The MRC CRASH trial collaborators’ simple prognostic model can be used to predict outcomes in patients with traumatic brain injury.1 Although the model considered time from injury to randomisation, the time at which the patient presented to hospital was not considered as a potential independent prognostic variable. This is important because provision of key aspects of hospital trauma services such as staffing, access to operating theatres, and interventional radiology is reduced after normal working hours.
In the UK, a recent study examined the process of care for 795 severely injured patients—493 with a head injury.2 Most presented to the accident and emergency department out of hours (18.00-07.59 hours or weekends). Initial management of the patient was inappropriate in 23.5% of cases when a senior house officer was the team leader or first reviewer compared with 3.1% when a consultant performed this role. Consultants were involved in 39.6% of cases during the day and only 11.5% of cases presenting at night. This trend was in the opposite direction for junior doctors, being highest during the night. In addition to a lack of senior medical staff to coordinate management out of hours, immediate intervention for more specialised injuries was often unavailable.
Organisational deficiencies in out of hours care are not unique to the UK or to trauma care. Increased mortality out of hours has also been identified in patients with myocardial infarction undergoing percutaneous coronary intervention,3 patients with cardiac arrest,4 and patients being discharged from intensive care.5
Competing interests: None declared.
References
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