title: Major traumatic brain injury: time to tertiary care and the impact of a clinical guideline.
abstract: BACKGROUND
  To achieve timely access to neurosurgical care for adult brain-injured patients, a Head Injury Guideline was implemented to standardize the emergency department evaluation and management of these patients. The goals of this study were to document times to neurosurgical care for patients with major traumatic brain injury presenting to a Provincial emergency room and to evaluate the impact of the Guideline on timely access to definitive care.
  
  
  METHODS
  Data collected prospectively and stored in the Nova Scotia Trauma Registry and the Emergency Health Services Communications and Dispatch Centre database were analyzed for patients with head abbreviated injury scale score (AIS)≥3. Several time intervals from admission to a referring hospital to access to tertiary care were determined and compared for the periods before Guideline implementation, the implementation phase, and after implementation.
  
  
  RESULTS
  The time elapsed before calling the provincial Trauma Hotline was not statistically different after Guideline implementation for polytrauma patients with head AIS score≥3 (n=388) during the preimplementation (2:34±1:30; median time in hours:minutes±standard deviation), implementation (1:57±2:33) and postimplementation (2:31±4:06) periods. Subset group analysis of patients with isolated head injuries AIS score≥3 (n=99) also showed no statistical difference in preimplementation (1:51±1:42), implementation (2:49±2:57), and postimplementation (3:10±4:58) times. Examination of overall time to tertiary care revealed prolonged transfer times and that the Guideline had no influence on either the polytrauma patient group (preimplementation, 4:20±1:41; implementation, 5:01±2:55; and postimplementation 4:46±4:22) or those with isolated head injuries (preimplementation, 3:39±1:47; implementation, 6:06±4:00; and postimplementation, 5:13±4:59).
  
  
  CONCLUSIONS
  Times to tertiary care are lengthy and have not been reduced by Guideline implementation. System changes beyond Guideline implementation are required to provide timely access to tertiary care for patients with major head injury.
authors: Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada.
authors: Ginette
authors: G
authors: Thibault-Halman
authors: John M
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authors: Tallon
authors: Stacy
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authors: Ackroyd-Stolarz
authors: Lynne
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authors: Fenerty
authors: Saleema A
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