D. Gupta, D. Sharma, N. Kannan, S. Prapruettham, C. Mock, J. Wang, et al. Guideline adherence and outcomes in severe adult traumatic brain injury for the
CHIRAG (Collaborative Head InjuRy and Guidelines) study. World Neurosurg. 2016.
The increase in number of traumatic brain injury (TBI) has been astounding in recent
times mostly attributed to road traffic accidents.[1]
[2] According to the global burden of disease study 2013, deaths from injury worldwide
increased by 10•7% from 4.3 million deaths in 1990 to 4.8 million in 2013.[3] Ultimately, it increases the socioeconomic burden in a nation.[1]
[2] To improve the outcome from TBI in 2007 brain trauma foundation[4] had formulated guidelines, but in true sense, the implementation and adherence to
the guidelines is always a key to improved outcome following TBI. No study till date
has assessed the rates of adherence and the impact of adherence on outcome following
TBI. The authors conducted this bi-institutional Indo-US collaborative project to
investigate Intensive Care Unit (ICU) TBI guideline adherence rates and to analyse
the relationship between ICU guideline adherence and in-patient mortality outcomes,
and long-term outcomes as well in severe adult TBI at tertiary level institutions
in India (Jai Prakash Narayan Apex Trauma Center [JPNATC], New Delhi, India), and
the United States (Harborview Medical Center [HMC], Seattle, WA, USA). The authors
hypothesise stern ICU guideline adherence would be associated with lower in-patient
mortality after severe TBI. The study design used was a retrospective analysis from
2009 to 2011 at HMC, whereas it was a prospective analysis from 2012 to 2014 at JPNATC.
They included participants older than 18 years with a diagnosis of severe TBI characterised
by an abbreviated injury severity of >3, post-resuscitation Glasgow Coma Scale <8,
alive with tracheal tube >48 h since admission, history of trauma and abnormal computed
tomography of head. Authors excluded patients who died within 48 h of admission as
per their belief that a minimum of 48 h of window is the necessary period for the
patients to be acquainted with adherence to guidelines so as to investigate its associated
outcome. Seventeen ICU clinical indicators were created to represent measures of adherence,
and the adherence rate were calculated for each patient by simply adding up the number
of indicators to which care was adherent divided by the sum of number of applicable
indicators for that patient. The mean adherence rates for patients were calculated
for first 72 h. Patient outcome was in-hospital mortality and also the post-discharge
Glasgow Outcome Scale (GOS) at 3, 6 and 12 months. The authors declared that this
study was not a comparison of the data between the two sites rather a representation
of the practices followed in the two sites.
The study showed the overall ICU adherence rate was 74.9% (standard deviation [SD]
11.0) at JPNATC. According to the study results, the following indicators had adherence
rates >90%: Achieving target temperature, not using prophylactic barbiturates, timely
start of nutritional support and avoidance of intravenous steroids. Intracranial pressure
(ICP) monitors were placed in 63% of patients, 52% of patients with intracranial hypertension
received some sort of ICP reduction strategy and among patients with ICP monitoring,
94% of patients had all cerebral perfusion pressures 50–70 mmHg. Ninety-nine percent
of patients received prophylactic antiepileptic medications. At HMC, the overall ICU
adherence rate was 71.6% (SD 10.4) and the following indicators had adherence rates
>90%: Achieving target temperature, not using prophylactic barbiturates, timely start
of nutritional support and avoidance of intravenous steroids. ICP monitors were placed
in 84% of patients and 98% of patients with intracranial hypertension received some
form of ICP reduction treatment. Among patients with ICP monitoring, 63% of patients
had all cerebral perfusion pressures 50–70 mmHg. Forty-two percent of patients received
prophylactic antiepileptic medications. At JPNATC, a rise in adherence rate by 1%
was associated with 3% lower in-patient mortality whereas an adherence rate <65% was
associated with nearly twice higher in-patient mortality. However, at HMC, there was
no significant association between adherence rate and in-patient mortality. In the
post-discharge period the mortality and functional status were assessed at both the
centres. At JPNATC, the number of deaths increased from 24% at discharge to 29% at
3 months, to 34% at 6 months and to 36% at 12 months. In HMC, there was only one new
known death among post-discharge patients. While investigating the functional status
in both centres, it was found out that, at discharge 8% of JPNATC and 21% of HMC patients
returned to baseline functional status. Hence to summarise, the main findings in this
Indo-US joint study early ICU guideline adherence was associated with lower in-patient
mortality, >65% adherence resulted in reduction in the in-patient mortality by 2 times
and even though 60% of patients shown improved functional status from discharge to
12 months post-discharge deaths and deterioration of GOS occurred at home. In this
study, authors found out that adherence to the guidelines improve discharge outcomes
at JPNATC but did not find any correlation at HMC. The authors described this discrepancy
in the two sites citing the more precise and real time data collection at JPNATC,
a Hawthorne effect at JPNATC, the very inclusion of patients itself is different at
these two sites (only TBI at JPNATC, whereas polytrauma patients at HMC). The Guideline
adherence may be important, but the importance of it is much more in low and middle
income countries like India. A recent study in ICP monitoring in severe TBI raised
questions regarding the generalisability of findings of US to Latin American countries.[5] The concept of early rehabilitation post-discharge is important. In this particular
study at JPNATC, there was not strong emphasis on rehabilitation whether in-patient
or any skilled nursing facility. Gupta and Taly[6] reported improvements in disability rating sale among 44 Indian patients with severe
TBI who initiated rehabilitation services 3 months post-TBI for 1 month. Furthermore,
Agrawal and Joshi[7] recently reported continued improvement to 6 months post-TBI among 58 TBI patients
who were followed to 12 months, and Sinha et al.
[8] reported 58–61% good cognitive, functional and psychosocial outcomes in 77 severe
TBI patients. In this study, TBI patients followed to 12 months in India, and it was
shown a greater increase in good outcomes observed between 6 and 12 months in the
absence of rehabilitation care. Differences are noted from other studies which may
be explained by early ICU guideline adherence and post-discharge TBI care. In India,
which has almost no rehabilitation facilities, whereas there is an overall improvement
in post-discharge TBI outcomes, many patients deteriorate at home during the follow-up.
These findings suggest while most patients improve despite the lack of organised rehabilitation
services, outcomes may be further improved with systematic rehabilitation. Therefore,
the authors suggested resource allocation for early rehabilitation for post-TBI patients
is important.
The authors were not able to draw substantial conclusion regarding the prehospital
TBI care because at JPNATC adherence to prehospital guidelines are practically non-existent
but adherence to ICU guidelines was realistic and impacted the overall outcome. There
are some limitations to this study as the authors operationalised some clinical indicators
based on feasibility of data collection. The difference of the two centres in prehospital
management. The difference in study design between the centres as the prospective
study design adopted at JPNATC could have affected the adherence rates as the staffs
were aware of the situation. The authors had the robust data from ICU only, because
data collection from prehospital setup, the emergency department, or the operation
theatres were not as complete as needed for analysis. Finally, they cannot conclude
which protective indicator is more effective than another nor can we generalise these
findings to other levels of trauma care.
In summary, in this largest prospective study of severe TBI with 12 month outcome
follow-up in India, the authors showed that achieving early ICU guideline adherence
above 65% adherence rate is attainable and improves discharge survival. They also
outlined that despite attaining survival with ICU guideline adherence, and while long-term
outcomes generally improved, patients discharged with favourable GOS often worsened
at home. This warrants the need for post-discharge rehabilitation services.
Conflicts of interest
There are no conflicts of interest.
