BRITISH MEDICAL JOURNAL
955
20 OCTOBER 1979
PAPERS AND ORIGINALS
Head injuries in three Scottish neurosurgical units Scottish Head Injury Management Study B JENNETT, A MURRAY,
J
CARLIN, MARY McKEAN, R MACMILLAN, I STRANG
British MedicalJournal, 1979, 2, 955-958
Summary and conclusions The organisation of care for patients with head injuries in Scotland was investigated by studying retrospectively 785 patients admitted in 1974 and 1975 to neurosurgical units in Glasgow, Aberdeen, and Dundee. The reasons for the injuries and the patients' clinical conditions were similar in each unit. The referral practices at the hospitals containing the units were compared and found to be different from that of the unit in Edinburgh. It is concluded that patients in the Glasgow, Aberdeen, and Dundee units, which operate a similar policy for head-injured patients, are in general similar. Transferring to a neurosurgical unit only selected patients rather than all patients with head injuries is safe practice only if policies are agreed with primary surgeons and patients can be transferred without delay. Introduction In Britain, as in most other countries where neurosurgical services are regionally organised, only a small proportion of head-injured patients are treated by neurosurgeons. To consider the consequences of this policy it is necessary to review the
Department of Neurosurgery, Institute of Neurological Sciences, Glasgow G51 4TF B JENNETT, MD, FRCS, professor of neurosurgery A MURRAY, MB, CHB, research assistant J CARLIN, MB, CHB, research assistant MARY McKEAN, MB, CHB, research assistant Health Services Operational Research Unit, Strathclyde University, Glasgow R MACMILLAN, BA, data analyst
Argyll and Clyde Health Board I STRANG, MB, CHB, consultant epidemiologist
patients who reach neurosurgical units in the context of all those with head injuries. The Scottish Head-Injury Management Study was set up to collect data from all parts of the hospital service in Scotland.' Detailed reports of surveys carried out on head-injured patients presenting to accident and emergency departments and on those admitted to primary surgical wards have already been published.2 3 The present paper considers patients with head injuries who were admitted to three neurosurgical units in Scotland. Methods Three of the four Scottish neurosurgical units (Glasgow, Dundee, and Aberdeen) serve 7500 of the population of Scotland and operate a selective admission policy such as is common elsewhere in Great Britain. All patients admitted to these three neurosurgical units during 1974 were studied; Scottish accident and emergency departments and primary surgical wards were also surveyed during 1974. To increase the numbers available for analysis data were also collected for 1975 in Glasgow and Aberdeen, but this was not possible for Dundee. Members of the team who had recently been junior staff in a neurosurgical unit developed a data form for retrieving information from existing case records. While a retrospective survey limits the amount of data that can be collected reliably, it avoids the possibility of bias arising from knowledge that a survey is being undertaken. The Glasgow neurosurgical unit serves a population of 2-7 million. About 400% of the patients with head injuries in this region are admitted to primary surgical wards in the city, 4% to the hospital in which the neurosurgical unit is sited; 15% go to hospitals more than 30 miles away. Twenty-five neurosurgical beds per million population were available at the time of the survey (now increased to 33). Aberdeen neurosurgical unit is within the campus of a teaching hospital, to which 310/ of patients with head injuries are primarily admitted. Although about 60% of patients with head injuries are admitted to hospitals in the city, 26% are in hospitals more than 30 miles away. The population served is 660 000, and there are 35 neurosurgical beds per million. Dundee neurosurgical unit is situated in one of two teaching hospitals in the city, but all cases of trauma come to this hospital, which admits (primarily) 630/ of the cases of head injuries in the region. There are no hospitals more than 30 miles distant; the population served is 500 000, and there are 51 neurosurgical beds per million.
956
20 OCTOBER 1979
BRITISH MEDICAL JOURNAL
Results The patients reaching each of the three neurosurgical units were largely similar (tables I and II), and the differences were readily accounted for by geographical and organisational features of the three units. Glasgow admitted fewer patients with injuries from road accidents and more with injuries from assault; fewer Glasgow patients had associated extracranial injuries, which are more common in victims of road-traffic accidents. This feature of Glasgow reflects its predominantly urban population. Fewer patients reached the Glasgow neurosurgical unit within six hours of injury (Z2 = 36; P15 years) Assault (age -15 years) Injury: .. Scalp laceration Skull fracture Major extracranial .. .. injury Time between injury and admission to NSU: .. .. 24 hours ..
Glasgow (n = 545)
Aberdeen (n = 182)
Dundee (n = 58)
Total (n = 785)
29 8
7 15
38 5
25 10
34 31 18
43 28 9
41 39 11
37 30 15
34 65
29 46
40 55
33 60
15
25
31
18
27 46
35 36
50 14
31 41
TABLE iv-Final diagnosis. Figures are percentages of patients
..
37
Unit Aberdeen (n = 182) 30
.. .. .. .
10 24 11 23
6 21 8 11
10 22 7 14
.. ..
6 8 26
21 9 29
21 17 15
Glasgow
(n = 545) Intracranial haematoma Site of clot*: .. Extradural .. Subdural Intracerebral Depressed skull fracture Altered consciousness: No focal signs With focal signs .. Other cases
Dundee (n = 58)
Total (n = 785)
33
35 9 23 10 19 11 9 26
*Some patients had clots at more than one site.
TABLE iI-Clinicalfeatures ofpatients at time of admission to neurosurgical unit. Figures are percentages of patients
Glasgow coma scale*: 3-5 6-9
Aberdeen (n = 182)
Dundee n = 58)
Total (n = 785)
15
8 15 13 64 40 42
9 28 12 52 40 41
13 21 11 56 41 43
46 27 18
36 33 5
44 30 13
22 9 54 42
10-11 > 12. . .. Not talking .. Not obeying Deteriorating conscious
level Never lost consciousness Non-reacting pupils
Glasgow (n = 545)
43
.45 31 . .
12
OUTCOME
Mortality for the combined series from the three cities was 15%h; there was little variation from place to place or from year to year (table V). The median duration of stay was between six and eight days in each centre but shortest in Glasgow. The mean stay, however, was much longer in Aberdeen and Dundee, since more patients in these centres stayed in the neurosurgical ward for over a month. The shorter stay in Glasgow was achieved by sending twice as many patients back to other hospitals rather than waiting until they were able to go home.
*Deepest coma scores 3; fully conscious scores 15.
Clinical state on admission to the neurosurgical ward-About 40"0 of the patients were not talking and not obeying when they arrived at the neurosurgical units. On the Glasgow coma scale, which is widely used in Europe and North America to assess conscious level after head injury,4 one-third of patients scored 9 or less. Of those who were fully conscious or only mildly confused (coma score more than 12), over one-third had been admitted because of a depressed fracture of the skull. Over 40% of patients had a history of deteriorating conscious state; one in five was suspected of having a change in pupil size, reaction, or equality; and one in 10 had had a fit before
MINIPRINT TABLES
Illm TABLE 111-M..napemeer ur the thIll al,s 1974 and
197;5. F,g-,, ar p.......g.,p .......
U.,
S-.rid, Si-e Oselsg-v ~rracheoslv.ms
Oin.flaio.
1975
n271
1975 n- 274
n=95
21 2
14
2h 2S,
S 11
34 22
2
2
13
h
1
5
21
14
9
57 26.
56 32
IO 16
47
5
19
27
1974
,h
Crno
transfer.
3m12
7
n
h.
5Cgp --Ilt
11Q74
1974
N
1 17 19
4 9
N'Im
Vm
discharged-7771 J.r o7 977797
7-f
.7........ T,p n.r77urp77a1.1 -a d,d, r-P,
~~~~~~~~~~~~~~~
PROCEDURE IN THE NEUROSURGICAL UNIT 545 M- d.,--
.t
P."< 2 d.),
d.y. d...
."..
IIQ
2' "'"
,,f p.,,-,, d,.,h..g.d .Ih, h-pl ' dmd .f
..h.
r
5
.F-l 785 .
7
7
1,.
24
13
21
27
22
52
3.
3" 14
19 29 2. 22
63
"I
33
Is
2
36
3:7, ddy,"
8 2. >
.
11
11
33
P.P.i
-'.
15
955
20 OCTOBER 1979
PAPERS AND ORIGINALS
Head injuries in three Scottish neurosurgical units Scottish Head Injury Management Study B JENNETT, A MURRAY,
J
CARLIN, MARY McKEAN, R MACMILLAN, I STRANG
British MedicalJournal, 1979, 2, 955-958
Summary and conclusions The organisation of care for patients with head injuries in Scotland was investigated by studying retrospectively 785 patients admitted in 1974 and 1975 to neurosurgical units in Glasgow, Aberdeen, and Dundee. The reasons for the injuries and the patients' clinical conditions were similar in each unit. The referral practices at the hospitals containing the units were compared and found to be different from that of the unit in Edinburgh. It is concluded that patients in the Glasgow, Aberdeen, and Dundee units, which operate a similar policy for head-injured patients, are in general similar. Transferring to a neurosurgical unit only selected patients rather than all patients with head injuries is safe practice only if policies are agreed with primary surgeons and patients can be transferred without delay. Introduction In Britain, as in most other countries where neurosurgical services are regionally organised, only a small proportion of head-injured patients are treated by neurosurgeons. To consider the consequences of this policy it is necessary to review the
Department of Neurosurgery, Institute of Neurological Sciences, Glasgow G51 4TF B JENNETT, MD, FRCS, professor of neurosurgery A MURRAY, MB, CHB, research assistant J CARLIN, MB, CHB, research assistant MARY McKEAN, MB, CHB, research assistant Health Services Operational Research Unit, Strathclyde University, Glasgow R MACMILLAN, BA, data analyst
Argyll and Clyde Health Board I STRANG, MB, CHB, consultant epidemiologist
patients who reach neurosurgical units in the context of all those with head injuries. The Scottish Head-Injury Management Study was set up to collect data from all parts of the hospital service in Scotland.' Detailed reports of surveys carried out on head-injured patients presenting to accident and emergency departments and on those admitted to primary surgical wards have already been published.2 3 The present paper considers patients with head injuries who were admitted to three neurosurgical units in Scotland. Methods Three of the four Scottish neurosurgical units (Glasgow, Dundee, and Aberdeen) serve 7500 of the population of Scotland and operate a selective admission policy such as is common elsewhere in Great Britain. All patients admitted to these three neurosurgical units during 1974 were studied; Scottish accident and emergency departments and primary surgical wards were also surveyed during 1974. To increase the numbers available for analysis data were also collected for 1975 in Glasgow and Aberdeen, but this was not possible for Dundee. Members of the team who had recently been junior staff in a neurosurgical unit developed a data form for retrieving information from existing case records. While a retrospective survey limits the amount of data that can be collected reliably, it avoids the possibility of bias arising from knowledge that a survey is being undertaken. The Glasgow neurosurgical unit serves a population of 2-7 million. About 400% of the patients with head injuries in this region are admitted to primary surgical wards in the city, 4% to the hospital in which the neurosurgical unit is sited; 15% go to hospitals more than 30 miles away. Twenty-five neurosurgical beds per million population were available at the time of the survey (now increased to 33). Aberdeen neurosurgical unit is within the campus of a teaching hospital, to which 310/ of patients with head injuries are primarily admitted. Although about 60% of patients with head injuries are admitted to hospitals in the city, 26% are in hospitals more than 30 miles away. The population served is 660 000, and there are 35 neurosurgical beds per million. Dundee neurosurgical unit is situated in one of two teaching hospitals in the city, but all cases of trauma come to this hospital, which admits (primarily) 630/ of the cases of head injuries in the region. There are no hospitals more than 30 miles distant; the population served is 500 000, and there are 51 neurosurgical beds per million.
956
20 OCTOBER 1979
BRITISH MEDICAL JOURNAL
Results The patients reaching each of the three neurosurgical units were largely similar (tables I and II), and the differences were readily accounted for by geographical and organisational features of the three units. Glasgow admitted fewer patients with injuries from road accidents and more with injuries from assault; fewer Glasgow patients had associated extracranial injuries, which are more common in victims of road-traffic accidents. This feature of Glasgow reflects its predominantly urban population. Fewer patients reached the Glasgow neurosurgical unit within six hours of injury (Z2 = 36; P15 years) Assault (age -15 years) Injury: .. Scalp laceration Skull fracture Major extracranial .. .. injury Time between injury and admission to NSU: .. .. 24 hours ..
Glasgow (n = 545)
Aberdeen (n = 182)
Dundee (n = 58)
Total (n = 785)
29 8
7 15
38 5
25 10
34 31 18
43 28 9
41 39 11
37 30 15
34 65
29 46
40 55
33 60
15
25
31
18
27 46
35 36
50 14
31 41
TABLE iv-Final diagnosis. Figures are percentages of patients
..
37
Unit Aberdeen (n = 182) 30
.. .. .. .
10 24 11 23
6 21 8 11
10 22 7 14
.. ..
6 8 26
21 9 29
21 17 15
Glasgow
(n = 545) Intracranial haematoma Site of clot*: .. Extradural .. Subdural Intracerebral Depressed skull fracture Altered consciousness: No focal signs With focal signs .. Other cases
Dundee (n = 58)
Total (n = 785)
33
35 9 23 10 19 11 9 26
*Some patients had clots at more than one site.
TABLE iI-Clinicalfeatures ofpatients at time of admission to neurosurgical unit. Figures are percentages of patients
Glasgow coma scale*: 3-5 6-9
Aberdeen (n = 182)
Dundee n = 58)
Total (n = 785)
15
8 15 13 64 40 42
9 28 12 52 40 41
13 21 11 56 41 43
46 27 18
36 33 5
44 30 13
22 9 54 42
10-11 > 12. . .. Not talking .. Not obeying Deteriorating conscious
level Never lost consciousness Non-reacting pupils
Glasgow (n = 545)
43
.45 31 . .
12
OUTCOME
Mortality for the combined series from the three cities was 15%h; there was little variation from place to place or from year to year (table V). The median duration of stay was between six and eight days in each centre but shortest in Glasgow. The mean stay, however, was much longer in Aberdeen and Dundee, since more patients in these centres stayed in the neurosurgical ward for over a month. The shorter stay in Glasgow was achieved by sending twice as many patients back to other hospitals rather than waiting until they were able to go home.
*Deepest coma scores 3; fully conscious scores 15.
Clinical state on admission to the neurosurgical ward-About 40"0 of the patients were not talking and not obeying when they arrived at the neurosurgical units. On the Glasgow coma scale, which is widely used in Europe and North America to assess conscious level after head injury,4 one-third of patients scored 9 or less. Of those who were fully conscious or only mildly confused (coma score more than 12), over one-third had been admitted because of a depressed fracture of the skull. Over 40% of patients had a history of deteriorating conscious state; one in five was suspected of having a change in pupil size, reaction, or equality; and one in 10 had had a fit before
MINIPRINT TABLES
Illm TABLE 111-M..napemeer ur the thIll al,s 1974 and
197;5. F,g-,, ar p.......g.,p .......
U.,
S-.rid, Si-e Oselsg-v ~rracheoslv.ms
Oin.flaio.
1975
n271
1975 n- 274
n=95
21 2
14
2h 2S,
S 11
34 22
2
2
13
h
1
5
21
14
9
57 26.
56 32
IO 16
47
5
19
27
1974
,h
Crno
transfer.
3m12
7
n
h.
5Cgp --Ilt
11Q74
1974
N
1 17 19
4 9
N'Im
Vm
discharged-7771 J.r o7 977797
7-f
.7........ T,p n.r77urp77a1.1 -a d,d, r-P,
~~~~~~~~~~~~~~~
PROCEDURE IN THE NEUROSURGICAL UNIT 545 M- d.,--
.t
P."< 2 d.),
d.y. d...
."..
IIQ
2' "'"
,,f p.,,-,, d,.,h..g.d .Ih, h-pl ' dmd .f
..h.
r
5
.F-l 785 .
7
7
1,.
24
13
21
27
22
52
3.
3" 14
19 29 2. 22
63
"I
33
Is
2
36
3:7, ddy,"
8 2. >
.
11
11
33
P.P.i
-'.
15
