The prevention of secondary brain damage and prompt treatment are basic needs to improve outcome of traumatic brain injury.
This is well recognized for severe brain injury but it is even more so for minor injury which has a strong social relevance.
Minor head injury represents about 80% of all observed cases ( 2 ). Even if these patients, most of whom are clinically asymptomatic, show minimum cerebral damage at the time of injury, about 10% of them may have a worsening of their neurological picture ( 3, 4, 6, 7 ).
Colohan et al. ( 1 ) compared the mortality following head injury in two different situations: Richmond (Virginia) where a cohordinated emergency service has been set up on a territorial basis and New Delhi were no such system exists. As one may imagine, the mortality rate was lower in Richmond, but when the emergency data were analysed the mortality rate in severe head injuried patients was more or less sovraimposable in the two centres, whilst that following mild head injuries greatly differed. This may therefore be considered a good indicator of the quality of treatment.
In Piemonte, a region in the
North-West of Italy, a plan for reduction of preventable mortality following mild head
injury has been developed. The plan is based on the widespread use, over the Piemonte
Region, of a treatment protocol for mild head injury and on the transmission of diagnostic
images (CT scan) between peripheral hospitals (provided with
CT Scan and neurological consultation) and hospital with Neurosurgical consultation.
In the first admission hospital the Peripheral Diagnostic Unit (PDU) (Fig.1) acquires the CT images with a scanner on a Personal Computer. Then a first applicational software deals with images in a multi-tasking platform (Windows NTŪ), while the second one allows real time communications between centers, clinical data links, data safety . A data bank feeding is still provided on a central server. The Neurosurgical Consultation Unit (NCU) is allowed to get the consultation call, to write and return a consultation safety linked to CT-scan and clinical data, a record storing, the whole data safety managing. All administration issues are developed in the applicational software too.
All hospital in Piemonte Region are allowed to transmit data along ISDN lines, due to Regional Emergency Service settings. Even faster lines (ATM) are used and GSM or Satellite pathways are planned too. It is assumed that the PATATRAC Plan value is on a network planning base. This is not a point to point image transfer. A single PDU can choose the Neurosurgical Consultation Unit to connect with. A safe link between CT images, clinical data and consultation is valuable too.
A regionalized head trauma care system like this may offer several advantages :
now 12 First Admission Hospital (with CT-scan over a 24 hours-shift
basis) and 4 Second Level Trauma Hospital
(with Neurosurgical Departments) are included into the network (Fig
The numbers of
consultations requested, of patients transferred to a Neurosurgical Hospital and operated
clearly indicate the efficacy of the plan. Only patients who needs to be operated are to
be admitted to a Neurosurgical Hospital. The others continue to be cared with an up to
date evaluation and treatment protocol. The more consultation are requested, the fewer
patients are tranferred to a Neurosurgical Hospital: a technological tool is modifying
clinical practice by changing admission criteria to a Neurosurgical Hospital.
An hourly-based analysis shows a delay in request of consultation related to the hour of trauma during the night-shift: a constant application of guidelines will reduce the delay in perform the right diagnostic procedure (Fig.4).
Piemonte Region granted
the plan in order to connect all the First Admission Hospitals within the next three
years. The network will be used for cerebrovascular disease too, with dedicated
applicational software; the first of new clinical settings which may take advantage on a
well trained communication tool. The aim in telemedicine is to spread a specialized
consultation tool but technological device are useless without a behavioural growth in