Traumatic Brain Injury Guidelines and Outcome: Please Don't Forget Postacute Care!

Abstract

n an article recently published in WORLD NEUROSURGERY, Gupta et al. examined Brain Trauma Foundation guidelines I adherence rates and their relationship to in-hospital mortality and long-term outcome in patients with severe traumatic brain injury (TBI). In this retrospective study, 400 adult patients were enrolled: 200 patients were treated in the United States at the Harborview Medical Center (HMC) in Seattle and 200 patients were treated in India at the Jai Prakash Narayan Apex Trauma Centre (JPNATC) in New Delhi. JPNATC and HMC are academic high-volume Level 1 trauma centers with a dedicated neurointensive care unit with similar characteristics, such as nursepatient ratios and monitoring. Glasgow Outcome Scale (GOS) scores at 3, 6, and 12 months after discharge were recorded at each site (GOS score 1e3 1⁄4 poor outcome, GOS score 4e5 1⁄4 favorable outcome). The main results of their study were as follows: 1) the overall adherence rate was 74.9% (SD 11.0) at JPNATC versus 71.6% (SD 10.4) at HMC; 2) intracranial pressure (ICP) monitors were placed in 63% of patients at JPNATC and in 84% of patients at HMC, and 52% of patients with intracranial hypertension at JPNATC received some form of ICP-lowering therapy compared with 98% of patients at HMC; 3) no relationship between guideline adherence rate and inpatient mortality was observed at HMC (absolute risk reduction 1.00; 95% confidence interval [0.97, 1.02]), whereas an increase in adherence rate by 1% was associated with a reduction (3%) of inpatient mortality at JPNATC (absolute risk reduction 0.97; 95% confidence interval [0.95, 0.99]); 4) there were 2 deaths in the postdischarge period at HMC versus 23 deaths at JPNATC; and 5)