Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients

The MRC CRASH trial collaborators have produced a simple prognostic model, which can be used to predict outcomes in patients with traumatic brain injury [1]. Although their prognostic model considered time from injury to randomisation, the time at which the patient presented to the hospital was not considered as a potential independent prognostic variable. This is important because provision of key aspects of hospital trauma services such as staffing, access to operating theatres and interventional radiology is reduced after normal working hours.

In the United Kingdom (UK) a recent study examined the process of care for 795 severely injured patients of whom 493 sustained a head injury [2]. The majority of these patients presented to the accident and emergency department out of hours (18.00-07.59 hours or weekends). Initial management of the patient was inappropriate in 23.5% of cases where a senior house officer was the team leader/first reviewer compared to 3.1% where a consultant performed this role. Consultant involvement was highest during the day (39.6%) of cases and fell over the evening and into the night (11.5% of cases presenting at night). The trend for involvement of junior doctors was in the opposite direction, being highest during the night. In addition to a lack of senior medical staff to coordinate management out of hours, immediate intervention for more specialised injuries was often unavailable.

Organisational deficiencies in out of hours care is not unique to the UK and similar problems are likely to exist in low, middle and high-income countries. Moreover this problem is not restricted to the provision of trauma care; increased mortality out of hours has also been identified in patients with myocardial infarcts undergoing primary coronary intervention [3], cardiac arrest [4] and discharge from intensive care [5].

Out of hours presentation to hospital may be associated with treatment delays and adverse outcomes. We suggest that the time of hospital presentation should have been considered in the MRC CRASH collaborators prognostic model for predicting outcome after traumatic brain injury.

Paul Frost, Consultant in Intensive Care Medicine, Critical Care Directorate, University Hospital of Wales, Cardiff CF14 4XW

Paul.Frost@CardiffandVale.wales.nhs.uk

Matt P Wise. Consultant in Intensive Care Medicine

Competing interests: None Declared

References

1. MRC CRASH Trial Collaborators Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients. BMJ 2008;336:425-9

2. Findlay G, Martin IC, Carter S, Smith N, Weyman D, Mason M. Trauma who cares? A report of the National Confidential Enquiry into Patient Outcome and Death. 2007. www.ncepod.org.uk/2007report2/Downloads/SIP_report.pdf

3. Kostis WJ, Demissie K, Marcella SW, Shao YH, Wilson AC, Moreyra AE, for the Myocardial Infarction Data Acquisition System (MIDAS 10) Study Group. Weekend versus Weekday Admission and Mortality from Myocardial Infarction. N Engl J Med 2007; 356:1099-1109

4. Peberdy MA, Ornato JP, Larkin GL, Braithwaite RS, Kashner MT, Carey SM; et al, for the National Registry of Cardiopulmonary Resuscitation Investigators. Survival From In-Hospital Cardiac Arrest During Nights and Weekends. JAMA 2008;299(7):785-792.

5. Goldfrad C, Rowan K. Consequences of discharges from intensive care at night. Lancet 2000; 355: 1138-1142.

Competing interests: None declared