NCEPOD: Trauma - Who Cares? - London Health Programmes

11Incidence of trauma andorganisation of trauma servicesNeurosurgery (page 102-107)One hundred and fourteen patients required neurosurgery asa result of head trauma. Fifty eight of these patients (50.9%)were initially taken to a non-neurosurgical centre. Only oneout of seven of these patients had surgery within four hours.Two out of three patients taken initially to a neurosurgicalcentre had surgery within four hours of injury.Availability of interventional radiology (page 25-33 and page 98-102)The use of interventional radiology has an increasing rolein the management of haemorrhage in the trauma patient.Only one patient in this study underwent an interventionalradiology technique. Only six out of 10 hospitals statedthat they had 24 hour access to this therapy and in manyof those this is ad hoc due to the small number of trainedindividuals.Secondary transfers (page 118-124)One in four severely injured patients required a secondarytransfer to receive defi nitive care. This underlines the inabilityof the original admitting facility to provide defi nitive care.Furthermore, these transfers were conducted in a haphazardfashion with little consultant oversight.Prehospital airway management (page 37-48)One in 10 patients arrived at hospital with an obstructed orpartially obstructed airway.Eleven out of 85 attempted prehospital intubations failed(12.9%). Eight of these patients were dead at 72 hours postinjury (72.7% mortality rate).These six issues have been used for illustrative purposesonly. It can be appreciated that not every hospital can havethe manpower, facilities, equipment and expertise to providedefi nitive care for all severely injured patients. Furthermore,many of the problems that exist in trauma management,including the prehospital phase, are organisational and donot refl ect on the abilities or enthusiasm of clinical teams.The infrequent incidence of major trauma compounds theseissues.As previously referenced, and shown in this study (Figure53), there is an association between the volume of casesand good outcomes 2,3 . It is also known that patients who areadmitted directly to a trauma centre have less morbidity anda lower mortality than patients who are initially admitted to amore local hospital and subsequently transferred to a traumacentre 12 .Regional reconfi guration of trauma services will allow theconcentration of relatively few patients in limited numberof centres that could develop their expertise. This willensure that all the staff, facilities, equipment and expertiseto manage these challenging patients will be immediatelyavailable. Sustainable rotas will be deliverable and will ensurebetter availability of consultants and other staff at all times.There will be more effi cient use of limited resources and itappears that the societal cost of such a system is favourable13. Concentration of major trauma will give opportunities toincrease the robustness of audit and quality control and willalso facilitate much needed research in this area. The currentdraft of National Institute for Health and Clinical Excellence(NICE) guidance on head injury management included aresearch question about the benefi t of direct transfer of headinjured patients to neurosurgical centres.However, the current system is likely to change slowly. Evenin a system of more regionalised trauma care there will bemany patients presenting to and managed at a number of129