Background: Case fatality rates after all types of blunt injury have not improved since 1994 in England and Wales, possibly because not all patients with severe head injury are treated in a neurosurgical centre. Our aims were to investigate the case fatality trends in major trauma patients with and without head injury, and to establish the effect of neurosurgical care on mortality after severe head injury. Methods: We analysed prospectively collected data from the Trauma Audit and Research Network database for patients presenting between 1989 and 2003. Mortality and odds of death adjust ed for case mix were compared for patients with and without head injury, and for those treated in a neurosurgical versus a non-neurosurgical centre. Findings: Patients with head injury (n=22 216) had a ten-fold higher mortality and showed less improvement in the adjusted odds of death since 1989 than did patients wit hout head injury (n=154 231). 2305 (33%) of patients with severe head injury (p resenting between 1996 and 2003) were treated only in non-neurosurgical centres ; such treatment was associated with a 26%increase in mortality and a 2.15-fol d increase (95%CI 1.77-2.60) in the odds of death adjusted for case mix compar ed with patients treated at a neurosurgical centre. Interpretation: Since 1989 t rauma system changes in England and Wales have delivered greater benefit to pati ents without head injury. Our data lend support to current guidelines, suggestin g that treatment in a neurosurgical centre represents an important strategy in the management of severe head injury.
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