330

and pulmonary arterial pressures, ICP (and possibly end-tidal CO2), continued intensive care should be possible during patient transport. Ideally secondary insults should not occur in head-injured patients during transport. We have shown that such insults can and do occur commonly during intra-hospital transport and are associated with insults that are present before and after transfer. Patients in the accident and emergency department or ICU should have appropriate monitoring and derangements of physiology should be corrected before any transfers. This is especially important in patients with high injury severity scores and/or raised ICP. If insults have arisen before and/or during transportation even greater problems are to be anticipated during the first four hours post-transfer.

venous

This study was supported by Medical Research Council special project grant (FPG 880 9197) and Action Research for the Crippled Child (NFRCD A/8

11671). REFERENCES et al. Ischaemic brain damage is still in fatal non-missile head injury. J Neurol Neurosurg Psychiatry 1989; 52: 346-50. 2. Miller JD, Sweet RC, Narayan R, Becker DP. Early insults in the injured brain. JAMA 1978; 240: 439-42. 3. Miller JD, Butterworth JF, Gudeman SK, et al. Further experience in the management of severe head injury. J Neurosurg 1981; 54: 289-99.

1. Graham

DI, Ford I, Adams JH,

common

4. Kohi

YM, Mendelow AD, Teasdale GM. Extracranial insults and in patients with acute head injury-relationship to the Glasgow Coma Scale. Injury 1984; 16: 25-79. 5. Gentleman D, Jennett B. Hazards of inter-hospital transfer of comatose head-injured patients. Lancet 1981; ii: 853-55. 6. Waddell G, Scott PDR, Lees NW, Ledingham IMcA. Effects of ambulance transport in critically ill patients. Br Med J 1975; i: 386-89. 7. Bion JF, Eldin SA, Ramsay G, McCabe S, Ledingham IMcA. Validation of a prognostic score in critically ill patients undergoing transport. outcome

Br Med J 1985; 291: 432-34. 8. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med 1985; 13: 818-29. 9. Waddell G. Movement of critically ill patients within hospital. Br Med J 1975; ii: 417-19. 10. Braman SS, Dunn SM, Amico CA, Millman RP. Complications of intrahospital transport in critically ill patients. Ann Intern Med 1987; 107: 469-73. 11. Wright I, Rodgers PN, Ridley S. Risks in intrahospital transport. Ann Intern Med 1988; 108: 638. 12. Insel JR, Wiessman C, Kemper M, Askenazi J, Hymen AI. Cardiovascular changes during transport of critically ill and postoperative patients. Crit Care Med 1986; 14: 539-42. 13. Gervais HW, Eberle B, Konietzke D, Hennes H, Dick W. Comparison of blood gases of ventilated patients during transport. Crit Care Med

1987; 15: 761-63. RG, Mihm FG, Rosenthal MH. Care of the adult patient during transport. Int Clin Anaesthesiol 1987; 25: 43-75. 15. Frankel LR. The evaluation, stabilization and transport of the critically ill child. Int Clin Anaesthesiol 1987; 25: 77-103. 16. Ehrenwerth J, Sorbo S, Hackel A. Transport of critically ill adults. Crit Care Med 1986; 14: 543-47.

14. Pearl

Audit of transfer of unconscious

patients to a

Features of

patients transferred

to a

head-injured neurosurgical unit

supine. Systemic hypoxia

or

hypertension

were

Even when computed tomography scanners become available in more hospitals, many patients who are unconscious after head injury will still need to be transferred to a neurosurgical unit. Detailed guidelines should be agreed locally to minimise the hazards of transfer of unconscious patients between hospitals. A rota of experienced doctors and nurses at the sending hospital should be responsible for deciding how each individual patient should be managed during transfer, according to the guidelines. Continuing audit of such cases is needed to indicate whether revision of local practice is needed.

associated with

a

poor outcome.

Introduction

regional

neurosurgical unit in coma after recent head injury were compared with a similar audit seven years previously. There were fewer avoidable adverse factors in the recent series, but some patients received inadequate care of the airway, while in some others major extracranial injuries were overlooked or poorly managed. Only 42% of the comatose patients had had an endotracheal tube inserted; half those in whom neither a tube nor an oral airway had been inserted were transported

Several thousand seriously head-injured patients are admitted to British neurosurgical units each year, most of them by road ambulance from other hospitals.! Mortality and morbidity from acute traumatic intracranial haematoma can be reduced by computed tomography (CT) screening of patients at risk, followed by expeditious surgery, as previously reported from our unit .2 This improvement followed changes in the local policies for the transfer of

patients, which doubled the number of patients being sent to the neurosurgical unit each year;3 these policies were later developed into national guidelines.4 The hazards of ambulance transfer for patients who are in coma are, however, not negligible. The frequency of avoidable factors contributing to death in patients transferred to our unit who had "talked and died" was reported in 1977.5 Review of 150 unconscious head-injured patients transferred to the Glasgow neurosurgical unit during 1979-80 showed that hypoxia and hypotension were second only to delayed treatment of intracranial haematoma

Department of Neurosurgery, Institute of Neurological Sciences, Glasgow (D. Gentleman, FRCS, Prof B Jennett, FRCS) Correspondence to Prof B. Jennett. ADDRESS:

331

TABLE II-FEATURES OF THE TRANSFER IN THE TWO SERIES

contributors to such deaths. A systemic insult had occurred in over 40%, and this often affected outcome adversely.6 Some patients had hypoxia because of a compromised airway or inadequate ventilation: others were in shock, usually because major extracranial injuries had been overlooked or inadequately treated. As more CT scanners become available in general hospitals, decisions will have to be made about where and when unconscious patients should be scanned, and recommendations will depend partly upon how the risks of transfer are viewed. It therefore seems opportune to re-examine the rate of occurrence of adverse systemic factors in unconscious head-injured patients transferred by ambulance to our regional neurosurgical units, and to consider practical means for reducing these risks. as

All

findings gIven

as

percentages.

Patients and methods The Glasgow Institute provides the only neurosurgical facilities for a population of 2-7 million in the West of Scotland, approximately half of whom live in and around the city of Glasgow. Seriously head-injured patients are first seen in one of the six city teaching hospitals, or one of the eleven district general hospitals; a few patients come, sometimes by air, from small local hospitals in remote areas. This report is based on 200 consecutive head-injured patients transferred in coma from other hospitals to the Glasgow neurosurgical unit during the 19 months from June, 1986, to December, 1987. We know of no head-injured patient treated by burr holes or craniotomy in a general hospital in the West of Scotland during that period. Details about each patient were recorded on a study proforma immediately after arrival; data about subsequent events and the rating on the Glasgow Outcome Scale7 6 months after injury were added later. Differences between this and our previous series5 were assessed, with 95% confidence intervals (CI) being calculated for the differences in the proportions between the two series.

Results

Many features of the patients in the two series were very similar (table I). However, fewer patients in the recent series underwent craniotomy, because changes in the transfer

policy2 had reduced the number of patients with haematoma who had deteriorated into coma before arrival at the neurosurgical unit. In the present study more patients reached the neurosurgical unit within 6 h of injury than previously (75% compared with 65%; CI - 0-20 to - 0-01). More were transferred directly from accident and emergency (A/E) departments rather than having first been admitted to a primary surgical ward for observation (78 % vs 56%;CI -032 to -012), perhaps because there are now more consultants and experienced middle-grade staff in A/E departments. Comatose patients were accompanied by a doctor in the ambulance in 89% of the recent series, compared with 70% previously (CI 0-10-0-28).

Other differences (table II) between the old and recent series showed a greater proportion with endotracheal tube in the new series (42% vs 28%; CI - 0-24 to - 004), and more than twice as many mechanically ventilated during transfer in 1986-87 (28% vs 11%; CI -0-25 to -0-09). The proportion of transfers who had neither an endotracheal tube nor an oral airway was similar in the two series (28% and 29%); half of these patients with an unprotected airway had been transported in the supine position in both series. Although there were fewer untoward events before or during the journey to the neurosurgical unit in the recent series (32% vs 41%), the airway was compromised on arrival at the neurosurgical unit in 23%. Generalised seizures occurred before or during the journey to the neurosurgical unit in 15 patients in the recent series, and 5 had had respiratory or cardiac arrest. The exact timing of these incidents was often unclear from the information provided by the referring hospital and escort, which suggests that these incidents (especially airway obstruction) had sometimes not been recognised. In the more recent series there were somewhat fewer patients with multiple injuries that had been inadequately treated (10% vs 14%), and fewer patients arrived in shock (7% vs 11%); none of these differences was significant, however. Hypoxia (Pa02 < 70 mm Hg) was found in 25 (15%) of the 164 recent patients in whom the arterial blood gases were measured on arrival. It was commoner among those with a compromised airway than among those without (32% vs 9%; CI 0-09 to 0.38) (table III). Only 7% of those who were both intubated and ventilated arrived hypoxic, but there was no significant difference in the occurrence of hypoxia

TABLE III-FREQUENCY OF HYPOXIA ON ARRIVAL AT A NEUROSURGICAL UNIT (1986-87)

TABLE I-FEATURES OF PATIENTS IN TWO SERIES

*4 not

operated on because moribund. tG CS = Glasgow coma score

*GCS= Glasgow

Coma Scale

332

TABLE IV-INFLUENCE OF SYSTEMIC INSULTS ON POOR

OUTCOME (1986-87)

Numbers in parentheses refer to denominator *Hypoxia, hypotension.

between those with no airway protection (20%) and those who were intubated but breathing spontaneously (26%). The likely explanation for this seeming paradox is that those who had been intubated were either more seriously brain damaged, or they had already undergone an attack of airway obstruction. This explanation is supported by the greater frequency of deep coma (Glasgow score 5) in patients who were intubated (69%), compared with those without a tube

(18%). However, deep

coma was

equally

common

among

those with a compromised airway as in those without. The initial management of major extracranial injuries, as assessed at the time of arrival in the neurosurgical unit, was judged to be unsatisfactory in 20 (24%) of 82 multiply injured patients. This clinical judgment was based on whether the extracranial injury had been recognised, whether necessary blood or plasma had been given, and whether appropriate first-line treatment had been carried out (eg, chest drain, Thomas splint, laparotomy). Hypotension on arrival was recorded in 14 patients (7%); hypotension was more common (35%) among the 20 patients with undiagnosed or inadequately treated major extracranial injuries than among other patients (4%; CI 0-10 to

0-52).

The 137 patients transferred from hospitals within 30 minutes’ driving time of the neurosurgical unit were not

TABLE V-CHECKLIST BEFORE TRANSFER OF SEVERELY HEAD INJURED PATIENT TO A NEUROSURGICAL UNIT

different from the 63 patients from hospitals further away in demographic characteristics, nature of their injuries, frequency of incidents before arrival at the neurosurgical unit, and proportion with hypoxia or hypotension on arrival there. Somewhat fewer of the distant cases reached the neurosurgical unit within 6 h of injury (66% vs 78%), a difference that was not significant. That there was not a greater difference may reflect a greater sense of urgency for transfer in more distant hospitals. In the recent series the outcome was poor for 76% of those who had either hypoxia or hypotension, but for only 44% of those without these features (CI - 0-48 to —0-15) (table IV). This adverse effect on outcome applied to patients with higher or lower coma scores, to those with diffuse injuries, and to those with an intracranial haematoma. As expected, the overall outcome in children was better, 72% making a good or moderate recovery compared with 42% of adults.

significantly

Discussion Provision of advanced care to accident victims before they reach hospital has attracted attention, but we have found few patients with fatal head injuries whio could have been saved by better initial care.8 Suboptimum care within the hospital system accounts for most avoidable deaths after head injury. Collaborative clinicopathological studies in Glasgow in the 1970s indicated that more than a third of deaths in patients referred to a neurosurgical unit had had avoidable factors that contributed to death. 5,8 A similar proportion of avoidable deaths was subsequently reported from another British neurosurgical unit.9 A recent review of 514 trauma deaths occurring after admission to hospitals in a representative sample of 11 Coroner’s districts in England and Wales showed that two-thirds were due to head or spinal injuries, of which only 17% were judged to be preventable. 10 However, preventable factors contributing to deaths after head injury were probably underestimated in this study, for three reasons-it did not distinguish head from spinal injuries; only a third of the fatal central nervous system injuries were transferred to an NSU; and the assessors included neither a neurosurgeon nor a

neuropathologist. An increasing number of seriously injured patients now have to be transported between hospitals because of regionalisation of several specialist services such as thoracic, maxillo-facial, vascular, or neurological surgery, renal dialysis, and the treatment of major bums. However, a recent study of ambulance transfers in and out of intensivecare units excluded the largest group of such cases, those admitted to specialist intensive-care units from accident departments.ll Another study of the transport of critically ill patients excluded head injuries.12 A system of care that requires the secondary transfer of seriously head injured patients to a neurosurgical unit involves

hazards

other

than

those

associated with

transportation. The division of responsibility between specialists who are in different hospitals can lead to disagreements about priorities in the management of individual patients. Extracranial injuries and complications are sometimes overlooked or inadequately managed, because clinicians in the first hospital mistakenly believe that there is great urgency to move the patient to the neurosurgical unit. The guidelines published in Britain for the initial management of adult head injuries include indications for

333

consultation with a neurosurgeon. But they also note the importance of initial resuscitation for extracranial injuries, and refer to precautions to reduce risks during transfer to the neurosurgical unit.4 Their implementation has resulted in more and quicker transfers to the regional unit in Glasgow.1,3 Moreover, there have been mortality and morbidity reductions in patients operated on for intracranial haematoma.12 However, the reduction in adverse factors before arrival at the neurosurgical unit has been only modest. The findings are similar in the Netherlands, where published guidelines for the care of severe head injuries include an instruction to intubate patients transferred in coma.13 Of head injury patients directly admitted to twelve Dutch hospitals, six of which had a neurosurgical unit, the injury was severe in 35-40% of patients. Some of these patients had been transferred to another non-neurological hospital before being sent to a neurosurgical unit and, of 81 reaching such a unit, 41 % were not intubated,14 compared with 58% in Glasgow. Three solutions to this problem have been proposed. One is to reduce the number of patients who need to be transferred, by providing CT scanners in more hospitals. This was urged by a Working Party of the Royal College of Surgeons of England,15 but it is happening anyway because of the wide applications of CT scanning in many specialties.16 However, only small numbers of head-injured patients who need scanning are admitted to any one general hospital. Many of them present outside normal working hours, when scanning may not be available in those hospitals. Because of these factors, the skills needed to secure good quality scans in seriously head-injured patients, and to

interpret them, are unlikely to develop. Transmitting images by telephone link to the neurosurgical unit, where the scan could be read by experts, has been suggested as a partial solution.17 However, if scanning in another hospital disclose a lesion that needed neurosurgery, the patient would still have to be transferred. More delay overall might result than if the patient had been sent to the neurosurgical unit in the first place. The main value of telephone transmission of images would be to reduce the number of patients who might be "unnecessarily" transferred for scanning. The second solution is to develop regional trauma centres, where all the specialist skills likely to be required are available on one site. Variations on this theme have been proposed repeatedly over the past 30 years, most recently by a Working Party of the Royal College of Surgeons of England. 18 It also has advocates in other countries, especially in the USA.19 Implicit in these schemes is that all seriously injured patients should go to the trauma centre directly from the scene of the accident. This system offers most to accident victims who have multiple injuries, but the numbers of such cases are likely to be small, at least within the effective catchment area of any one proposed trauma centre. It seems likely that many patients would in practice have to be secondarily transferred from another hospital to the trauma centre. In any event, intracranial haematoma, the commonest cause of avoidable death after head injury, often occurs in patients who are not multiply injured and who initially did not seem to have been seriously brain injured;2O such patients would probably therefore not have been sent to the trauma centre initially. The third solution is to make further attempts to improve the existing system of secondary referral to regional neurosurgeons-and this is the most realistic in the were to

foreseeable future. The challenge is to reduce delay in appropriate referral to specialist care for the head injury without increasing the hazards associated with extracranial injuries. One problem is to deal with overconcern about the rapid transfer of patients in coma, to the exclusion of the more immediate requirements of ensuring an adequate airway and dealing with blood loss, shock, and unstable fractures.21 It can be done, as a report of 158 traffic fatalities in southern Sweden indicates.22 There were very few possibly preventable deaths, and not a single case of internal haemorrhage-intracranial or elsewhere. A population of 1 -7 million people live there in 21 towns and cities spread over 30 000 sq km; there are 15 local hospitals, but neurosurgeons are available only in the two university hospitals, and seriously head-injured patients have to be transferred to them. Although termed "decentralised", the Swedish system is well organised, involving a commitment to trauma by senior general surgeons, who are themselves on call, in all hospitals. An American commentator contrasted this with his country’s "non-system of trauma care", where there is no requirement for a hospital to make a commitment to trauma, although accident cases are accepted.23 The question of how to do better in future has been addressed before in the UK.15 The answer should lie in simple educational and organisational measures. What needs to be done is not in dispute, but general advice to anticipate, recognise, and treat extracranial injuries and complications, and to protect the airway, seems not to be sufficient. One reason why this advice is sometimes not translated into appropriate action may be that head injuries requiring urgent transfer occur relatively seldom in the experience of individual doctors in general hospitals. Consultant staff responsible for such cases in all hospitals should draw up guidelines based on discussion between local surgeons, anaesthetists and A/E consultants, senior nursing staff, and the regional neurosurgeons. These guidelines should make clear to junior doctors what has been agreed, and should include a protocol for the practical steps necessary to ensure the safety of a patient whom it has been decided should be transferred. An expanded version of the published guidelines is shown in table v, as a basis for local discussions. Once guidelines have been agreed, consultant staff should ensure that,on taking up post, junior staff are made aware of what should be done in various circumstances and when they should seek advice. Each hospital should designate senior members of staff (consultants, senior registrars, or senior nurses from intensive care), one of whom has to be consulted before a patient in coma is transferred. They would decide what airway care was appropriate for a particular patient, and would instruct whoever was to escort the patient on how to deal with various events that might occur en route. Routine audit of transfers, such as that which formed the basis of this report, could be helpful in discovering how well the system is working in

undiagnosed

practice. REFERENCES Jennett B, Murray A, Carlin J, et al. Head injuries in three Scottish neurosurgical units. Br Med J 1979; ii: 955-58. 2. Teasdale G, Galbraith S, Murray L, et al. Management of traumatic intracranial haematoma. Br Med J 1982; 285: 1965-97. 3. Bryden JS, Jennett B. Neurosurgical resources and transfer policies for head injuries. Br Med J 1983; 286: 1791-93. 1.

334

Group of neurosurgeons: Guidelines for initial management after head injury in adults. Br Med J 1984; 288: 983-85. 5. Rose J, Valtonen S, Jennett B. Avoidable factors contributing to death after head injury. Br Med J 1977; ii: 615-18. 6. Gentleman D, Jennett B. Hazards of inter-hospital transfer of comatose head-injured patients. Lancet 1981; ii: 853-55. 7. Jennett B, Bond M. Assessment of outcome after severe brain damage. A practical scale. Lancet 1975; i: 480-84. 8. Jennett B, Carlin J. Preventable mortality and morbidity after head injury. Injury 1978; 10: 31-39. 9. Jeffreys RV, Jones JJ. Avoidable factors contributing to the death of head injury patients in general hospitals in Mersey Region. Lancet 1981; ii:

4.

459-61. 10. Anderson

ID, Woodford M, de Dombal FT, Irving M. Retrospective study of 1000 deaths from injury in England and Wales. Br Med J 1988;

296: 1305-08.

Wright IH, McDonald JC, Rogers PN, Ledingham IMcA. Provision of facilities for secondary transport of seriously ill patients in the United Kingdom. Br Med J 1988; 296: 543-45. 12. Bion JF, Wilson IH, Taylor PA. Transporting critically ill patients by ambulance: audit by sickness scoring. Br Med J 1988; 296: 170. 13. Van Alphen HAM, Braakman R. Richtlijnen voor de behandeling van patienten met ernstig traumatisch hersenletsel (Guidelines for the treatment of patients with severe traumatic brain damage). Ned Tijdschr 11.

14. Draaisma JMTh. Mogelijkheden tot evaluatie van zorg aan patienten met enrstig hersenletsel door ambulancehulpverleners (Methods of evaluating the care of patients with severe head injuries by ambulance personnel). De Ambulance 1986; 7: 15-17. 15. Commission on the Provision of Surgical Services. Report of the Working Party on Head Injuries. London: Royal College of Surgeons of England. 1986. 16. Hewer RL, Wood VA. Availability of computed tomography of the brain in the United Kingdom. B Med J 1989 298: 1219-20. 17. Marsh H, Maurice-Williams RS, Hatfield R. Closed head injuries: where does delay occur in the process of transfer to neurosurgical care? BrJ Neurosurg 1989; 3: 13-20. 18. Yates DW. Action for accident victims: plans to stop patients dying unnecessarily from major trauma. Br Med J 1988; 297: 1419-20. 19. Smith RW. Guidelines for establishment of trauma centers. J Neurosurg

1986; 65: 569-71. Jennett B. Some international comparisons. In: Levin HS, Eisenberg HM, Benton AL, eds. Mild Head Injury. Oxford: Oxford University Press, 1989; 23-34. 21. McLaren CAN, Robertson C, Little K. Missed orthopaedic injuries in the resuscitation room. J R Coll Surg Edin 1983; 28: 399-401. 22. Ottosson A, Krantz P. Traffic fatalities in a system with decentralized trauma care. JAMA 1984; 251: 2668-71. 23. Frey CF. Care of serious trauma in Southern Sweden. JAMA 1984; 251:

20.

2698-99.

Geneeskd 1985; 129: 645-49.

EPIDEMIOLOGY Effect of diarrhoeal disease control on infant and childhood mortality in Egypt

Report from the National Control of Diarrheal Diseases Project

The effect of the National Control of Diarrheal Diseases Project, started in 1983, on infant and childhood mortality in Egypt was assessed by of national civil registration data, means nationwide cluster sample surveys of households, and local area studies. Packets of oral rehydration salts are now widely accessible; oral rehydration therapy is used correctly in most episodes of diarrhoea; most mothers continue to feed infants and children during the child’s illness; and most physicians prescribe oral rehydration therapy. These changes in the management of acute diarrhoea are associated with a sharp decrease in mortality from diarrhoea, while death from other causes remains nearly constant.

Diarrheal Diseases Project (NCDDP) was established in 1983 after successful trials in 1980 of oral rehydration therapy (ORT) in rural villages in the Dakahlia Governorate of Lower Egypt.2,6A full national programme was underway by 1984,’ and has continued since then. It is unusual for a single health intervention in a developing country to have a proven beneficial effect,8 and the value of narrowly targeted interventions has been questioned.9 We have assessed the effect of the NCDDP on infant and childhood mortality in Egypt, to the end of 1987.

Methods We used various methods to measure NCDDP impact because we did not regard any one method as sufficiently comprehensive or robust. Our analyses are therefore descriptive and are not based on

significance testing.

Introduction In 1978, when oral rehydration salts (ORS) were first introduced into Egypt, infant mortality was about 100 per 1000 live births; at least half the infant and childhood deaths were diarrhoea-associated.1-5 The National Control of

ADDRESS: National Control of Diarrheal Diseases

Project, 55 Mosaddaq Street, Dokki, Giza, Egypt (M. EI-Rafie, MD, W. A.

Hassouna, MD, N. Hirschhorn, MD, S. Loza, PhD, P. Miller, MA, A. Nagaty, MD, S. Nasser, MD, and R. Riyad, MD). Correspondence to Dr Said Madkour, executive director, National Control of Diarrheal Diseases

Project.