An audit of the quality of care of traumatic brain injury at a busy regional hospital in South Africa
AbstractAbstract INTRODUCTION: Access to care by a dedicated neurosurgical unit is limited in the developing world, and the vast majority of patients sustaining a head injury are managed by general surgeons. The prevention of secondary brain injury is paramount. Whilst the principles of management are relatively straightforward, delivering this care may be difficult. This audit looks at the spectrum of head injury presenting to a busy regional hospital and attempts to measure the quality of care offered to these patients. PATIENTS AND METHODS This 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 over a two 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 twenty-five referral letters and twenty-eight AE inpatient notes were randomly chosen for review and compared with agreed standardized markers for quality of care. RESULTS: Over the two 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. Forty-nine were admitted to the general wards, eleven were admitted to the surgical ICU, ten were referred through to the neurosurgical centre in Durban, and four died in AE. Of the ten who needed advanced neurosurgical care, three required urgent burr holes prior to referral. One of these patients died. All the remaining nine patients who were transferred to neurosurgery survived. The referral letters and the AE clerking notes revealed major deficits. CONCLUSION: TBI is a common problem. Only a small subset of patients require specialized neurosurgical care. Although many patients with intracranial pathology can tolerate the delay associated with transfer, some pathologies are acute and necessitate urgent intervention by non-neurosurgeons. Prevention of secondary brain injury is poorly understood and not prioritized. This needs to be improved. The introduction of formalized standard referral and management sheets may help improve care.
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