITS The overall planning of the reception and treatment of patients with head injuries 3

4 should be the remit of the regional or sub-regional neurosciences centre. The neuroscience unit should formulate clearly defined protocols with each linked A&E department (in the area to which it is linked), indicating the subsequent pathways of patient referral consistent with nationally agreed guidelines. Neuroscience units at present lack adequate resources, especially with respect to neurosurgical beds (para 4.4). There should be sufficient neuroscience beds (including neurosurgical, neurointensive care and rehabilitation) to enable each A&E department to transfer patients who may require neurosurgical intervention to their linked neurosurgical unit at the appropriate time and for patients who require emergency decompressive surgery to undergo such surgery within four hours of the time of injury. Within departments of neuroscience, patients with head injuries requiring intervention (including neurosurgery, neurointensive care and rehabilitation) should be admitted to appropriate beds and units as follows: those patients requiring surgery must be admitted to neurosurgical beds; those patients requiring intensive care should be admitted to neurointensive care units; those patients requiring rehabilitation must be admitted into rehabilitation beds and not into acute neurosurgical, neurology or other acute beds; and those patients requiring neuropsychological management must be admitted to appropriate units. Appropriate criteria for admission and discharge for each category of patient should be established and local arrangements made for the onward referral of patients as required. For example, any patient who still requires hospitalisation in an acute hospital bed, after discharge from an Intensive Care Unit, should be admitted to the most appropriate unit, depending on the severity of their injuries and which injuries require continued hospitalisation (para 12.3). Neurosurgeons should be part of a multidisciplinary neuroscience unit that houses an intensive care unit with trauma beds and neuroanaesthetists. All neurosurgical units should be sited in major acute hospitals and should have input from neurosurgeons, neuroradiologists, neuroanaesthetists, rehabilitationists and neuropsychologists. Neurosurgeons should be available at all times for advice regarding patients with head injuries. Patients with multisystem severe injuries require treatment from a multidisciplinary team at major acute hospitals with the input of the full range of surgical, anaesthetic and imaging specialties. General surgeons and orthopaedic surgeons must retain a key role in the management of patients with multisystem injuries. 4

5 ELDERLY PATIENTS Elderly patients who do not require surgical intervention but are not fit for discharge after 48 hours should be transferred to the care of the local department of medicine for the elderly where there should be input from the local neurologist and rehabilitation unit where appropriate. CHILDREN Different arrangements should be made for children (under the age of 16). All children requiring admission, including those with any suspicion of non-accidental injury, should be admitted under the care of a paediatrician or paediatric surgeon trained in the care of children with head injuries. REHABILITATION There are inadequate resources, in terms of manpower and facilities, for rehabilitation and neuropsychological management (para 16) as a result of which many patients languish for months in acute hospital beds. This has two adverse effects. Firstly, the longer necessary treatment is delayed, the more intractable the problem becomes and the less likely the patient is to make a good recovery and become a useful member of the community. Secondly, acute beds are blocked, thus preventing their use by other patients who require admission to hospital. This lack of facilities also applies to rehabilitation in the community. MANAGEMENT OF PATIENTS IN REMOTE AREAS Surgeons in remote areas should be trained to treat patients admitted with head injuries and have the ability to carry out burr holes and craniotomies when necessary. These surgeons will need a specific period of training in neurosurgery after appointment to but before taking up their consultant posts. Such training would be provided in the form of a fixed-term training appointment. FOLLOW-UP OF PATIENTS All patients attending hospital with a head injury should be followed up. This includes those with minor head injuries who did not require in-patient admission. Such minor head injuries should be followed up by general practitioners. General practitioners, specialist nurses or neuropsychologists need to be informed which patients would benefit from specialist referral and to whom such referrals should be made. The minimum follow-up is a neurological and neuropsychological assessment which should be undertaken two to three months after the injury to determine whether the 5

6 patient has been left with any on-going symptoms (para 17). This assessment should be undertaken by suitably trained neuropsychologists and specialist nurses and need not involve neurologists, neurosurgeons or A&E consultants unless the patient has been left with any on-going symptoms, in which case the patient should be referred to the appropriately trained specialist. Community paediatricians or community paediatric nurses should follow up children following admission for head injury, but will require additional resources for this task. Training, Audit and Research Training in the assessment and management of patients with head injuries should be an essential component of the training of all doctors in A&E medicine, paediatrics, paediatric surgery and neurosciences, and should be part of their continuing professional development and education. Audit of the results (which are likely to depend on the severity of the case mix), treatments and the organisational pathway, is essential. Further research is required into the outcomes of all grades of head injury and their effects on patients of different ages and the costs, not only to the NHS but also to the community at large. Implementation The maintenance of the status quo in the provision of services to patients with head injuries is not a viable option. A strategic five-year implementation programme should be instituted as an urgent priority of the quality agenda. Medical directors and chief executives of Trusts and health authorities should view the recommendations of this report as a quality issue and take responsibility for implementing the changes under clinical governance. Those responsible for strategic health planning must seek to implement the recommendations of this report and provide the necessary resources and staffing levels to achieve them. Indeed, the Secretary of State for Health recently announced that additional funding will be made available to upgrade A&E departments and it is hoped that some of these monies will be used to provide improved facilities for patients with head injuries. 6

7 Neuroscience units must assume immediate responsibility for the co-ordination of the care of patients with head injuries within their catchment population and work with A&E departments, Trusts and health authorities and, for children, children s departments, local education authorities, and those responsible for strategic health planning to implement a five-year development programme. We have deliberately not proposed interim measures prior to the full implementation of the recommendations of this report because the Working Party feels that the report should be implemented in its entirety, although it is recognised that this may take several years. Individual specialties must work with all the other specialties involved in the management of patients with head injuries towards full implementation of the recommendations. For example, general surgeons should not attempt to withdraw from taking responsibility for patients with head injuries until such time as A&E departments have sufficient resources, staff and observation beds to assume this new role. However, it would be reasonable to pilot the recommendations in three regions without any delay. Resources In order to implement the recommendations of this report, significant increases are required in resources (in terms of both staffing levels and physical space/beds) in: A&E departments; observation wards; neuroscience units; neurointensive care units; and rehabilitation units. 7

8 SUMMARY OF KEY RECOMMENDATIONS THE OVERALL SYSTEM OF CARE Each A&E department should establish close relationships with a single neuroscience unit (para 23). In all but exceptional cases, patients needing neuroscience input should be referred to that unit. Each neuroscience unit, together with the host Trust and purchasers, should ensure that: an adequate referral system is in place for their catchment population; that local A&E departments work to agreed protocols on the initial assessment of all types of head injury; and that there are appropriate protocols for the safe transfer of patients between hospitals. PRE-HOSPITAL CARE The pre-hospital care of patients with head injuries should comply with the principles of the Pre-hospital Trauma Life Support (PHTLS) and the Pre-hospital Paediatric Life Support (PHPLS) courses (para 5). Patients should be transported smoothly and efficiently to the nearest appropriate receiving hospital without delay (para 5). Pre-hospital treatment must not be allowed to delay unduly the transfer of the patient to the nearest appropriate hospital (para 5). APPROPRIATE RECEIVING HOSPITALS An appropriate hospital to receive patients with head injuries is one that (para 6): complies with the recommendations of this report; has a 24-hour multidisciplinary resuscitative trauma team, as detailed in the report; has 24-hour head scanning, on-call radiologists and image transfer facilities; can transfer patients to a neuroscience unit according to recent guidelines; has an A&E department with properly resourced short-stay facilities; and has a paediatric in-patient service or suitable arrangements with a local children s department. 8

9 PATIENTS REQUIRING ASSESSMENT PRIOR TO DISCHARGE FROM A&E A&E departments should develop protocols with their linked neuroscience unit, consistent with national guidelines, to determine which patients with head injuries may be discharged directly from the department. These patients should be discharged to the care of a competent adult, who should be given written instructions on the circumstances that would necessitate re-attendance. PATIENTS REQUIRING A PERIOD OF OBSERVATION PRIOR TO DISCHARGE FROM HOSPITAL General and orthopaedic surgeons should normally no longer be involved in the care of patients requiring a short period of observation for an isolated head injury (para 9). This cannot occur immediately, however, but only after the full implementation of the recommendations of this report (para 9). Those adult patients with minor head injuries who need a period of observation would best be cared for under the auspices of the A&E department (para 9). Adult patients needing a period of observation must be admitted to a dedicated observation ward within or adjacent to the A&E department. This ward must be adequately resourced and appropriately staffed (para 9). Local policies, consistent with nationally agreed guidelines, must be developed with the linked neuroscience unit on the most appropriate management of patients who have not fully recovered within 48 hours (para 9). Agreed criteria for admission and discharge should be established, consistent with nationally agreed guidelines (para 9). All children (under 16) requiring admission should be admitted under the care of a paediatrician or a paediatric surgeon. Elderly patients who do not need surgical intervention but who are not fit for discharge after 48 hours should be transferred to the care of the local department of medicine for the elderly (para 9). PATIENTS NEEDING NEUROSCIENCE CARE The clinical management of patients with head injuries should be in accordance with the recommendations of the Society of British Neurological Surgeons (Appendix A). 9

10 Patients with severe head injuries or focal signs should be transferred to the care of neurosciences units regardless of whether they need surgical intervention (para 10). Patients needing ventilation and/or intra-cranial pressure monitoring should be transferred to intensive care units with on-site neurosurgeons and neuroanaesthetists (para 10). Neurosurgeons should work within a multidisciplinary neuroscience unit that has an intensive care unit with trauma beds and neuroanaesthetists. These units should be based on major acute sites and should have input from neurosurgeons, neurologists, neuroanaesthetists, neuroradiologists and specialists in rehabilitation medicine (para 10). An image transfer facility must be available between the district general hospital and the neuroscience unit (para 10). Neurosurgeons should be contactable at all times for advice regarding patients with head injuries (para 10). Neurosciences units should not be located on isolated sites (para 10). PATIENTS WITH SEVERE MULTIPLE INJURIES The management of these patients requires a multidisciplinary effort at a major acute hospital, with the input of the full range of surgical, anaesthetic and imaging specialties. General and orthopaedic surgeons should retain a key role in the management of patients with multisystem injuries, along with the full range of surgical specialties (para 12.3). TRANSFER ARRANGEMENTS Patient transfers should follow the agreed protocols (para 11). CHILDREN WHOSE HEAD INJURIES MAY BE THE RESULT OF CHILD ABUSE Children whose head injuries may be the result of child abuse should be admitted under the care of paediatricians (either solely, or jointly with paediatric neurosurgeons, paediatric surgeons or paediatric intensivists as appropriate) who can institute child abuse procedures as necessary. 10

11 PATIENTS NEEDING REHABILITATION AFTER SEVERE HEAD INJURY Patients needing rehabilitation require the expertise of trained rehabilitationists working in an adequately-resourced multidisciplinary rehabilitation unit. They should not be cared for on an acute general surgical, orthopaedic, neurosurgical or general medical ward whilst awaiting transfer to a rehabilitation unit (para 15). It is vital that there is early liaison with the local education authorities when a child needs rehabilitation. DISCHARGE OF PATIENTS FROM NEUROSURGICAL UNITS Resources and arrangements must be put in place for the appropriate care and rehabilitation of patients no longer requiring acute neurosurgical care (para 16). Patients no longer needing acute neurosurgical care should not be managed on acute neurosurgical, general surgical, orthopaedic or general medical wards (para 16.1). MANAGEMENT OF PATIENTS IN REMOTE CENTRES Surgeons working in remote centres should be trained to treat patients with head injuries and have the ability to perform burr holes/craniotomies when necessary. Such surgeons will need a specific period of training in neurosurgery prior to taking up their consultant posts (para 13). RECORD-KEEPING Standardised clinical record forms should be used wherever possible (paragraph 19). Examples are given in Appendix E. Standardised forms should be used to keep a permanent record of all telephone conversations (para 19). FOLLOW-UP OF PATIENTS WITH PERSISTING SYMPTOMS AFTER HEAD INJURIES Local arrangements should be established for the follow-up of patients who have sustained a head injury (para 17.2). Special arrangements should be made for the follow-up of children by community paediatricians (para 17.3). Information should be provided for general practitioners regarding the management of such patients, together with details of the local referral policies (para 17.2). 11

12 TRAINING All doctors likely to have to care for patients who have sustained head injuries should ensure that the appropriate aspects of management are included in training programmes and in continuing medical education (CME) (para 20). RESEARCH AND AUDIT Further resources and effort must be invested in research into the management of head injuries and audit of the outcomes achieved (para 22). IMPLEMENTATION Maintenance of the status quo in the provision of services to patients with head injuries is not a viable option. A strategic five-year implementation programme should be instituted (para 23). Medical directors of Trusts and health authorities should view the recommendations of this report as a quality issue (para 23). Those responsible for strategic health planning must seek to implement the recommendations of this report and provide the necessary resources and staffing levels to achieve them (para 23). Neuroscience units should assume responsibility for the co-ordination of the care of patients with head injuries within their catchment population (para 23). 12

13 1 Aims The aims of this report are to: establish current practice in the provision of services for the management of patients with head injuries in the United Kingdom and the Republic of Ireland; identify any deficiencies in the provision of these services; assess the magnitude of the problem and resulting morbidity; make recommendations to correct these deficiencies and to monitor outcome; and update the guidelines on The Provision of Surgical Services to Patients with Head Injuries (published by The Royal College of Surgeons of England in 1986). 1 The intention of this report is to stimulate changes in the provision of services to patients with head injuries that will lead to improvements in the quality of care that they receive and the outcomes achieved. In addition, we hope to promote higher standards of training for all specialists involved in the management of patients with head injuries. 2 Background and Scope of this Report In 1986, The Royal College of Surgeons of England published guidelines on the provision of surgical services for patients with head injuries. 1 In 1997, the College set up a multidisciplinary working party to update these guidelines. The membership of the working party is set out in para 26. Several issues have stimulated the re-drafting of these guidelines. These include: The possibility that patients were dying unnecessarily or suffering long-term sequelae due to inappropriate treatment. Public expectations that increasingly demand that staff with appropriate training and knowledge of the nervous system care for patients with head injuries. The fact that a proportion of patients with head injuries require transfer between units. There have been several recent cases where limited resources have led to organisational and service difficulties that have attracted considerable media and political concern. 13

14 The fact that those patients needing transfer between units undertake potentially hazardous journeys. The Neuroanaesthesia Society of Great Britain and Ireland and The Association of Anaesthetists of Great Britain and Ireland have produced recommendations on the transfer of patients with acute head injuries to neurosurgical units. 2 It is clear, however, that the current organisation of services often makes it difficult to implement the report s recommendations. The fact that in many hospitals general or orthopaedic surgeons are responsible for the care of patients with head injuries. At a local level, the specialty that assumes this responsibility usually does so for historical reasons. Few of these consultants have had recent or specific training in the management of patients with head injuries. This situation will be compounded as new consultants are appointed having been through the shorter, more focused, specialist registrar training scheme. The fact that limitations in the amount, and distribution of, health service resources restrict or are inadequate for the optimum treatment of head-injured patients. The fact that although head injuries affect people of all ages, they impact disproportionately on young people in the prime of life. The long-term sequelae of head injuries cause considerable costs to individuals, families and society. The fact that although audit systems are available, there is no national requirement to undertake routine data collection or to monitor clinical activity and its effectiveness. This report aims to stimulate improvements in the systems involved in the treatment of patients with head injuries. It does not seek to provide guidelines on the clinical management of people with head injuries. Methodologically sound, evidence-based guidelines for clinical decision-making have already been produced in both the US and Europe. 3,4,5 3 Introduction 3.1 EPIDEMIOLOGY Almost one million patients in the United Kingdom present to hospital each year having suffered a head injury. 6 Almost half are children under 16 years. The most common causes of injury are falls (41%), assaults (20%) and road traffic accidents (13%). Road traffic accidents are a common cause of more serious injuries accounting for one-third of patients transferred to 14

15 neurosurgeons and 58% of all deaths. For all ages, the death rate for a head injury in the United Kingdom is nine per 100,000 per year; this accounts for 1% of all deaths, but for 15-20% of deaths aged between 5 and 35 years. 6 In addition, head injuries may have significant behavioural, cognitive, emotional, social and economic effects. Some 63% of intermediate and 85% of severely head-injured patients remain disabled one year after their accident. 7 Even minor head injuries cause considerable problems. Three months after sustaining a minor head injury, 79% of patients have persistent headaches, 59% have memory problems and 34% of previously employed persons are still unemployed. 8 Only 45% of minor head-injured patients have made a good recovery one year after their admission. 9 (The data presented in this paragraph applies specifically to adults.) The initial injury may cause a primary insult to the brain. Only preventative measures can affect primary brain injury. The major concern in the management of patients with head injuries is to detect early and minimise any secondary brain injuries. 10 The means of preventing head injuries is outside the terms of reference of the Working Party, but head injuries are an important public health issue. 3.2 SEVERITY OF INJURY Clinically, closed head injuries are classified at the onset as being minor, intermediate or severe. Since this is a classification at presentation, it depends on data available at that time and takes no account of subsequent implications or eventual outcome. In this report we have used the following definitions of severity: Minor head injuries These are defined as patients who are admitted for less than 48 hours. Intermediate head injuries These are defined as patients who are admitted to hospital for more than 48 hours but who do not require intensive care and who do not require surgery. Severe head injuries These are defined as patients who require intensive care or who require neurosurgery. Note: The definitions for children with minor, intermediate and severe head injuries differ from those given above (see paras ). 15

16 3.3 CLASSIFICATION OF PATIENTS Patients with head injuries who attend hospital may fall into one or more of the following categories: patients with minor injuries requiring assessment prior to discharge from A&E; patients with intermediate injuries needing a period of observation and intermediate level care prior to discharge from hospital; patients with severe injuries not needing neurosurgical intervention; patients with severe injuries needing neurosurgical intervention; patients with multisystem severe injuries; patients with other associated injuries; patients with non-operable terminal injuries; children whose head injuries may be the result of child abuse and who need the institution of child abuse procedures; patients needing rehabilitation after severe head injury; and patients with persistent symptoms after head injuries of any severity. 4 Current Practice To establish current practice in the management of head injuries, the Working Party studied results of surveys of A&E departments, general surgeons, orthopaedic surgeons and neurosurgeons (paras 4.1, 4.2, 4.3 and 4.4). 4.1 A&E DEPARTMENTS In December 1997 and January 1998, The Royal College of Surgeons of England conducted a survey of all A&E departments in Great Britain and Ireland. Seventy-one percent (243 out of 318) of these departments returned questionnaires Observation facilities Thirty-eight percent of A&E departments which responded to the survey had on-site, short-stay facilities for head-injured patients. These tended to be the larger hospitals, particularly those with neurosurgeons on-site. Patients were transferred or discharged from these beds by 44% of these departments within 24 hours and 69% within 48 hours. Admissions were made under the care of the A&E consultant in 49% 16

17 of departments. Some 59% of departments admitting head-injured patients under their own care allowed A&E SHOs to admit patients to their short-stay wards without referral to a senior doctor. However, respondents to the questionnaire generally commented that, where possible, referral to a more senior A&E doctor is desirable. Sixty-seven percent of departments offering an observation ward had written protocols for admission of head-injured patients to this ward Care of intermediate level injuries Adult patients with isolated head injuries needing a period of observation and who are not admitted to A&E short-stay facilities are cared for by: general surgeons 55% orthopaedic surgeons 30% other specialties 15% A total of 63% of departments had written protocols to guide such referrals CT scanning facilities Seventy-nine percent of hospitals had the capability to perform on site CT of the head 24 hours a day. Sixty-six percent of departments without neurosurgeons on site had the facility to transfer electronic images to a neuroscience unit. Emergency CT scans could be requested by A&E staff in 84% of departments, although 48% required the prior approval of a radiology consultant. Fifty-one percent of A&E departments had a written protocol for the use of CT scans in headinjured patients Referral to neurosurgeons Twelve percent of responding A&E departments had neurosurgeons on site with in-patient facilities, 18% had visiting neurosurgeons, and 70% had no on-site neurosurgical cover. Seventy-three percent of departments had either an on-site or a visiting neurologist. In 20% of A&E departments, A&E staff were not allowed to refer patients directly to neurosurgeons and had to first refer patients to another discipline. Sixty percent of departments had a written protocol covering 17

18 neurosurgical referrals. Unless the patient required immediate transfer, pre-transfer CT of the head was required by neurosurgeons in 74% of A&E departments. Seventy-eight percent of departments referred to a single named neuroscience unit. Twenty-one percent, however, referred to several designated units. Seventy-seven percent of departments stated that their designated unit is rarely, hardly ever or never unable to accept a referral. There were, however, significant regional variations and particular problems in the Thames regions Emergency pre-transfer burr holes/craniotomies Ninety-two percent of 171 responding A&E departments without onsite neurosurgical cover reported that no burr holes or craniotomies had been performed prior to transfer within the previous 12-month period. Eleven A&E departments without on-site neurosurgical cover (6%) had performed one or more burr holes or craniotomies in previous 12-month period Transfer arrangements Thirty-three percent of A&E departments without on-site neurosurgery facilities were within ten miles of the nearest neurosurgical unit. However, 12% of A&E departments were over 50 miles from the nearest neurosurgical unit. The national average was 23 miles but there were significant regional variations. It was also noted that some receiving paediatric intensive care units sent a team to collect head-injured children Paediatric facilities Ninety-six percent of surveyed departments treated children with head injuries. Of these, three percent were dedicated children s hospitals. Most children (80%) requiring admission with head injuries were treated on a general paediatric ward. 4.2 GENERAL SURGEONS In conjunction with the Association of Surgeons of Great Britain and Ireland, the Working Party surveyed consultant general surgeons with regard to their involvement in the management of head-injured patients. The response rate was 46% (540 out of 1,176). Of these 56.2% (303) were responsible for the management of patients with head injuries. 12 Of those 303 surgeons looking after head-injured patients, only 48% (145) had received specific training in 18

19 neurosurgery and the management of head injuries; 32% (98) of these consultant surgeons had undertaken a provider ATLS course; and 9% (27) were ATLS instructors. Thirty-four percent (102) of surgeons looking after head-injured patients were dissatisfied with the referral process and transfer arrangements to neuroscience units. Sixty-six percent of these general surgeons felt that they ought not to look after head-injured patients, and 91% felt that they should not be responsible for the postoperative management of patients with head injuries after neurosurgical procedures Emergency pre-transfer burr holes/craniotomies General surgeons looking after head-injured patients had performed craniotomies or burr holes: in training: 64% as a consultant: 33% under supervision: 49.5% Of those who had performed burr holes as a consultant, 28.5% had done so within the previous three years Rehabilitation Sixty-eight percent of consultants were required to look after longterm head-injured patients. Sixty-four percent of general surgeons did not have easy access to rehabilitation facilities and 49% of general surgeons found that their patients had to wait more than a month from referral to actual transfer to a rehabilitation unit. 4.3 ORTHOPAEDIC SURGEONS The 1997 British Orthopaedic Association annual census of its members included questions on the management of head injuries. 11 Responses were obtained from 759 of 1,270 (60%) consultants. Twenty-eight percent of orthopaedic surgeons had responsibility for the management of head-injured patients. Forty percent had specific training in the management of head-injured patients and this was the same irrespective of whether or not they had to manage such patients. Thirty-three percent of orthopaedic surgeons had attended ATLS provider course and 10% were ATLS instructors. 19

20 4.4 NEUROSURGEONS Consultant members of the Society of British Neurological Surgeons were surveyed regarding their practice in the management of head-injured patients. There was a 66% response rate (110 of 166 consultants in 33 units). Twenty-four of the 33 units (73%) did not care for patients with minor head injuries not requiring surgery, although not all of these units had on-site A&E departments. Twenty-eight of 33 units (85%) accepted children with head injuries. Two of these units had minimum age limits, one of seven years and one of four years. Thirteen of 32 (41%) adult units had no exclusive access to adult ITU beds. In the units with exclusive access, there was a mean of 1.2 ITU beds per consultant. Twenty-seven of 31 units (87%) were aware of severely head-injured patients being managed in non-neurosurgical ITUs within their region. Sixtyfive percent of consultants felt they had inadequate access to ITU facilities, 62% to HDU facilities, 60% to ward beds, 71% to trained nurses and 54% to paediatric nurses. All but one unit would accept severely head-injured patients not needing surgery, subject to bed constraints. Of the 33 responding units, five turned away referrals on a daily basis and nine weekly. Ten units never turned away referrals. Of the 26 units that did turn away referrals, 15 (58%) expected the referring hospital (sometimes with the assistance of the Emergency Bed Service) to find an alternative bed. Eighty-one of 106 neurosurgeons (76%) would be prepared, given adequate resources, to care for head-injured patients still in hospital after 48 hours. Sixteen of 32 units either had no protocol/guidelines on the management of head injuries or did not distribute them to referring hospitals. 5 Pre-hospital Care It is recommended that pre-hospital care of patients with head injuries should comply with the principles of the Pre-hospital Trauma Life Support (PHTLS) course and the Pre-hospital Paediatric Life Support (PHPLS) course. It is further recommended that patients should be transported smoothly and efficiently to the nearest appropriate hospital, without delay, according to the guidelines advised by the Emergency 20

21 Medicine Research Group. 13 If ambulance personnel are unclear about the location of the nearest appropriate hospital, they should contact the A&E unit at the closest major acute hospital. The Emergency Medicine Research Group concluded that there are three prioritisation categories: Category A An immediate life-threatening situation requiring urgent assistance. The objective is to provide immediate aid by telephone advice, followed by rapid on-scene assistance. Category B A serious condition which is not immediately life-threatening. The objective is to provide intervention as soon as possible. Category C Other non-serious or non-life-threatening conditions which require conveyance to a hospital. The Department of Health review of ambulance performance has proposed the following response time standards for these categories: Category A 75% of calls within eight minutes Category B 95% of calls within 14 minutes Category C currently using the same standards as B (These standards apply to urban ambulance services.) The report also stated that: Unknown or decreased conscious level must be an A response. Third-party caller calls must be classified as A, unless sufficient information is obtained. A compromise would be that a response to a road traffic accident (RTA) should be an A, unless there is definite evidence that everyone is conscious and breathing without difficulty. Falls from a significant height are associated with high risk of serious injury and should therefore be categorised as A. The category for falls should have a different definition for children (for example, three times their height). 21

22 Only those head injuries with a clearly low energy accident resulting in minor wounds should be assigned to category C. The pre-hospital care of head injuries may be divided into assessment, management and transfer phases. As stated above, the care of head-injured patients should comply with the principles of the Pre-hospital Trauma Life Support (PHTLS) course which is derived from the Advanced Trauma Life Support (ATLS) course. For children, the Pre-hospital Paediatric Life Support (PHPLS) course is derived from the Advanced Paediatric Life Support (APLS) course. Treatment of the patient must not be allowed to delay unduly the transfer of the patient to the nearest appropriate receiving hospital. Patients with significant ABCD (airway, breathing, circulation or disability) problems should be viewed as potentially critical and should have an at scene time of eight minutes or less. They require smooth and efficient transport, without delay, to the most appropriate receiving hospital. The initial assessment Glasgow Coma Score should be recorded and handed over to the receiving A&E department. En route to the receiving hospital, the priorities are maintenance of the airway and breathing and haemorrhage control. The receiving hospital should be alerted to the patient s condition and the management instituted should be accurately described and recorded. All relevant clinical information (including the mechanism of injury) should be conveyed to the receiving medical team. 6 Appropriate Receiving Hospital for Head-injured Patients An appropriate receiving hospital is one that: complies with the recommendations of this report; has a 24-hour multidisciplinary resuscitative trauma team, at least one of whom is ATLS qualified. Hospitals accepting children should include at least one APLS-trained specialist registrar in paediatrics as part of a dedicated trauma team; has 24-hour CT head scanning, on call radiologists and image transfer facilities; 14 can transfer patients to a neuroscience unit according to recent NSGBI and AAGBI guidelines; 2 has an A&E department with properly resourced short-stay facilities; and has a paediatric in-patient service or suitable arrangements with a local children s hospital. 22

23 As referred to in para 5 above, ambulance personnel should contact the A&E unit in the nearest major acute hospital if they are in doubt as to where a patient should be taken. 7 Management in the A&E Department A&E staff are ideally placed to integrate pre-hospital and specialist in-patient care. A&E departments should draw up protocols and agree local policies, consistent with nationally agreed guidelines, in conjunction with their linked neuroscience receiving unit. These protocols and policies should confirm the most appropriate management of patients with head injuries who have not fully recovered within 48 hours. 8 Investigations The criteria for investigations such as skull X-rays and CT scans have been described elsewhere. 3,15 We would emphasise that all hospitals receiving patients with head injuries must be able to perform on-site CT scans 24 hours a day, have a radiologist on call and have the facilities and staff to transfer images to their usual receiving neuroscience unit. The decision as to whether any investigations are performed in the referring or receiving hospital will depend upon local circumstances, the individual clinical case and, usually, discussion with the neurosurgical unit. The priority must at all times be the welfare of the patient. CT scanning of the head at the referring unit must not be allowed to delay any necessary patient transfer. Patient transfer to and monitoring in radiology departments is potentially hazardous. Where practical and safe, steps should be taken to ensure that patients only require a single visit to the radiology department for all their imaging needs. 9 Management of Patients Needing Intermediate Level Care Traditionally patients needing admission to hospital have been cared for by general or orthopaedic surgeons. The decision as to which specialty has this responsibility is 23

24 largely random and dictated by local tradition. The lines of responsibility are often unclear. Many general and orthopaedic surgeons feel inadequately trained in the management of patients with head injuries. With the new specialist registrar programmes, it will be extremely unusual for new consultants to have had any formal training in neurosurgery as part of their higher surgical training. For many of them, their only training may be an ATLS course. It is unacceptable for patients with head injuries to be cared for by inadequately trained doctors. The surveys reported in paras 4.2 and 4.3 showed that the majority of patients are treated by such staff. We recommend that general and orthopaedic surgeons no longer be responsible for the intermediate tier of care of patients with isolated head injuries, but it is recognised that this can only occur after full implementation of this report. Such patients would be best admitted under the care of A&E medical/nursing staff to a dedicated observation unit in a observation ward within or adjacent to the A&E department which must be adequately resourced and appropriately staffed, consistent with nationally agreed guidelines. They should be reviewed by a competent member of staff prior to discharge. Agreed criteria for admission and discharge should be established with the sub-regional neuroscience unit. Observation wards should have a time limit of 48 hours, and neuroscience units and A&E departments should establish local arrangements for the appropriate referral of those patients not fit for discharge after this period. These arrangements should be subject to audit and review. Some elderly patients who do not need surgical intervention are not fit for discharge after 48 hours. Such patients often have complex medical and social needs and should be transferred to the care of the local department of medicine for the elderly. 10 Referral to Neurosurgeons Each A&E department should establish a formal link with a single neurosciences unit for the purposes of management of patients with head injuries. This should be the first point of contact for all head-injured patients needing transfer to, or discussion with, a neurosurgeon. All patients with severe head injuries should be transferred to the care of the neurosciences unit, regardless of whether they need surgical intervention. The neuroscience unit should assume responsibility for the development of clear and uniform protocols for the management of head-injured patients within their referral area. Health service commissioners and Trusts with neuroscience units must assume responsibility for providing sufficient resources to treat all head-injured patients within their catchment area. If they are unable to accept further referrals, it should 24

25 be the responsibility of the management of the hospital housing the neuroscience unit to ensure that alternative arrangements are identified. On rare occasions, a patient may need to be transferred for immediate life-saving decompressive surgery for haematoma, and the usual referring hospital will have no ITU/HDU bed available. Under these circumstances the patient should be transferred for surgery and an ITU/HDU bed found post-operatively within the same unit. In all circumstances, life-saving decompressive surgery must be available to all patients who require it within four hours. Patients with severe head injuries needing ventilation and/or intra-cranial pressure monitoring but not surgical intervention should be transferred to intensive care units with on-site neurosurgeons and neuroanaesthetists. Neurosurgeons should work within a multidisciplinary neuroscience unit that has an intensive care unit with trauma beds and neuroanaesthetists. In addition, these units should have neurologists, neuroradiologists and specialists in rehabilitation medicine. Such units must be located in major acute hospitals and should not be on isolated sites. An image transfer facility must be available between the district general hospital and the neuroscience unit. Increasing use of CT/MRI in local hospitals requires local expertise in examining the nervous system. Neurosurgeons should be contactable at all times for advice regarding a patient with head injuries because many patients who need neurosurgical intervention will have other injuries. After discussion, the patient may be transferred to the neuroscience unit or retained at the district general hospital. Once the recommendations of this report have been implemented, together with the provision of adequate resources, it should be extremely unusual for a neuroscience unit to be unable to accept acute referrals from its linked A&E departments. Sufficient resources should be provided to ensure that patients are only referred outside the linked A&E and neuroscience units in exceptional circumstances. Once this has been achieved, it would be most unusual and inappropriate to admit a patient to one unit for surgery and transfer to another for intensive care post-operatively. This would only occur when facilities were inadequate for a patient who required life-saving decompressive surgery and the admitting hospital has no ITU/HDU bed available for post-operative care. Life-saving decompressive surgery must be available for all patients who require it within four hours of injury INDICATIONS FOR REFERRAL TO NEUROSURGEONS AND/OR URGENT CT SCAN Patients of all ages in the following categories should be discussed with a neuroscience unit to ascertain whether or not they need neurosurgical intervention: 3 25