Title : An avoidable delay: Audit of the neurosurgical referral pathway for head injury in Galway University Hospital
Abstract:
Introduction: Head injuries are a common Emergency Department (ED) presentation and may require urgent CT brain imaging and timely specialist neurosurgical input. At Galway University Hospital (GUH), the current adult head injury pathway involves ED assessment, referral to the General Surgical team for repeat review, and subsequent discussion with Beaumont neurosurgery. Most comparator Irish hospitals identified in this audit use direct ED-to-neurosurgery referral, meaning the GUH pathway contains an additional intermediary step.
Aim: To quantify delays at each stage of the GUH neurosurgical referral pathway and assess whether direct ED-to-Beaumont referral for selected isolated head injury patients could streamline care.
Methods: A retrospective chart review was conducted from January 2024 to July 2025. Adult patients presenting with mechanical head injury who underwent CT brain and required neurosurgical referral/discussion through the current GUH pathway were included. Of 193 patients identified, 64 were excluded because of age under 18 years, non-mechanical mechanism, or incomplete data, leaving 129 patients for analysis. Documented time intervals were extracted from ED doctor assessment to CT brain, CT to surgical referral, surgical referral to surgical review, and surgical review to Beaumont discussion. The primary outcome was total time from ED doctor assessment to Beaumont neurosurgical discussion.
Results: Mean time from ED assessment to CT brain was 2 h 40 min, CT to surgical referral 1 h 36 min, surgical referral to surgical review 1 h 36 min, and surgical review to Beaumont discussion 1 h 25 min. The total mean pathway duration was 7 h 17 min. The clearest pathway-dependent delay was the 1 h 36 min wait for surgical review; the combined post-surgical-referral interval was approximately 3 hours. Contributing factors included surgical SHO availability, duplication of assessment, referral documentation, handover gaps, and callback/logistical delays. In several cases, Beaumont referral was initiated using the ED assessment and verbal handover before formal surgical review.
Conclusion: The current GUH pathway is associated with prolonged time to neurosurgical discussion. Direct ED-to-Beaumont referral for selected isolated head injury patients, with surgical input retained for complex trauma or when specifically required, may reduce avoidable delay. Formal pathway revision and prospective re-audit with balancing measures are recommended.
