Compliance With Evidence-Based Guidelines and Interhospital Variation in Mortality for Patients With Severe Traumatic Brain Injury.

IMPORTANCE: Compliance with evidence-based guidelines in traumatic brain injury (TBI) has been proposed as a marker of hospital quality. However, the association between hospital-level compliance rates and risk-adjusted clinical outcomes for patients with TBI remains poorly understood. OBJECTIVE: To examine whether hospital-level compliance with the Brain Trauma Foundation guidelines for intracranial pressure monitoring and craniotomy is associated with risk-adjusted mortality rates for patients with severe TBI. DESIGN, SETTING, AND PARTICIPANTS: All adult patients (N = 734) who presented to a regional consortium of 14 hospitals from January 1, 2009, through December 31, 2010, with severe TBI (ie, blunt head trauma, Glasgow Coma Scale score of <9, and abnormal intracranial findings from computed tomography of the head). Data analysis took place from December 2013 through January 2015. We used hierarchical mixed-effects models to assess the association between hospital-level compliance with Brain Trauma Foundation guidelines and mortality rates after adjusting for patient-level demographics, severity of trauma (eg, mechanism of injury and Injury Severity Score), and TBI-specific variables (eg, cranial nerve reflexes and findings from computed tomography of the head). MAIN OUTCOMES AND MEASURES: Hospital-level risk-adjusted inpatient mortality rate and hospital-level compliance with Brain Trauma Foundation guidelines for intracranial pressure monitoring and craniotomy. RESULTS: Unadjusted mortality rates varied by site from 20.0% to 50.0% (median, 42.6; interquartile range, 35.5-46.2); risk-adjusted rates varied from 24.3% to 56.7% (median, 41.1; interquartile range, 36.4-47.8). Overall, only 338 of 734 patients (46.1%) with an appropriate indication underwent placement of an intracranial pressure monitor and only 134 of 335 (45.6%) underwent craniotomy. Hospital-level compliance ranged from 9.6% to 65.2% for intracranial pressure monitoring and 6.7% to 76.2% for craniotomy. Despite widespread variation in compliance across hospitals, we found no association between hospital-level compliance rates and risk-adjusted patient outcomes (Spearman ρ = 0.030 [P = .92] for ICP monitoring and Spearman ρ = -0.066 [P = .83] for craniotomy). CONCLUSIONS AND RELEVANCE: Hospital-level compliance with evidence-based guidelines has minimal association with risk-adjusted outcomes in patients with severe TBI. Our results suggest that caution should be taken before using compliance with these measures as independent quality metrics. Given the complexity of TBI care, outcomes-based metrics, including functional recovery, may be more accurate than current process measures at determining hospital quality.

Intracranial pressure monitoring and inpatient mortality in severe traumatic brain injury: A propensity score-matched analysis.

BACKGROUND: Although intracranial pressure (ICP) monitoring in severe traumatic brain injury (TBI) is recommended by the Brain Trauma Foundation, the benefits remain controversial. We sought to determine the impact of ICP monitor placement on inpatient mortality within a regional trauma system after correcting for selection bias through propensity score matching. METHODS: Data were collected on all severe TBI cases presenting to 14 trauma centers during the 2-year study period (2009-2010). Inclusion criteria were as follows: blunt injury, Glasgow Coma Scale (GCS) score of 8 or lower in the emergency department, and abnormal intracranial findings on head computed tomography (CT). Two separate multivariate logistic regression models were used to predict ICP monitor placement and inpatient mortality after controlling for demographics, severity of injury, comorbidities, and TBI-specific variables (GCS score, pupil reactivity, international normalized ratio, and nine specific head CT findings). To account for selection bias, we developed a propensity score-matched model to estimate the "true" effect of ICP monitoring on in-hospital mortality. RESULT: A total of 844 patients met inclusion criteria; 22 died on arrival to the emergency department. Inpatient mortality was 38.8%; 46.0% of the patients underwent ICP monitor placement. Unadjusted mortality rates were significantly lower in the ICP monitoring group (30.7% vs. 45.7%, p < 0.001). ICP monitor placement was positively associated with CT findings of subdural hematoma, intraparenchymal contusion, and mass effect and negatively associated with age, alcoholism, and elevated international normalized ratio. After adjusting for selection bias via propensity score matching, ICP monitor placement was associated with an 8.3 percentage point reduction in the risk-adjusted mortality rate. CONCLUSION: ICP monitor placement occurred in only 46% of eligible patients but was associated with significantly decreased mortality after adjusting for baseline risk profile and the propensity to undergo monitoring. As the individual impact of ICP monitoring may vary, future efforts must determine who stands to benefit from invasive monitoring techniques. LEVEL OF EVIDENCE: Therapeutic/care management study, level III.

Decompressive craniectomy: surgical control of traumatic intracranial hypertension may improve outcome.

INTRODUCTION: The purpose of this study was to assess the role of decompressive craniectomy (DC) inpatients with post-traumatic intractable intracranial hypertension (ICH) in the absence of an evacuable intracerebral haemorrhage. METHODS: Retrospective study at LAC+USC Medical Centre including patients who underwent DC for post-traumatic malignant brain swelling or ICH without space occupying haemorrhage, during the period 01/2004 to 12/2008. The analysis included the effect of DC on intracranial pressure (ICP) and timing of DC on functional outcomes and survival. RESULTS: Of 106 patients who underwent DC, 43 patients met inclusion criteria. Of those, 34 were operated within the first 24 h from admission. DC decreased the ICP significantly from 37.8 ± 12.1 mmHg to 12.7 ± 8.2 mmHg in survivors and from 52.8 ± 13.0 to 32.0 ± 17.3 mmHg in non-survivors. Overall 25.6%died (11 of 43), and 32.5% (14 of 43) remained in vegetative state or were severely disabled. Favourable outcome (Glasgow Outcome Scale 4 and 5) was observed in 41.9% (18 of 43). No tendency towards either increased or decreased incidence in favourable outcome was found relative to the time from admission to DC.Six of the 18 patients (33.3%) with favourable outcome were operated on within the first 6 h. CONCLUSIONS: DC lowers ICP and raises CPP to high normal levels in survivors compared to non-survivors.The timing of DC showed no clear trend, for either good neurological outcome or death. Overall, the survival rate of 74.4% is promising and 41.9% had favourable neurological outcome.

Hemodynamic and oxygen transport patterns after head trauma and brain death: implications for management of the organ donor.

OBJECTIVES: The aims of the present study were to describe the temporal hemodynamic and oxygen transport patterns of patients with head injuries as well as the patterns of those who became brain dead to better understand the role of underlying central regulatory hemodynamic mechanisms and ultimately to improve rates of organ donation. METHODS: We studied 388 consecutive noninvasively monitored patients with severe head trauma; 79 of these became brain dead. Monitoring was started shortly after admission to the emergency department and was designed to describe the sequence of cardiac, pulmonary, and tissue perfusion functions by cardiac index (CI), mean arterial pressure, heart rate, arterial saturation by pulse oximetry (Sapo2), and transcutaneous oxygen and carbon dioxide (Ptco2/Fio2 and Ptcco2) patterns. The latter were used as markers of tissue perfusion or oxygenation. RESULTS: Patients with head injuries who subsequently became brain dead initially had low CI with poor tissue perfusion beginning shortly after emergency department admission. This was followed by a prolonged period characterized by high CI (4.43 +/- 1.3 L x min(-1) x m2) and enhanced tissue oxygenation (Ptco2/Fio2 238 +/- 186). In the late or end stage of brain death, hemodynamic deterioration and collapse led rapidly to arrest. In attempts to maintain hemodynamic stability for organ donation, the effects of various therapies on the hemodynamic patterns were preliminarily described. CONCLUSIONS: The hyperdynamic state with exaggerated peripheral tissue perfusion or oxygenation in brain-dead patients associated with loss of central vasoconstrictive mechanisms of the stress response resulted in unopposed peripheral metabolic vasodilatation producing high CI and tissue perfusion.

Survival, hemodynamics, and tissue oxygenation after head trauma.

BACKGROUND: The aims of this study were to describe the early time course of hemodynamic and tissue perfusion and oxygenation patterns in survivors and nonsurvivors after head injury; to suggest physiologic mechanisms responsible for the observed patterns; and to evaluate postinjury parameters that might be useful for treatment. The hypothesis was that reduced hemodynamics and tissue oxygenation and reduced arterial oxygen saturation affect outcomes. STUDY DESIGN: Sixty patients with head trauma were noninvasively monitored on arrival in the emergency department to assess the temporal hemodynamic patterns associated with head injury; patients who were brain dead were excluded because they have very different hemodynamic patterns. Cardiac index, mean arterial pressure, and heart rate were monitored to assess cardiac function, pulse oximetry to reflect changes in pulmonary function, and transcutaneous oxygen and carbon dioxide to reflect tissue perfusion function. Patients were stratified by inhospital survival outcomes, the Glasgow Coma Scale, and the presence or absence of associated somatic injuries. RESULTS: When all head injured patients were considered together, the predominant findings were high cardiac index, hypertension, mild tachycardia, normal pulmonary function, and reduced tissue oxygenation. The subset of survivors and those with high Glasgow Coma Scale had greater than normal cardiac index responses (4.02 +/- 0.01 (SEM) L/min/m2, p < 0.01 versus normal) and better tissue oxygenation (217 +/- 2 mmHg PtcO2/FiO2) than nonsurvivors (70 +/- 3 mmHg, p < 0.01) and those with low Glasgow Coma Scale (160 +/- 2, p < 0.05). Patterns of patients with associated somatic injuries were similar to those with isolated head injury. CONCLUSIONS: The study suggested that survivors' cardiac index, tissue oxygenation, and arterial oxygen saturation may be considered as markers of resuscitation. Nonsurvivors of head injury had normal blood flow with reduced tissue oxygenation that might have contributed to unfavorable outcomes.

Minimally invasive lateral mass screws in the treatment of cervical facet dislocations: technical note.

OBJECTIVE: The technique of lateral mass screw and rod or plate fixation is a major advancement in the posterior instrumentation of the cervical spine. This technique provides rigid three-dimensional fixation, restores the dorsal tension band, and provides highly effective stabilization in patients with many types of traumatic injuries. METHODS: Patient 1 was a 32-year-old man who had been in a motor vehicle accident. He presented with right C5 radiculopathy. X-ray findings included 45% anterolisthesis of C4 on C5, bilateral facet disruption, and right unilateral C4-C5 facet fracture and dislocation. The patient was placed in Gardner-Wells tongs, and the fracture was reduced with 25 pounds of traction. Patient 2 was a 56-year-old woman who had been in a motor vehicle accident that resulted in complete quadriplegia. Her initial imaging studies revealed a C3-C4 right unilateral facet fracture with subluxation. She was placed in traction, and her neurological status was reassessed. The findings of her neurological examination revealed improvement: she was found to have Brown-Séquard syndrome. Patient 3 was a 33-year-old man who was involved in a diving accident that resulted in bilaterally jumped facets at C3-C4. The patient was neurologically intact, and attempts at closed reduction were not successful. RESULTS: Patients 1 and 2 underwent anterior cervical discectomy with iliac crest autograft fusion and plating. They were then placed in the prone position, and a dilator tubular retractor system was used to access the facet joint at the level of interest. The facet joints were then denuded and packed with autograft. Lateral mass screws were then placed by means of the Magerl technique, and a rod was used to connect the top-loading screws. Patient 3 underwent posterior surgery that included only removal of the superior facet, intraoperative reduction, and bilateral lateral mass screw and rod placement. CONCLUSION: This technical note describes the successful placement of lateral mass screw and rod constructs with the use of a minimally invasive approach by means of a tubular dilator retractor system. This approach preserves the integrity of the muscles and ligaments that maintain the posterior tension band of the cervical spine.

Brain death documentation: analysis and issues.

OBJECTIVE: Specific guidelines for documenting the complete loss of brain function, for the declaration of brain death, have been established for 3 decades. This study assessed the quality and completeness of brain death notes and the effects of delays between notes on organ procurement. METHODS: A retrospective review of brain death declarations at a major medical center was performed. Fifty-eight cases, with a total of 121 brain death notes, were identified in a 12-month period. Notes were assessed for clinical and confirmatory tests of brain and brainstem function. Adverse physiological events that occurred in the time intervals between notes were also identified. RESULTS: The clinical tests most likely to be documented were tests of pupillary (86%) and gag (78%) reflexes. Corneal reflexes were tested in only 57% of cases, and motor responses were noted in only 66%. Documentation by the neurosurgery department was generally more complete. The delays between brain death declarations were highly variable but did not result in any loss of donor organs because of hemodynamic derangements. CONCLUSION: To meet the needs of organ recipients and donor families and to comply with hospital, legal, and legislative mandates, hospitals may need to increase quality assurance activities with respect to declarations of brain death. Increased physician education should improve awareness of uniform brain death declaration guidelines.