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

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.