Trauma SAJS 120 VOL 47, NO. 4, NOVEMBER 2009 SAJS Traumatic brain injury (TBI) is a common clinical prob- lem with significant long-term morbidity. Minimising this morbidity requires aggressive attempts to prevent secondary brain injury. The major early causes of secondary brain injury are hypoxia, hypovolaemia, hypoglycaemia and raised intra- cranial pressure (ICP). The first three conditions may be prevented by relatively simple clinical interventions that can be performed at almost any level of health facility. However, a subset of patients will have an acute space-occupying lesion contributing to raised ICP, which exacerbates the isch- aemic insult to the brain; reducing ICP is more difficult and may require more complex interventions. These range from simply placing the patient in the reverse Trendelenburg position to facilitate venous drainage of the cranium to administering mannitol and hypertonic saline, progressive hypocapnia, pharmacological manipulation using intrave- nous barbiturates, and possibly neuromuscular blockade, ventricular drainage and decompressive craniectomy. These interventions can only be undertaken at advanced facilities where specialist neurosurgical and intensive care is avail- able. Limitations on resources mean that it is unlikely that all head-injured patients will have the benefit of care in a dedicated neurosurgical unit. The vast majority will continue to be managed by non-neurosurgeons, be they referring staff, An audit of the quality of care of traumatic brain injury at a busy regional hospital in South Africa T. ALEXANDER, M.B. CH.B. G. FULLER, M.B. CH.B. P. HARGOVAN, L.LM. R.C.P., L.LM. R.C.S. (IREL.), F.R.C.S. (GLASG.) Accident and Emergency Department, Edendale Hospital, Pietermaritzburg D. L. CLARKE, F.C.S. (S.A.), M.MED.SCI., M.B.A. D. J. MUCKART, F.R.C.S., M.MED.SCI. S. R. THOMSON, F.R.C.S., CH.M. Department of General Surgery, University of KwaZulu-Natal, Durban Trauma SAJS 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, de- livering this care may be dificult. This audit looks at the spec- trum 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 irst is a prospective audit of all patients with a traumatic brain injury presenting to the Accident and Emer- gency (AE) department at Edendale Hospital, Pietermaritz- burg, 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 depart- ment. 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 neurosur- gical 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 neu- rosurgery unit survived. The referral letters and AE clerking notes revealed major deicits. Conclusion. Traumatic brain injury is a common problem. Only a small subset of patients require specialised neurosur- gical 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 need- ed. 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. An audit.indd 120 11/13/09 1:48:29 PM