TRAUMA

 

An audit of the quality of care of traumatic brain injury at a busy regional hospital in South Africa

 

 

T. Alexander^I; G. Fuller^I; P. Hargovan^II; D. L. Clarke^III; D. J. Muckart^IV; S. R. Thomson^V

^IM.B. CH.B; Accident and Emergency Department, Edendale Hospital, Pietermaritzburg
^IIL.LM. R.C.P., L.LM. R.C.S. (IREL.), F.R.C.S. (GLASG.); Accident and Emergency Department, Edendale Hospital, Pietermaritzburg
^IIIF.C.S. (S.A.), M.MED.SCI., M.B.A; Department of General Surgery, University of KwaZulu-Natal, Durban
^IVF.R.C.S., M.MED.SCI; Department of General Surgery, University of KwaZulu-Natal, Durban
^VF.R.C.S., CH.M; Department of General Surgery, University of KwaZulu-Natal, Durban

 

 

---

ABSTRACT

Access to care by a dedicated neurosurgical unit is limited in the developing world, and the vast majority of patients who sustain a head injury are managed by general surgeons. Prevention of secondary brain injury is paramount. While the principles of management are relatively straightforward, delivering this care may be difficult. This audit looks at the spectrum of head injuries presenting to a busy regional hospital and attempts to measure the quality of care offered to these patients.
PATIENTS AND METHODS: The audit includes three separate sections. The first is a prospective audit of all patients with a traumatic brain injury presenting to the Accident and Emergency (AE) department at Edendale Hospital, Pietermaritzburg, over a 2-month period. The next two sub-audits consist of a random review of referral letters and AE clerking notes to assess the quality of care received by these patients. A total of 25 referral letters and 28 AE inpatient notes were randomly chosen for review and compared with agreed standardised markers for quality of care.
RESULTS: Over the 2 months October and November 2007, 150 patients with a head injury were seen in the AE department. Of these 117 were male. A total of 76 were discharged home after investigation with a head injury warning chart, 49 were admitted to the general wards, 11 were admitted to the surgical intensive care unit, 10 were referred to the neurosurgical centre in Durban, and 4 died in the AE department. Of the 10 who needed advanced neurosurgical care, 3 required urgent burr-holes before referral. One of these patients died. All the remaining 9 patients who were transferred to the neurosurgery unit survived. The referral letters and AE clerking notes revealed major deficits.
CONCLUSION: Traumatic brain injury is a common problem. Only a small subset of patients require specialised neurosurgical care. Although many patients with intracranial injury can tolerate the delay associated with transfer, some cases are acute and urgent intervention by non-neurosurgeons is needed. Prevention of secondary brain injury is poorly understood and not prioritised. This situation needs to be improved. The introduction of formalised standard referral and management sheets may help to improve care.

---

 

 

“Full text available only in PDF format”

 

 

REFERENCES

1. Hyder AA, Wunderlich CA, Puvanachandra P, Gururaj G, Kobusingye OC. The impact of traumatic brain injuries: a global perspective. Neurorehabilitation 2007; 22(5): 341-353.         [ Links ]

2. Harris OA, Bruce CA, Reid M, et al. Examination of the management of traumatic brain injury in the developing and developed world: focus on resource utilization, protocols, and practices that alter outcome. J Neurosurg 2008; 109(3): 433-438.         [ Links ]

3. Cohn SM, Price MA, Stewart RM, et al. A crisis in the delivery of care to patients with brain injuries in South Texas. J Trauma 2007; 62(4): 951-962; discussion 962-963.         [ Links ]

4. Valadka AB, Andrews BT, Bullock MR. How well do neurosurgeons care for trauma patients? A survey of the membership of the American Association for the Surgery of Trauma. Neurosurgery 2001; 48(1): 17-24.         [ Links ]

5. Zulu BM, Mulaudzi TV, Madiba TE, Muckart DJ. Outcome of head injuries in general surgical units with an off-site neurosurgical service. Injury 2007; 38(5): 576-583.         [ Links ]

6. Nadvi SS, Parboosing R, van Dellen JR. Benefits to a regional neurosurgical unit following the introduction of a decentralised imaging facility. S Afr Med J 1997; 87(12): 1669-1671.         [ Links ]

7. Guha A. Management of traumatic brain injury: some current evidence and applications. Postgrad Med J 2004; 80: 650-653.         [ Links ]

8. Chesnut RM. Care of central nervous system injuries. Surg Clin North Am 2007; 87(1): 119-156, vii.         [ Links ]

9. Wallace SA, Gullan RW, Byrne PO, Bennett J, Perez-Avila CA. Use of a pro forma for head injuries in the accident and emergency department - the way forward. J Accid Emerg Med 1994; 11(1): 33-42.         [ Links ]

10. Fisher RB, Dearden CH. Improving the care of patients with major trauma in the accident and emergency department. BMJ 1990; 300: 1560-1563.         [ Links ]

11. O'Connor AE, Finnel L, Reid J. Do preformatted charts improve doctors' documentation in a rural hospital emergency department? A prospective trial. N Z Med J 2001; 114: 443-444.         [ Links ]

12. Thomson R, Gray J, Madhok R, Mordue A, Mendelow AD. Effect of guidelines on management of head injury on record keeping and decision making in accident and emergency departments. Qual Health Care 1994; 3(2): 86-91.         [ Links ]

13. Myburgh JA. An appraisal of the impact of management guidelines in traumatic brain injury. Crit Care Resusc 1999; 1(1): 55-62.         [ Links ]

14. Livingston DH, Loder PA, Hunt CD. Minimal head injury: is admission necessary? Am Surg 1991; 57(1): 14-17.         [ Links ]

15. Roddy SP, Cohn SM, Moller BA, et al. Touloukian RJ. Minimal head trauma in children revisited: is routine hospitalization required? Pediatrics 1998; 101(4 Pt 1): 575-577.         [ Links ]

16. Nagy KK, Joseph KT, Krosner SM, et al. The utility of head computed tomography after minimal head injury. J Trauma 1999; 46(2): 268-270.         [ Links ]

17. Jacobson S, Abbühl S. Mild head injury: a plea for routine early CT scanning. J Trauma 1993; 35(3): 491.         [ Links ]

18. Harrington DT, Connolly M, Biffl WL, Majercik SD, Cioffi WG. Transfer times to definitive care facilities are too long: a consequence of an immature trauma system. Ann Surg 2005; 241(6): 961-966; discussion 966-968.         [ Links ]

19. Rinker CF, McMurry FG, Groeneweg VR, Bahnson FF, Banks KL, Gannon DM. Emergency craniotomy in a rural level III trauma center. J Trauma 1998; 44(6): 984-989; discussion 989-990.         [ Links ]

20. Hesdorffer DC, Ghajar J. Marked improvement in adherence to traumatic brain injury guidelines in United States trauma centers. J Trauma 2007; 63(4): 841-847.         [ Links ]