Risks/Outcomes/PredictorsMortality reduction after implementing a clinical practice guidelines–based management protocol for severe traumatic brain injury
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
References (29)
- et al.
Epidemiology of major trauma and trauma deaths in Los Angeles County
J Am Coll Surg
(1998) - et al.
Road traffic accidents in Saudi Arabia
Public Health
(1994) - et al.
Causes and effects of road traffic accidents in Saudi Arabia
Public Health
(2000) Death and disability from injury: a global challenge
J Trauma
(1998)- et al.
Treatment results of patients with multiple trauma: an analysis of 3406 cases treated between 1972 and 1991 at a German level I trauma center
J Trauma
(1995) - et al.
Surveillance for traumatic brain injury deaths—United States, 1989-1998
MMWR Surveill Summ
(2002) - et al.
The epidemiology of traumatic death. A population-based analysis
Arch Surg
(1993) - et al.
Epidemiology of trauma deaths: a reassessment
J Trauma
(1995) - et al.
Incidence of traumatic brain injury in the United States, 2003
J Head Trauma Rehabil
(2006) - et al.
Trends in hospitalization associated with traumatic brain injury
Jama
(1999)
Trends in death associated with traumatic brain injury, 1979 through 1992. Success and failure
JAMA
Severe traumatic brain injury—epidemiology, external causes, prevention, and rehabilitation of mental and physical sequelae
Acta Neurol Scand Suppl
The diagnostic yield and clinical impact of a chest x-ray after percutaneous dilatational tracheostomy: a prospective cohort study
Anaesth Intensive Care
Survey of critical care management of comatose, head-injured patients in the United States
Crit Care Med
Cited by (98)
Is Early Tracheostomy Better for Severe Traumatic Brain Injury? A Meta-Analysis
2018, World NeurosurgeryCitation Excerpt :We identified no benefit of ET on mortality rate in these patients, however. Airway problems represent one of the most important sources of secondary morbidity and mortality in patients with severe TBI, who typically develop respiratory failure requiring intubation and mechanical ventilation.17,18 Tracheostomy is traditionally suggested for patients who cannot be extubated or who require mechanical ventilation for >14 days.19
Facilitators and barriers in the donor family interview process from the perspective of hospital staff: a cross-sectional study
2023, Korean Journal of TransplantationEffect of an early occupational therapy intervention on length of stay in moderate and severe traumatic brain injury patients
2023, Irish Journal of Medical Science