Elsevier

The Lancet

Volume 366, Issue 9496, 29 October–4 November 2005, Pages 1538-1544
The Lancet

Articles
Trends in head injury outcome from 1989 to 2003 and the effect of neurosurgical care: an observational study

https://doi.org/10.1016/S0140-6736(05)67626-XGet rights and content

Summary

Background

Case fatality rates after all types of blunt injury have not improved since 1994 in England and Wales, possibly because not all patients with severe head injury are treated in a neurosurgical centre. Our aims were to investigate the case fatality trends in major trauma patients with and without head injury, and to establish the effect of neurosurgical care on mortality after severe head injury.

Methods

We analysed prospectively collected data from the Trauma Audit and Research Network database for patients presenting between 1989 and 2003. Mortality and odds of death adjusted for case mix were compared for patients with and without head injury, and for those treated in a neurosurgical versus a non-neurosurgical centre.

Findings

Patients with head injury (n=22 216) had a ten-fold higher mortality and showed less improvement in the adjusted odds of death since 1989 than did patients without head injury (n=154 231). 2305 (33%) of patients with severe head injury (presenting between 1996 and 2003) were treated only in non-neurosurgical centres; such treatment was associated with a 26% increase in mortality and a 2·15-fold increase (95% CI 1·77–2·60) in the odds of death adjusted for case mix compared with patients treated at a neurosurgical centre.

Interpretation

Since 1989 trauma system changes in England and Wales have delivered greater benefit to patients without head injury. Our data lend support to current guidelines, suggesting that treatment in a neurosurgical centre represents an important strategy in the management of severe head injury.

Introduction

The recorded 40% reduction in odds of dying (adjusted for case mix) after major trauma between 1989 and 1994 has been attributed to improvements in hospital care; specifically, implementation of recommendations from the Royal Colleges, increased involvement of senior medical staff, and improved integration of trauma services.1 Unfortunately, a continuing reduction in mortality, or a change in the process of care has been not been apparent since 1994.2 Head injury remains an important factor in the cause of death and disability after trauma.2, 3

Most head injury deaths occur in those presenting in coma (Glasgow coma score less than 9). In the UK, neurosurgeons have the main responsibility for treating such patients. Since 1948, neurosurgical care in the UK has been confined to regional neurosurgical centres, necessitating hospitals without neurosurgical services on site to seek advice for management (including the need for transfer) of severely head injured patients.4, 5 Within US and Canadian trauma systems, most patients with severe head injuries are taken directly to an appropriate trauma centre with neurosurgical facilities on site. However, trauma system coverage is not ubiquitous in Europe or North America, and not all trauma centres offer 24-hour neurosurgical cover.6, 7, 8, 9 This situation suggests that throughout the developed world many patients with severe head injuries are initially managed in facilities without continuous access to neurosurgical care.

Treatment of patients with severe head injury in neurosurgical centres is driven by guidelines. The initial 1984 guidelines recommended treatment based on early identification and intervention for neurosurgical mass lesions (eg, extradural haematoma, subdural haematoma).10 This approach was justified by a review of a 1980s head injury cohort that suggested a low rate of apparently preventable deaths from severe head injury in patients not transferred to neurosurgical centres.11 However, contemporary guidelines have recommended that all patients with a severe head injury should be treated in a neurosurgical centre.3 Despite these updated recommendations, many patients with a severe head injury, particularly those without surgical lesions, are currently not treated in or transferred to a neurosurgical centre.12, 13

We wished to establish whether case fatality trends were the same in major trauma patients with and without head injury. Our collaboration, which represents the largest trauma registry in Europe, compared the odds of death (adjusted for case mix) in patients with severe head injury managed in neurosurgical centres as opposed to hospitals without neurosurgical services on site, within the context of reporting temporal odds of death trends.

Section snippets

Patients

We studied patients injured by blunt trauma between 1989 and 2003 who were treated by participating hospitals in the Trauma Audit and Research Network (TARN=60% of trauma receiving hospitals within England and Wales). TARN includes patients of any age who sustain injury resulting in immediate admission to hospital for 3 days or longer, subsequent death, intensive or high dependency care, or interhospital transfer. Initial admitting data, including presenting age, Glasgow coma scale, blood

Results

22 216 patients (13% of 176 447 eligible patients) had a head injury AIS greater than 2. Patients with head injury were on average 9–14 years younger than those without such injury, although age ranges overlapped considerably. Head injured patients were much more likely to be male, have more severe injury, and have higher mortality (table 1) than those without head injury.

Patients with head injury constituted less than an eighth of the patients on the database. However, such injuries were

Discussion

In patients presenting with blunt trauma, we observed a ten-fold increased mortality in those who had sustained a head injury (of any severity visible on CT) compared with those who had not. Further, although substantial improvement in the odds of death adjusted for case mix was recorded from 1989 to 2003 in patients without head injury, a less pronounced improvement was seen in those with head injury. For patients with severe head injury, the overall mortality was 44%. This crude mortality was

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