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    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

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    Author
    Lecky, Fiona E.
    Russell, Wanda
    McClelland, Graham cc
    Pennington, Elspeth
    Fuller, Gordon W.
    Goodacre, Steve
    Han, Kyee cc
    Curran, Andrew
    Holliman, Damian
    Chapman, Nathan
    Freeman, Jennifer
    Byers, Sonia
    Mason, Suzanne
    Potter, Hugh
    Coats, Tim
    Mackway-Jones, Kevin
    Peters, Mary
    Shewan, Jane
    Show allShow less

    Keyword
    Emergency Medical Services
    Glasgow Outcome Scale
    Traumatic Brain Injuries
    Neurosurgery
    Transportation of Patients
    Journal title
    BMJ Open
    
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    Show full item record
    URI
    http://hdl.handle.net/20.500.12417/236
    DOI
    10.1136/bmjopen-2017-016355
    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 This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ http://dx.doi.org/10.1136/bmjopen-2017-016355
    ae974a485f413a2113503eed53cd6c53
    10.1136/bmjopen-2017-016355
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