696
Hospital Practice HEAD INJURIES IN SCOTTISH HOSPITALS Scottish Head Injury Management Study*
study was designed to discover how patients with a head injury are managed in Scotland. Preliminary findings based on retrospective examination of hospital records describe and compare the characteristics of 3035 patients arriving at accident and emergency departments, 1181 admitted to primary surgical wards, and 424 treated in neurosurgical units in Scotland, excluding the Lothians. These data are being.
Summary
A
used for further studies to define the needs of these patients and to explore alternative management policies which could make better use of existing health-service resources.
INTRODUCTION
HEAD injuries figure prominently in the work of accident and emergency departments, surgical wards in general hospitals, and neurosurgical units. Hospital statistics in the U.K. deal only with patients admitted, and according to the Field report’ there have been no published studies in Britain of the pattern of attendances at emergency departments for head injury; the only relevant studies appear to be those of Klonoff and Thompson2 at the Vancouver General Hospital. There have been reports on patients with head injuries admitted to the surgical wards of a Scottish peripheral hospital3 and of a Scottish teaching hospital;4 there have also been several series reported from children’s hospitals in England. A series of adults admitted to the neurosurgical unit in Newcastle upon Tyne has been described by Kerr.s Jennett6 has pointed out that the dispersion of head injuries amongst many different disciplines in the hospital service makes it difficult to appreciate the scale and scope of the problem either in the acute stage or when the patients have returned to the community or moved on to long-term accommodation in hospital. One object of the Scottish Head Injury Management Study (s.H.i.M.s.), set up two years ago, is the collection of comprehensive data in order to discover how head injuries are distributed and managed. This first report describes some features of head injury in accident and emergency departments, in primary surgical wards, and in neurosurgical units in Scottish hospitals. Later reports will deal in more detail with patients in each of these situations. METHODS
We
were
interested in the first instance in
finding
out
how
*Participants: BRYAN JENNETT and ANDREW MURRAY, Department of Neurosurgery, Institute of Neurological Sciences, Glasgow G511 4TF; ROBERT MCMILLAN and JOHN MACFARLANE, Health Services Operational Research Unit, Strathclvde Universitv, Glasgow; CECILY BENTLEY, Greater Glasgow Area Health Board; IAN STRANG, Argyll Clyde Area Health Board; VICTOR HAWTHORNE, University Department of Community Medicine, Glasgow.
head injuries are managed by Scottish hospitals. As prospective studies tend to alter patient management it was decided to begin with a retrospective survey. Possible limitations in the amount of data likely to be available were considered acceptable, especially as previous experience of retrospective surveys in patients with head injuries had proved successful (post-traumatic epilepsy’ and compound depressed fractures’). In particular it seemed likely that most of the management data required for a baseline could be derived from existing records. We also wished the data to be extracted by personnel who were not themselves involved in the management of head injuries, and who would not therefore make value judgements. Draft questionnaires were devised and a pilot survey undertaken to discover how much information was available in existing records and how reliably this could be coded by team members. Before data collection began a meeting was convened with representatives from neurosurgery, general surgery, orthopoedic surgery, accident departments, and administration, from all the various regions, in order to discuss the objectives of the study and the ways in which these might most readily be achieved. The study was then described briefly to the annual meeting of Scottish chief administrative medical officers, in order to secure their approval; at their suggestion we decided to survey all the hospitals in Scotland. We next wrote to clinicians and records officers in all hospitals. A preliminary visit to many hospitals was made by one of us to explain what was required and to offer guarantees of confidentiality (although patients’ names were not recorded on our questionnaires). Sometimes records officers were able to collect the necessary records and have them ready for the visit of the member of the team, but often the team members had to extract the records themselves. During the pilot stage one of us (A.M.), who had experience in neurosurgical and accident surgery, supervised the transcription of data to questionnaire forms. The term "primary surgical ward" includes orthopaedic, accident, general surgical, short-stay, and paediatric wards-wherever
patients
were
initially admitted, excluding neurosurgical
units. In most of Scotland, as in most of Britain and Europe, neurosurgeons accept only the more seriously injured patients, usually by transfer from other surgeons. Review of hospital inpatient statistics in Scotland from 1968 to 1972 showed that 3 of Scotland’s neurosurgical units (Glasgow, Aberdeen, and Dundee) each took in 4% of the head injuries admitted to hospital in their regions. In the South-East region the proportion was 44%, because in the Edinburgh Royal Infirmary (the major hospital for accidents) the neurosurgeons have a special ward to which all head injuries are admitted. In order to make comparisons between Edinburgh and the rest of Scotland it would have been necessary to decide how many patients in this neurosurgical-trauma ward corresponded to primary surgical admissions (asdistinct from direct neurosurgicaladmissions)elsewhere. As there were difficulties in making such decisions, this report is restricted to all Scottish hospital admissions except those in the Lothians. We did, however, survey the accident and emergency departments in the Lothians, and a preliminary analysis of the data obtained shows no material difference from the rest of Scotland. Once we decided to include all hospitals, it was necessary to have a relatively short sampling period, in order to complete the survey in reasonable time. We sampled accident and emergency departments for two randomly selected weeks, one in summer and one in winter; primary surgical wards were sampled for two periods of two weeks, one week of each period being the same week as that for the accident and emergency survey in the same hospital; the three neurosurgical units (Glasgow, Aberdeen, and Dundee) were "sampled" for the whole year (1974). In all, 49 hospitals were surveyed. A patient was classified as one with a head injury if he had one or more of the following features:
and
1. A history of a blow to the head.
697 2. Altered consciousness after a relevant injury.
are extrapolated for one year, arrive at an estimate of 15 000 admissions for head injury for Scotland as a whole (with a correction for the Lothians); this corresponds closely to the 15 229 hospital discharges recorded as head injuries in the Scottish Hospital In-patient Statistics (S.H.I.P.S.).10 The mortality-rate was 1% in the patients surveyed, and 1% were transferred to neurosurgical units. Two-thirds were dis-
in
primary surgical wards
we
3. A scalp or forehead laceration. 4. An X-ray of skull had been
taken, whether a fracture was
revealed or not. Facial lacerations, fractures of the lower jaw, foreign bodies in the eye, ear, or nose, and epistaxis were excluded unless associated with any of the above features. For practical purposes the definition of head injury used in this study approximates to rubrics N800, 801, 803, 804, and 850-854 inclusive of the International Classification of Diseases
TABLE II-PROPORTION OF PATIENTS WITH SELECTED
CHARACTERISTICS IN POPULATIONS SURVEYED
(8th revision).’ RESULTS
Accident and
Emergency Departments (3035 patients, excluding Lothians) Head injuries formed about 10% of new attendances at accident and emergency departments in Scotland. A previous survey by one of us (J.M.) in the Glasgow Royal Infirmary, which has the largest number of head injuries of any Scottish hospital, had shown little difference in the proportion of head injuries from one month to another throughout the year. If the weekly rate is extrapolated for a year it amounts to approximately 84 000 head-injury attendances a year for Scottish hospitals; for the U.K., this would be almost 1 000 000 new attenders with head injuries each year. Half the patients presented between 1700 and 2400 hours, and 34% of the new attendances were on Fridays and Saturdays. A third of these patients were under 10 years of age and more than half (54%) under 20 years. Recent consumption of alcohol was recorded in the casualty notes in 22% of patients over 14 years of age. 40% of all patients had a scalp laceration, which was closed by suture in three-quarters and by ’Steristrip’ (dumb-bell sutures) in the remainder (steristrip was more commonly used in children). Half the patients had a skull X-ray at their first attendance, but 2% of patients were asked to reattend for skull X-ray; 16% were asked to report for review and 14% did in fact report back to hospital for one reason or another; 19% were recommended to go to their general practitioner.
Primary Surgical Wards (1181 patients, excluding Lothians) When the numbers for the 4 weeks of data collection
TABLE I-PROPORTION OF PATIENTS ACCORDING TO
charged within 2 days and only 14% stayed more 7 days. 80% were not seen again by the hospital.
than
Neurosurgical Units (424 patients in Glasgow, Aberdeen, and Dundee) This figure represented 3% of hospital admissions in the regions served by these centres, which corresponds the 4% estimated on the basis of S.H.I.P.S. for 1968-72. There was no doubt about the need for transfer to neurosurgical units, because twothirds of the patients had more than one special investigation, and more than two-thirds had an intracranial operation; many were found to have an intracranial haematoma. The mortality was 14% in the neurosurgical to
returns
AGE, SEX,
AND ALCOHOL CONSUMPTION IN POPULATIONS SURVEYED
698
units. The neurosurgeons did not follow-up a third of the survivors, many of whom were returned to primary surgical wards and not to their homes.
Comparison between Different Patient Groups The characteristics of four groups of patients are considered in tables I and II. Because the patients who are admitted from accident and emergency departments represent an overlap with those surveyed in primary surgical wards, a distinction has been made between the total number of patients attending accident and emergency departments and those who were sent home. 44% of patients attending accident departments were children (14 years and under), compared with 36% of surgical and 25% of neurosurgical admissions, differences which are significant. The ratio of boys to girls was 2/1 in accident departments and in surgical wards but in neurosurgical units this ratio was 5/1, which means that many more boys suffered severe injuries. 9% of all admissions were aged over 65 compared with 5% of attenders who were not admitted. Those over 65 made up 15% of women admitted and 7% of men. Traffic accidents accounted for 13% of attenders not admitted (18% of all attenders), and for 35% of all admissions. 22% of adults attending the accident department were victims of an assault, although the figure was lower in those admitted, and 10% of adults had been injured at work. Sport injuries accounted for 10% of attenders, 14% of surgical admissions, and for 7% in the neurosurgical wards. About a fifth of adult accident department attenders were recorded as having recently consumed alcohol; this proportion was significantly higher in patients admitted both to primary surgical wards and to neurosurgical units. It was twice as common in men
in women. Scalp lacerations requiring closure were commoner in patients who were not admitted than in those taken into hospital. As would be expected the proportion of patients X-rayed who showed a fracture of the vault or base of the skull was quite low in the accident department ; 3% of all attenders had a fracture, as had 0-3% of those patients who had been sent home. 7% of admissions to the surgical ward and 65% of admissions to the neurosurgical units had a skull fracture. The mortality rate was 1% for the surgical wards and 14% for the neurosurgical units; a few patients died in the accident department before admission. as
study by Kerr et al.was that 17% of men 60-69 compared with 7% in our study.
were
aged
The close agreement between the present survey and these other reports is evidence that the samples in this study are representative. However, differences do exist in characteristics other than age and sex, and these will be described in future communications, which will also attempt to analyse the differences between hospitals in Scotland.
ImplicationsforHead-injury Care There is no doubt that head injuries cause concern to many hospital doctors, particularly during the acute stage after injury, because of uncertainty about the best course of action, taking account of the practical, economic, and medico-legal considerations. The main worryis about the small number of apparently mildly injured patients in whom serious complications develop later. There is evidence that under the present system complications which develop in a considerable number of patients might have been prevented, and that there can be undue delay in recognising and treating both these and also unavoidable complications.8,11 How best to improve the situation is not clear; suggestions about modifying the traditional admission policy have provoked protest.12-14 One of us has suggested6 that radical reorganisation may be required, with more discussion and collaboration between the specialists involved at the three levels-accident departments, primary surgical wards, and neurosurgical units. If there were agreement on general policies of management there would be less need for discussion of individual cases, something which would indeed be impractical, considering the great number of head injuries. The implications of any reorganisation of head-injury care cannot be considered without statistics which relate to all parts of the hospital service. The Scottish study is acquiring a baseline and has begun to provide these data; and it should be possible to ask practical rather than theoretical questions about the management of patients with head injuries. We are grateful to chief administrative medical officers and to clinicians for permission to abstract data from hospital records. We acknowledge the help received from the medical-records officers and their staffs. The Scottish Head Injury Management Study is su ported by a grant from the Chief Scientist Organisation of the Scottish Home and Health Department.
Requests for reprints should be addressed to B. J., Department of Neurosurgery, Institute of Neurological Sciences, Glasgow G51 4TF. REFERENCES H. Research Division, Department of Health and Social Security. H.M. Stationery Office, 1976. 2. Klonoff, H., Thompson, G. B. Can. med. Ass.J. 1969, 100, 235. 3. Barr, J. B., Ralston, G. J. Lancet, 1964, ii, 519. 4. Galbraith, S., Murray, W. R., Patel, A. R. Scott. med. J. 1977, 22, 129. 5. Kerr, T. A., Kay, D. W. K., Lassman, L. P. Br. J. prev. soc. Med. 1971, 25, 179. 6. Jennett, B. Br. med.J. 1975, iii, 267. 7. Jennett, B.J. Neurol. Neurosurg. Psychiat. 1975, 38, 4, 378. 8. Jennett, B., Miller, J.J. Neurosurg. 1972, 36, 333. 9. World Health Organisation Manual of the International Statistical Classification of Diseases, Injuries and Causes of Death, 8th revision, Geneva, 1967. 10. Scottish Home and Health Department Scottish Hospital In-patient Statistics, 1974. Information Services Division of the Common Services Agency, 1.
DISCUSSION
The age and sex distribution of adults (15 years and in the accident and emergency sample did not
over)
differ significantly from that found by Klonoff and Thompson2 in their study of 348 consecutive cases of head injury patients visiting the emergency department at the Vancouver General Hospital. The proportions by age and sex in the primary surgical ward sample was not significantly different from those of all head injury discharges from Scottish hospidid they differ from the one-year studies in two separate Scottish hospitals.3,4 The only difference in the Newcastle neurosurgical
tals,’O
nor
Field, J.
Edinburgh, 1975. 11. Rose, J., Valtonen, S., Jennett, B. Br. 12. Galbraith, S. Lancet, 1973, i, 1217. 13. Potter, J. M. ibid. p. 1381. 14. Galbraith, S. ibid. 1973, ii, 104.
med. J. 1977, ii, 615.
Hospital Practice HEAD INJURIES IN SCOTTISH HOSPITALS Scottish Head Injury Management Study*
study was designed to discover how patients with a head injury are managed in Scotland. Preliminary findings based on retrospective examination of hospital records describe and compare the characteristics of 3035 patients arriving at accident and emergency departments, 1181 admitted to primary surgical wards, and 424 treated in neurosurgical units in Scotland, excluding the Lothians. These data are being.
Summary
A
used for further studies to define the needs of these patients and to explore alternative management policies which could make better use of existing health-service resources.
INTRODUCTION
HEAD injuries figure prominently in the work of accident and emergency departments, surgical wards in general hospitals, and neurosurgical units. Hospital statistics in the U.K. deal only with patients admitted, and according to the Field report’ there have been no published studies in Britain of the pattern of attendances at emergency departments for head injury; the only relevant studies appear to be those of Klonoff and Thompson2 at the Vancouver General Hospital. There have been reports on patients with head injuries admitted to the surgical wards of a Scottish peripheral hospital3 and of a Scottish teaching hospital;4 there have also been several series reported from children’s hospitals in England. A series of adults admitted to the neurosurgical unit in Newcastle upon Tyne has been described by Kerr.s Jennett6 has pointed out that the dispersion of head injuries amongst many different disciplines in the hospital service makes it difficult to appreciate the scale and scope of the problem either in the acute stage or when the patients have returned to the community or moved on to long-term accommodation in hospital. One object of the Scottish Head Injury Management Study (s.H.i.M.s.), set up two years ago, is the collection of comprehensive data in order to discover how head injuries are distributed and managed. This first report describes some features of head injury in accident and emergency departments, in primary surgical wards, and in neurosurgical units in Scottish hospitals. Later reports will deal in more detail with patients in each of these situations. METHODS
We
were
interested in the first instance in
finding
out
how
*Participants: BRYAN JENNETT and ANDREW MURRAY, Department of Neurosurgery, Institute of Neurological Sciences, Glasgow G511 4TF; ROBERT MCMILLAN and JOHN MACFARLANE, Health Services Operational Research Unit, Strathclvde Universitv, Glasgow; CECILY BENTLEY, Greater Glasgow Area Health Board; IAN STRANG, Argyll Clyde Area Health Board; VICTOR HAWTHORNE, University Department of Community Medicine, Glasgow.
head injuries are managed by Scottish hospitals. As prospective studies tend to alter patient management it was decided to begin with a retrospective survey. Possible limitations in the amount of data likely to be available were considered acceptable, especially as previous experience of retrospective surveys in patients with head injuries had proved successful (post-traumatic epilepsy’ and compound depressed fractures’). In particular it seemed likely that most of the management data required for a baseline could be derived from existing records. We also wished the data to be extracted by personnel who were not themselves involved in the management of head injuries, and who would not therefore make value judgements. Draft questionnaires were devised and a pilot survey undertaken to discover how much information was available in existing records and how reliably this could be coded by team members. Before data collection began a meeting was convened with representatives from neurosurgery, general surgery, orthopoedic surgery, accident departments, and administration, from all the various regions, in order to discuss the objectives of the study and the ways in which these might most readily be achieved. The study was then described briefly to the annual meeting of Scottish chief administrative medical officers, in order to secure their approval; at their suggestion we decided to survey all the hospitals in Scotland. We next wrote to clinicians and records officers in all hospitals. A preliminary visit to many hospitals was made by one of us to explain what was required and to offer guarantees of confidentiality (although patients’ names were not recorded on our questionnaires). Sometimes records officers were able to collect the necessary records and have them ready for the visit of the member of the team, but often the team members had to extract the records themselves. During the pilot stage one of us (A.M.), who had experience in neurosurgical and accident surgery, supervised the transcription of data to questionnaire forms. The term "primary surgical ward" includes orthopaedic, accident, general surgical, short-stay, and paediatric wards-wherever
patients
were
initially admitted, excluding neurosurgical
units. In most of Scotland, as in most of Britain and Europe, neurosurgeons accept only the more seriously injured patients, usually by transfer from other surgeons. Review of hospital inpatient statistics in Scotland from 1968 to 1972 showed that 3 of Scotland’s neurosurgical units (Glasgow, Aberdeen, and Dundee) each took in 4% of the head injuries admitted to hospital in their regions. In the South-East region the proportion was 44%, because in the Edinburgh Royal Infirmary (the major hospital for accidents) the neurosurgeons have a special ward to which all head injuries are admitted. In order to make comparisons between Edinburgh and the rest of Scotland it would have been necessary to decide how many patients in this neurosurgical-trauma ward corresponded to primary surgical admissions (asdistinct from direct neurosurgicaladmissions)elsewhere. As there were difficulties in making such decisions, this report is restricted to all Scottish hospital admissions except those in the Lothians. We did, however, survey the accident and emergency departments in the Lothians, and a preliminary analysis of the data obtained shows no material difference from the rest of Scotland. Once we decided to include all hospitals, it was necessary to have a relatively short sampling period, in order to complete the survey in reasonable time. We sampled accident and emergency departments for two randomly selected weeks, one in summer and one in winter; primary surgical wards were sampled for two periods of two weeks, one week of each period being the same week as that for the accident and emergency survey in the same hospital; the three neurosurgical units (Glasgow, Aberdeen, and Dundee) were "sampled" for the whole year (1974). In all, 49 hospitals were surveyed. A patient was classified as one with a head injury if he had one or more of the following features:
and
1. A history of a blow to the head.
697 2. Altered consciousness after a relevant injury.
are extrapolated for one year, arrive at an estimate of 15 000 admissions for head injury for Scotland as a whole (with a correction for the Lothians); this corresponds closely to the 15 229 hospital discharges recorded as head injuries in the Scottish Hospital In-patient Statistics (S.H.I.P.S.).10 The mortality-rate was 1% in the patients surveyed, and 1% were transferred to neurosurgical units. Two-thirds were dis-
in
primary surgical wards
we
3. A scalp or forehead laceration. 4. An X-ray of skull had been
taken, whether a fracture was
revealed or not. Facial lacerations, fractures of the lower jaw, foreign bodies in the eye, ear, or nose, and epistaxis were excluded unless associated with any of the above features. For practical purposes the definition of head injury used in this study approximates to rubrics N800, 801, 803, 804, and 850-854 inclusive of the International Classification of Diseases
TABLE II-PROPORTION OF PATIENTS WITH SELECTED
CHARACTERISTICS IN POPULATIONS SURVEYED
(8th revision).’ RESULTS
Accident and
Emergency Departments (3035 patients, excluding Lothians) Head injuries formed about 10% of new attendances at accident and emergency departments in Scotland. A previous survey by one of us (J.M.) in the Glasgow Royal Infirmary, which has the largest number of head injuries of any Scottish hospital, had shown little difference in the proportion of head injuries from one month to another throughout the year. If the weekly rate is extrapolated for a year it amounts to approximately 84 000 head-injury attendances a year for Scottish hospitals; for the U.K., this would be almost 1 000 000 new attenders with head injuries each year. Half the patients presented between 1700 and 2400 hours, and 34% of the new attendances were on Fridays and Saturdays. A third of these patients were under 10 years of age and more than half (54%) under 20 years. Recent consumption of alcohol was recorded in the casualty notes in 22% of patients over 14 years of age. 40% of all patients had a scalp laceration, which was closed by suture in three-quarters and by ’Steristrip’ (dumb-bell sutures) in the remainder (steristrip was more commonly used in children). Half the patients had a skull X-ray at their first attendance, but 2% of patients were asked to reattend for skull X-ray; 16% were asked to report for review and 14% did in fact report back to hospital for one reason or another; 19% were recommended to go to their general practitioner.
Primary Surgical Wards (1181 patients, excluding Lothians) When the numbers for the 4 weeks of data collection
TABLE I-PROPORTION OF PATIENTS ACCORDING TO
charged within 2 days and only 14% stayed more 7 days. 80% were not seen again by the hospital.
than
Neurosurgical Units (424 patients in Glasgow, Aberdeen, and Dundee) This figure represented 3% of hospital admissions in the regions served by these centres, which corresponds the 4% estimated on the basis of S.H.I.P.S. for 1968-72. There was no doubt about the need for transfer to neurosurgical units, because twothirds of the patients had more than one special investigation, and more than two-thirds had an intracranial operation; many were found to have an intracranial haematoma. The mortality was 14% in the neurosurgical to
returns
AGE, SEX,
AND ALCOHOL CONSUMPTION IN POPULATIONS SURVEYED
698
units. The neurosurgeons did not follow-up a third of the survivors, many of whom were returned to primary surgical wards and not to their homes.
Comparison between Different Patient Groups The characteristics of four groups of patients are considered in tables I and II. Because the patients who are admitted from accident and emergency departments represent an overlap with those surveyed in primary surgical wards, a distinction has been made between the total number of patients attending accident and emergency departments and those who were sent home. 44% of patients attending accident departments were children (14 years and under), compared with 36% of surgical and 25% of neurosurgical admissions, differences which are significant. The ratio of boys to girls was 2/1 in accident departments and in surgical wards but in neurosurgical units this ratio was 5/1, which means that many more boys suffered severe injuries. 9% of all admissions were aged over 65 compared with 5% of attenders who were not admitted. Those over 65 made up 15% of women admitted and 7% of men. Traffic accidents accounted for 13% of attenders not admitted (18% of all attenders), and for 35% of all admissions. 22% of adults attending the accident department were victims of an assault, although the figure was lower in those admitted, and 10% of adults had been injured at work. Sport injuries accounted for 10% of attenders, 14% of surgical admissions, and for 7% in the neurosurgical wards. About a fifth of adult accident department attenders were recorded as having recently consumed alcohol; this proportion was significantly higher in patients admitted both to primary surgical wards and to neurosurgical units. It was twice as common in men
in women. Scalp lacerations requiring closure were commoner in patients who were not admitted than in those taken into hospital. As would be expected the proportion of patients X-rayed who showed a fracture of the vault or base of the skull was quite low in the accident department ; 3% of all attenders had a fracture, as had 0-3% of those patients who had been sent home. 7% of admissions to the surgical ward and 65% of admissions to the neurosurgical units had a skull fracture. The mortality rate was 1% for the surgical wards and 14% for the neurosurgical units; a few patients died in the accident department before admission. as
study by Kerr et al.was that 17% of men 60-69 compared with 7% in our study.
were
aged
The close agreement between the present survey and these other reports is evidence that the samples in this study are representative. However, differences do exist in characteristics other than age and sex, and these will be described in future communications, which will also attempt to analyse the differences between hospitals in Scotland.
ImplicationsforHead-injury Care There is no doubt that head injuries cause concern to many hospital doctors, particularly during the acute stage after injury, because of uncertainty about the best course of action, taking account of the practical, economic, and medico-legal considerations. The main worryis about the small number of apparently mildly injured patients in whom serious complications develop later. There is evidence that under the present system complications which develop in a considerable number of patients might have been prevented, and that there can be undue delay in recognising and treating both these and also unavoidable complications.8,11 How best to improve the situation is not clear; suggestions about modifying the traditional admission policy have provoked protest.12-14 One of us has suggested6 that radical reorganisation may be required, with more discussion and collaboration between the specialists involved at the three levels-accident departments, primary surgical wards, and neurosurgical units. If there were agreement on general policies of management there would be less need for discussion of individual cases, something which would indeed be impractical, considering the great number of head injuries. The implications of any reorganisation of head-injury care cannot be considered without statistics which relate to all parts of the hospital service. The Scottish study is acquiring a baseline and has begun to provide these data; and it should be possible to ask practical rather than theoretical questions about the management of patients with head injuries. We are grateful to chief administrative medical officers and to clinicians for permission to abstract data from hospital records. We acknowledge the help received from the medical-records officers and their staffs. The Scottish Head Injury Management Study is su ported by a grant from the Chief Scientist Organisation of the Scottish Home and Health Department.
Requests for reprints should be addressed to B. J., Department of Neurosurgery, Institute of Neurological Sciences, Glasgow G51 4TF. REFERENCES H. Research Division, Department of Health and Social Security. H.M. Stationery Office, 1976. 2. Klonoff, H., Thompson, G. B. Can. med. Ass.J. 1969, 100, 235. 3. Barr, J. B., Ralston, G. J. Lancet, 1964, ii, 519. 4. Galbraith, S., Murray, W. R., Patel, A. R. Scott. med. J. 1977, 22, 129. 5. Kerr, T. A., Kay, D. W. K., Lassman, L. P. Br. J. prev. soc. Med. 1971, 25, 179. 6. Jennett, B. Br. med.J. 1975, iii, 267. 7. Jennett, B.J. Neurol. Neurosurg. Psychiat. 1975, 38, 4, 378. 8. Jennett, B., Miller, J.J. Neurosurg. 1972, 36, 333. 9. World Health Organisation Manual of the International Statistical Classification of Diseases, Injuries and Causes of Death, 8th revision, Geneva, 1967. 10. Scottish Home and Health Department Scottish Hospital In-patient Statistics, 1974. Information Services Division of the Common Services Agency, 1.
DISCUSSION
The age and sex distribution of adults (15 years and in the accident and emergency sample did not
over)
differ significantly from that found by Klonoff and Thompson2 in their study of 348 consecutive cases of head injury patients visiting the emergency department at the Vancouver General Hospital. The proportions by age and sex in the primary surgical ward sample was not significantly different from those of all head injury discharges from Scottish hospidid they differ from the one-year studies in two separate Scottish hospitals.3,4 The only difference in the Newcastle neurosurgical
tals,’O
nor
Field, J.
Edinburgh, 1975. 11. Rose, J., Valtonen, S., Jennett, B. Br. 12. Galbraith, S. Lancet, 1973, i, 1217. 13. Potter, J. M. ibid. p. 1381. 14. Galbraith, S. ibid. 1973, ii, 104.
med. J. 1977, ii, 615.
