Risk Adjustment In Neurocritical care (RAIN)--prospective validation of risk prediction models for adult patients with acute traumatic brain injury to use to evaluate the optimum location and comparative costs of neurocritical care: a cohort study

Survivorship After Neurocritical Care: A Scoping Review of Outcomes Beyond Physical Status

Following intensive care unit hospitalization, survivors of acute neurological injury often experience debilitating short-term and long-term impairments. Although the physical/motor impairments experienced by survivors of acute neurological injury have been described extensively, fewer studies have examined cognitive, mental health, health-related quality of life (HRQoL), and employment outcomes. This scoping review describes the publication landscape beyond physical and/or motor sequelae in neurocritical care survivors. Databases were searched for terms related to critical illness, intensive care, and outcomes from January 1970 to March 2022. English-language studies of critically ill adults with a primary neurological diagnosis were included if they reported on at least one outcome of interest: cognition, mental health, HRQoL or employment. Data extraction was performed in duplicate for prespecified variables related to study outcomes. Of 16,036 abstracts screened, 74 citations were identified for inclusion. The studies encompassed seven worldwide regions and eight neurocritical diagnosis categories. Publications reporting outcomes of interest increased from 3 before the year 2000 to 71 after. Follow-up time points included ≤ 1 (n = 15 [20%] citations), 3 (n = 28 [38%]), 6 (n = 28 [38%]), and 12 (n = 21 [28%]) months and 1 to 5 (n = 19 [26%]) and > 5 years (n = 8 [11%]), with 28 (38%) citations evaluating outcomes at multiple time points. Sixty-six assessment tools were used to evaluate the four outcomes of interest: 22 evaluating HRQoL (56 [76%] citations), 21 evaluating cognition (20 [27%] citations), 21 evaluating mental health (18 [24%] citations), and 2 evaluating employment (9 [12%] citations). This scoping review aimed to better understand the literature landscape regarding nonphysical outcomes in survivors of neurocritical care. Although a rising number of publications highlight growing awareness, future efforts are needed to improve study consistency and comparability and characterize outcomes in a disease-specific manner, including outlining of a minimum core outcomes set and associated assessment tools.

Association of Neurocritical Care Services With Mortality and Functional Outcomes for Adults With Brain Injury: A Systematic Review and Meta-analysis

Importance

Neurocritical care (NCC) aims to improve the outcomes of critically ill patients with brain injury, although the benefits of such subspecialized care are yet to be determined.

Objective

To evaluate the association of NCC with patient-centered outcomes in adults with acute brain injury who were admitted to intensive care units (ICUs). The protocol was preregistered on PROSPERO (CRD42020177190).

Data Sources

Three electronic databases were searched (Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials) from inception through December 15, 2021, and by citation chaining.

Study Selection

Studies were included for interventions of neurocritical care units (NCCUs), neurointensivists, or NCC consulting services compared with general care in populations of neurologically ill adults or adults with acute brain injury in ICUs.

Data Extraction and Synthesis

Data extraction was performed in keeping with PRISMA guidelines and risk of bias assessed through the ROBINS-I Cochrane tool by 2 independent reviewers. Data were pooled using a random-effects model.

Main Outcomes and Measures

The primary outcome was all-cause mortality at longest follow-up until 6 months. Secondary outcomes were ICU length of stay (LOS), hospital LOS, and functional outcomes. Data were measured as risk ratio (RR) if dichotomous or standardized mean difference if continuous. Subgroup analyses were performed for disease and models of NCC delivery.

Results

After 5659 nonduplicated published records were screened, 26 nonrandomized observational studies fulfilled eligibility criteria. A meta-analysis of mortality outcomes for 55 792 patients demonstrated a 17% relative risk reduction (RR, 0.83; 95% CI, 0.75-0.92; P = .001) in those receiving subspecialized care (n = 27 061) compared with general care (n = 27 694). Subgroup analyses did not identify subgroup differences. Eight studies including 4667 patients demonstrated a 17% relative risk reduction (RR, 0.83; 95% CI, 0.70-0.97; P = .03) for an unfavorable functional outcome with subspecialized care compared with general care. There were no differences in LOS outcomes. Heterogeneity was substantial in all analyses.

Conclusions and Relevance

Subspecialized NCC is associated with improved survival and functional outcomes for critically ill adults with brain injury. However, confidence in the evidence is limited by substantial heterogeneity. Further investigations are necessary to determine the specific aspects of NCC that contribute to these improved outcomes and its cost-effectiveness.

Sugar or salt ("SOS"): A protocol for a UK multicentre randomised trial of mannitol and hypertonic saline in severe traumatic brain injury and intracranial hypertension

Hyperosmolar solutions are widely used to treat raised intracranial pressure following severe traumatic brain injury. Although mannitol has historically been the most frequently administered, hypertonic saline solutions are increasingly being used. However, definitive evidence regarding their comparative effectiveness is lacking. The Sugar or Salt Trial is a UK randomised, allocation concealed open label multicentre pragmatic trial designed to determine the clinical and cost-effectiveness of hypertonic saline compared with mannitol in the management of patients with severe traumatic brain injury. Patients requiring intensive care unit admission and intracranial pressure monitoring post-traumatic brain injury will be allocated at random to receive equi-osmolar boluses of either mannitol or hypertonic saline following failure of routine first-line measures to control intracranial pressure. The primary outcome for the study will be the Extended Glasgow Outcome Scale assessed at six months after randomisation. Results will inform current clinical practice in the routine use of hyperosmolar therapy as well as assess the impact of potential side effects. Pre-planned longer term clinical and cost effectiveness analyses will further inform the use of these treatments.

Hospitals with and without neurosurgery: a comparative study evaluating the outcome of patients with traumatic brain injury

BACKGROUND

We leveraged the data of the international CREACTIVE consortium to investigate whether the outcome of traumatic brain injury (TBI) patients admitted to intensive care units (ICU) in hospitals without on-site neurosurgical capabilities (no-NSH) would differ had the same patients been admitted to ICUs in hospitals with neurosurgical capabilities (NSH).

METHODS

The CREACTIVE observational study enrolled more than 8000 patients from 83 ICUs. Adult TBI patients admitted to no-NSH ICUs within 48 h of trauma were propensity-score matched 1:3 with patients admitted to NSH ICUs. The primary outcome was the 6-month extended Glasgow Outcome Scale (GOS-E), while secondary outcomes were ICU and hospital mortality.

RESULTS

A total of 232 patients, less than 5% of the eligible cohort, were admitted to no-NSH ICUs. Each of them was matched to 3 NSH patients, leading to a study sample of 928 TBI patients where the no-NSH and NSH groups were well-balanced with respect to all of the variables included into the propensity score. Patients admitted to no-NSH ICUs experienced significantly higher ICU and in-hospital mortality. Compared to the matched NSH ICU admissions, their 6-month GOS-E scores showed a significantly higher prevalence of upper good recovery for cases with mild TBI and low expected mortality risk at admission, along with a progressively higher incidence of poor outcomes with increased TBI severity and mortality risk.

CONCLUSIONS

In our study, centralization of TBI patients significantly impacted short- and long-term outcomes. For TBI patients admitted to no-NSH centers, our results suggest that the least critically ill can effectively be managed in centers without neurosurgical capabilities. Conversely, the most complex patients would benefit from being treated in high-volume, neuro-oriented ICUs.

Primary versus early secondary referral to a specialized neurotrauma center in patients with moderate/severe traumatic brain injury: a CENTER TBI study

Background

Prehospital care for patients with traumatic brain injury (TBI) varies with some emergency medical systems recommending direct transport of patients with moderate to severe TBI to hospitals with specialist neurotrauma care (SNCs). The aim of this study is to assess variation in levels of early secondary referral within European SNCs and to compare the outcomes of directly admitted and secondarily transferred patients.

Methods

Patients with moderate and severe TBI (Glasgow Coma Scale < 13) from the prospective European CENTER-TBI study were included in this study. All participating hospitals were specialist neuroscience centers. First, adjusted between-country differences were analysed using random effects logistic regression where early secondary referral was the dependent variable, and a random intercept for country was included. Second, the adjusted effect of early secondary referral on survival to hospital discharge and functional outcome [6 months Glasgow Outcome Scale Extended (GOSE)] was estimated using logistic and ordinal mixed effects models, respectively.

Results

A total of 1347 moderate/severe TBI patients from 53 SNCs in 18 European countries were included. Of these 1347 patients, 195 (14.5%) were admitted after early secondary referral. Secondarily referred moderate/severe TBI patients presented more often with a CT abnormality: mass lesion (52% vs. 34%), midline shift (54% vs. 36%) and acute subdural hematoma (77% vs. 65%). After adjusting for case-mix, there was a large European variation in early secondary referral, with a median OR of 1.69 between countries. Early secondary referral was not associated with functional outcome (adjusted OR 1.07, 95% CI 0.78–1.69), nor with survival at discharge (1.05, 0.58–1.90).

Conclusions

Across Europe, substantial practice variation exists in the proportion of secondarily referred TBI patients at SNCs that is not explained by case mix. Within SNCs early secondary referral does not seem to impact functional outcome and survival after stabilisation in a non-specialised hospital. Future research should identify which patients with TBI truly benefit from direct transportation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00930-1.

Long-Term Outcomes after Severe Traumatic Brain Injury in Older Adults. A Registry-based Cohort Study

Rationale: Older adults (≥65 yr old) account for an increasing proportion of patients with severe traumatic brain injury (TBI), yet clinical trials and outcome studies contain relatively few of these patients.Objectives: To determine functional status 6 months after severe TBI in older adults, changes in this status over 2 years, and outcome covariates.Methods: This was a registry-based cohort study of older adults who were admitted to hospitals in Victoria, Australia, between 2007 and 2016 with severe TBI. Functional status was assessed with Glasgow Outcome Scale Extended (GOSE) 6, 12, and 24 months after injury. Cohort subgroups were defined by admission to an ICU. Features associated with functional outcome were assessed from the ICU subgroup.Measurements and Main Results: The study included 540 older adults who had been hospitalized with severe TBI over the 10-year period; 428 (79%) patients died in hospital, and 456 (84%) died 6 months after injury. There were 277 patients who had not been admitted to an ICU; at 6 months, 268 (97%) had died, 8 (3%) were dependent (GOSE 2-4), and 1 (0.4%) was functionally independent (GOSE 5-8). There were 263 patients who had been admitted to an ICU; at 6 months, 188 (73%) had died, 39 (15%) were dependent, and 32 (12%) were functionally independent. These proportions did not change over longer follow-up. The only clinical features associated with a lower rate of functional independence were Injury Severity Score ≥25 (adjusted odds ratio, 0.24 [95% confidence interval, 0.09-0.67]; P = 0.007) and older age groups (P = 0.017).Conclusions: Severe TBI in older adults is a condition with very high mortality, and few recover to functional independence.

The development of neonatal neurointensive care

Brain injury remains one of the major unsolved problems in neonatal care, with survivors at high risk of lifelong neurodisability. It is unlikely that a single intervention can ameliorate neonatal brain injury, given the complex interaction between pathological processes, developmental trajectory, genetic susceptibility, and environmental influences. However, a coordinated, interdisciplinary approach to understand the root cause enables early detection, and diagnosis with enhanced clinical care offering the best chance of improving outcomes and facilitate new lines of neuroprotective treatments. Adult neurointensive care has existed as a speciality in its own right for over 20 years; however, it is only recently that large prospective studies have demonstrated the benefit of this model of care. The 'Neuro-intensive Care Nursery' model originated at the University of California San Francisco in 2008, and since then a growing number of units worldwide have adopted this approach. As well as providing consistent coordinated care for infants from a multidisciplinary team, it provides opportunities for specialist education and training in neonatal neurology, neuromonitoring, neuroimaging and nursing. This review outlines the origins of brain-oriented care of the neonate and the development of the Neuro-NICU (neonatal intensive care unit) and discusses some of the challenges and opportunities in expanding this model of care.

Evaluation of traumatic brain injury patients with signs of alcohol intoxication

OBJETIVE

to evaluate the influence of alcohol intoxication in the time to perform head computed tomography and tomographic findings in traumatic brain injury patients.

METHODS

a retrospective study of 183 traumatic brain injury patients, divided into two groups: 90 alcoholics and 93 non-alcoholics. Time interval from patient's arrival at emergency room to tomography was calculated for comparison between the groups, and tomographic findings were analyzed.

RESULTS

in the alcoholic group, the percentage of male patients was higher, the predominant age was between 31 and 40 years, aggression was the most frequent trauma mechanism, and these patients showed lower values on the Glasgow coma scale. It was observed that there was no statistical difference between the two groups regarding the time interval for tomography execution, as well as regarding the tomographic findings. In addition, in the alcoholic patients, when the Glasgow coma scale values were correlated with the time interval, there was no difference from scores 13 to 15 (mild traumatic brain injury) and those equal to or inferior than 12 (moderate and severe traumatic brain injury).

CONCLUSION

signs of alcoholic intoxication did not influence the time interval for tomography execution. Patients under alcohol influence showed lower scores on the Glasgow coma scale due to the direct effect of alcohol and not due to a higher prevalence of tomographic findings.

Standards for Neurologic Critical Care Units: A Statement for Healthcare Professionals from The Neurocritical Care Society

Neurocritical care is a distinct subspecialty focusing on the optimal management of acutely ill patients with life-threatening neurologic and neurosurgical disease or with life-threatening neurologic manifestations of systemic disease. Care by expert healthcare providers to optimize neurologic recovery is necessary. Given the lack of an organizational framework and criteria for the development and maintenance of neurological critical care units (NCCUs), this document is put forth by the Neurocritical Care Society (NCS). Recommended organizational structure, personnel and processes necessary to develop a successful neurocritical care program are outlined. Methods: Under the direction of NCS Executive Leadership, a multidisciplinary writing group of NCS members was formed. After an iterative process, a framework was proposed and approved by members of the writing group. A draft was then written, which was reviewed by the NCS Quality Committee and NCS Guidelines Committee, members at large, and posted for public comment. Feedback was formally collated, reviewed and incorporated into the final document which was subsequently approved by the NCS Board of Directors.

Developments in hybrid operating room, neurointensive care unit, and ward composition and organization for stroke management

Stroke is the leading cause of adult disability in the US. Rapid diagnosis and treatment of stroke, in addition to efficacious rehabilitation, is invaluable. The present review aims to report the recent improvements in hybrid operating rooms (hybrid ORs), and in the organization of Neurological intensive care unit (NICUs) and dedicated stroke wards (SWs), which contribute to enhanced stroke treatment. A PubMed literature review was conducted in addition to the collection of other online media releases regarding recent organizational advances in stroke care. PubMed keywords included but were not limited to “neurological intensive care unit,” “hybrid operating room,” and “stroke ward,” while all other online information regarding recent advances in the physical organization was selected and synthesized in accord with its relevance. The current research indicates that hybrid ORs facilitate surgical innovation and improved patient care through the colocation of advanced imaging modalities and surgical capabilities. Moreover, the recent reorganization of NICUs and SWs may lead to better-quality initial treatment and rehabilitation. The present review also considers the current ER triage protocol for stroke patients, and it concludes with relevant considerations relating to the role of the physical hospital structure and organization in stroke care.

Why Does Brain Trauma Research Fail?

Traumatic brain injury (TBI) represents a major health care problem and a significant social and economic issue worldwide. Considering the generalized failure in introducing effective drugs and clinical protocols, there is an urgent need for efficient treatment modalities, able to improve devastating posttraumatic morbidity and mortality. In this work, the status of brain trauma research is analyzed in all its aspects, including basic and translational science and clinical trials. Implicit and explicit challenges to different lines of research are discussed and clinical trial structures and outcomes are scrutinized, along with possible explanations for systematic therapeutic failures and their implications for future development of drug and clinical trials. Despite significant advances in basic and clinical research in recent years, no specific therapeutic protocols for TBI have been shown to be effective. New potential therapeutic targets have been identified, following a better understanding of pathophysiologic mechanisms underlying TBI, although with disappointing results. Several reasons can be pinpointed at different levels, from inaccurate animal models of disease to faulty preclinical and clinical trials, with poor design and subjective outcome measures. Distinct strategies can be delineated to overcome specific shortcomings of research studies. Identifying and contextualizing the failures that have dominated TBI research is mandatory. This review analyzes current approaches and discusses possible strategies for improving outcomes.

Handling of Missing Outcome Data in Traumatic Brain Injury Research: A Systematic Review

Traumatic brain injury (TBI) research commonly measures long-term functional outcome, but studies often suffer from missing data as patients are lost to follow-up. This review assesses the extent and handling of missing outcome data in the TBI literature and provides a practical guide for future research. Relevant electronic databases were searched from January 1, 2012 to October 27, 2017 for TBI studies that used the Glasgow Outcome Scale or Glasgow Outcome Scale-Extended (GOS/GOSE) as an outcome measure. Studies were screened and data extracted in line with Cochrane guidance.

A total of 195 studies, 21 interventional, 174 observational, with 104,688 patients were included. Using the reported follow-up rates in a mixed model, on average 91% of patients were predicted to return to follow-up at 6 months post-injury, 84% at 1 year, and 69% at 2 years. However, 36% of studies provided insufficient information to determine the number of subjects at each time-point. Of 139 studies that did report missing outcome data, only 50% attempted to identify why data were missing, with just 4 reporting their assumption on the “missingness mechanism.” The handling of missing data was heterogeneous, with the most common method being its exclusion from analysis. These results confirm substantial variability in the standard of reporting and handling of missing outcome data in TBI research. We conclude that practical guidance is needed to facilitate meaningful and accurate study interpretation, and therefore propose a framework for the handling of missing outcome data in future TBI research.

Chronic pain in critical care survivors: a narrative review

Chronic pain is an important problem after critical care admission. Estimates of the prevalence of chronic pain in the year after discharge range from 14% to 77% depending on the type of cohort, the tool used to measure pain, and the time point when pain was assessed. The majority of data available come from studies using health-related quality of life tools, although some have included pain-specific tools. Nociceptive, neuropathic, and nociplastic pain can occur in critical care survivors, but limited information about the aetiology, body site, and temporal trajectory of pain is currently available. Older age, pre-existing pain, and medical co-morbidity have been associated with pain after critical care admission. No trials were identified of interventions to target chronic pain in survivors specifically. Larger studies, using pain-specific tools, over an extended follow-up period are required to confirm the prevalence, identify risk factors, explore any association between acute and chronic pain in this setting, determine the underlying pathological mechanisms, and inform the development of future analgesic interventions.

A retrospective review of patients with significant traumatic brain injury transported by emergency medical services within the south east of England

Introduction:

Traumatic brain injury (TBI) will be a leading cause of death and disability within the Western world by 2020. Currently, 80% of all TBI patients in England are transported to hospital by an ambulance service. The aim of this retrospective study is to compare TBI patients transported to a major trauma centre (MTC) against those transported to a trauma unit (TU).

Method:

All patients with a primary injury of TBI who were transported to hospital by South East Coast Ambulance Service NHS Foundation Trust (SECAmb) from 1 January 2016 to 31 December 2016 and entered into the Trauma Audit & Research Network (TARN) registry were reviewed. Patients were stratified by hospital designation (MTC or TU). Severity of TBI was categorised using the patients’ pre-hospital Glasgow Coma Scale (GCS) and Abbreviated Injury Score (AIS) Head. The outcomes of interest were 30-day mortality and Glasgow Outcome Score (GOS) at discharge.

Results:

Between 1 January and 31 December 2016, 549 TBI patients were identified in the TARN database as being transported by SECAmb to either an MTC or a TU. The majority of patients were transported to a TU (77.96%), and the median age of the TU cohort was older than the MTC group (TU 82.15 IQR 16.73 vs. MTC 62.1 IQR 42.6). The median Injury Severity Score (ISS) was greater in the MTC cohort (22 IQR 10 vs. 17 IQR 9), where falls from height and road traffic collisions (RTCs) contributed to 50.51% of all injuries. Within the TU cohort, falls from less than 2 metres (standing height) were the main mechanism of injury (MOI) (77.62%). The median length of hospital stay (LOS) was longer in the MTC cohort compared to the TU cohort (10 IQR 13.25 vs. 8 IQR 14).

Conclusion:

The high proportion of mild TBI and absence of reliable triage guidelines make it difficult for ambulance clinicians to identify patients who will benefit from transport to an MTC. Future research should focus on how TBI triage influences outcomes and how ambulance services can better identify patients with a TBI and who would benefit from specialist care.

Post-traumatic stress disorder and self-reported outcomes after traumatic brain injury in victims of assault

Introduction

Assault is the third most common cause of traumatic brain injury (TBI), after falls and road traffic collisions. TBI can lead to multiple long-term physical, cognitive and emotional sequelae, including post-traumatic stress disorder (PTSD). Intentional violence may further compound the psychological trauma of the event, in a way that conventional outcome measures, like the Glasgow Outcome Scale (GOS), fail to capture. This study aims to examine the influence of assault on self-reported outcomes, including quality of life and symptoms of PTSD.

Methods

Questionnaire were completed by 256 patients attending a TBI clinic, including Quality of Life after Brain Injury (QOLIBRI) and PTSD checklist (PCL-C). Medical records provided demographics, clinical data and aetiology of injury. Subjective outcomes were compared between assault and other causes.

Results

Of 202 patients analysed, 21% sustained TBI from assault. There was no difference in severity of injuries between assault and non-assault groups. No relationship was found between self-reported outcomes and TBI severity or GOS. The assault group scored worse in all self-reported questionnaires, with statistically significant differences for measures of PTSD and post-concussion symptoms. However, using threshold scores, the prevalence of PTSD in assaulted patients was not higher than non-assault. After adjusting for age, ethnicity and the presence of extra-cranial trauma, assault did not have a significant effect on questionnaire scores. Exploratory analysis showed that assault and road traffic accidents were associated with significantly worse outcomes compared to falls.

Conclusion

Quality of life is significantly related to functional and psychological outcomes after TBI. Assaulted patients suffer from worse self-reported outcomes than other patients, but these differences were insignificant when adjusted for demographic factors. Intentionality behind the traumatic event is likely more important than cause alone. Differences in quality of life and other self-reported outcomes are not reflected by the Glasgow Outcome Scale. This information is useful in arranging earlier and targeted review and support.

Should We Assess Pituitary Function in Children After a Mild Traumatic Brain Injury? A Prospective Study

Objective: The aim of this study was to evaluate the frequency of hypopituitarism following TBI in a cohort of children who had been hospitalized for mild TBI and to identify the predictive factors for this deficiency. Design: A prospective study was conducted on children between 2 and 16 years of age who had been hospitalized for mild TBI according to the Glasgow Coma Scale between September 2009 and June 2013. Clinical parameters, basal pituitary hormone assessment at 0, 6, and 12 months, as well as a dynamic testing (insulin tolerance test) 12 months after TBI were performed. Results: The study included 109 children, the median age was 8.5 years. Patients were examined 6 months (n = 99) and 12 months (n = 96) after TBI. Somatotropic deficiency (defined by a GH peak <20 mUI/l in two tests, an IGF-1 <-1SDS and a delta height <0SDS) were confirmed in 2 cases. One case of gonadotrophic deficiency occurred 1 year after TBI among 13 pubertal children. No cases of precocious puberty, 5 cases of low prolactin level, no cases of corticotropic insufficiency (cortisol peak <500 nmol/l) and no cases diabetes insipidus were recorded. Conclusion: Pituitary insufficiency was present 1year after mild TBI in about 7% of children. Based on our results, we suggest testing children after mild TBI in case of clinical abnormalities. i.e., for GH axis, IGF-1, which should be assessed in children with a delta height <0 SDS, 6 to 12 months after TBI, and a dynamic GH testing (preferentially by an ITT) should be performed in case of IGF-1 <-1SDS, with a GH threshold at 20 mUI/L. However, if a systematic pituitary assessment is not required for mild TBI, physicians should monitor children 1 year after mild TBI with particular attention to growth and weight gain.

The Age of BLood Evaluation (ABLE) randomised controlled trial: description of the UK-funded arm of the international trial, the UK cost-utility analysis and secondary analyses exploring factors associated with health-related quality of life and health-care costs during the 12-month follow-up

BACKGROUND

At present, red blood cells (RBCs) are stored for up to 42 days prior to transfusion. The relative effectiveness and safety of different RBC storage times prior to transfusion is uncertain.

OBJECTIVE

To assess the clinical effectiveness and cost-effectiveness of transfusing fresher RBCs (stored for ≤ 7 days) compared with current standard-aged RBCs in critically ill patients requiring blood transfusions.

DESIGN

The international Age of BLood Evaluation (ABLE) trial was a multicentre, randomised, blinded trial undertaken in Canada, the UK, the Netherlands and France. The UK trial was funded to contribute patients to the international trial and undertake a UK-specific health economic evaluation.

SETTING

Twenty intensive care units (ICUs) in the UK, as part of 64 international centres.

PARTICIPANTS

Critically ill patients aged ≥ 18 years (≥ 16 years in Scotland) expected to require mechanical ventilation for ≥ 48 hours and requiring a first RBC transfusion during the first 7 days in the ICU.

INTERVENTIONS

All decisions to transfuse RBCs were made by clinicians. One patient group received exclusively fresh RBCs stored for ≤ 7 days whenever transfusion was required from randomisation until hospital discharge. The other group received standard-issue RBCs throughout their hospital stay.

MAIN OUTCOME MEASURES

The primary outcome was 90-day mortality. Secondary outcomes included development of organ dysfunction, new thrombosis, infections and transfusion reactions. The primary economic evaluation was a cost-utility analysis.

RESULTS

The international trial took place between March 2009 and October 2014 (UK recruitment took place between January 2012 and October 2014). In total, 1211 patients were assigned to receive fresh blood and 1219 patients to receive standard-aged blood. RBCs were stored for a mean of 6.1 days [standard deviation (SD) ± 4.9 days] in the group allocated to receive fresh blood and 22.0 days (SD ± 8.4 days) in the group allocated to receive standard-aged blood. Patients received a mean of 4.3 RBC units (SD ± 5.2 RBC units) and 4.3 RBC units (SD ± 5.5 RBC units) in the groups receiving fresh blood and standard-aged blood, respectively. At 90 days, 37.0% of patients in the group allocated to receive fresh blood and 35.3% of patients in the group allocated to receive standard-aged blood had died {absolute risk difference 1.7% [95% confidence interval (CI) -2.1% to 5.5%]}. There were no between-group differences in any secondary outcomes. The UK cohort comprised 359 patients randomised and followed up for 12 months for the cost-utility analysis. UK patients had similar characteristics and outcomes to the international cohort. Mean total costs per patient were £32,346 (95% CI £29,306 to £35,385) in the group allocated to receive fresh blood and £33,353 (95% CI £29,729 to £36,978) in the group allocated to receive standard-aged blood. Approximately 85% of the total costs were incurred during the index hospital admission. There were no significant cost differences between the two groups [mean incremental costs for those receiving fresh vs. standard-aged blood: -£231 (95% CI -£4876 to £4415)], nor were there significant differences in outcomes (mean difference in quality-adjusted life-years -0.010, 95% CI -0.078 to 0.057).

LIMITATIONS

Adverse effects from the exclusive use of older RBCs compared with standard or fresh RBCs cannot be excluded.

CONCLUSIONS

The use of RBCs aged ≤ 7 days confers no clinical or economic benefit in critically ill patients compared with standard-aged RBCs.

FUTURE WORK

Future studies should address the safety of RBCs near the end of the current permitted storage age.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN44878718.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 62. See the NIHR Journals Library website for further project information. The international ABLE trial was also supported by peer-reviewed grants from the Canadian Institutes of Health Research (177453), Fonds de Recherche du Québec - Santé (24460), the French Ministry of Health Programme Hospitalier de Recherche Clinique (12.07, 2011) and by funding from Établissement Français du Sang and Sanquin Blood Supply.

Improvement in Quality Metrics Outcomes and Patient and Family Satisfaction in a Neurosciences Intensive Care Unit after Creation of a Dedicated Neurocritical Care Team

Introduction

Dedicated neurointensivists have been shown to improve outcome measurements in the neurosciences intensive care unit (NSICU). Quality outcome data in relation to patient and family satisfaction is lacking. This study evaluated the impact of newly appointed neurointensivists and creation of a neurocritical care team on quality outcome measures including patient satisfaction in a NSICU.

Methods

This is a retrospective study of data over 36 months from a 14-bed NSICU evaluating quality outcome measures and anonymous patient satisfaction questionnaires before and after neurointensivists appointment.

Results

After appointment of neurointensivists, patient acuity of the NSICU increased by 33.4% while LOS decreased by 3.5%. There was a decrease in neurosciences mortality (35.8%), catheter-associated urinary tract infection (50%), central line associated bloodstream infection (100%), and ventilator-associated pneumonia (50%). During the same time, patient satisfaction increased by 28.3% on physicians/nurses consistency (p = 0.025), by 69.5% in confidence/trust in physicians (p < 0.0001), by 78.3% on physicians treated me with courtesy/respect (p < 0.0001), and by 46.4% on physicians' attentiveness (p < 0.0001). Ultimately, patients recommending the hospital to others increased by 67.5% (p < 0.0001).

Conclusion

Dedicated neurointensivists and the subsequent development of a neurocritical care team positively impacted quality outcome metrics, particularly significantly improving patient satisfaction.

The aggressiveness of neurotrauma practitioners and the influence of the IMPACT prognostic calculator

Published guidelines have helped to standardize the care of patients with traumatic brain injury; however, there remains substantial variation in the decision to pursue or withhold aggressive care. The International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) prognostic calculator offers the opportunity to study and decrease variability in physician aggressiveness. The authors wish to understand how IMPACT’s prognostic calculations currently influence patient care and to better understand physician aggressiveness. The authors conducted an anonymous international, multidisciplinary survey of practitioners who provide care to patients with traumatic brain injury. Questions were designed to determine current use rates of the IMPACT prognostic calculator and thresholds of age and risk for death or poor outcome that might cause practitioners to consider withholding aggressive care. Correlations between physician aggressiveness, putative predictors of aggressiveness, and demographics were examined. One hundred fifty-four responses were received, half of which were from physicians who were familiar with the IMPACT calculator. The most frequent use of the calculator was to improve communication with patients and their families. On average, respondents indicated that in patients older than 76 years or those with a >85% chance of death or poor outcome it might be reasonable to pursue non-aggressive care. These thresholds were robust and were not influenced by provider or institutional characteristics. This study demonstrates the need to educate physicians about the IMPACT prognostic calculator. The consensus values for age and prognosis identified in our study may be explored in future studies aimed at reducing variability in physician aggressiveness and should not serve as a basis for withdrawing care.

How to Appropriately Extrapolate Costs and Utilities in Cost-Effectiveness Analysis

Costs and utilities are key inputs into any cost-effectiveness analysis. Their estimates are typically derived from individual patient-level data collected as part of clinical studies the follow-up duration of which is often too short to allow a robust quantification of the likely costs and benefits a technology will yield over the patient's entire lifetime. In the absence of long-term data, some form of temporal extrapolation-to project short-term evidence over a longer time horizon-is required. Temporal extrapolation inevitably involves assumptions regarding the behaviour of the quantities of interest beyond the time horizon supported by the clinical evidence. Unfortunately, the implications for decisions made on the basis of evidence derived following this practice and the degree of uncertainty surrounding the validity of any assumptions made are often not fully appreciated. The issue is compounded by the absence of methodological guidance concerning the extrapolation of non-time-to-event outcomes such as costs and utilities. This paper considers current approaches to predict long-term costs and utilities, highlights some of the challenges with the existing methods, and provides recommendations for future applications. It finds that, typically, economic evaluation models employ a simplistic approach to temporal extrapolation of costs and utilities. For instance, their parameters (e.g. mean) are typically assumed to be homogeneous with respect to both time and patients' characteristics. Furthermore, costs and utilities have often been modelled to follow the dynamics of the associated time-to-event outcomes. However, cost and utility estimates may be more nuanced, and it is important to ensure extrapolation is carried out appropriately for these parameters.

Neuro, trauma, or med/surg intensive care unit: Does it matter where multiple injuries patients with traumatic brain injury are admitted? Secondary analysis of the American Association for the Surgery of Trauma Multi-Institutional Trials Committee decompressive craniectomy study

INTRODUCTION

Patients with nontraumatic acute intracranial pathology benefit from neurointensivist care. Similarly, trauma patients with and without traumatic brain injury (TBI) fare better when treated by a dedicated trauma team. No study has yet evaluated the role of specialized neurocritical (NICU) and trauma intensive care units (TICU) in the management of TBI patients, and it remains unclear which TBI patients are best served in NICU, TICU, or general (Med/Surg) ICU.

METHODS

This study is a secondary analysis of The American Association for the Surgery of Trauma Multi-Institutional Trials Committee (AAST-MITC) decompressive craniectomy study. Twelve Level 1 trauma centers provided clinical data and head computed tomography (CT) scans of patients with Glasgow Coma Scale score of 13 or less and CT evidence of TBI. Non-ICU admissions were excluded. Multivariate logistic regression was performed to measure the association between ICU type and survival and calculate the probability of death for increasing Injury Severity Score (ISS). Multiple injuries patients (ISS > 15) with TBI and isolated TBI patients (other Abbreviated Injury Scale score < 3) were analyzed separately.

RESULTS

There were 3641 patients with CT evidence of TBI with 2951 admitted to an ICU. Before adjustment, patient demographics, injury severity, and survival differed significantly by unit type. After adjustment, unit type, age, and ISS remained independent predictors of death. Unit type modified the effect of ISS on mortality. TBI multiple injuries patients admitted to a TICU had improved survival across increasing ISS. Survival for isolated TBI patients was similar between TICU and NICU. Med/surg ICU carried the greatest probability of death.

CONCLUSION

Multiple injuries patients with TBI have lower mortality risk when admitted to a trauma ICU. This survival benefit increases with increasing injury severity. Isolated TBI patients have similar mortality risk when admitted to a neuro ICU compared with a trauma ICU. Med/surg ICU admission carries the highest mortality risk.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Prognostication in critically ill patients with severe traumatic brain injury: the TBI-Prognosis multicentre feasibility study

OBJECTIVE

Severe traumatic brain injury is a significant cause of morbidity and mortality in young adults. Assessing long-term neurological outcome after such injury is difficult and often characterised by uncertainty. The objective of this feasibility study was to establish the feasibility of conducting a large, multicentre prospective study to develop a prognostic model of long-term neurological outcome in critically ill patients with severe traumatic brain injury.

DESIGN

A prospective cohort study.

SETTING

9 Canadian intensive care units enrolled patients suffering from acute severe traumatic brain injury. Clinical, biological, radiological and electrophysiological data were systematically collected during the first week in the intensive care unit. Mortality and functional outcome (Glasgow Outcome Scale extended) were assessed on hospital discharge, and then 3, 6 and 12 months following injury.

OUTCOMES

The compliance to protocolised test procedures was the primary outcome. Secondary outcomes were enrolment rate and compliance to follow-up.

RESULTS

We successfully enrolled 50 patients over a 12-month period. Most patients were male (80%), with a median age of 45 years (IQR 29.0-60.0), a median Injury Severity Score of 38 (IQR 25-50) and a Glasgow Coma Scale of 6 (IQR 3-7). Mortality was 38% (19/50) and most deaths occurred following a decision to withdraw life-sustaining therapies (18/19). The main reasons for non-enrolment were the time window for inclusion being after regular working hours (35%, n=23) and oversight (24%, n=16). Compliance with protocolised test procedures ranged from 92% to 100% and enrolment rate was 43%. No patients were lost to follow-up at 6 months and 2 were at 12 months.

CONCLUSIONS

In this multicentre prospective feasibility study, we achieved feasibility objectives pertaining to compliance to test, enrolment and follow-up. We conclude that the TBI-Prognosis prospective multicentre study in severe traumatic brain injury patients in Canada is feasible.

Correlating optic nerve sheath diameter with opening intracranial pressure in pediatric traumatic brain injury

INTRODUCTION

The use of clinical markers to predict intracranial pressure (ICP) is desirable as a first-line measure to assist in decision making as to whether invasive monitoring is required. Correlations between ICP and optic nerve sheath diameter (ONSD) using CT and MRI have been observed in adult populations. However, data on this modality in children is less well documented.

METHODS

ONSD was measured by independent observers and correlated with opening ICP at insertion of invasive monitoring probes in pediatric traumatic brain injury patients admitted to Addenbrookes Hospital between January 2009 and December 2013.

RESULTS

Thirty-six patients with a mean age of 8.2 y were admitted to the Pediatric Intensive Care Unit (PICU) with a traumatic head injury and required invasive neurosurgical monitoring. The median ICP was 18 ± 10 mmHg (median ± IQR), the median right ONSD was 5.6 ± 2.5 mm and the left was 5.9 ± 3.2 mm. The Intraclass correlation between observers was 0.91 (P < 0.0001). The correlation of mean ONSD and max ONSD with ICP was 0.712 (P < 0.0001) and 0.713 (P < 0.0001), respectively. Area under ROC curve for both mean and max ONSD is 0.85 (95% CI: 0.73-0.98).

CONCLUSION

Where pediatric patients present with an ONSD of over 6.1 mm following a traumatic brain injury (TBI), ICP monitoring should be implemented.

Implementation of a Neurocritical Care Program: Improved Seizure Detection and Decreased Antiseizure Medication at Discharge in Neonates With Hypoxic-Ischemic Encephalopathy

BACKGROUND

We report the impact of implementing continuous video electroencephalography monitoring for neonates with hypoxic-ischemic encephalopathy via a protocol in the context of neonatal neuro-critical care program.

METHODS

Neonates with hypoxic-ischemic encephalopathy were studied retrospectively two years before and after implementing continuous video electroencephalography for 72 hours as a care protocol. Before continuous video electroencephalography, a 60-minute routine electroencephalography was performed at the discretion of the provider.

PRIMARY OUTCOME

electrographic seizure detection; secondary outcome: use of maintenance antiseizure medications, discharge antiseizure medications, and cumulative burden for each antiseizure medication defined as total mg/kg during hospital stay.

RESULTS

A total of 157 patients with a median gestation of 40 weeks were analyzed; 103 (66%) underwent therapeutic hypothermia. Baseline and clinical characteristics including disease severity and cooling were similar. Before continuous video-electroencephalography (n = 86), 44 (51.2%) had clinical seizures, of those 35 had available routine electroencephalography; 12 of 35 (34%) had electrographic seizures. None of the infants without clinical seizures showed electrographic seizures. After continuous video-electroencephalography (n = 71), 34 (47.9%) had clinical seizures, of those 18 (53%) had electrographic seizures; five of 37 (14%) of infants with no clinical seizures had electrographic seizures. The introduction of continuous video-electroencephalography significantly increased electrographic seizure detection (P = 0.016). Although there was no significant difference in the initiation and maintenance use of antiseizure medications after continuous video-electroencephalography, fewer infants were discharged on any antiseizure medication (P = 0.008). Also, the mean phenobarbital burden reduced (P = 0.04), without increase in other antiseizure medications use or burden.

CONCLUSION

Use of continuous video-electroencephalography as part of the neonatal neuro-critical care program was associated with improved electrographic seizure detection, decreased phenobarbital burden, and antiseizure medication use at discharge.

The Head Injury Transportation Straight to Neurosurgery (HITS-NS) randomised trial: a feasibility study

BACKGROUND

Reconfiguration of trauma services, with direct transport of traumatic brain injury (TBI) patients to neuroscience centres (NCs), bypassing non-specialist acute hospitals (NSAHs), could potentially improve outcomes. However, delays in stabilisation of airway, breathing and circulation (ABC) and the difficulties in reliably identifying TBI at scene may make this practice deleterious compared with selective secondary transfer from nearest NSAH to NC. National Institute for Health and Care Excellence guidance and systematic reviews suggested equipoise and poor-quality evidence - with regard to 'early neurosurgery' in this cohort - which we sought to address.

METHODS

Pilot cluster randomised controlled trial of bypass to NC conducted in two ambulance services with the ambulance station (n = 74) as unit of cluster [Lancashire/Cumbria in the North West Ambulance Service (NWAS) and the North East Ambulance Service (NEAS)]. Adult patients with signs of isolated TBI [Glasgow Coma Scale (GCS) score of < 13 in NWAS, GCS score of < 14 in NEAS] and stable ABC, injured nearest to a NSAH were transported either to that hospital (control clusters) or bypassed to the nearest NC (intervention clusters).

PRIMARY OUTCOMES

recruitment rate, protocol compliance, selection bias as a result of non-compliance, accuracy of paramedic TBI identification (overtriage of study inclusion criteria) and pathway acceptability to patients, families and staff. 'Open-label' secondary outcomes: 30-day mortality, 6-month Extended Glasgow Outcome Scale (GOSE) and European Quality of Life-5 Dimensions.

RESULTS

Overall, 56 clusters recruited 293 (169 intervention, 124 control) patients in 12 months, demonstrating cluster randomised pre-hospital trials as viable for heath service evaluations. Overall compliance was 62%, but 90% was achieved in the control arm and when face-to-face paramedic training was possible. Non-compliance appeared to be driven by proximity of the nearest hospital and perceptions of injury severity and so occurred more frequently in the intervention arm, in which the perceived time to the NC was greater and severity of injury was lower. Fewer than 25% of recruited patients had TBI on computed tomography scan (n = 70), with 7% (n = 20) requiring neurosurgery (craniotomy, craniectomy or intracranial pressure monitoring) but a further 18 requiring admission to an intensive care unit. An intention-to-treat analysis revealed the two trial arms to be equivalent in terms of age, GCS and severity of injury. No significant 30-day mortality differences were found (8.8% vs. 9.1/%; p > 0.05) in the 273 (159/113) patients with data available. There were no apparent differences in staff and patient preferences for either pathway, with satisfaction high with both. Very low responses to invitations to consent for follow-up in the large number of mild head injury-enrolled patients meant that only 20% of patients had 6-month outcomes. The trial-based economic evaluation could not focus on early neurosurgery because of these low numbers but instead investigated the comparative cost-effectiveness of bypass compared with selective secondary transfer for eligible patients at the scene of injury.

CONCLUSIONS

Current NHS England practice of bypassing patients with suspected TBI to neuroscience centres gives overtriage ratios of 13 : 1 for neurosurgery and 4 : 1 for TBI. This important finding makes studying the impact of bypass to facilitate early neurosurgery not plausible using this study design. Future research should explore an efficient comparative effectiveness design for evaluating 'early neurosurgery through bypass' and address the challenge of reliable TBI diagnosis at the scene of injury.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN68087745.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 1. See the NIHR Journals Library website for further project information.

Chronic impact of traumatic brain injury on outcome and quality of life: a narrative review

Traditionally seen as a sudden, brutal event with short-term impairment, traumatic brain injury (TBI) may cause persistent, sometimes life-long, consequences. While mortality after TBI has been reduced, a high proportion of severe TBI survivors require prolonged rehabilitation and may suffer long-term physical, cognitive, and psychological disorders. Additionally, chronic consequences have been identified not only after severe TBI but also in a proportion of cases previously classified as moderate or mild. This burden affects the daily life of survivors and their families; it also has relevant social and economic costs.

Outcome evaluation is difficult for several reasons: co-existing extra-cranial injuries (spinal cord damage, for instance) may affect independence and quality of life outside the pure TBI effects; scales may not capture subtle, but important, changes; co-operation from patients may be impossible in the most severe cases. Several instruments have been developed for capturing specific aspects, from generic health status to specific cognitive functions. Even simple instruments, however, have demonstrated variable inter-rater agreement.

The possible links between structural traumatic brain damage and functional impairment have been explored both experimentally and in the clinical setting with advanced neuro-imaging techniques. We briefly report on some fundamental findings, which may also offer potential targets for future therapies.

Better understanding of damage mechanisms and new approaches to neuroprotection-restoration may offer better outcomes for the millions of survivors of TBI.

International multidisciplinary consensus conference on multimodality monitoring: ICU processes of care

There is an increased focus on evaluating processes of care, particularly in the high acuity and cost environment of intensive care. Evaluation of neurocritical-specific care and evidence-based protocol implementation are needed to effectively determine optimal processes of care and effect on patient outcomes. General quality measures to evaluate intensive care unit (ICU) processes of care have been proposed; however, applicability of these measures in neurocritical care populations has not been established. A comprehensive literature search was conducted for English language articles from 1990 to August 2013. A total of 1,061 articles were reviewed, with 145 meeting criteria for inclusion in this review. Care in specialized neurocritical care units or by neurocritical teams can have a positive impact on mortality, length of stay, and in some cases, functional outcome. Similarly, implementation of evidence-based protocol-directed care can enhance outcome in the neurocritical care population. There is significant evidence to support suggested quality indicators for the general ICU population, but limited research regarding specific use in neurocritical care. Quality indices for neurocritical care have been proposed; however, additional research is needed to further validate measures.

Ensuring comparisons of health-care providers are fair: development and validation of risk prediction models for critically ill patients

Background

National clinical audit has a key role in ensuring quality in health care. When comparing outcomes between providers, it is essential to take the differing case mix of patients into account to make fair comparisons. Accurate risk prediction models are therefore required.

Objectives

To improve risk prediction models to underpin quality improvement programmes for the critically ill (i.e. patients receiving general or specialist adult critical care or experiencing an in-hospital cardiac arrest).

Design

Risk modelling study nested within prospective data collection.

Setting

Adult (general/specialist) critical care units and acute hospitals in the UK.

Participants

Patients admitted to an adult critical care unit and patients experiencing an in-hospital cardiac arrest attended by the hospital-based resuscitation team.

Interventions

None.

Main outcome measures

Acute hospital mortality (adult critical care); return of spontaneous circulation (ROSC) greater than 20 minutes and survival to hospital discharge (in-hospital cardiac arrest).

Data sources

The Case Mix Programme (adult critical care) and National Cardiac Arrest Audit (in-hospital cardiac arrest).

Results

The current Intensive Care National Audit & Research Centre (ICNARC) model was externally validated using data for 29,626 admissions to critical care units in Scotland (2007–9) and outperformed the Acute Physiology And Chronic Health Evaluation (APACHE) II model in terms of discrimination (c-index 0.848 vs. 0.806) and accuracy (Brier score 0.140 vs. 0.157). A risk prediction model for cardiothoracic critical care was developed using data from 17,002 admissions to five units (2010–12) and validated using data from 10,238 admissions to six units (2013–14). The model included prior location/urgency, blood lactate concentration, Glasgow Coma Scale (GCS) score, age, pH, platelet count, dependency, mean arterial pressure, white blood cell (WBC) count, creatinine level, admission following cardiac surgery and interaction terms, and it had excellent discrimination (c-index 0.904) and accuracy (Brier score 0.055). A risk prediction model for admissions to all (general/specialist) adult critical care units was developed using data from 155,239 admissions to 232 units (2012) and validated using data from 90,017 admissions to 216 units (2013). The model included systolic blood pressure, temperature, heart rate, respiratory rate, partial pressure of oxygen in arterial blood/fraction of inspired oxygen, pH, partial pressure of carbon dioxide in arterial blood, blood lactate concentration, urine output, creatinine level, urea level, sodium level, WBC count, platelet count, GCS score, age, dependency, past medical history, cardiopulmonary resuscitation, prior location/urgency, reason for admission and interaction terms, and it outperformed the current ICNARC model for discrimination and accuracy overall (c-index 0.885 vs. 0.869; Brier score 0.108 vs. 0.115) and across unit types. Risk prediction models for in-hospital cardiac arrest were developed using data from 14,688 arrests in 122 hospitals (2011–12) and validated using data from 7791 arrests in 143 hospitals (2012–13). The models included age, sex (for ROSC > 20 minutes), prior length of stay in hospital, reason for attendance, location of arrest, presenting rhythm, and interactions between rhythm and location. Discrimination for hospital survival exceeded that for ROSC > 20 minutes (c-index 0.811 vs. 0.720).

Limitations

The risk prediction models developed were limited by the data available within the current national clinical audit data sets.

Conclusions

We have developed and validated risk prediction models for cardiothoracic and adult (general and specialist) critical care units and for in-hospital cardiac arrest.

Future work

Future development should include linkage with other routinely collected data to enhance available predictors and outcomes.

Funding details

The National Institute for Health Research Health Services and Delivery Research programme.

Evaluation of the Effect of a Continuous Treatment: A Machine Learning Approach with an Application to Treatment for Traumatic Brain Injury

For a continuous treatment, the generalised propensity score (GPS) is defined as the conditional density of the treatment, given covariates. GPS adjustment may be implemented by including it as a covariate in an outcome regression. Here, the unbiased estimation of the dose-response function assumes correct specification of both the GPS and the outcome-treatment relationship. This paper introduces a machine learning method, the 'Super Learner', to address model selection in this context. In the two-stage estimation approach proposed, the Super Learner selects a GPS and then a dose-response function conditional on the GPS, as the convex combination of candidate prediction algorithms. We compare this approach with parametric implementations of the GPS and to regression methods. We contrast the methods in the Risk Adjustment in Neurocritical care cohort study, in which we estimate the marginal effects of increasing transfer time from emergency departments to specialised neuroscience centres, for patients with acute traumatic brain injury. With parametric models for the outcome, we find that dose-response curves differ according to choice of specification. With the Super Learner approach to both regression and the GPS, we find that transfer time does not have a statistically significant marginal effect on the outcomes.

Economic Evaluations in the Diagnosis and Management of Traumatic Brain Injury: A Systematic Review and Analysis of Quality

BACKGROUND

Economic evaluations provide a unique opportunity to identify the optimal strategies for the diagnosis and management of traumatic brain injury (TBI), for which uncertainty is common and the economic burden is substantial.

OBJECTIVE

The objective of this study was to systematically review and examine the quality of contemporary economic evaluations in the diagnosis and management of TBI.

METHODS

Two reviewers independently searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, Health Technology Assessment Database, EconLit, and the Tufts CEA Registry for comparative economic evaluations published from 2000 onward (last updated on August 30, 2013). Data on methods, results, and quality were abstracted in duplicate. The results were summarized quantitatively and qualitatively.

RESULTS

Of 3539 citations, 24 economic evaluations met our inclusion criteria. Nine were cost-utility, five were cost-effectiveness, three were cost-minimization, and seven were cost-consequences analyses. Only six studies were of high quality. Current evidence from high-quality studies suggests the economic attractiveness of the following strategies: a low medical threshold for computed tomography (CT) scanning of asymptomatic infants with possible inflicted TBI, selective CT scanning of adults with mild TBI as per the Canadian CT Head Rule, management of severe TBI according to the Brain Trauma Foundation guidelines, management of TBI in dedicated neurocritical care units, and early transfer of patients with TBI with nonsurgical lesions to neuroscience centers.

CONCLUSIONS

Threshold-guided CT scanning, adherence to Brain Trauma Foundation guidelines, and care for patients with TBI, including those with nonsurgical lesions, in specialized settings appear to be economically attractive strategies.

Single-center large-cohort study into quality of life in Dutch intensive care unit subgroups, 1 year after admission, using EuroQoL EQ-6D-3L

PURPOSE

The goal of this study was to describe long-term survival and health-related quality of life (HRQoL), measured by EQ-6D, in a general intensive care unit (ICU) population.

MATERIALS AND METHODS

We included 5934 consecutive adult patients admitted to a mixed-population ICU. There were no exclusion criteria. One-year survival status was determined using the Dutch municipal population register. Subsequently, all survivors received the EuroQoL EQ-6D-3L questionnaire. The primary outcome was overall HRQoL and survival of the ICU survivors, compared to overall QoL of an age- and sex-matched reference population.

RESULTS

A total of 5138 patients (86.6%) survived until hospital discharge, with 4647 (78.3%) patients surviving the 1-year of follow-up. The EuroQoL questionnaire was sent to 4465 survivors and returned by 3034 (68.0%) of 4465. The median HRQoL in surviving patients was 0.83 (interquartile range [IQR], 0.64-1.00) vs 0.86 (IQR, 0.85-0.86) in the reference population (P < .001). There was marked variation across admission diagnosis groups: cardiac surgery patients had an HRQoL of 0.94 (IQR, 0.74-1.00), whereas patients admitted with chronic renal failure had an HRQoL of 0.65 (IQR, 0.47-0.83).

CONCLUSIONS

One year after ICU admission, HRQoL was significantly lower than in the reference population. Notably, marked variations were found across subgroups.

Patterns of surgical care and complications in elderly adults

OBJECTIVES

To determine whether procedures, hospitals visited, and complications would differ according to decade in elderly adults and from those of younger adults.

DESIGN

Retrospective cohort study.

SETTING

The Anesthesia Quality Institute National Anesthesia Clinical Outcomes Registry (NACOR) is the largest database of anesthesia cases from academic and community hospitals and includes all insurance and facility types across the United States.

PARTICIPANTS

Eight million six hundred thirty-two thousand nine hundred seventy-nine cases from January 2010 to March 2013 were acquired. After exclusion of individuals younger than 18, nonapplicable locations, and brain death, 2,851,114 remained and were placed into age categories (18-64, 65-69, 70-79, 80-89, ≥ 90).

MEASUREMENTS

Participant, surgical, anesthetic, and hospital descriptors and short-term outcomes (major complications, mortality at <48 hours).

RESULTS

The largest number of older adults had surgery in medium-sized community hospitals. The oldest age group (≥ 90) underwent the smallest range of procedures; hip fracture, hip replacement, and cataract procedures accounted for more than 35% of all surgeries. Younger old adults underwent these procedures plus a significant proportion of spinal fusion, cholecystectomy, and knee surgery. Older adults had greater mortality and more complications than younger adults. Participants undergoing exploratory laparotomy had the greatest likelihood of death in any age category except 90 and older, in which small bowel resection predominated. The proportion of emergency surgery and the mortality associated with emergency surgery was 30% higher in the oldest group (≥ 90) than in adults aged 18 to 64.

CONCLUSION

This article reports the pattern of surgical procedures, complications, and mortality found in NACOR, which is one of the few data sets that contains data from community hospitals and individuals with all types of insurance. Because the outcomes portion of the data set is under development, it is not possible to investigate the relationship between hospital type and complications or mortality, but this study underscores the magnitude of geriatric surgery that occurs in community hospitals as an area for future outcomes studies.

The accuracy of alternative triage rules for identification of significant traumatic brain injury: a diagnostic cohort study

INTRODUCTION

Traumatic brain injury (TBI) is a leading cause of death and disability in young adults. Reorganisation of trauma services with direct triage of suspected head injury patients to trauma centres may improve outcomes following TBI. This study aimed to determine the sensitivity of principal English triage tools for identifying significant TBI.

METHODS

We performed a diagnostic cohort study using data prospectively collated from the Trauma Audit and Research Network database between 2005 and 2011. Adult head injury patients were retrospectively classified according to London Ambulance Service (LAS) and Head Injury Transportation Straight to Neurosurgery study (HITS-NS) triage criteria. Sensitivity and specificity were then calculated against a reference standard of significant TBI, comprising head region abbreviated injury score (AIS) ≥3 or neurosurgical operation.

RESULTS

6559 patients were included in complete case analyses. The LAS and HITS-NS triage tools demonstrated sensitivities of 44.5% (95% CI 43.2 to 45.9) and 32.6% (95% CI 31.4 to 33.9), respectively, for identifying significant TBI patients. False negative significant TBI cases were relatively older, more likely to be female, more frequently secondary to low-level falls, and were less likely to have very severe AIS five or six head injuries, p<0.01.

CONCLUSIONS

A considerable proportion of significant head injury patients may not be triaged directly to trauma centres. Investment is therefore necessary to improve the accuracy of existing triage rules and maintain expertise in TBI diagnosis and management in non-specialist emergency departments.

Changing patterns in the epidemiology of traumatic brain injury

Traumatic brain injury (TBI) is a critical public health and socio-economic problem throughout the world. Reliable quantification of the burden caused by TBI is difficult owing to inadequate standardization and incomplete capture of data on the incidence and outcome of brain injury, with variability in the definition of TBI being partly to blame. Reports show changes in epidemiological patterns of TBI: the median age of individuals who experience TBI is increasing, and falls have now surpassed road traffic incidents as the leading cause of this injury. Despite claims to the contrary, no clear decrease in TBI-related mortality or improvement of overall outcome has been observed over the past two decades. In this Perspectives article, we discuss the strengths and limitations of epidemiological studies, address the variability in its definition, and highlight changing epidemiological patterns. Taken together, these analyses identify a great need for standardized epidemiological monitoring in TBI.