System Analysis of Patient Management During the Pre- and Early Clinical Phase in Severe Head Injury

Summary

Head injury with or without polytrauma is the most important cause of death and severe morbidity in an age bracket of up to 45 years. Two major factors are determining its outcome, the extent and nature of the primary irreversible brain injury, and the subsequently developing manifestations of secondary brain damage, which in principle can be prevented by the management procedures and therapeutical interventions. Therefore, a better outcome from severe head injury depends exclusively on a higher efficiency of the management and treatment in order to inhibit secondary brain damage.

In a novel nationwide research program on “Neurotraumatology and Neuropsychological Rehabilitation” sponsored by the Federal Government, the University of Munich in collaboration with the Max-Planck-Institute of Neurobiology, Martinsried, formed a research consortium with major city hospitals in Munich, Augsburg, Ingolstadt, Murnau, Vogtareuth, and the Southern Bavaria rural area, which are caring for neurotrauma patients with severe head- or spinal cord injury. Together with the corresponding rescue- and emergency organizations, such as the Red Cross, fire brigades, etc. • the consortium is carrying out a system analysis as a joint venture on the organization, logistics, management, patient referral, etc. in severe head injury. The analysis includes the assessment of outcome-relevant time intervals of providing emergency care during the pre-clinical phase until admission of the patient to the hospital, until termination of the diagnostic procedures after hospital admission, and of the clinical management. The present findings and results are based on these comprehensive investigations by the study group in collaboration with more than 30 hospitals, institutions, organizations, and of more than forty physicians, students, and statisticians. In total 194 patients suspected to suffer from severe head injury were prospectively documented with onset of the assessment in the preclinical rescue phase. Confirmation of severe head injury according to a priori established selection criteria was obtained in 100 patients, the remaining number of cases was excluded. The protocol by purpose did not impose study-specific requirements outside of the routine procedures, which are established for the preclinical care and early hospital management. An exception, however, was to collect arterial blood samples, if possible prior to intubation and ventilation, or administration of 02, in order to obtain early information on the acute respiratory state as a potential risk factor of the outcome. Arterial blood samples could be collected in 60 cases at the scene, in no less than 37 patients prior to intubation and ventilation. The data collected during the prehospital and early clinical phase on the temporal course of these patients provide valuable information with unmatched accuracy for evaluation of the management efficiency of the rescue system, transportation, and the clinical care.

In conclusion, the prospective system analysis on the organization and management of patients with severe head injury is the first study of this type carried out in Germany. Due to the specific efforts of quasi on-line documentation of the patients’ state and course of events, beginning at the scene of an accident and covering the first days at the hospital, data of high quality were obtained. The data flow during the investigation was maintained among others by regular conferences of the Study Group including the crew of documentation assistants at regular intervals. The presently reported phase-I study was concluded in October 1997. It is followed by a phase-2 study with the attempt to collect prehospital- and early clinical management and care data in the catchment area on an epidemiological basis. Information of approximately 800-1,000 cases per year is expected providing a valuable basis to analyse the current state and quality of patient management and care for identification of remaining problems, which might be involved in the development of secondary brain damage from severe head injury.