Most children with head injuries are seen in hospitals not equipped to treat them

Around 210,000 children attend hospital every year with a head injury and around 34,500 are admitted. A few children with serious head injuries will require emergency surgery and intensive care, and delays to the provision of this can prove fatal or result in severe disability.

The authors surveyed 245 hospitals in England, Wales, Northern Ireland, the Channel Islands and Isle of Man about their procedures and facilities for head injuries in children, and how many such patients they see.

They found that 87% of hospitals (which see 82% of children attending the emergency department with a head injury) could not care for a critically ill child on site.

"This will not be problematic for minor trauma (the vast majority), but those requiring intensive care and/or neurosurgical intervention then have to undergo further transfer, resulting in critical delay before definitive care with anticipated poorer outcome," write the authors.

Many hospitals designated as specialist trauma or neurosurgical centres had no intensive care service for children, and only two thirds of the hospitals surveyed had an established pathway for management of head injuries in children.

Of the 578 children aged up to 14 years in England, Wales and Northern Ireland who experience a serious head injury requiring intensive care every year, only 104 will present to an emergency department of a hospital capable of providing that care; the remaining 474 will need urgent transfer to another hospital.

A total of 117 of these 578 children will require emergency surgery, but only 20 of these will have attended a hospital with paediatric intensive care facilities and only 16 a hospital that can also provide that surgery.

"Hospitals that do offer such care are much more likely to have children's trained staff available in the emergency department. They are also more likely to have access to surgical support beyond neurosurgery," say the authors.

While there has been a move over the past 20 years to centralise paediatric trauma services, the authors point out that many of the benefits of centralisation rely on close proximity to paediatric intensive care.

"Since 70 per cent of the hospitals claiming 'trauma centre' status in this survey did not provide intensive care for children, it is likely they may not experience the improved outcomes," the authors conclude.

"Head injured adults are moved to specialist centres if neurosurgical intervention is required. In paediatric practice, the decision about transfer is made on the basis of the need for intensive care rather than neurosurgical intervention. It is therefore much more likely that a head injured child will need to be transferred between institutions and even more pertinent in this group to consider primary transfer to specialist centres from the scene."

Provided by British Medical Journal