improving the outcome of severely head injured children in the uk

SYMPOSIUM: ACCIDENTS AND POISONING

Improving the outcome ofseverely head injuredchildren in the UKPhilip Hyde

Kevin Morris

AbstractTraumatic brain injury (TBI) causes significant morbidity and mortality in

children. After the primary injury, subsequent physiological insults worsen

morbidity and mortality and are particularly common in the pre-hospital

setting. Management of severe TBI in hospital is largely focused on the

prevention of secondary brain injury, the management of raised intracra-

nial pressure and preservation of cerebral perfusion. Large potential

improvements in outcomes for severely brain injured children are

possible if the child’s entire NHS journey is appreciated. The first hour

of this journey is spent outside of hospital where neuroprotection is

not provided. Taking clinical expertise to the child, to start neuroprotec-

tion shortly after their injury and transfer them directly to definitive

care, offers potential to significantly improve outcomes. This could be

achieved across the nation by doctor led pre-hospital critical care teams.

Keywords critical care; paediatric; pre-hospital; primary retrieval;

traumatic brain injury

Introduction

Trauma is the leading cause of death for children in the UK and

severe brain injury (with GCS <8) is the largest overall cause of

these deaths. The current mortality rate among severely brain

injured children who survive to PICU admission is 9.2% with

many more dying at the scene or in the Emergency Department.

Primary prevention strategies to reduce the incidence of severe

injury should be prioritised and are well described elsewhere.

Once an accident has occurred, it is not possible to influence

the severity of the primary brain injury and our focus shifts to

neuroprotective measures aiming to reduce secondary brain

injury and providing neurosurgery if required. In order to reach

definitive care these children are taken on an NHS journey that

starts soon after the accident. There are 3 problems with the

current NHS system of moving severely brain injured children:

1) Most children are transported from the scene to hospital

without the initiation of neuroprotective measures.

Philip Hyde MBBS MRCPCH is a Paediatric Intensive Care Specialist

Registrar at the Paediatric Intensive Care Unit, Birmingham Children’s

Hospital, West Midlands, United Kingdom.

Kevin Morris MBBS MRCP(UK) MD FRCPCH is a Consultant in Paediatric

Intensive Care at the Paediatric Intensive Care Unit, Birmingham

Children’s Hospital, West Midlands, United Kingdom.

PAEDIATRICS AND CHILD HEALTH 19:11 487

2) Most children are taken to local hospitals and subsequent

transfer to definitive care is delayed by a number of hours.

3) National inequity exists, as some areas of the country

provide a higher standard of pre-hospital care than others.

This article will review the current national process of moving

severely brain injured children to definitive care and describe

future changes to the system that may have the potential to

significantly improve outcomes for this group of patients.

Transfer from scene to hospital

Severely brain injured children are conveyed from the scene of

road traffic, sporting and domestic incidents in ambulances

staffed by combinations of paramedics, technicians, emergency

care practitioners or emergency care assistants. The child is

taken to the nearest available hospital that accepts injured

children. Travel times for this pre-hospital phase are significant.

The UK paediatric brain injury study group reported the travel

times for 446 severely brain injured children from accident scene

to hospital. They found a median road ambulance travel time of

36 minutes, with 1 in 4 children taking longer than 1 hour. In the

National Confidential Enquiry into Patient Outcome and Death

(NCEPOD) report, the average time to hospital admission from

a serious road traffic accident was 55 minutes.

The current standard of pre-hospital care for severely brain

injured children

Severely brain injured children spend the first hour of their

critical injury outside of hospital. The standard of care these

children receive was recently described within the NCEPOD

report. The enquiry assessed the pre-hospital care that 608 adult

and 68 paediatric severely injured patients received in England,

Wales and Northern Ireland. Separate analysis of the paediatric

subgroup showed that the overall findings and recommendations

made within the report are as applicable to children’s care as

they are to adult care.

Within the population studied, 62% had a brain injury and

28% had a severe brain injury. One fifth of these brain injured

patients did not receive oxygen during their ambulance journey

to hospital. On arriving in hospital, 15% of brain injured patients

had a partially or completely obstructed airway and 42% had

oxygen saturations less than 95%. In the severe brain injury

group (215 patients), 70% were intubated within hospital,

indicating the standard of airway care that their injuries required.

The 72 hour mortality rate more than doubled for those severely

brain injured patients whose pre-hospital airway or ventilator

management was deemed inadequate by the investigators. The

NCEPOD investigators concluded:

‘The current structure of pre-hospital management is insuf-

ficient to meet the needs of the severely injured patient . and

change is urgently required’

These patients are complex and difficult to manage, however,

the standards of care that severely brain injured children receive

for the first crucial hour of their NHS ambulance journey fall well

below that received once they arrive in hospital. Much research

effort has gone into hospital interventions aimed at reducing

secondary brain injury and maximizing the outcomes for these

children. The time between injury and arrival to hospital offers

� 2009 Elsevier Ltd. All rights reserved.

PICU/Neuro

a

b

c

d

Percentage all journeys

36–56 mins

4.3 hours

6.3 hours

30%

49%

21%

PICU/Neuro

PICU/NeuroDistrict General

PICU/Neuro

Ambulance service

Critical care team

Mobile critical care bed

Intra-hospital transfers

District General

Figure 2 Current NHS journey for severely brain injured children aec

showing level of care, secondary transfers, transit times and the

percentage of children experiencing each journey type. Figure d shows

a potential future NHS journey for severely brain injured children. a Child

taken directly by ambulance to the regional centre with neurosurgical and

PICU facilities. b Child taken to nearest district general hospital and

transferred to the regional centre by DGH team. c Child taken to the


a therapeutic window that as a profession we have largely

ignored.

Critical care teams transport severely brain injured children

within and between hospitals

Once in hospital, a critical care team will stabilize a severely

brain injured child and maintain neuroprotective intensive care

for transfer to CT scan and neurosurgery if required (Figure 1).

The initial package of neuroprotective care has been well

described previously and includes the provision of advanced

airway management, ventilatory support, circulatory access,

cardiovascular support, analgesia and anaesthesia.

The child’s NHS journey from incident to definitive care is

shown in Figure 2. After a team (red) has commenced critical

care, the child is effectively in a mobile intensive care bed

(purple) and is always transported with critical care continuing.

Transporting these children is recognized as a high risk activity

and should only be carried out by an experienced doctor with an

appropriately trained assistant; following clear standards set out

by the Paediatric Intensive Care Society in 2001 and by the

Association of Anaesthetists of Great Britain and Ireland in 2006.

These transport standards are only adhered to after the child has

been moved by ambulance to hospital. It is inconsistent to

require the use of doctors in hospital but deny an equivalent level

of care to the same patients for the hour before reaching hospital.

Most severely brain injured children take hours to reach

definitive care

In 30% of paediatric severe brain injuries the nearest hospital to

the incident is one with paediatric intensive care and neurosur-

gical facilities. For these children their journey time before

reaching definitive care is the same as their pre-hospital time

(Figure 2a). However, in 70% of cases the nearest hospital is

Critical care team

Doctor

Skilled assistant

Monitoring

APLS equipment

Critical care team

Mobile critical care bed

Doctor

Skilled assistant

Monitoring

APLS equipment

Figure 1 Children receive critical care in hospital from teams. This is

achieved during transport by creating a mobile ‘virtual critical care bed’

with a doctor and a skilled assistant present at all times.

nearest district general hospital and transferred to the regional centre by

a paediatric intensive care team. d Child attended at scene by a critical

care team (doctor and paramedic), appropriate critical care commenced

and transferred directly to the regional centre.


a district general hospital (DGH) without definitive care. After

critical care has been commenced, the child is transferred to

a hospital with definitive care capacity either by the DGH’s own

staff (49% of all cases, Figure 2b) or retrieved by the regional

paediatric retrieval team (21% of all cases, Figure 2c). These

additional transfers increase the child’s time to definitive care to

4.3 and 6.3 hours respectively. Recommendations from the Royal

College of Surgeons state that patients with traumatic intracranial

haemorrhage causing compression should have these surgically

decompressed within 4 hours. For the majority of severely brain

injured children this is not being delivered within the current

national transport framework.

There is considerable geographical variation in transport

distances to neurosurgical units between regions of the UK, with

transport distances of up to 80 km (Figure 3). In general, urban

centres show shorter transfer distances and times, with less

variability, compared to centres situated in more rural areas. This

reinforces the need to consider local factors when developing

models of pre-hospital service delivery.


90

75

60

45

30

15

0

Dis

tan

ce (

km

)

Surgical centres

Figure 3 Distance from site of accident to the tertiary paediatric neuro-

surgical centre for 17 surgical centres across the UK. Data for individual

units (blue circles) are ordered by increasing median distance from home.

The solid black square depicts the median and interquartile range for the

children undergoing surgical evacuation of haematoma.

Figure 4 Pre-hospital critical care is provided on the Hampshire and Isle of

Wight Air Ambulance by volunteer BASICS doctors.


Improving the service provided to severely brain injured children

The delays in severely brain injured children receiving critical

care and reaching definitive care could be reduced substantially if

they were transported directly from incident scene to tertiary

hospitals by critical care providers. A team of a doctor and skilled

assistant could achieve this.

Paediatric retrieval teams already exist to transfer children

between hospitals and have a lower incidence of complications

during transport of medical cases than non-specialist referring

hospital teams. However, most paediatric retrieval teams have

limited trauma exposure, cannot mobilise immediately and do

not have experience or training in providing critical care in the

pre-hospital environment.

An alternative model of provision is to use pre-hospital critical

care teams composed of a critical care doctor and paramedic.

These teams have large trauma exposure, are trained specifically

to work safely outside of hospital, can immediately mobilise to

a severely brain injured child, provide neuroprotective critical

care and can triage the child to an appropriate hospital

(Figure 2d). This is known as primary retrieval and already

occurs in France, Germany, Holland, Sweden, Finland, Norway,

Iceland, Slovenia, Australia and pockets of the USA.

Pre-hospital critical care already exists in parts of the UK

In London for the past 20 years, an NHS critical care doctor and

paramedic team has been attached to London’s Air Ambulance.

This combination of resources enables hospital level expertise

and equipment to be placed at the seriously ill or injured

patient’s side within 12 minutes anywhere within the M25

perimeter during daylight hours. This regional service is

provided for adults and children and means that for part of the

24-hour clock critically injured patients are given the same level


of care outside of hospital that they would receive during the first

hour in hospital.

Children also sustain severe head injuries in other parts of the

country. Pre-hospital critical care provision for these children

depends on doctors volunteering their spare time for local air

ambulances and the charity - British Association of

Immediate Care (BASICS) (Figure 4). These doctors provide

a high quality service to many fortunate patients. However, the

voluntary nature of provision means that geographical coverage

is patchy and availability is limited, particularly at night. Some

areas of the country have no BASICS or air ambulance volunteers

and so critically injured children in these regions will only

receive the standard of care described in the NCEPOD report.

Each region of the UK is different, with varied natural and

social geography. Therefore, by necessity there will be variations

in the organisation of pre-hospital critical care. The overarching

need of critically injured children for critical care, however, does

not change according to their postcode.

Pre-hospital critical care improves outcomes for severely injured

patients

Evidence for improved patient outcomes from doctor-led critical

care teams has a worldwide base.

A prospective observational study comparing paramedic to

doctor-led care for severely brain injured patients in San Diego

County, USA, showed a 9% reduction in mortality for the doctor-

led team versus the paramedic team ( p < 0.001). The same

group in a randomised controlled trial showed a reduction in

mortality of 35% ( p < 0.05) for blunt trauma patients treated by

doctor-led teams when compared to nurse/paramedic teams.

In a retrospective observational study of severely head injured

patients in New South Wales, Australia, Garner et al reported an

odds ratio of 2.7 (1.5e5.0) for an improved Glasgow Outcome Score

for the doctor/paramedic treated group versus paramedic treatment

alone. In a Slovenian retrospective observational study of severely

brain injured patients treated by doctor/paramedic critical care

teams compared to paramedic teams, an odds ratio of 3.8 (1.8e6.9,

p < 0.001) was reported for survival to discharge from hospital.



In a prospective cohort study, Oppe et al reported that across

all trauma groups the involvement of a doctor led critical care

team compared to paramedic teams reduced mortality by

19e29% ( p < 0.05). Following this research in 1998 the Dutch

Department of Health created 4 separate pre-hospital critical care

teams to serve the Netherlands.

The vast majority of the UK continue transporting children from

incident scene to hospital without NHS funded critical care teams.

This is despite growing international evidence for improved

outcomes and repeated national reports calling for change in the

quality of care that critically injured adults and children receive.

This has recently been clearly reiterated within the NCEPOD report:

‘Patients with severe head injury require early definitive

airway control and rapid delivery to a centre with onsite

neurosurgical service. This implies regional planning

of trauma services, including pre-hospital physician involve-

ment, and reconfiguration of services’

The upcoming Confidential Enquiry into Maternal and Child

Health (CEMACH) study will specifically look at paediatric

traumatic brain injury and the management that children receive

in the UK focussing on pre-hospital and early hospital care. This

should provide an unrivalled view of the level of care severely

brain injured children receive nationally and could provide

impetus to drive change.

Future pre-hospital critical care in the UK

Pre-hospital critical care involves treating undifferentiated crit-

ical illness and injury in adults and children. If each strategic

health authority in the country provided a pre-hospital critical

care service, the majority of doctors would be from an adult

critical care background. Can such doctors safely provide initial

critical care for children?

Across the country adult trained emergency physicians,

anaesthetists and intensivists stabilise critically injured children

brought to their hospitals. These children receive high quality

care within the framework of paediatric critical care networks.

To extend this concept beyond the hospital is no quantum leap.

In order to gain and maintain the additional competencies in the

transport of critically injured children, clinicians involved in this

field could have periodic rotations to work with their regional

inter-hospital paediatric retrieval service.

Training within pre-hospital medicine is regulated by the

Faculty of Pre-hospital Care of the Royal College of Surgeons of

Edinburgh. At present the faculty is developing the curriculum

competencies required for future consultants within the pre-

hospital domain; paediatric transport competencies represent

a key component. In addition, in February 2009 the Association

of Anaesthetists published standards for adult and paediatric

anaesthesia in the pre-hospital domain. These provide clear and

realistic guidelines, which demand that pre-hospital critical care

is provided to hospital standards.

Conclusion

Providing critical care through an integrated model of continuous

pre-hospital and hospital care could provide the next large

improvement in outcomes for severely brain injured children.

Within paediatrics we should embrace this innovative solution to


our national need for higher quality paediatric brain injury and

trauma care. A

FURTHER READING

Association of Anaesthetists of Great Britain and Ireland, Recommenda-

tions for the safe transfer of patients with brain injury, 2006.

Association of Anaesthetists of Great Britain and Ireland, Pre-hospital

anaesthesia, 2009.

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mortality of severely brain-injured patients. J Trauma 1987; 27: 365e9.

Baxt WG, Moody P. The impact of a physician as part of the aeromedical

prehospital team in patients with blunt trauma. J Am Med Assoc 1987;

257: 3246.

Garner A, Crooks J, Lee A, Bishop R. Efficacy of prehospital critical care

teams for severe blunt head injury in the Australian setting. Injury

2001; 32: 455e60.

Klemen P, Grmec S. Effect of pre-hospital advanced life support with rapid

sequence intubation on outcome of severe traumatic brain injury. Acta

Anaesthesiol Scand 2006; 50: 1250e4.

Mackenzie R, Bevan D. For debate... a license to practise pre-hospital and

retrieval medicine. Emerg Med J 2005 Apr; 22(4): 286e93.

National Confidential Enquiry into Patient Outcome and Death (NCEPOD).

Trauma; who cares?; 2007.

Oppe S, De Charro FT. The effect of medical care by a helicopter trauma

team on the probability of survival and quality of life of hospitalised

victims. Accid Anal Prev 2001; 33: 129e38.

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Great Britain and Ireland. London: BMA; 1961.

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Injury Study Group and the Paediatric Intensive Care Society Study

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Practice points

C The pre-hospital care that critically injured children currently

receive in the UK is below international standards particularly

with respect to management of airway, breathing and

circulation

C Severely brain injured children could benefit from enhanced

pre-hospital management

C Volunteer doctors working when off duty currently provide

pre-hospital critical care in some areas of the UK

C Pre-hospital critical care allows neuroprotective interventions

to commence rapidly after initial brain injury and reduces

transport times to definitive care

C The upcoming CEMACH study, collecting data on pre-hospital

and early hospital management of children with traumatic

brain injury, may provide specific evidence of the need for NHS

provision of pre-hospital critical care


PAEDIATRICS AND CHILD HEALTH 19:11 491 � 2009 Elsevier Ltd. All rights reserved.

improving the outcome of severely head injured children in the uk

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