Bypassing nearest hospital for more distant neuroscience care in head-injured adults with suspected traumatic brain injury: findings of the head injury transportation straight to neurosurgery (HITS-NS) pilot cluster randomised trial
Lecky, Fiona E. Russell, Wanda McClelland, Graham
Pennington, Elspeth Fuller, Gordon W. Goodacre, Steve Curran, Andrew Holliman, Damian Chapman, Nathan
Lecky, Fiona E.
Russell, Wanda
Pennington, Elspeth
Fuller, Gordon W.
Goodacre, Steve
Curran, Andrew
Holliman, Damian
Chapman, Nathan
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Abstract
Objective Reconfiguration of trauma services, with
direct transport of patients with traumatic brain injury
(TBI) to specialist neuroscience centres (SNCs)—
bypassing non-specialist acute hospitals (NSAHs), could
improve outcomes. However, delays in stabilisation of
airway, breathing and circulation (ABC) may worsen
outcomes when compared with selective secondary
transfer from nearest NSAH to SNC. We conducted a
pilot cluster randomised controlled trial to determine
the feasibility and plausibility of bypassing suspected
patients with TBI —directly into SNCs—producing a
measurable effect.
Setting Two English Ambulance Services.
Participants 74 clusters (ambulance stations) were
randomised within pairs after matching for important
characteristics. Clusters enrolled head-injured adults—
injured nearest to an NSAH—with internationally accepted
TBI risk factors and stable ABC. We excluded participants
attended by Helicopter Emergency Medical Services or
who were injured more than 1 hour by road from nearest
SNC.
Interventions Intervention cluster participants were
transported directly to an SNC bypassing nearest NSAH;
control cluster participants were transported to nearest
NSAH with selective secondary transfer to SNC.
Outcomes Trial recruitment rate (target n=700 per
annum) and percentage with TBI on CT scan (target 80%)
were the primary feasibility outcomes. 30-day mortality,
6-month Extended Glasgow Outcome Scale and quality of
life were secondary outcomes.
Results 56 ambulance station clusters recruited 293
patients in 12 months. The trial arms were similar in terms
of age, conscious level and injury severity. Less than 25%
of recruited patients had TBI on CT (n=70) with 7% (n=20)
requiring neurosurgery. Complete case analysis showed
similar 30-day mortality in the two trial arms (control=8.8
(2.7–14.0)% vs intervention=9.4(2.3–14.0)%).
Conclusion Bypassing patients with suspected TBI to
SNCs gives an overtriage (false positive) ratio of 13:1 for
neurosurgical intervention and 4:1 for TBI. A measurable
effect from a full trial of early neuroscience care following
bypass is therefore unlikely
https://bmjopen.bmj.com/content/bmjopen/7/10/e016355.full.pdf
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http://dx.doi.org/10.1136/bmjopen-2017-016355