Risks/Outcomes/Predictors
Mortality reduction after implementing a clinical practice guidelines–based management protocol for severe traumatic brain injury

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Abstract

Introduction

The objective of this study was to examine the effect of implementing a clinical practice guidelines–based management protocol on the outcome of patients with severe traumatic brain injury (TBI).

Methods

We carried out a pre-post guideline implementation study using previously collected data in the Intensive Care Unit (ICU). All patients older than 12 years with severe TBI, defined as a Glasgow Coma Scale score of 8 or less, from March 1999 to January 2001 (control group) and from February 2001 to December 2006 (protocol group) were identified and included in this study. Patients in the protocol group were managed using a clinical practice guidelines–based management protocol, derived from the guidelines published by the Brain Trauma Foundation. Primary outcome was hospital mortality, whereas the secondary outcome was ICU mortality. To assess whether the ICU protocol might have led to an increase in the number of surviving patients with severe disability, we examined the association of the protocol use and the need for tracheostomies, mechanical ventilation duration, and ICU and hospital length of stay (LOS) among survivors.

Results

During the study period, a total of 434 patients met the inclusion criteria. After adjustment for several prognostic factors, the use of protocol was independently associated with a significant reduction in hospital and ICU mortality (odds ratio, 0.45; 95% confidence interval, 0.24-0.86; and odds ratio, 0.47; 95% confidence interval, 0.23-0.96, respectively). The use of the protocol was not associated with an increase in the need for tracheostomies, mechanical ventilation duration, ICU LOS, and hospital LOS.

Conclusion

The protocol implementation was associated with a reduction in hospital and ICU mortality. This improvement was not associated with an increase in the frequency of tracheostomies and in ICU or hospital LOS, suggesting that the improved survival was not associated with the increased number of surviving patients with severe disability and that the functional status might have also improved.

Introduction

Traumatic brain injury (TBI) is an important public health problem and is the leading cause of mortality, morbidity, and disabilities in children and young adults [1], especially in young males (15-35 years old). Among trauma victims, TBI remains the most common cause of death and disability [2].

In the United States, approximately 95 per 100 000 inhabitants sustain a fatal or severe enough injury to require hospital admission every year [3], leading to approximately 60 000 to 75 000 deaths [4], [5], [6] and an estimated 70 000 to 90 000 patients with permanent neurologic disabilities [7], [8], [9]. In Europe, 14 to 30 per 100 000 of the population die of TBI, accounting for 2% of overall mortality and 35% to 42% of deaths in people between 15 and 25 years of age [10].

In Saudi Arabia, the incidence of TBI is high [11], [12], with an extrapolated incidence rate of 116 per 100 000 population. There, TBI is associated with higher severity and fatality compared with Western countries because of higher driving speed and variable prehospital emergency care. One of the striking epidemiologic features is the high male-female ratio, reaching [13] 13:1 and reflecting the local driving regulations that restricts driving to males.

Various studies showed considerable variation in the care of patients with severe TBI [14], [15], [16]. To improve and standardize neurocritical care management, the Brain Trauma Foundation (BTF) has developed evidence-based guidelines [17], [18], [19].

Few studies have reported the impact of implementation of these guidelines on patients' treatment and outcome [20]. The purpose of this study was to examine the effect of the implementation of a clinical practice guidelines–based management protocol on the mortality of patients with severe TBI. To assess whether the Intensive Care Unit (ICU) protocol led to an increase in the number of surviving patients with severe disability, we examined whether the protocol increased the need for tracheostomies or led to prolongation of the duration of mechanical ventilation and ICU and hospital length of stay (LOS).

Section snippets

Study design

We carried out a retrospective analysis of prospectively collected information, stored in an electronic database. The ICU database included data on all ICU patients and was collected by a full-time data collector. The study was approved by the institutional review board.

Setting

This study was conducted in a 21-bed, tertiary care medical-surgical ICU in an 800-bed teaching hospital trauma center in Riyadh, Saudi Arabia. The ICU, which admits more than a thousand patients per year, is run as a closed

Baseline characteristics

During the study period, a total of 434 patients were included (control group, n = 72 patients; protocol group, n = 362). Patients in the protocol group, compared with patients in the control group, had slightly higher APACHE II scores and lower GCS scores (19.8 ± 5.4 vs 18.4 ± 5.4, P = .06; and 4.9 ± 1.8 vs 5.3 ± 1.9, P = .06; respectively) and were less likely to have ICP monitoring (8.6% and 34.7%, respectively, P < .001) (Table 1).

Hospital mortality

Crude hospital mortality was 27.8% in the control group vs

Discussion

Our study shows that the implementation of a clinical practice guidelines–based management protocol for the management of severe TBI is associated with a significant reduction in ICU and hospital mortality. The use of the protocol was not associated with an increase in the need for tracheostomy or in prolonging the duration of mechanical ventilation, ICU LOS, or hospital LOS among survivors.

It is now clear that only part of the damage to the brain during head trauma occurs at the moment of

Conclusion

The implementation of a clinical practice guidelines–based management protocol in patients with severe TBI was associated with a significant reduction in hospital and ICU mortality without increasing the need for tracheostomy or prolonging the duration of mechanical ventilation and ICU and hospital LOS, suggesting that the improved survival was not associated with the increased number of surviving patients with severe disability and that the functional status might have also improved. We

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