Examination of the management of traumatic brain injury in the developing and developed world: focus on resource utilization, protocols, and practices that alter outcome

Abstract

We evaluated management and outcome of traumatic brain injury (TBI) in a developed country (US) and a developing country (Jamaica). Data were collected prospectively at Grady Memorial Hospital (GMH) in the US and at University Hospital of the West Indies (UHWI) and Kingston Public Hospital (KPH) in Jamaica between September 1, 2003, and September 30, 2004. Complete data were available for 1607 patients. Grady Memorial Hospital had a higher proportion of females (p = 0.003), and patients were older at GMH (p = 0.0009) compared with patients at KPH and UHWI. The most common mode of injury was a motor vehicle accident at KPH and GMH (42 and 66%, respectively) and assaults at UHWI (37%). Grady Memorial Hospital admitted more patients with severe head injuries (25.5%) than KPH (18.5%) and UHWI (14.4%). More CT scans were performed (p < 0.0001) and a higher proportion of patients were admitted to the intensive care unit (p < 0.0001) at GMH. There were no statistically significant differences in median days in the intensive care unit among the 3 hospitals. Patients experienced statistically significant differences in days undergoing ventilation between GMH, KPH, and UHWI (p = 0.004). Intracranial pressure monitoring was performed in 1 patient at KPH, in 6 at UHWI, and in 91 at GMH. There were 174 total deaths, but no statistically significant differences in mortality rates between the 3 sites (p = 0.3). Hospital location and TBI severity were associated with a decreased risk of mortality; patients with severe TBI at GMH had a 53% decrease in the risk of mortality (odds ratio = 0.47, p = 0.04). Patients at GMH had lower mean Glasgow Outcome Scale scores (p < 0.0001) and lower Functional Independence Measure self-feed (p = 0.0003), locomotion (p = 0.04), and verbal scores (p < 0.0001). Despite the availability of advanced technology and more aggressive neurological support at GMH, the overall mortality rate for TBI was similar at all locations. Patients identified with severe TBI had a significantly decreased risk of mortality if they were treated at GMH compared with those patients treated at hospitals in the developing world.