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.
The treatment protocol is represented by the Guidelines for treatment of mild head injury suggested by the Study Group on Head Injury of the Italian Society of Neurosurgery ( 8 ). Additional value to the plan is given by implementation of a network for transmission of diagnostic images (DEAnet) endowed with clinical data from the peripheral hospitals to the 5 neurosurgical units for real time consultation, avoiding useless patient transfer. In the trauma admission hospital the neurological evaluation and, if suggested by the guidelines, the CT scan are performed. In the Neurosurgical hospital the CT scan is evaluated by a Neurosurgeon and a therapeutic action in suggested.

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 :

  • reduction of avoidable mortality by a well recognized treatment of mild head injured patients and a widespread use on a territorial basis. This has to be seen as an aid to medical practicioner in peripheral hospital.

  • decreased number of patients admitted to the Trauma Centers with neurosurgical facilities because only the cases requiring neurosurgical care will be trasnsferred. Harmful, useless transfer of patients are avoided with significant economic impact too.

  • increase expertise among physicians due to their larger clinical exposure. A larger area is then provided by prompt and safe consultation.

  • Data Bank institution for epidemiologic surveillance. A continuous control is then made about epidemiology of trauma strictly related to enviromental (Regional) features. A feed-back on the whole procedure is then made too.

  • the neurosurgical consultation is more efficient because it comes earlier and wider. A choice between consultation centers is avalaible too for the requesting hospital.

  • a global cost-saving procedure in health care giving: fewer hospital days for clinical surveillance, lover morbidity related to minor head injury.

  • such a pathway is ready for different clinical settings.

Up to 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 2).

From the 1st January 1999 to the 31st December 2002, 2331 telematic consultations were performed by the Neurosurgical Department of Trauma Center of Torino. Just 239 patients were admitted to the neurosurgical hospital; in 137 of them a surgical treatment was performed (Fig 3). In 359 patients more than one consultation had been requested: it means that these patiens were cared in the periferal hospital and controlled by seriated CT-scan and neurosurgical consultations. Additional 25 transmissions were related to case different from traumatic brain injury: it means that new clinical settings are still using the network.

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 epidemiological surveillance program, as developed in Piemonte Region will be used to measure the clinical impact of these behavioural changes. Differences between hospitals requesting consultation suggest that neurologist often are taking a role in decision making in mild head injury: a strict relatioship between neurologists and neurosurgeons is advisable in order to apply a correct diagnostic and therapeutic protocol.

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 healthcare providers.
That is the real challenge for telemedicine and that’s why we must measure the results of plan such these on an epidemiological basis, with data recording and management. This is more needed when evidence based option cannot be stated. We’ll allways find a phisician using a technological device: they must grow together.

 

References:

  1. Colohan AR et al.
    Head injury mortality in two centers with different emergency medical services and intensive care
    J Neurosurg 71; 202 - 7; 1989
  2. Klauber M et al.
    Determinants of head injury mortality : importance of the low risk patient
    J Neurosurg 61; 695 - 9; 1984
  3. Marshall LF, Toole BM, Bowers SA
    The National Traumatic Coma Data Bank : Part 2. Patients who talk and deteriorate: implications for treatment
    J Neurosurg 59; 285 - 8; 1983
  4. Massaro F., Lanotte M., Faccani G.
    Analisi di 24 casi di trauma cranico con evoluzione tipo " Talk and deteriorate "
    J Em Surg 17;167 - 70; 1994
  5. Miller DJ
    Emergency care and Treatment in Acute Cerebral Insults
    Acta Neurochir [suppl ] 57;137-140; 1993
  6. Reilly PL, Adams JH, Grahm DI, Jennet B
    Patients with head injury who talk and die
    Lancet 2; 375 - 7; 1975
  7. Rose J, Valtonen S, Jennet B
    Avoidable factors contributing to deaths after head injury
    Br Med J 2;615 - 8; 1977
  8. The Study Group on Head Injury of the Italian Society for Neurosurgery
    Guidelines for minor head injured patients' management in adult age
    J Neurosurg Sci 40; 11 - 5; 1996