Suboptimal compliance with evidence-based guidelines in patients with traumatic brain injuries

Clinical article

Shahid Shafi M.D., M.P.H.1, Sunni A. Barnes Ph.D.1, D Millar M.D.8, Justin Sobrino M.D.1, Rustam Kudyakov M.D., M.P.H.1, Candice Berryman B.S.1, Nadine Rayan M.H.A.1, Rosemary Dubiel M.D.2, Raul Coimbra M.D., Ph.D.3, Louis J. Magnotti M.D.4, Gary Vercruysse M.D.5, Lynette A. Scherer M.D.6, Gregory J. Jurkovich M.D.7, and Raminder Nirula M.D., M.P.H.8
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  • 1 Institute for Health Care Research and Improvement and
  • | 2 Baylor Institute for Rehabilitation, Baylor Health Care System, Dallas, Texas;
  • | 3 Department of Surgery, University of California San Diego, California;
  • | 4 Department of Surgery-General, University of Tennessee Health Science Center, Memphis, Tennessee;
  • | 5 Division of Trauma/Surgical Critical Care, Emory University, Atlanta, Georgia;
  • | 6 Department of Surgery, University of California Davis, Sacramento, California;
  • | 7 Department of Surgery, Denver Health Medical Center, Denver, Colorado; and
  • | 8 Department of Surgery, University of Utah, Salt Lake City, Utah
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Object

Evidence-based management (EBM) guidelines for severe traumatic brain injuries (TBIs) were promulgated decades ago. However, the extent of their adoption into bedside clinical practices is not known. The purpose of this study was to measure compliance with EBM guidelines for management of severe TBI and its impact on patient outcome.

Methods

This was a retrospective study of blunt TBI (11 Level I trauma centers, study period 2008–2009, n = 2056 patients). Inclusion criteria were an admission Glasgow Coma Scale score ≤ 8 and a CT scan showing TBI, excluding patients with nonsurvivable injuries—that is, head Abbreviated Injury Scale score of 6. The authors measured compliance with 6 nonoperative EBM processes (endotracheal intubation, resuscitation, correction of coagulopathy, intracranial pressure monitoring, maintaining cerebral perfusion pressure ≥ 50 cm H2O, and discharge to rehabilitation). Compliance rates were calculated for each center using multivariate regression to adjust for patient demographics, physiology, injury severity, and TBI severity.

Results

The overall compliance rate was 73%, and there was wide variation among centers. Only 3 centers achieved a compliance rate exceeding 80%. Risk-adjusted compliance was worse than average at 2 centers, better than average at 1, and the remainder were average. Multivariate analysis showed that increased adoption of EBM was associated with a reduced mortality rate (OR 0.88; 95% CI 0.81–0.96, p < 0.005).

Conclusions

Despite widespread dissemination of EBM guidelines, patients with severe TBI continue to receive inconsistent care. Barriers to adoption of EBM need to be identified and mitigated to improve patient outcomes.

Abbreviations used in this paper:

AIS = Abbreviated Injury Scale; BTF = Brain Trauma Foundation; CMS = Centers for Medicare and Medicaid Services; EBM = evidence-based management; GCS = Glasgow Coma Scale; ICP = intracranial pressure; ISS = Injury Severity Score; O-E = observed-to-expected; POC = process of care; SBP = systolic blood pressure; TBI = traumatic brain injury.

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