The changing radiation oncology landscape in New Zealand.

INTRODUCTION: This paper outlines the New Zealand (NZ) responses to the biennial facilities surveys of The Royal Australian and New Zealand College of Radiologists (RANZCR), Faculty of Radiation Oncology (FRO) from 2011 to 2019. METHODS: The facilities survey is conducted by the FRO Economics and Workforce Committee (FROEWC) and focuses on equipment, treatment activities and staffing. RESULTS: The number of facilities increased by two to 10, both in the private sector. The total number of linear accelerators (linacs) increased by four; one in public and three in private. The majority of linacs were over 8 years old (62.5%). Treatment courses have increased by 19% and fraction numbers by 13.7%. Courses per linac have remained relatively constant. There was growth in IMRT, orthovoltage, high dose rate brachytherapy and paediatric treatments. There was a slow increase in number of radiation oncologists and trainees. The number of radiation therapists was unchanged with a 20% increase in treatment courses per radiation therapist. Physicist numbers have increased but 61.4% of physicists are overseas-trained and vacancies persist. CONCLUSION: The survey results indicate a rapidly changing radiation oncology landscape in NZ between 2011 and 2019. The challenges of increases in cancer numbers, treatment courses and complexity of treatments and a need to focus on quality standards against a set of minimal increase in machine numbers, ageing machines, static or slowly increasing staffing numbers and heavy reliance on overseas staffing require a national review of radiation oncology services to ensure a sustainable future.

Faculty of Radiation Oncology 2018 workforce census: the status of the radiation oncology workforce in New Zealand.

AIM: This paper outlines the results of the Royal Australian and New Zealand College of Radiologists (RANZCR) Faculty of Radiation Oncology (FRO) 2018 workforce census. Here we report the responses of New Zealand radiation oncologists and trainees in order to understand characteristics of the New Zealand radiation oncology workforce. METHOD: The workforce census was conducted online during July-September 2018. Distribution was by Survey Monkey to all radiation oncologists (fellows, life members, educational affiliates, retired) and trainees on the RANZCR membership database, including members from Australia, New Zealand and Singapore. All responses were aggregated for analysis. This paper addresses only responses from New Zealand members. The census was designed to explore issues relevant to the New Zealand workforce, and questions from previous workforce censuses were repeated in order to monitor trends. RESULTS: The response rate for New Zealand radiation oncologists was 73.3% (44/60). The majority (67%) were male. The average age was 50.8 years. Three-fifths (59.5%) reported New Zealand ethnicity. One-third obtained their specialist qualifications outside of Australia and New Zealand. Most worked in the public sector only (63.4%), with only two in exclusive private practice. Most radiation oncologists attained a consultant post immediately on completion of training, but there were 26 who pursued an overseas fellowship. Most worked one full-time equivalent or greater (FTE), with 17.5% working less than 1.0 FTE. Radiation oncologists reported working a median of 50.0 hours per week, with half working over 10 hours above their contracted hours. Most time was spent on clinical duties with minimal time spent on research. Radiation oncologists reported seeing an average of 235 new patients per year (median: 230). Leadership positions were held by 21/43 respondents. Within 15 years, 55% of the current workforce reported an intention to retire, including 30% of those currently practising highly specialised brachytherapy. Females in the workforce were less likely to work fulltime and spent less time in research and management activities. All trainees reported full-time work, although 50% expressed a desire for part-time training. Half of the trainees reported working 6-10 hours on call, and 60% reported two or less hours of protected teaching per week. Despite this, 90% of trainees were satisfied with their career choice. CONCLUSIONS: Radiation oncology is a small specialty in New Zealand, with a significant reliance on overseas-trained specialists. The specialty continues to work significant overtime hours while time spent on research and non-clinical duties remains low. The growth in staffing between the 2014 and 2018 census has been low. Trainee numbers do not appear sufficient to meet the demand for replacing staff, due to retirements and the reduction of hours. Radiation intervention rates are low in New Zealand, but growth would be reliant on an expansion of the workforce beyond simply replacing staff losses. The radiation oncology workforce in New Zealand remains vulnerable, and careful consideration must be given to expansion and retention to ensure a viable workforce for the future.

Measuring radiologist workload: Progressing from RVUs to study ascribable times.

INTRODUCTION: The need to measure reporting workload in teaching departments remains a current pertinent need. In Australia, the Pitman-Jones reporting RVUs have been in the public domain since 2003 (revised in 2009). These are expressed in arbitrary units. In New Zealand, single-site Christchurch Hospital reporting times have been validated and placed in the public domain. Concurrently, the RANZCR has been developing a formulaic descriptor lexicon for imaging studies (the Body System Framework). There is a need to bring these three strands of work together into a common public resource. In 2015, under the auspices of the Chief Accreditation Officer, RANZCR convened the Radiologist Workload Working Group. The goal of the group was to develop a robust method of measuring radiologist workload in teaching departments in Australia and New Zealand for the RANZCR accreditation processes of teaching departments as training sites. This paper concerns itself with one aspect of the group's work, namely reaching a consensus on radiologist study ascribable times for common imaging studies. METHOD: The BSF examination descriptors were reduced to a smaller, generic dataset of descriptors at the expense of loss of specificity. BSF study ascribable times had been previously obtained by stopwatch observation. The dataset was harmonized with the Christchurch descriptors to ensure commonality of case mix. The two lead authors reached an approximate consensus study ascribable time for each descriptor in agreement with the BSF and Christchurch data. Specifically, the Christchurch reporting times were relied on extensively to validate the new dataset's study ascribable times. The first draft of descriptors and times was tabled at the meetings of the RANZCR Radiologist Workload Working Group, and was progressively refined by iterative consensus. RESULTS: The output of the Radiologist Workload Working Group comprises a simplified modality-based table of robust descriptors and 'best estimate' corresponding study ascribable times. These can be used with the extant Pitman-Jones methodology in order to estimate the reporting workload of a medical imaging teaching department in units of time. As a first for Australia and New Zealand, nuclear medicine and PET study ascribable times have been incorporated and balanced against radiology study ascribable times. CONCLUSION: The RANZCR 2016 study ascribable times are ready for use by the Australian and New Zealand radiologist and nuclear medicine specialist community. We hope these times will also stimulate further data collection in our two countries towards a robust, bi-national study ascribable times database.

Audit of demand for after-hours CT scanning services in RANZCR-accredited training departments.

INTRODUCTION: The aims of this study were to measure: (i) the growth in after-hours emergency department--referred CT (ED-CT) performed in accredited training departments between 2011 and 2013; (ii) the growth in ED CT relative to growth in ED presentations at the same hospitals; and (iii) trainee workload resulting from after-hours ED CT. METHODS: Ethics approval was obtained for all participating sites. Accredited training facilities in Australia and New Zealand with three or more trainees and serving one or more EDs were invited to participate (N = 32). Four nights were surveyed between August and December 2013. For data collection, the number of ED patients having one or more CT scans; ED CT scan total images; non-contrast head CTs; and ED patients (total and categories 1 and 2) attending the ED in the preceding 24 h and first half of calendar year were collected for 2013 and corresponding days in 2012 and 2011. Trainee staffing levels were measured. RESULTS: Eleven of 32 sites provided data for all four nights and 14 of 32 for one or more nights. A 15.7% increase in number of ED CTs between 1700 and 2200 h and 16.8% increase between 2201 and 0730 h occurred in the 2 years between 2011 and 2013 compared with a 6.9% increase in overall ED and 26% increase in categories 1 and 2 presentations over the same period. The number of CT images, however, increased 23%. CONCLUSION: Growth in demand by EDs for after-hours CT services has implications for service provision and trainee workloads in Royal Australian and New Zealand College of Radiologists-accredited training departments.

Faculty of Radiation Oncology 2014 workforce census.

INTRODUCTION: This paper reports the key findings of the Faculty of Radiation Oncology 2014 workforce census and compares the results with earlier surveys. METHODS: The census was conducted in mid-2014 with distribution to all radiation oncologists, educational affiliates and trainees listed on the college database. There were six email reminders and responses were anonymous. The overall response rate was 76.1%. RESULTS: The age range of fellows was 32-96 (mean = 49 years, median = 47 years). The majority of the radiation oncologists were male (n = 263, 63%). The minority of radiation oncologists were of Asian descent (n = 43, 13.4%). Radiation oncologists graduated from medical school on average 23 years ago (median = 22 years). A minority of fellows (n = 66, 20%) held another postgraduate qualification. Most radiation oncologists worked, on average, at two practices (median = 2, range 1-7). Practising radiation oncologists worked predominantly in the public sector (n = 131, 49%), but many worked in both the public and private sectors (n = 94, 37%), and a minority worked in the private sector only (n = 38, 14%). The largest proportion of the workforce was from New South Wales accounting for 29% of radiation oncologists. Radiation oncologists worked an average of 43 h/week (median = 43 h, range 6-80). Radiation oncologists who worked in the private sector worked less hours than their public sector or public/private sector colleagues. (38.3 vs. 42.9 vs. 44.3 h, P = 0.042). Victorians worked the fewest average hours per week at 38 h and West Australians the most at 46 h/week. Radiation oncologists averaged 48 min for each new case, 17 min per follow up and 11 min for a treatment review. Radiation oncologists averaged 246 new patients per year (median = 250, range = 20-600) with men (average = 268), Western Australians (average = 354) and those in private practice seeing more (average = 275). Most radiation oncologists considered themselves as specialists (n = 151, 60%), but nearly all those from South Australia were generalists (n = 15, 94%) as were three-quarters of those from private practice. A minority of radiation oncologist respondents (10%) intended to retire within 5 years with a further 16% within 10 years.There was a stabilisation of trainee numbers in Australia and New Zealand with no increase compared with 2010 (142 in 2014 vs. 143 in 2010). The most common age bracket for trainees remained 31-35 years. One-third of trainees were of Asian descent and nearly half held other degrees. The majority of trainees were satisfied with their career, but 30% were not entirely satisfied. Nearly half of trainee respondents would have reconsidered their choice of specialty had they known about the possible oversupply in the workforce with 12.4% undecided about continuing their career in radiation oncology. There were still 16% of trainees with no protected time during the working week, and a further 21% with only 1 h. Only one trainee respondent preferred to work in private practice, and job availability remained a concern for 89% of respondents. CONCLUSIONS: The radiation oncologist workforce numbers have increased at a much slower rate, and unemployment remained low. Many parameters remained similar to the 2010 survey. However, there has been a decrease in the average number of new patients seen per year, working hours and also a slight decrease in the time spent per new patient. The trainee numbers have stabilised, but job availability remained a concern. A significant proportion of trainees were not satisfied with their career.

Faculty of Radiation Oncology 2014 Workforce Census: a comparison of New Zealand and Australian responses.

AIM: This paper outlines the key results of the Royal Australian and New Zealand College of Radiologists (RANZCR) Faculty of Radiation Oncology (FRO) 2014 workforce census, and compares the results of New Zealand and Australian responses in order to identify similarities and differences in workforce characteristics. METHODS: The workforce census was conducted online in mid-2014. The census was distributed to all radiation oncologists (Fellows, life members, educational affiliates, retired) and radiation oncology trainees on the RANZCR membership database. Six weekly reminders were sent to non-respondents and all responses were aggregated for analysis. This paper addresses only consultant radiation oncologist responses. RESULTS: The combined response rate for New Zealand radiation oncologists was 85.7% (compared with 76% from Australian respondents). The census found that the demographic characteristics of New Zealand and Australian radiation oncologists are similar. Points of difference include (i) the role of educational affiliates in New Zealand, (ii) New Zealand radiation oncologists reporting higher hours spent at work, (iii) New Zealand radiation oncologists spending a higher proportion of time on clinical duties, (iv) A lower proportion of New Zealand radiation oncologists with higher degrees, and (v) private/ public workplace mix. CONCLUSION: A comparison by country would suggest that there are many similarities, but also some important differences that may affect workforce issues in New Zealand. Separate datasets are useful for RANZCR to better inform members, governments and other key stakeholders in each country. Separate datasets also provide a basis for comparison with future surveys to facilitate the monitoring of trends.

Stress, satisfaction and burnout amongst Australian and New Zealand radiation oncologists.

INTRODUCTION: The aim of this study was to determine the self-reported prevalence of stress, job satisfaction and burnout among radiation oncologists in Australia and New Zealand. A secondary aim was to determine the association between stress and satisfaction parameters with burnout. METHODS: An anonymous online survey was distributed to all radiation oncologists listed on Royal Australian and New Zealand College of Radiologists membership database. There were 37 Likert scale questions on stress, 17 Likert scale questions on job satisfaction and burnout assessed by the Maslach Burnout Inventory - Human Services Survey (MBI-HSS). A principal component analysis was done for stress and satisfaction to identify specific areas. Independent samples t-tests and analysis of variances were done. RESULTS: There were 220 responses out of 348 eligible respondents (63.2% response rate).For stress, a principal component analysis identified five areas: delivery demands, demands on time, continuing professional development (CPD), value and security, and interpersonal/teaching demands. Specialist radiation oncologists were more stressed by value and security than generalists (P < 0.01). Lung cancer specialists had higher levels of stress associated with delivery demands, demands on time and CPD compared with others (P = 0.01). Those over 60 years were less stressed by delivery demands (P = 0.02), demands on time (P = 0.01) and CPD (P = 0.01) than their younger colleagues. Four satisfaction factors were identified in the principal component analysis: resources/remuneration, status/security, delivery of services and professional activities. [Correction added on 15 August 2014, after first online publication: stress/security was replaced with status/security.] Males and Australian radiation oncologists were more satisfied with professional activities (P = 0.02). Brachytherapy specialists were more satisfied with status/security (P = 0.01) while those interested in urology were more satisfied with resources/renumeration (P = 0.01) and professional activities (P = 0.01). The burnout results revealed at least 48.5% of respondents scoring highly in at least one of the three measures of burnout (emotional exhaustion, depersonalisation and personal accomplishment) while 37.5% scoring highly in the emotional exhaustion and depersonalisation subscales. Public sector radiation oncologists had higher levels of emotional exhaustion and lower levels of personal accomplishment than their private sector counterparts, while those interested in lung cancer had higher levels of emotional exhaustion. Multiple regression analysis revealed that the stress subscale demands on time had a significant effect on emotional exhaustion. Higher CPD stress and interpersonal/teaching demands increased the feeling of depersonalisation, while satisfaction with delivery of services was associated with lower levels of depersonalisation and higher levels of personal accomplishment. CONCLUSIONS: This first study of stress, satisfaction and burnout among radiation oncologists in Australia and New Zealand had a reasonable response rate and identified specific areas of stress and satisfaction. Nearly half of the respondents scored highly in one burnout subscale. Some of the stress and satisfaction subscales correlated with certain aspects of burnout. Further research will be undertaken to refine the stress and satisfaction parameters and address burnout interventions.

Use of prothrombin complex concentrates: 4-year experience of a national aeromedical retrieval service servicing remote and rural areas.

INTRODUCTION: Prothrombin complex concentrates (PCCs) are recommended as first-line treatment for acquired or congenital factor II, VII, IX and X deficiencies in situations of major haemorrhage. The Emergency Medical Retrieval Service (EMRS) provides critical care and aeromedical retrieval to patients in remote and rural Scotland. It has an important role in the care of these patients. METHOD: We sought to determine the incidence of haemorrhage requiring PCC administration in our cohort of patients, and to assess compliance with current national guidelines regarding their storage and use. We searched our database for all patients that received PCCs, or met current guidelines for their administration, and followed them through to hospital discharge. We also conducted a telephone survey of all hospitals served by the EMRS to determine compliance with national standards. RESULTS: During the 42-month study period, 1170 retrieval missions were conducted. Twenty-six retrieved patients had a congenital or acquired clotting factor deficiency and seven met criteria for PCC administration. Of these, only three received PCCs prior to transfer to definitive care. Telephone survey revealed that all the rural general hospitals were served by the EMRS stock PCCs, but only one out of 15 GP-led community hospitals had access to PCCs. CONCLUSIONS: In the remote and rural setting where access to definitive care may be limited or delayed, timely administration of PCCs in appropriate patients may improve outcomes. As many rural hospitals do not have access to PCCs, the ability of the EMRS to provide this treatment may improve patient care.

Faculty of Radiation Oncology 2012 trainee survey: perspectives on choice of specialty training and future work practice preferences.

INTRODUCTION: This paper reports the key findings of the first Faculty of Radiation Oncology survey of trainees dealing with experiences and perceptions on work practices and choice of specialty. METHODS: The survey was conducted in mid 2012 using a 37-question instrument. This was distributed by email to 159 current trainees and advertised through the Radiation Oncology Trainees Committee and other channels. There were six email reminders. Respondents were reassured that their responses were anonymous. RESULTS: The overall response rate was 82.8%. Gender was balanced among respondents with 67 (51.5%) being male and 63 (48.5%) being female. The most common age bracket was the 31 to 35 years range. There were similar proportions of trainee responders in each of the five years of training. A substantial number of trainees held other degrees besides medical degrees. The large majority were satisfied with radiation oncology as a career choice and with the Training Network within which they were training. Interest in oncology patients, lifestyle after training and work hours were given as the major reasons for choosing radiation oncology as a career. Nearly half of trainees were interested in undertaking some of their training in a part-time capacity and working part time as a radiation oncologist in the future. Over 70% of trainees stated they were working 36-55 clinical hours per week with additional non-clinical tasks, after-hours work and on-call duties. Nearly half of all trainees reported having one or less hours of protected time per week. Nonetheless, 40% of respondents indicated they had enough time to pursue outside interests. Radiation treatment planning and maintaining currency in general medicine were considered the most difficult aspects of training in radiation oncology. Most respondents were keen on the concept of fostering a research mentor. In terms of views on practice after completion of training, the majority were interested in pursuing a fellowship, and nearly all expressed an interest in maintaining an element of academic practice. The large majority of respondents preferred to work in an urban department as a component of their practice after training and nearly all wanted a component of public sector practice. There were only four per cent who preferred to work only within the private sector. Job availability was a concern for 94% of trainees, which far outweighed any other concerns. CONCLUSIONS: Trainees in radiation oncology are generally satisfied with their choice of specialty and their training. Most trainees are interested in fellowship positions, links with academia and largely public sector work in the future. Job availability for the future is their major concern.

Do peripheral blood cultures taken in the emergency department influence clinical management?

BACKGROUND: Blood cultures are routinely used to investigate suspected sepsis in the emergency department despite several studies showing their limited influence on patient management. OBJECTIVES: To quantify the use and clinical relevance of blood cultures obtained in the emergency department. METHODS: A retrospective study of blood cultures taken in the emergency department between 1 January 2003 and 31 December 2004. Microbiology results and patients' records were reviewed to determine the influence of positive cultures on subsequent patient management. RESULTS: 2213 blood cultures were taken in the emergency department over the study period. 132 (6%) yielded a positive result. Three positive cultures had incomplete information. Of the remaining 129 positive cultures, 30 (1.4% of all cultures) were "true positives" and 4 (0.18%) influenced subsequent patient management. CONCLUSIONS: Blood cultures taken in our emergency department (Southern General Hospital, Glasgow, UK) rarely yield bacterial growth, and over 2 years only four cultures seemed to directly influence patient management. Better guidelines are required for targeted use of blood cultures in the emergency department.

Do peripheral blood cultures taken in the emergency department influence clinical management?

BACKGROUND: Blood cultures are routinely used to investigate suspected sepsis in the emergency department despite several studies demonstrating their limited influence on patient management. OBJECTIVES: To quantify the use and clinical relevance of blood cultures obtained in the emergency department. METHODS: A retrospective study of blood cultures taken in the emergency department between 1 January 2003 and 31 December 2004. Microbiology results and patient records were reviewed to determine the influence of positive cultures on subsequent patient management. RESULTS: 2213 blood cultures were taken in the emergency department over the study period. 132 (6%) yielded a positive result. Three positive cultures cases had incomplete information. Of the remaining 129 positive cultures, 30 (1.4% of all cultures) were "true positives" and 4 (0.18%) influenced subsequent patient management. CONCLUSIONS: Blood cultures taken in our emergency department rarely yield bacterial growth and over 2 years, only four seemed to directly influence patient management. Better guidelines are required for targeted use of blood cultures in the emergency department.

Mortality after trauma intubation without drugs in Scottish emergency departments.

BACKGROUND: Trauma patients who are intubated without anaesthetic drugs in the pre-hospital phase of care have universally poor outcomes. This study aimed to determine the mortality of trauma patients intubated without drugs in emergency departments in Scotland. METHODS: This retrospective cohort study used the prospective Scottish Trauma Audit Group (STAG) database to identify how many patients were intubated and how many required drugs for intubation between 1 January 1999 and 31 December 2002. The mortality of those intubated with drugs and without drugs was determined from the database. RESULTS: 24,756 patients were included in the STAG database. There were 1469 intubations: 1287 with drugs and 182 without drugs. 92.5% of all intubations were for blunt trauma. There was no difference in the proportion of males or median age between groups. Median GCS was 8 (E1M5V2) in the drugs group and 3 (E1M1V1) in the no drugs group (p<0.001). Median ISS was higher in those intubated without drugs (33 versus 25, p<0.001). Median RTS and probability of survival were lower in those intubated without drugs (both p<0.001). Mortality was higher in those intubated without drugs (91.2% versus 29.4%, p<0.001). Sixteen patients, intubated without drugs, survived. These patients had a higher median respiratory rate (9 versus 0, p=0.013) and higher median systolic blood pressure (80 mmHg versus 0 mmHg, p=0.041) than non-survivors. CONCLUSION: Trauma patients in Scottish emergency departments who are intubated without drugs have high mortality rates. Outcomes are not universally fatal and aggressive resuscitation efforts may be of benefit to a small number of such patients.

Paracetamol and salicylate testing: routinely required for all overdose patients?

OBJECTIVES: To determine whether it is necessary to routinely measure serum salicylate levels in addition to serum paracetamol levels in alert overdose patients who deny ingestion of that substance. METHODS: Prospective observational study of overdose patients attending an urban emergency department. RESULTS: A total of 171 patients attended with an alleged overdose. Thirty-seven patients were excluded; 24 patients had a reduced conscious level (Glasgow Coma Scale <15), nine patients could not recall the time of overdose and four patients had a staggered overdose. In all, 47.0% (63/134) claimed to have taken paracetamol and 5.2% (7/134) claimed to have taken salicylate. No patient who denied taking paracetamol or salicylate subsequently tested positive for them. In all, 51.5% (69/134) of patients reported that they had taken alcohol at the time of their overdose. CONCLUSION: Given the relatively low clinical risk and evident symptoms and signs from salicylate overdose, routine testing may not be required for fully conscious asymptomatic patients who deny taking it. The risks of delayed toxicity and lack of initial symptoms in those ingesting paracetamol suggests that continued routine testing is necessary.

Is spinal immobilisation necessary for all patients sustaining isolated penetrating trauma?

INTRODUCTION: Previous work suggests that patients with isolated penetrating trauma rarely require spinal immobilisation. This study aimed to identify the incidence of mechanically unstable, or potentially mechanically unstable, spinal column injuries in penetrating trauma patients. The study also aimed to identify the incidence of spinal cord injury as a result of penetrating trauma in Scotland. DESIGN: Retrospective analysis of prospectively collected data from the Scottish Trauma Audit Group (STAG). METHODS: Study patients were identified from the period 1992-1999. Patients coded for both penetrating trauma and spinal column or spinal cord injury were included. Case records, theatre notes and post mortem information were also examined. RESULTS: 34903 patients were available for study. Twenty-seven patients were coded as having had penetrating trauma and concurrent spinal injury. 15 were excluded as they also had a major blunt mechanism of injury or had no actual injury to the spinal cord or column. In the remaining 12 patients, four cervical, one combined cervical and thoracic and seven thoracic spinal cord injuries were identified. 11 were male and 11 were assaulted. One assault was due to a gunshot wound; 10 resulted from sharp weapons. Four complete cord transections and nine partial cord lesions were identified. All 12 patients with spinal cord injury associated with isolated penetrating trauma either had obvious clinical evidence of a spinal cord injury on initial assessment or were in traumatic cardiac arrest. All had spinal immobilisation. CONCLUSION: Fully conscious patients (GCS=15) with isolated penetrating trauma and no neurological deficit do not require spinal immobilisation.

Blunt cervical spine injuries in Scotland 1995-2000.

BACKGROUND: In the Accident and Emergency Department, the management of patients who have sustained head injuries (HI) is often made more complicated by the suspicion of a cervical spine injury (CSI). This study aimed to evaluate the incidence of CSI in patients sustaining blunt head injuries in a Scottish population. METHODS: Retrospective analysis of prospectively collected data for a 5-year period from the Scottish Trauma Audit Group (STAG) database. Logistic regression and other comparisons were used to investigate the relationship between Glasgow coma score/scale (GCS) and the incidence of CSI. RESULTS: A total of 5154 patients met the criteria for the study and 273 of the HI patients had associated CSI giving an overall incidence of 5.3%. Patients presenting with GCS of 3 were almost three times more likely to have a CSI compared to patients with an initial GCS of 4 or more (12.5% versus 4.4%, chi(2)=62.9, d.f.=1, P<0.001). When patients with GCS of 3 were excluded, there was no evidence of an increase in the incidence of CSI with a lower GCS (logistic regression chi(2)=0.09, d.f.=1, P=0.75). CONCLUSION: The risk of CSI in patients with blunt head trauma and an admission GCS of > or =4 does not decrease as GCS increases. Patients with blunt head injuries who present with a GCS of 3 are much more likely to have a concomitant CSI. The overall incidence of 5.3% compares with published series from other countries.

Effect of patients' age on management of acute intracranial haematoma: prospective national study.

OBJECTIVE: To determine whether the management of head injuries differs between patients aged > or =65 years and those <65. DESIGN: Prospective observational national study over four years. SETTING: 25 Scottish hospitals that admit trauma patients. PARTICIPANTS: 527 trauma patients with extradural or acute subdural haematomas. MAIN OUTCOME MEASURES: Time to cranial computed tomography in the first hospital attended, rates of transfer to neurosurgical care, rates of neurosurgical intervention, length of time to operation, and mortality in inpatients in the three months after admission. RESULTS: Patients aged > or =65 years had lower survival rates than patients <65 years. Rates were 15/18 (83%) v 165/167 (99%) for extradural haematoma (P=0.007) and 61/93 (66%) v 229/249 (92%) for acute subdural haematoma (P<0.001). Older patients were less likely to be transferred to specialist neurosurgical care (10 (56%) v 142 (85%) for extradural haematoma (P=0.005) and 56 (60%) v 192 (77%) for subdural haematoma (P=0.004)). There was no significant difference between age groups in the incidence of neurosurgical interventions in patients who were transferred. Logistic regression analysis showed that age had a significant independent effect on transfer and on survival. Older patients had higher rates of coexisting medical conditions than younger patients, but when severity of injury, initial physiological status at presentation, or previous health were controlled for in a log linear analysis, transfer rates were still lower in older patients than in younger patients (P<0.001). CONCLUSIONS: Compared with those aged under 65 years, people aged 65 and over have a worse prognosis after head injury complicated by intracranial haematoma. The decision to transfer such patients to neurosurgical care seems to be biased against older patients.