A major trauma centre is a specialty hospital not a hospital of specialties.

BACKGROUND: High estimates of preventable death rates have renewed the impetus for national regionalization of trauma care. Institution of a specialist multidisciplinary trauma service and performance improvement programme was hypothesized to have resulted in improved outcomes for severely injured patients. METHODS: This was a comparative analysis of data from the Royal London Hospital (RLH) trauma registry and Trauma Audit and Research Network (England and Wales), 2000-2005. Preventable mortality was evaluated by prospective analysis of the RLH performance improvement programme. RESULTS: Mortality from critical injury at the RLH was 48 per cent lower in 2005 than 2000 (17.9 versus 34.2 per cent; P = 0.001). Overall mortality rates were unchanged for acute hospitals (4.3 versus 4.4 per cent) and other multispecialty hospitals (8.7 versus 7.3 per cent). Secondary transfer mortality in critically injured patients was 53 per cent lower in the regional network than the national average (5.2 versus 11.0 per cent; P = 0.001). Preventable death rates fell from 9 to 2 per cent (P = 0.040) and significant gains were made in critical care and ward bed utilization. CONCLUSION: Institution of a specialist trauma service and performance improvement programme was associated with significant improvements in outcomes that exceeded national variations.

The management of penetrating injuries of the anterior triangle of the neck.

The management of penetrating injuries of the anterior triangle of the neck is controversial and poses several problems. A policy of mandatory neck exploration of these injuries is followed in the Department of General Surgery at the State Hospital, Windhoek. A retrospective study of patients presenting to one of the four surgical firms at The State Hospital was performed to see if this policy was justified. Twenty-seven patients were reviewed of which 25 presented acutely and two presented late with severe complications. The clinical and operative findings and the mortality rate of 7 per cent were similar to previous reports. The negative exploration of 30 per cent was less than previous reports of mandatory neck exploration for penetrating trauma. This may have been because exploration was limited to injuries involving the anterior triangle of the neck in this series. All 14 patients with positive clinical findings were found to have injuries at exploration and five of 13 patients (38 per cent) with no clinical signs were found to have injuries. Given these results and in the setting of The State Hospital it was felt that the policy of mandatory exploration was justified.

Necrotizing fasciitis: 10 years' experience in a district general hospital.

Of 14 patients with necrotizing fasciitis who presented between 1979 and 1988, six (43 per cent) died. The deaths were associated with delays in diagnosis, poor surgical technique and diabetes. Prompt diagnosis, resuscitation and early radical surgery are essential to the successful management of necrotizing fasciitis.