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WORK OF AN ACCIDENT UNIT
1286
Special
Articles
WORK OF AN ACCIDENT UNIT P. A. RING Lond., F.R.C.S.
M.S.
CONSULTANT ORTHOPÆDIC
SURGEON,
REDHILL GROUP OF HOSPITALS, SURREY
IN the past few years the organisation of the accident services of this country has attracted the attention of several organisations, and reports have been published by the British Orthopaedic Association (1959), the Nuffield Provincial Hospitals Trust (1960), and the Accident Services Review Committee (1961). In each of these reports stress has been laid on the more efficient organisation of casualty departments to deal with the injured, and on the advantages of treating these patients in accident units sited in large general hospitals. The organisation of any accident service must take into account the type and the number of injuries it must be expected to receive. Owing to wide variations in the pattern of accidents and in population density, it is impossible to impose on all regions a standardised unit. The practice has in the past been to transport the injured to the nearest hospital, and, after examination, to send on to larger units those patients requiring specialised investigation or treatment. Such a system works adequately for all but the most seriously injured patients, whose survival may be jeopardised by the absence of experienced personnel or facilities for transfusion, radiography, and emergency surgery. The pressure for the centralisation of accident services has arisen largely from the increasing numbers of road accidents, their increasing severity, and the larger numbers of people who may be involved in any one incident. It is usually accepted that these patients travel well during the first hour after an accident, provided that respiratory difficulties are absent or can be overcome. Their subsequent treatment may demand pathological, radiological, and surgical facilities that are available only at the larger hospitals, and their nursing may present considerable difficulty. To maintain in every hospital the appropriate staff on a twenty-four hour basis is clearly uneconomic and impracticable. The number of patients whose survival depends on these facilities is small, at least as far as
Fig. I-Area of Redhill group of hospitals.
emergency treatment is concerned: really serious injuries form only a minute proportion of the total accident load. The object of the present study was to determine the nature and severity of accidents occurring within the area which this group serves, and to comment on the organisation of -the accident services. For the year Sept. 1, 1962, to Aug. 31, 1963, every accident admission to hospital has been ahalysed. Accidents vary too widely for such a survey to have epidemiological significance, although the incidence of such common injuries as fractures of the neck of the femur in the elderly is probably a reasonable reflection of the incidence in the country as a whole. I was principally concerned to determine the adequacy of our present arrangements, and of our hospital facilities; the extent to which specialised services, such as neurosurgery, were required; and the use which might be made of a central accident unit as envisaged in the interim report of the Accident Services Review Committee. The Redhill group of hospitals covers a population of 330,000; and the area it serves, and the distribution of the hospitals within it, are shown in fig. 1. In the past two years Redhill General Hospital has been responsible for all the major accident work within the group, and the outlying hospitals have been designated as suitable for the reception of minor injuries only. Casualty departments with resident staff are included in Crawley, Dorking, and East Surrey Hospitals; and in the others minor injuries are treated by the general practitioners, organised upon a duty rota. At Crawley Hospital four beds in the casualty department are designated for the overnight treatment of minor injuries; in all the other hospitals in the group, patients with minor injuries must be admitted to the wards if the stay in hospital is to exceed an hour or two. In Redhill General Hospital 34 beds are designated for the treatment of accidents; into these beds are admitted all the major accidents of the group together with minor injuries which require overnight observation and treatment. The selection of cases for treatment at the main unit, and of those which can safely be taken to the hospital nearest the scene of the accident, has been left to the ambulance The arguments for complete centralisation of crews. accident work are well known; but we were concerned to maintain both the status of the smaller hospital, and the interest of its staff in accident work, and did not feel that their elimination completely from such a scheme was good for the patient or for the hospital. Furthermore, the distance to the major centre from the outlying parts of the group is considerable, and difficulties arise at times in the summer when the roads are congested, and in winter when fog and ice may make travel difficult. In discussing the types of patient who should be taken directly to the accident centre we have tried to avoid rigid rules, and have relied on the good sense of the ambulance personnel; their judgment rarely errs. We have impressed on them the need to bring into the main unit those patients who are unconscious, those who clearly have major or multiple injuries, and those with compound fractures. We have also stressed the need for caution with patients whose injuries after a high-velocity accident seem to be minor, and have encouraged them to bring the casualties to the main centre when the total number of injured exceeds 3 or 4, even if the injuries are minor, since an outlying hospital may be unable to deal with such cases expeditiously. The accident admissions and transfers are shown in table 1.
1287 Distribution
TABLE I-ADMISSIONS AND TRANSFERS
A third of the accident admissions in this group have therefore been treated in the outlying hospitals-a practice which has proved largely satisfactory to patients and staff. Many of the patients with minor injuries, however, never reach the wards, and the overall proportion of the accident work treated outside the main unit is very much larger than table I suggests. Some of the patients detained in the outlying hospitals had sustained injuries which in a larger unit might not have merited inpatient treatment. Thus many patients were admitted for a day or two after closed manipulation of simple fractures and dislocations of the upper limbs. Admission is dictated partly by local tradition, partly by the availability of beds, but in many cases because the casualty departments lack the accommodation needed for recovery from general anaesthesia. ADMISSIONS
TO
Source of Accidents The pattern of accidents must vary
In the
considerably present survey, just
over
nan
tne
acimis-
sions to the accident unit arose as a result of road accidents, and only a tenth from accidents in industry (fig. 2). There can be little doubt that almost all the major injuries, and most of the problems of resuscitation, were incurred on the roads. Accidents at home are numerous, and often Fig. 2-Sources of major accidents. fatal; but the cause of death is commonly intercurrent disease in an elderly patient whose death is only indirectly related to the injuries sustained. .
Age-distribution In the male, injuries
are commonest
the Year
The monthly admissions to the accident unit varied between 49 and 79 around a mean of 65 (fig. 4). The monthly fluctuations are of little significance, and might be expected to vary from year to year with changes in local conditions and perhaps in the weather. Apparently from injuries road accidents are much less frequent in the months of January and
February-a feature which might be expected in a district in which much of the traffic
is
passing on pleasure trips the coast. Fractures of the neck of the femur to
were
com-
moner
in
winterr months. This
THE ACCIDENT UNIT
between different districts.
Throughout
in the late teens,
only partly be explained by falls on slipcan
pery leaves
or
Fig. 3-Age-distribution of injuries.
icy surfaces-most of these accidents occur within the house or in a nursing-home, and many, of course, are osteoporotic in origin. Mortality Some deaths occur at the scene of an accident, and others on the way to hospital; and occasionally it is difficult to be certain when death occurred. We have examined the recorded causes of death in those patients who were dead on arrival, and have seen the postmortems of those who died after arrival at hospital. Centralisation of accident services always carries a risk of an increased number of deaths in the ambulance, some of which might be avoided by more rapid medical attention, perhaps at an
outlying hospital. Dead on arrival.-21 patients were brought in dead, and the major causes of death are recorded in table 11. 2 of these patients died of myocardial infarction, and the road
and, after the age of thirty, slowly decrease in frequency (fig. 3). There can be little doubt that this is almost entirely due to the acquisition of a driving licence, and commonly due to the possession of a motor-cycle. Many of the older
men are
involved in industrial accidents
or
in
accidents at home. A similar but smaller age peak is evident in accidents to the female (fig. 3); this is mainly attributable to their accompanying their male contemporaries. After the age of twenty accidents are much less frequent, perhaps because the female is so often tied to the home; and the slowly rising accident-rate, reaching its peak in the seventies, is due largely to domestic injuries, in which fracture of the femoral neck play a prominent part.
Fig. 4-Distribution of accident admissions by months.
1288 TABLE II-CAUSES OF DEATH IN PATIENTS DEAD ON ARRIVAL
TABLE III-CAUSES OF DEATH IN PATIENTS ADMITTED TO WARDS
accident was irrelevant; 2 died from the inhalation of vomit or of blood, and these deaths might in theory have been avoided; but the causes of death in the others were injuries which were so gross that no treatment could’ have been expected to succeed. Died in casualty.-5 patients died in the casualty department within an hour or two of arrival-1 from a head injury, and the others from multiple injuries so severe that their survival at the time of the accident seemed surprising. It is unlikely that any method of treatment would have influenced the outcome. Deaths in the wards.-These numbered 36 in all-13 following road accidents, and 23 domestic. These figures reinforce the general impression that a patient who survives the immediate effects of a road accident, and can be resuscitated, will usually survive. The lethal injuries are those of the head and of the chest, as table ill indicates; and even though some of these patients had other injuries, such other injuries contributed little to the cause of death. Deaths following domestic accidents were confined to patients over seventy, and were associated almost entirely with fractures of the femoral neck. The mortality of this injury is not generally appreciated-in this series there were 106 patients with this injury; and of these 20 died-a
mortality of 19%. Types of Injury The purpose of the present classification is to indicate the types of injury which had been treated, in order to determine the range of services which had been drawn on, and to indicate in what respects a general hospital might be unable to cover the whole field of accident surgery. In table IV the major injury alone has been recordedmany of the patients of course sustained injuries involving several systems; but in most cases one of the injuries was the outstanding one, and presented the major problems of treatment. In those patients with head injuries a distinction has been drawn between the severe group, in which unconsciousness lasted for more than four days, and the relatively minor incidents. The management of fractures and soft tissue injuries, TABLE IV-TYPES OF
INJURY
and the subsequent rehabilitation of these patients, lies well within the compass of any general hospital with an orthopaedic department; and, except in the occasional patient with paraplegia associated with a spinal injury, the services of a special unit are not required. Injuries of the abdomen (usually treated by a general surgeon) are relatively uncommon, and their management in a general hospital presents no special problems. The majority of head injuries are minor; most of these patients are admitted for observation and are discharged within a few days. Their care demands a high standard of management for a few hours; but the very volume of the work rapidly produces in the medical and nursing staff the experience necessary to detect the occasional patient with a progressive intracranial lesion. The major head injuries demand intensive nursing and medical care, and in a hospital without a neurosurgical unit the operative treatment of many of these patients may well become the responsibility of the orthopaedic surgeon. Although the regional neurosurgical unit is less than an hour away by ambulance, the urgency of many of these cases has often prevented us seeking the assistance of this unit. Of the 25 patients with severe head injuries, no fewer than 12 died. These deaths from head injury are the hard core of the mortality in accident surgery, and seem likely to remain so. The number of burns is small, and few of these were severe. It is doubtful whether their number would justify any special accommodation available for their management under aseptic conditions; for much of the year such accommodation would remain idle. 4 patients sustained fractures of the jaw as the major injury, and these were transferred to the faciomaxillary unit at East Grinstead; but several other patients with multiple injuries were treated at Redhill by surgeons from this unit. It is a pleasure to acknowledge how well these arrangements have worked. Injuries of the chest are common, but their management in a hospital without a thoracic surgical unit has given rise to relatively few problems. The increasing demand for positive-pressure ventilation in these patients may, however, produce difficulties, since an accident unit alone cannot provide enough experience for nurses to be trained in this technique. Duration
of Stay
In the absence of beds suitable for overnight observation and treatment within the casualty department, all patients requiring admission were treated in the accident wards. Of the total of 784 patients, 337 were discharged within forty-eight hours. The majority had minor head injuries requiring observation, and the remainder had fractures which could not be managed in the casualty department. These short-stay admissions often require intensive observation by the nursing staff, and the administrative work involved in their reception and discharge is disproportionate to the severity of their
injuries. COMMENTS
The organisation of the accident service in this group has been based upon a single hospital designated for the reception of major injuries and several peripheral hospitals for the reception of minor injuries only. The decision to take a patient to one hospital rather than another is made by the ambulance attendant, who can contact both the controller and the hospital for advice. This arrangement has worked well-it prevents many
1289
unnecessary journeys to a major hospital, which could not: in any case, accommodate all the casualties in the area. It also retains the interest of the local hospitals in the treatment of its own minor injuries. The area which a hospital serves for the reception of severely injured must be decided by the nature of the district and by the facilities elsewhere. In general, a journey of more than half an hour from the scene of an
accident seems undesirable; but in a rural district such as this, this time must sometimes be exceeded. It would be difficult to extend the area covered by Redhill to the southeast or west without subjecting some patients to a journey which might be excessive. To the north, the area covered is at present relatively small, and this district is still served by a number of units. Some expansion in this direction might be advisable as part of a regional accident plan. To cover a larger area would create a more even flow of work for the nursing and medical staff, but could hardly be undertaken with the present facilities. During the year in question, 1156 patients were treated in hospital following an accident, and, of these, roughly two-thirds in the main unit. The 34 beds in this unit were used to 110% bed occupancy; and, bearing in mind that the recommended bed occupancy for such an accident unit is 75%, it seems that approximately 50 beds are required for the treatment of major injuries in this group. Such an allowance of beds would still leave some patients with minor injuries under treatment in the outlying
hospitals. The flow of work in an accident unit is not even, nor is the proportion of men, women, and children admitted consistent; and any unit which is designed to serve such patients should have accommodation which is suitable for patients of either sex and for children until their transfer to a children’s ward can be arranged. The specialised services which are required, other than those which now exist in the general hospital, are neurosurgery, faciomaxillary surgery, and, to a minor extent, thoracic surgery. The neurosurgical needs are too small to justify any more formal commitment than the present service which the regional neurosurgical unit affords, and the arrangements in respect of faciomaxillary work have always been excellent. The development of a respiratory unit in the general hospital would no doubt improve the treatment of many patients with the more severe chest
injuries. Few of the seriously ill patients can be transported to any other units, and the need for any specialised accident service at regional level seems very small. Patients
occasionally require dialysis for anuria or the services of a paraplegic unit, but such cases are very rare and do not present as emergencies. Placing our patients in an appropriate unit rarely causes difficulty. Conditions in the accident wards would be much
improved by provision of a small number of beds associated with the casualty department. Such an arrangement not only would afford accommodation for overnight stay but would relieve the wards of the disturbance associated with the admission of patients in the small hours and allow readier observation of these patients than is possible in a darkened ward at night. One of the most important features of any accident unit is the training of medical and nursing staff in the care of the injured. Although the treatment of limb injuries will probably remain the major part of the work of such a department, the increasing complexity and variety of injuries means that an orthopxdic training alone is not
enough. Any
surgeon dealing with accidents in a major be equipped to deal with head and chest injuries, since he will rarely be working in a hospital containing a neurosurgical or a thoracic unit. Improvement in the training of surgeons and nurses in the treatment of these injuries demands a much closer link between the regional centres and the outlying accident unitsnot for the treatment of individual patients, because time rarely permits such consultation-but for the teaching of the staffs of the accident units at all levels. centre must
OPERATING ON CHILDREN AS DAY-CASES REX LAWRIE M.D., M.S. Lond., F.R.C.S., M.R.C.P. SURGEON, GUY’S HOSPITAL, LONDON, S.E.1, CHILDREN’S HOSPITAL, LONDON, BOLINGBROKE HOSPITAL, LONDON, AND EDENBRIDGE HOSPITAL, KENT
CONSULTANT
EVELINA
The Evelina Children’s Hospital has 79beds, of which 19 are listed as surgical and 12 more are allocated to the ear, nose, and throat surgeons. The hospital caters principally for the day-to-day medical and surgical needs of the neighbourhood, but long-stay orthopaedic cases and patients needing reconstructive surgery for trauma, burns, and congenital abnormalities, are admitted as well. Acute appendicitis takes up most of the remaining surgical beds and cots, and the rate of bed-occupancy is
usually 80-85%. This article has been written to point out that a variety operations can with advantage be done without admitting the children to hospital, and to counteract the habit of writing " T.e.I."; there are special reasons why children should not be admitted unnecessarily. of
DAY-CASE OPERATIONS
Soon after I was appointed to the staff of the Evelina Children’s Hospital in 1949,I started a policy of operating " on infants and children as day-cases ". The children came into the ward on the morning of the operation and went home on the afternoon after recovering from the anxsthetic. The original reason was that children-who at that time were kept in hospital for a week after operation-not infrequently acquired infections during their postoperative stay and had to be kept in, sometimes for long periods. In good children’s hospitals 14% of the children were in hospital for illnesses acquired after admission.1 In addition, it soon became apparent that parents preferred their children to have their operations as daycases, that the children preferred it, and that there was much less disturbance in the family both at the time and afterwards. Many young children are very unhappy in hospital, and on their return home they are disturbedand disturbing-for some days or weeks. In contrast, the child who goes home on the same day does not suffer these effects of separation. One of my own family, for example, who had a small but critical operation as a day-case was round from his anaesthetic in time to enjoy his lunch, was driven home, and spent the afternoon skirmishing in the garden as if nothing had happened; in his recollection, the whole episode was fun. The policy of day-case operations was soon adopted as a routine-not as a cheap expedient but as a considered attempt to do what was best for the patient and his family. Because separation from the mother is undesirable, the admission to hospital of children under the age of about 1.
Watkins, A. G., Lewis-Faning, E. Brit. med.J. 1944, ii, 616.
Special
Articles
WORK OF AN ACCIDENT UNIT P. A. RING Lond., F.R.C.S.
M.S.
CONSULTANT ORTHOPÆDIC
SURGEON,
REDHILL GROUP OF HOSPITALS, SURREY
IN the past few years the organisation of the accident services of this country has attracted the attention of several organisations, and reports have been published by the British Orthopaedic Association (1959), the Nuffield Provincial Hospitals Trust (1960), and the Accident Services Review Committee (1961). In each of these reports stress has been laid on the more efficient organisation of casualty departments to deal with the injured, and on the advantages of treating these patients in accident units sited in large general hospitals. The organisation of any accident service must take into account the type and the number of injuries it must be expected to receive. Owing to wide variations in the pattern of accidents and in population density, it is impossible to impose on all regions a standardised unit. The practice has in the past been to transport the injured to the nearest hospital, and, after examination, to send on to larger units those patients requiring specialised investigation or treatment. Such a system works adequately for all but the most seriously injured patients, whose survival may be jeopardised by the absence of experienced personnel or facilities for transfusion, radiography, and emergency surgery. The pressure for the centralisation of accident services has arisen largely from the increasing numbers of road accidents, their increasing severity, and the larger numbers of people who may be involved in any one incident. It is usually accepted that these patients travel well during the first hour after an accident, provided that respiratory difficulties are absent or can be overcome. Their subsequent treatment may demand pathological, radiological, and surgical facilities that are available only at the larger hospitals, and their nursing may present considerable difficulty. To maintain in every hospital the appropriate staff on a twenty-four hour basis is clearly uneconomic and impracticable. The number of patients whose survival depends on these facilities is small, at least as far as
Fig. I-Area of Redhill group of hospitals.
emergency treatment is concerned: really serious injuries form only a minute proportion of the total accident load. The object of the present study was to determine the nature and severity of accidents occurring within the area which this group serves, and to comment on the organisation of -the accident services. For the year Sept. 1, 1962, to Aug. 31, 1963, every accident admission to hospital has been ahalysed. Accidents vary too widely for such a survey to have epidemiological significance, although the incidence of such common injuries as fractures of the neck of the femur in the elderly is probably a reasonable reflection of the incidence in the country as a whole. I was principally concerned to determine the adequacy of our present arrangements, and of our hospital facilities; the extent to which specialised services, such as neurosurgery, were required; and the use which might be made of a central accident unit as envisaged in the interim report of the Accident Services Review Committee. The Redhill group of hospitals covers a population of 330,000; and the area it serves, and the distribution of the hospitals within it, are shown in fig. 1. In the past two years Redhill General Hospital has been responsible for all the major accident work within the group, and the outlying hospitals have been designated as suitable for the reception of minor injuries only. Casualty departments with resident staff are included in Crawley, Dorking, and East Surrey Hospitals; and in the others minor injuries are treated by the general practitioners, organised upon a duty rota. At Crawley Hospital four beds in the casualty department are designated for the overnight treatment of minor injuries; in all the other hospitals in the group, patients with minor injuries must be admitted to the wards if the stay in hospital is to exceed an hour or two. In Redhill General Hospital 34 beds are designated for the treatment of accidents; into these beds are admitted all the major accidents of the group together with minor injuries which require overnight observation and treatment. The selection of cases for treatment at the main unit, and of those which can safely be taken to the hospital nearest the scene of the accident, has been left to the ambulance The arguments for complete centralisation of crews. accident work are well known; but we were concerned to maintain both the status of the smaller hospital, and the interest of its staff in accident work, and did not feel that their elimination completely from such a scheme was good for the patient or for the hospital. Furthermore, the distance to the major centre from the outlying parts of the group is considerable, and difficulties arise at times in the summer when the roads are congested, and in winter when fog and ice may make travel difficult. In discussing the types of patient who should be taken directly to the accident centre we have tried to avoid rigid rules, and have relied on the good sense of the ambulance personnel; their judgment rarely errs. We have impressed on them the need to bring into the main unit those patients who are unconscious, those who clearly have major or multiple injuries, and those with compound fractures. We have also stressed the need for caution with patients whose injuries after a high-velocity accident seem to be minor, and have encouraged them to bring the casualties to the main centre when the total number of injured exceeds 3 or 4, even if the injuries are minor, since an outlying hospital may be unable to deal with such cases expeditiously. The accident admissions and transfers are shown in table 1.
1287 Distribution
TABLE I-ADMISSIONS AND TRANSFERS
A third of the accident admissions in this group have therefore been treated in the outlying hospitals-a practice which has proved largely satisfactory to patients and staff. Many of the patients with minor injuries, however, never reach the wards, and the overall proportion of the accident work treated outside the main unit is very much larger than table I suggests. Some of the patients detained in the outlying hospitals had sustained injuries which in a larger unit might not have merited inpatient treatment. Thus many patients were admitted for a day or two after closed manipulation of simple fractures and dislocations of the upper limbs. Admission is dictated partly by local tradition, partly by the availability of beds, but in many cases because the casualty departments lack the accommodation needed for recovery from general anaesthesia. ADMISSIONS
TO
Source of Accidents The pattern of accidents must vary
In the
considerably present survey, just
over
nan
tne
acimis-
sions to the accident unit arose as a result of road accidents, and only a tenth from accidents in industry (fig. 2). There can be little doubt that almost all the major injuries, and most of the problems of resuscitation, were incurred on the roads. Accidents at home are numerous, and often Fig. 2-Sources of major accidents. fatal; but the cause of death is commonly intercurrent disease in an elderly patient whose death is only indirectly related to the injuries sustained. .
Age-distribution In the male, injuries
are commonest
the Year
The monthly admissions to the accident unit varied between 49 and 79 around a mean of 65 (fig. 4). The monthly fluctuations are of little significance, and might be expected to vary from year to year with changes in local conditions and perhaps in the weather. Apparently from injuries road accidents are much less frequent in the months of January and
February-a feature which might be expected in a district in which much of the traffic
is
passing on pleasure trips the coast. Fractures of the neck of the femur to
were
com-
moner
in
winterr months. This
THE ACCIDENT UNIT
between different districts.
Throughout
in the late teens,
only partly be explained by falls on slipcan
pery leaves
or
Fig. 3-Age-distribution of injuries.
icy surfaces-most of these accidents occur within the house or in a nursing-home, and many, of course, are osteoporotic in origin. Mortality Some deaths occur at the scene of an accident, and others on the way to hospital; and occasionally it is difficult to be certain when death occurred. We have examined the recorded causes of death in those patients who were dead on arrival, and have seen the postmortems of those who died after arrival at hospital. Centralisation of accident services always carries a risk of an increased number of deaths in the ambulance, some of which might be avoided by more rapid medical attention, perhaps at an
outlying hospital. Dead on arrival.-21 patients were brought in dead, and the major causes of death are recorded in table 11. 2 of these patients died of myocardial infarction, and the road
and, after the age of thirty, slowly decrease in frequency (fig. 3). There can be little doubt that this is almost entirely due to the acquisition of a driving licence, and commonly due to the possession of a motor-cycle. Many of the older
men are
involved in industrial accidents
or
in
accidents at home. A similar but smaller age peak is evident in accidents to the female (fig. 3); this is mainly attributable to their accompanying their male contemporaries. After the age of twenty accidents are much less frequent, perhaps because the female is so often tied to the home; and the slowly rising accident-rate, reaching its peak in the seventies, is due largely to domestic injuries, in which fracture of the femoral neck play a prominent part.
Fig. 4-Distribution of accident admissions by months.
1288 TABLE II-CAUSES OF DEATH IN PATIENTS DEAD ON ARRIVAL
TABLE III-CAUSES OF DEATH IN PATIENTS ADMITTED TO WARDS
accident was irrelevant; 2 died from the inhalation of vomit or of blood, and these deaths might in theory have been avoided; but the causes of death in the others were injuries which were so gross that no treatment could’ have been expected to succeed. Died in casualty.-5 patients died in the casualty department within an hour or two of arrival-1 from a head injury, and the others from multiple injuries so severe that their survival at the time of the accident seemed surprising. It is unlikely that any method of treatment would have influenced the outcome. Deaths in the wards.-These numbered 36 in all-13 following road accidents, and 23 domestic. These figures reinforce the general impression that a patient who survives the immediate effects of a road accident, and can be resuscitated, will usually survive. The lethal injuries are those of the head and of the chest, as table ill indicates; and even though some of these patients had other injuries, such other injuries contributed little to the cause of death. Deaths following domestic accidents were confined to patients over seventy, and were associated almost entirely with fractures of the femoral neck. The mortality of this injury is not generally appreciated-in this series there were 106 patients with this injury; and of these 20 died-a
mortality of 19%. Types of Injury The purpose of the present classification is to indicate the types of injury which had been treated, in order to determine the range of services which had been drawn on, and to indicate in what respects a general hospital might be unable to cover the whole field of accident surgery. In table IV the major injury alone has been recordedmany of the patients of course sustained injuries involving several systems; but in most cases one of the injuries was the outstanding one, and presented the major problems of treatment. In those patients with head injuries a distinction has been drawn between the severe group, in which unconsciousness lasted for more than four days, and the relatively minor incidents. The management of fractures and soft tissue injuries, TABLE IV-TYPES OF
INJURY
and the subsequent rehabilitation of these patients, lies well within the compass of any general hospital with an orthopaedic department; and, except in the occasional patient with paraplegia associated with a spinal injury, the services of a special unit are not required. Injuries of the abdomen (usually treated by a general surgeon) are relatively uncommon, and their management in a general hospital presents no special problems. The majority of head injuries are minor; most of these patients are admitted for observation and are discharged within a few days. Their care demands a high standard of management for a few hours; but the very volume of the work rapidly produces in the medical and nursing staff the experience necessary to detect the occasional patient with a progressive intracranial lesion. The major head injuries demand intensive nursing and medical care, and in a hospital without a neurosurgical unit the operative treatment of many of these patients may well become the responsibility of the orthopaedic surgeon. Although the regional neurosurgical unit is less than an hour away by ambulance, the urgency of many of these cases has often prevented us seeking the assistance of this unit. Of the 25 patients with severe head injuries, no fewer than 12 died. These deaths from head injury are the hard core of the mortality in accident surgery, and seem likely to remain so. The number of burns is small, and few of these were severe. It is doubtful whether their number would justify any special accommodation available for their management under aseptic conditions; for much of the year such accommodation would remain idle. 4 patients sustained fractures of the jaw as the major injury, and these were transferred to the faciomaxillary unit at East Grinstead; but several other patients with multiple injuries were treated at Redhill by surgeons from this unit. It is a pleasure to acknowledge how well these arrangements have worked. Injuries of the chest are common, but their management in a hospital without a thoracic surgical unit has given rise to relatively few problems. The increasing demand for positive-pressure ventilation in these patients may, however, produce difficulties, since an accident unit alone cannot provide enough experience for nurses to be trained in this technique. Duration
of Stay
In the absence of beds suitable for overnight observation and treatment within the casualty department, all patients requiring admission were treated in the accident wards. Of the total of 784 patients, 337 were discharged within forty-eight hours. The majority had minor head injuries requiring observation, and the remainder had fractures which could not be managed in the casualty department. These short-stay admissions often require intensive observation by the nursing staff, and the administrative work involved in their reception and discharge is disproportionate to the severity of their
injuries. COMMENTS
The organisation of the accident service in this group has been based upon a single hospital designated for the reception of major injuries and several peripheral hospitals for the reception of minor injuries only. The decision to take a patient to one hospital rather than another is made by the ambulance attendant, who can contact both the controller and the hospital for advice. This arrangement has worked well-it prevents many
1289
unnecessary journeys to a major hospital, which could not: in any case, accommodate all the casualties in the area. It also retains the interest of the local hospitals in the treatment of its own minor injuries. The area which a hospital serves for the reception of severely injured must be decided by the nature of the district and by the facilities elsewhere. In general, a journey of more than half an hour from the scene of an
accident seems undesirable; but in a rural district such as this, this time must sometimes be exceeded. It would be difficult to extend the area covered by Redhill to the southeast or west without subjecting some patients to a journey which might be excessive. To the north, the area covered is at present relatively small, and this district is still served by a number of units. Some expansion in this direction might be advisable as part of a regional accident plan. To cover a larger area would create a more even flow of work for the nursing and medical staff, but could hardly be undertaken with the present facilities. During the year in question, 1156 patients were treated in hospital following an accident, and, of these, roughly two-thirds in the main unit. The 34 beds in this unit were used to 110% bed occupancy; and, bearing in mind that the recommended bed occupancy for such an accident unit is 75%, it seems that approximately 50 beds are required for the treatment of major injuries in this group. Such an allowance of beds would still leave some patients with minor injuries under treatment in the outlying
hospitals. The flow of work in an accident unit is not even, nor is the proportion of men, women, and children admitted consistent; and any unit which is designed to serve such patients should have accommodation which is suitable for patients of either sex and for children until their transfer to a children’s ward can be arranged. The specialised services which are required, other than those which now exist in the general hospital, are neurosurgery, faciomaxillary surgery, and, to a minor extent, thoracic surgery. The neurosurgical needs are too small to justify any more formal commitment than the present service which the regional neurosurgical unit affords, and the arrangements in respect of faciomaxillary work have always been excellent. The development of a respiratory unit in the general hospital would no doubt improve the treatment of many patients with the more severe chest
injuries. Few of the seriously ill patients can be transported to any other units, and the need for any specialised accident service at regional level seems very small. Patients
occasionally require dialysis for anuria or the services of a paraplegic unit, but such cases are very rare and do not present as emergencies. Placing our patients in an appropriate unit rarely causes difficulty. Conditions in the accident wards would be much
improved by provision of a small number of beds associated with the casualty department. Such an arrangement not only would afford accommodation for overnight stay but would relieve the wards of the disturbance associated with the admission of patients in the small hours and allow readier observation of these patients than is possible in a darkened ward at night. One of the most important features of any accident unit is the training of medical and nursing staff in the care of the injured. Although the treatment of limb injuries will probably remain the major part of the work of such a department, the increasing complexity and variety of injuries means that an orthopxdic training alone is not
enough. Any
surgeon dealing with accidents in a major be equipped to deal with head and chest injuries, since he will rarely be working in a hospital containing a neurosurgical or a thoracic unit. Improvement in the training of surgeons and nurses in the treatment of these injuries demands a much closer link between the regional centres and the outlying accident unitsnot for the treatment of individual patients, because time rarely permits such consultation-but for the teaching of the staffs of the accident units at all levels. centre must
OPERATING ON CHILDREN AS DAY-CASES REX LAWRIE M.D., M.S. Lond., F.R.C.S., M.R.C.P. SURGEON, GUY’S HOSPITAL, LONDON, S.E.1, CHILDREN’S HOSPITAL, LONDON, BOLINGBROKE HOSPITAL, LONDON, AND EDENBRIDGE HOSPITAL, KENT
CONSULTANT
EVELINA
The Evelina Children’s Hospital has 79beds, of which 19 are listed as surgical and 12 more are allocated to the ear, nose, and throat surgeons. The hospital caters principally for the day-to-day medical and surgical needs of the neighbourhood, but long-stay orthopaedic cases and patients needing reconstructive surgery for trauma, burns, and congenital abnormalities, are admitted as well. Acute appendicitis takes up most of the remaining surgical beds and cots, and the rate of bed-occupancy is
usually 80-85%. This article has been written to point out that a variety operations can with advantage be done without admitting the children to hospital, and to counteract the habit of writing " T.e.I."; there are special reasons why children should not be admitted unnecessarily. of
DAY-CASE OPERATIONS
Soon after I was appointed to the staff of the Evelina Children’s Hospital in 1949,I started a policy of operating " on infants and children as day-cases ". The children came into the ward on the morning of the operation and went home on the afternoon after recovering from the anxsthetic. The original reason was that children-who at that time were kept in hospital for a week after operation-not infrequently acquired infections during their postoperative stay and had to be kept in, sometimes for long periods. In good children’s hospitals 14% of the children were in hospital for illnesses acquired after admission.1 In addition, it soon became apparent that parents preferred their children to have their operations as daycases, that the children preferred it, and that there was much less disturbance in the family both at the time and afterwards. Many young children are very unhappy in hospital, and on their return home they are disturbedand disturbing-for some days or weeks. In contrast, the child who goes home on the same day does not suffer these effects of separation. One of my own family, for example, who had a small but critical operation as a day-case was round from his anaesthetic in time to enjoy his lunch, was driven home, and spent the afternoon skirmishing in the garden as if nothing had happened; in his recollection, the whole episode was fun. The policy of day-case operations was soon adopted as a routine-not as a cheap expedient but as a considered attempt to do what was best for the patient and his family. Because separation from the mother is undesirable, the admission to hospital of children under the age of about 1.
Watkins, A. G., Lewis-Faning, E. Brit. med.J. 1944, ii, 616.