Proceedings of the British Trauma Society 371

intracranial injury. In all, four patients died from their head injury, only one of whom had a skull fracture.

We conclude that the presence of a fracture on the skull X-ray is not a reliable indication of intracranial injury in children. A policy of admission on clinical grounds with selective CT where indicated would be safe and would avoid unnecessary skull X-rays.

H. R. Williams, P. A. Templeton, R. M. Smith (Leeds, UK) Documentation audit of trauma patients Trauma is the major cause of morbidity and mortality under the age of 35 years in the UK. Reports including the Royal College of Surgeons’ report of the Working Party on ‘The Management of Patients with Major Injuries’ and the UK ‘Multiple Trauma Outcome Study’, depend on accurate and complete docu- mentation. Inadequate records make assessment of severity of injury and quality of care almost impossible and are unacceptable medico-legally.

Before 1992 no hospital in Yorkshire routinely used trauma charts to document injuries. In 1992 trauma documentation was introduced into the Accident and Emergency department of the Leeds General Infirmary. To evaluate the problem we audited the standard of trauma documentation in the Yorkshire region prior to the introduction of trauma charts. We then audited the standard of documentation before and after the introduction of this documentation in the Leeds General Infirmary.

Using the Leeds University School of Public health database of major trauma victims in the Yorkshire region, case notes of 226 patients who had died as a result of major injuries (Injury Severity Score > 15) during the 12 month period I October 1988 to 30 September 1989 were obtained. Using a standard appraisal form, the case notes were inspected for completeness of documentation of respiratory, circulatory and neurological status.

The notes of a second group of 102 patients who died as a result of major injuries over the last year in the Leeds General Infirmary were studied. The group comprised both primary and tertiary referrals to the hospital. The notes included the use of the new trauma documentation and were inspected with regard to the same parameters and compared with the results obtained from the previous group.

The results from 1988-1989 showed that the standard of documentation was poor, only 39.4 per cent being complete. In 1992-1994 the standard of documentation had improved. Without the use of a trauma chart the documentation increased to 90 per cent, but with the use of the trauma chart in primary referrals the result improved to 97 per cent. Within the 1992-1994 set the poorest standard of documentation was within that group of patients who were tertiary referrals without the use of trauma charts. Only 56 per cent of notes were complete in their documentation of the parameters being assessed.

The standard of documentation in major trauma has improved. This has important implications concerning audit, research and medico-legal matters. We therefore recommend that: (1) trauma charts are used routinely for all primary and tertiary referrals of injured patients; (2) tertiary referral patients are reassessed fully after transfer and a new trauma chart is completed.

L. C. Luke, D. A. Ritchie, A. Jone, C. Walker, M. Hartley (Liverpool, UK) The Trauma Forum: how to win friends and conhue to influence people Although the case for better trauma care in the UK has been well described over the past decade and there have been a number of h’ h- fil t lg pro e m erventions such as the Advanced Trauma Life

Support course, the hlajor Trauma Outcome Study, the Trauma Centre experiment in Staffordshire and the development of a British paramedic service, there has been relatively little pub- lished on the lower profile but often effective local responses to injuries in the UK. In this article, we describe the evolution of the Trauma Forum, a multidisciplinary monthly meeting at the Royal Liverpool University Hospital, which was established in 1993 and has been widely acknowledged as a pivotal factor in the improvement of the hospital’s overall response to the victims of injuries. The audience has exceeded 1000 over 24 months, with an average consultant attendance of over 20 per meeting, and the number of disciplies involved has increased steadily until the present time. This is in contrast to many other similar institutions throughout the UK where trauma audits have failed due to apathy. We describe the gradual development and restructuring of the meeting in response to audience surveys and the current educational climate and examine our successes and failures and the many difficulties encountered in sustaining widespread interest in trauma audits.

M. Hobbs, R. Mayou, P. Warlock (Oxford, UK) A randomized controlled trial of psychological debriefing for victims of road frafic

accidents Psychiatric problems-are common and disabling after major or minor road traffic accidents (RTAs). One-fifth of victims develop an acute stress reaction, and one-quarter display significant psychiatric problems within the first year. Psychiatric problems may obstruct recovery from the physical injuries sustained.

Awareness of post-accident psychiatric morbidity has stim- ulated interest in preventative psychological interventions, especially routine psychological debriefing. Although widely advocated after many types of injuries, debriefing has not been shown to be effective in preventing post-injury sympto- matology. No randomized controlled trials have yet been published, and the few studies which include comparison groups have shown variable responses to debriefing.

This prospective study aimed at testing whether a single, clincially feasible debriefing intervention, based on widely accepted principles, could reduce post-traumatic psychopath- ology in the injured victims of RTAs.

Consecutive patients admitted to a trauma centre following injury in RTAs were allocated randomly to the intervention or the non-intervention control groups. Patients in the experimen- tal group were offered a single debriefing intervention which combined a review of the traumatic experience, encouragement of emotional expression, and the promotion of early cognitive processing. In addition advice was given, both verbally and in a leaflet, about common post-traumatic psychological reactions and the value of talking to others about the experience, and advising early return to normal road travel. Experimental and control groups were followed up at 4 months.

One hundred and fourteen subjects entered the study, 59 in the intervention group and 55 controls. The intervention group displayed higher mean Injury Severity Scores (ISS) and mean duration of hospital stay, but no significant difference was found between the two groups at entry to the study in levels of psychiatric symptoms. Significantly fewer of the intervention group responded to follow-up than did patients in the control group.

Serious methodological problems were encountered, not least because investigations, surgical interventions and rapid dis- charge from hospital made it difficult to interview some patients and necessitated an earlier psychological intervention in others than was clinically desirable, within 24 to 48 h in most cases.

At follow up, there was evidence of persisting psychiatric skmptoms in both experimental and control groups. There were