title: The impact of major trauma centre implementation on the pathways and outcome of traumatic intracranial extradural haematoma in a regional centre.
abstract: BACKGROUND
  A new trauma care system with regional major trauma centres (MTC) was implemented on 1st April 2012 across England. We aimed to assess whether this has affected the referral pathways and mortality of patients undergoing emergency craniotomy for extradural haematoma (EDH), where clinical outcome is correlated with the time to intervention.
  
  
  METHODS
  This was a retrospective cohort comparison study. All patients who had undergone evacuation of EDH from January 2011 to December 2013 were identified. Only those in whom a decision for emergency craniotomy had been made at the time of referral to the on-call neurosurgeon were included. The CRASH predicted risk of mortality was calculated for individual patients. Mortality was assessed at 14 days in order to compute standardised mortality ratios (SMR).
  
  
  RESULTS
  Overall, 65 patients underwent EDH evacuation during the study period (21 pre-MTC and 44 post-MTC). Of those, 43 emergency procedures according to the aforementioned definition were included for further analysis (13 pre-MTC, 30 post-MTC). The mean CRASH predicted risk of mortality was 0.21 for the pre-MTC cohort (95% CI: 0.07-0.34) and 0.094 for the post-MTC cohort (95% CI: 0.039-0.15; p = 0.052). There was no significant difference in the rate of secondary transfers before and after MTC implementation (9/13 vs. 23/30, p = 0.71). The mean interval from referral to operation was 198 min for the pre-MTC cohort (95% CI: 123-273) and 201 min for the post-MTC cohort (95% CI: 141-262; p = 0.95). The SMR was 0.37 for the pre-MTC cohort (95% CI: 0.02-1.81; 1 death) and 0.71 for the post-MTC cohort (95% CI: 0.12-2.34; 2 deaths).
  
  
  CONCLUSIONS
  MTC implementation has not affected the time to operation or the mortality following EDH evacuation.
authors.affiliation: a Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge , Cambridge , UK.
authors.forename: Richard D C
authors.initials: RD
authors.lastname: Moon
authors.affiliation: a Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge , Cambridge , UK.
authors.forename: Mutwakil A H
authors.initials: MA
authors.lastname: Abdulla
authors.affiliation: a Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge , Cambridge , UK.
authors.forename: Angelos G
authors.initials: AG
authors.lastname: Kolias
authors.affiliation: a Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge , Cambridge , UK.
authors.forename: Krunal
authors.initials: K
authors.lastname: Patel
authors.affiliation: a Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge , Cambridge , UK.
authors.forename: Ramez W
authors.initials: RW
authors.lastname: Kirollos
authors.affiliation: a Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge , Cambridge , UK.
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Hutchinson
authors.affiliation: a Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge , Cambridge , UK.
authors.forename: Ivan S
authors.initials: IS
authors.lastname: Timofeev
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D015331:Cohort Studies; D003399:Craniotomy / Q000379:methods; D004632:Emergency Medical Services; D004739:England; D005260:Female; D006406:Hematoma / Q000401:mortality / Q000601:surgery*; D006407:Hematoma, Epidural, Cranial / Q000401:mortality / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000379:methods; D011379:Prognosis; D012017:Referral and Consultation; D012189:Retrospective Studies; D018570:Risk Assessment; D061665:Time-to-Treatment; D014193:Trauma Centers / Q000458:organization & administration*; D016896:Treatment Outcome; D055815:Young Adult
keywords: Craniotomy; extradural haematoma; head injury; neurosurgery; traumatic brain injury