Assistant professor Dr.

Hiwa Omer Ahmed

AUDIT

AUDIT
 Is

a process  Used by clinicians who seeks to improve patient care  By comparing aspects of care

aspects

What to do

What to do
 If

the care falls short of the criteria > some changes in the way that care is recognized is proposed. at once individual team levels institutional level regional level national level

Types

Cycle

quesions
 Auditor

address a series of questions

Traditional
 `measures

process  Depends on compliance.

Surgical
 Measures

contr

outcome 9 no placebo or

How to do audit

1. prepare
 Think

broadly  Funding  Ownership  Skills  Time  teamwork

2. Selecting data
 Think

big  It must be measurable  Check guidelines  Systemic review  Process or outcome  Case mix; fixed and variables

3. Measuring the level of performance
 Routine

data  Electronic data  Medical controls ?  Abstract data  legalities

4. Making improvements
 Barriers

to ch  Feedback  Discussion  Implementation methods  Clinical governance structure model

5. Sustaining improvements
 Re-audit  Structural

changes  Cultural changes; must society earns

AUDIT OF MANAGEMENT OF HEAD TRAUMA IN SLEMANI TEACHING HOSPITAL 2001 – 2002
DR. HIWA OMER AHMED MB.CHB. C.A.B.S CONSULTANT SURGEON STH PROF. ASSIST – COLLEGE OF MEDICINE– UNIVERSITOF SLEMANI

SUMMARY:
 Trauma

remains the leading killer of children and young adults, specially head trauma injuries of different types from fall from height (FFH) in children to road traffic accident (RTA) and quarrelling in adolescence and young adults.

 Every

day many victims with head trauma will arrive the Surgical Casualty Department of STH, managed first by house officer and senior house officers in general Surgery.  As long as there is no uniform method for management of these cases the author is trying in this paper to audit the lines of management for these victims in two different surgical unites, each using away of management different in many aspects. Aiming that the conclusions may help in promoting the practice in this field

INTRODUCTLON
 Trauma

in general is the most common cause of death in children, adolescence and young adults. Minor head injury is common in modern society (1). Care of the head injured patients begins with assessment of severity and protection of the brain from further insult. Outcome depends on recognition, severity and treatment of two fundamentally distinct types of head injury: diffuse and focal

 To

achieve correct management of this common problem, we need accurate medical data recording and detailed and repeated neurosurgical examinations; including records of repeated evaluation of the level of consciousness by Glasgow Coma Scale (GCS), to assess the severity of the injury, diagnosing the life threatening conditions, to protect the brain from second trauma. This recognition needs precise clinical evaluation and imaging to differentiate the type of the injury: is it focal or diffuse, which need different methods of treatment

 On

the other hand (GCS) will help in classifying the head injury into minor (13,14,15 scores), moderate (9,10,11,12 Scores) and severe (8 or less scores)(2), which have different outcome & may need different levels of care and treatment. The objective of scoring is to provide a uniform way of describing injuries, which can only be achieved by obeying the rules, this still requires practice, as there are many pitfalls for the unwary, clinical outcome in patients with minor head injury, might have been predicted from history & clinical examination alone, and less than (1%) of these patients will develop an intracranial complication.

 The

aim of this study is to audit two different methods of management of head trauma patients in two surgical unites, to assess methods, which may improve the outcome.

PATIENTS AND METHODS:

 

The retrospective study was carried out at Slemani Teaching Hospital (STH), in two surgical unites on (160) consecutive patients who were admitted between 1st of April 2001 to 1st April 2002, with acute trauma to the head, of these (80) patients (Group- A) managed in the authors surgical unit and the rest (Group B) managed by a colleague surgeon in another surgical unit. Demographic details were extracted from action taken on basis of the finding was noted. Comparative analysis between the two groups through multiple variables was done to identify any different between them in the aspect of management and outcome.

RESULTS
 Most

of the patients in both groups (A & B) were males as in (Group A); male/ female ratio was 5/3 and in (Group B); was 5.1/2.9. Majority of the patients was in the age group of (0-19 years) as shown in table I

Age groups in years 0 10 20 30 40 50 60 70 + 9 19 29 39 49 59 69 79

No. of patients Group A 25 14 9 13 7 6 2 4

No. of patents Group B 38 15 14 6 3 2 2

Table I: Showing age groups in both groups (A &B) of patients

The most common type of trauma was fall from height as shown in table II

Types of the trauma

No. of patients Group A

No. of patients Group B

Fall From height

48

43

Road traffic accident

21

29

Quarrelling

11

8

Table II: showing types of the trauma in both groups (A&B) of patients

Most of the injuries were mild (64patients in group-A), (52patients in group-B), as showed in table III, which is clarifying the GCS of the patients on arrival.

Severity

Glasgow Coma Scale Scores 15 14 13 12 11 10 9 8 7 6 5

No. of patients Group -A 60 4 6 1 2 2 2 3

No. of patients Group -B 43 4 5 7 12 1 1 1 6 -

Minor

Moderate

Severe

Table III. Showing GCS scoring in both groups (A&B) of patients

Most of the patients (63 patients in group-A, 56 patients in group –B) remained in hospital for up to 47 hours as shown in table IV. .

Period of admission 0 24 3 23 hours 47 hours 9 days

No. of patients Group -A 19 44 14 1 0 1 1

No. of patients Group -B 23 31 23 1 0 1 0 0

13 days 21 days 39 days 42 days 45 days

Table IV: showing period of admission in both groups (A-B) of patients.

GCS scoring was full (15 scores) in most (64patients in group-A) of the patients Within 24 hours of admission, while there was no any records of this in the files of the (group-B) as shown in Table V.

Day in which GCS scores became full (15) Same day of admission 2nd day of admission 3rd day of admission 4th day of admission 8th day of admission 16th day of admission 44th day of admission 45th day of admission

No. of patients Group –A 64 5 5

No. of patients in Group -B

NO RECORD

2 1 1 1 1

Table V: showing time when the GCS became full scored

Minority of the patients had positive physical finding as shown in table VI:
Physical Findings Cranial nerve palsy Black eye due to Ant. cranial fossa # 14 Rhinorrhea, Rhinorrhagia Otorrhagia Battle Sign 10 4 3 1 No. of patents Group A No. of patents Group B No. Record

5

4 1 1

Table VI: Showing physical findings in both groups (A & B) of patients.

Skull radiographs were taken routinely for every patient in both groups, but revealing skull # just in 9 and 5 patients in Group A and Group B respectively, and there was no any correlation between # skull and physical findings as most of the patients with physical findings like (black eyes, rhinorrhea …etc), has no # in the skull radiographs, as shown in table VII.
Findings # on skull X ray Rhinorrhia + Otorrhia 1 1 2 4 No. of patients Group A 3 No. of patients Group B

Battle sign +

1

1 -

Table VII: Showing correlation Between # skull and physical findings

Minority was sent for CT scan, it was normal in 3, 2 of the scans in group A, grope –B respectively.

CT scan

No. of patients Group -A

No. of patients Group- B

Not done

76 Normal 3

75 1

Done

Extradural haematoma

1

4 No. recording or paper

Table IIX: Showing results of the CT scans in patients form both groups (A, B).

These patients were managed in the casualty department and later in the surgical unite on follow up as showing in table IX. No. of patients GroupA 80 21 2 10 1 2 1 2 2

Management Elevation of the head of the patient IVF Craniotomy Phenobarbiturate Steroids Diuretic Antibiotics Analgesia Diazepam Antiemetic Blood Tracheostomy

No. of patients Group-B 60 39 No Record 7 61 4 72 63 4 3 6 -

Table IX: lines of the treatment in the both groups (A & B)

DISCUSSION:
 We

may notice from the results, that majority of the victims were children, adolescence, sustaining minor head trauma (64.4% =116 patients) as shown in table I, with GCS Scoring of (13,14,15). Majority were kept under observation for necessary time (48) hours (table II), but routinely expressed to two views of skull radiographs with only (14 patients) positive skull radiographs findings (table IV), while the majority of the patients (64.4%) with minor head trauma may be evaluated clinically alone & skull radiographs adds no further information to the decision weather to admit or send home patients with a minor head injury and there in a report from Annals of Royal college of Surgeons of England claiming that “ not to take skull radiographs routinely, “specially for patients who are able to walk and talk when they reached medical contact”(3).

On the other hand there was no hard correlation between findings in the skull radiographs and the physical findings for example (table VI), there was seven cases of rhinorrhea and rhinorrhagia which means anterior cranial fossa #, with only radiological finding in one of them. Also there was four cases of otorrhagia with only one radiological report of # in one of them. These may be either due to the fact that most of the # usually are in the base of skull, which are not evident on AP & lateral skull views, but need Special (Town view) which in not in practice at least in Surgical Casualty Department or there is a gush of routing skull X-rays (100%) which will put a have burden on radiological staff who is alone on duty personal, the result will be bad quality skull radiographs which add nothing to the clinical evaluation and decision

Few patients (9 patients) send selectively for CTscanning of the skull & brain (Table IIX), with (4) normal results, one extradural haematoma, and unfortunately there is no paper or report or data recording in the files of the patents with the rest (5 patients in group B). Majority of our patients were with minor hand injury which need just observation and elevation of the head, unfortunately we found the elevation of the head not practiced for all the patients in group-B (Table IX). Different drugs used in most of the patients which is not necessary for patients with full GCS scoring for example patient with file number (21211) had full Scoring (15), had no any injury, but received all the types of the drugs & lines of treatment which you will see in (Table IX).

ELEVATION OF THE HEAD
 Now

it is clear that cerebral edema & hemorrhage within the cranial vault will rapidly increase intracranial pressure (ICP), because the brain, unlike other organs is rigidly confined with the skull (4) and in trauma the Brain Blood Barrier (BBB) will disrupt. So elevation of the head will help in facilitation of venous drainage, which is the only way, as there are no lymphatic vessels in the brain, and the veins are thin walled, containing no muscle fibers in their wall which make them capable to distend considerably.

IVF
 It

is better not to give intravenous fluid (IVF) routinely for head injured patients, specially when there is no vomiting & the patient is conscious, and able to take orally. When IVF is indicated, it is better to restrict the IVF therapy at least to 2/3 of that of normal maintenance. Also it is better to avoid 5% glucose in water as it enhances the edema process. So IVF “Should be administered Judiousely to prevent overhydration which augments cerebral edema as mild dehydration wile protect the brain from insult secondary to fluid over load (5).

PHENOBARBITONE:
 It

will help in decreasing agitation, controls Seizures and decreases brain edema.

STEROIDES:

Are

not recommended for the treatment of acute head injury.

DIURETICS:

In the emergency department should be administered only with the consent of a neurosurgeon or to gain time when neurosurgical capabilities will be delayed and the patient’s condition is deteriorating, because its beneficial effect is transient, the drug can severely alter serum electrolyte and osmolarity Patients who are given Steroid, osmotic diuretics, anticonvulsant & hyperosmolar feeding are prone to develop hyperosmolar state, some times leading to hyperglycemic nonketotic coma (6). when may be analyzed as deterioration of the neurosurgical condition of the patient.

ANTIBIOTICS
 Prophylactic

antibiotics are not used routinely because recent prospective studies have failed to demonstrate any benefit from their use (7), so rarely indicated

ANALGESIA
 Aspirin

& other nonsteroidal Analgesia all increase the risk of upper GIT bleeding and peptic stress ulcers, so it is better not to be used routinely.

DIAZEPAM
 Sedation

reduces posturing & combat activity, both of which elevate ICP

ANTIEMETIC
 When

used, it has symptomatic benefit but also may induces occulogyric crises, which will be misinterpreted for unwary personal. There is a large difference between the line of treatment in these two groups, but the mortality was same in both groups (A&B), one patient in each group

CONCLUSION
 We

may conclude from this audit, that skull radiographs and many drugs with steroid, antibiotics, IVF, diuretics were used routinely without any additional benefit to the standard management of the head injured patients, we need a uniform standard revised updated schedule for management of head injured patients in our casualty, aiming in saving lives and time of the physician, nursing and radiological Staffs

AKWOWLEAAEMENT
I

would like to thank all the house officers & nursing staffs in my surgical unite & statistical staffs in STH, Forensic medicine for their valuable technical help

B. R. Duns, T. Boesen, prognostic Signs in the evaluation of patients with minor head injuries, British journal of surgery. 1997, Vol. 80, No. 8 ,page (989) American College of Surgeons Committee on Trauma: Head trauma in Advanced Trauma life Support, Ed.6, American College of Surgeons. 1997. Chap 6, pp.184. F. W. cross: Care of RTA victims in district general hospital: Annals of the Royal college of England, Nov 1992, Vol. 74, No 6, Page 438. Nigel. We6ster. Monitoring the critically ill patients: Journal of College of Surgeons of Edinburgh. 1999, Vol. 44, No.6, page 395. Robert H. Wilkins, Settee S. Rengachary. Text book of Neurosurgery 1st edition Vol. I, McGraw Hill company New York, 1985, page 404. 6. Spencer, Shires, Neurosurgery cited in Schwartz, Spencer, Shires & Daleys Principles of Schwartz, 1999, Vol. 3, (1879), McGraw Hill 7. Raymond H. Alexander, Herbert J, Advanced Trauma life Support, 1st edition American College of Surgeons, 1993, Page 179.

REFERENCES

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