Snapshot view of emergency neurosurgical head injury care in Great Britain and Ireland

Crimmins, Darach

doi:10.1136/jnnp.68.1.8

Cited by 21 publications

(13 citation statements)

References 20 publications

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“…Such practice is consistent with management in which referral patterns are still dominated by the need to address surgical lesions [11,12]. This would seem inappropriate, since up to 25% of patients with severe head injury have evidence of raised ICP in the absence of a surgical lesions, and suffer morbidity and mortality equal to those with surgical lesions [1,13].…”

Section: Introductionmentioning

confidence: 76%

Specialist neurocritical care and outcome from head injury

et al. 2002

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Specialist neurocritical care with protocol-driven therapy is associated with a significant improvement in outcome for all patients with severe head injury. Such management may also benefit patients requiring no surgical therapy, some of whom may need complex therapeutic interventions. We found it impossible to predict need for such interventions from clinical features at presentation. These data suggest that specialist critical care with ICP/CPP guided therapy may benefit patients with severe head injury.

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Section: Introductionmentioning

confidence: 76%

Specialist neurocritical care and outcome from head injury

et al. 2002

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“…Surveys of SNC capacity suggest that many units are operating close to their maximum volume, 104,105 and admitting increasing numbers of patients for neurocritical care in routine transfer or bypass strategies may not be possible. The potential impact of overcrowding in EDs or ICUs arising from treatment of additional patients, possibly unlikely to benefit from specialist care, has also not been examined.…”

Section: Hits-ns Stream Bmentioning

confidence: 99%

The Head Injury Transportation Straight to Neurosurgery (HITS-NS) randomised trial: a feasibility study

Lecky

Russell

Fuller

et al. 2016

Health Technol Assess

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BackgroundReconfiguration of trauma services, with direct transport of traumatic brain injury (TBI) patients to neuroscience centres (NCs), bypassing non-specialist acute hospitals (NSAHs), could potentially improve outcomes. However, delays in stabilisation of airway, breathing and circulation (ABC) and the difficulties in reliably identifying TBI at scene may make this practice deleterious compared with selective secondary transfer from nearest NSAH to NC. National Institute for Health and Care Excellence guidance and systematic reviews suggested equipoise and poor-quality evidence – with regard to ‘early neurosurgery’ in this cohort – which we sought to address.MethodsPilot cluster randomised controlled trial of bypass to NC conducted in two ambulance services with the ambulance station (n = 74) as unit of cluster [Lancashire/Cumbria in the North West Ambulance Service (NWAS) and the North East Ambulance Service (NEAS)]. Adult patients with signs of isolated TBI [Glasgow Coma Scale (GCS) score of < 13 in NWAS, GCS score of < 14 in NEAS] and stable ABC, injured nearest to a NSAH were transported either to that hospital (control clusters) or bypassed to the nearest NC (intervention clusters). Primary outcomes: recruitment rate, protocol compliance, selection bias as a result of non-compliance, accuracy of paramedic TBI identification (overtriage of study inclusion criteria) and pathway acceptability to patients, families and staff. ‘Open-label’ secondary outcomes: 30-day mortality, 6-month Extended Glasgow Outcome Scale (GOSE) and European Quality of Life-5 Dimensions.ResultsOverall, 56 clusters recruited 293 (169 intervention, 124 control) patients in 12 months, demonstrating cluster randomised pre-hospital trials as viable for heath service evaluations. Overall compliance was 62%, but 90% was achieved in the control arm and when face-to-face paramedic training was possible. Non-compliance appeared to be driven by proximity of the nearest hospital and perceptions of injury severity and so occurred more frequently in the intervention arm, in which the perceived time to the NC was greater and severity of injury was lower. Fewer than 25% of recruited patients had TBI on computed tomography scan (n = 70), with 7% (n = 20) requiring neurosurgery (craniotomy, craniectomy or intracranial pressure monitoring) but a further 18 requiring admission to an intensive care unit. An intention-to-treat analysis revealed the two trial arms to be equivalent in terms of age, GCS and severity of injury. No significant 30-day mortality differences were found (8.8% vs. 9.1/%;p > 0.05) in the 273 (159/113) patients with data available. There were no apparent differences in staff and patient preferences for either pathway, with satisfaction high with both. Very low responses to invitations to consent for follow-up in the large number of mild head injury-enrolled patients meant that only 20% of patients had 6-month outcomes. The trial-based economic evaluation could not focus on early neurosurgery because of these low numbers but instead investigated the comparative cost-effectiveness of bypass compared with selective secondary transfer for eligible patients at the scene of injury.ConclusionsCurrent NHS England practice of bypassing patients with suspected TBI to neuroscience centres gives overtriage ratios of 13 : 1 for neurosurgery and 4 : 1 for TBI. This important finding makes studying the impact of bypass to facilitate early neurosurgery not plausible using this study design. Future research should explore an efficient comparative effectiveness design for evaluating ‘early neurosurgery through bypass’ and address the challenge of reliable TBI diagnosis at the scene of injury.Trial registrationCurrent Controlled Trials ISRCTN68087745.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 1. See the NIHR Journals Library website for further project information.

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“…Twenty-three per cent of head injury patients were managed in non-specialist critical care units at that time 28. In another survey,9 only 43 neurocritical care beds were available nationally ‑ far from sufficient to cope with the projected 28.6 head injuries per day, when trauma forms only part of the neurosurgical workload. The same study demonstrated large regional variations in bed availability.…”

Section: Resultsmentioning

confidence: 99%

“…Care is currently hampered by a number of barriers including the shortage of specialist beds,9 30 variations in travel times, and ‘haphazard’ transfer arrangements. Although the lack of neurosurgical beds is not a new problem, there has been little action to improve the situation 3 54…”

Section: Discussionmentioning

confidence: 99%

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Republished paper: The implications of the NICE guidelines on neurosurgical management for all severe head injuries: systematic review

Barratt

Moore²,

Raine³

2010

Postgraduate Medical Journal

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Head injury is an important cause of death among young adults in the UK, and a significant burden on NHS resources. However, management is inconsistent, governed largely by local resources. The latest version of the NICE head injury guidelines suggests that more patients with traumatic brain injury should be transferred to receive specialist care. However, this raises issues about the capacity of regional neurosurgical units, particularly to accommodate patients who do not require surgical intervention. Objectives To critically evaluate the basis of the NICE recommendations about transfer for neurosurgical care, and examine the configuration of specialist services to assess the implications of increasing the existing number of transfers. Methods A systematic literature review was conducted of articles discussing the provision of emergency neurosurgical care for adult head injuries in the UK. Results Fifty-eight papers met the criteria for inclusion in the literature review, including seven papers cited in the NICE guidance. Fifty-one papers related to neurosurgical care, including papers on bed occupancy, transfer times and transfer policies. Conclusions The evidence NICE cited is of variable quality. Much of the research was conducted outside the UK, which raises questions about its relevance to the NHS. Care of traumatic brain injuries in the UK is already hampered by the inadequate capacity of regional neurosurgical units to meet demand, and transferring more patients would be likely to exacerbate this. Increasing the number of transfers could also worsen inequalities of access for other groups, such as elective patients, particularly in areas where facilities are most stretched.

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Snapshot view of emergency neurosurgical head injury care in Great Britain and Ireland

Cited by 21 publications

References 20 publications

Specialist neurocritical care and outcome from head injury

Specialist neurocritical care and outcome from head injury

The Head Injury Transportation Straight to Neurosurgery (HITS-NS) randomised trial: a feasibility study

Republished paper: The implications of the NICE guidelines on neurosurgical management for all severe head injuries: systematic review

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