Piper LC, Zogg CK, Schneider EB, Orman JA, Rasmussen TE, Blackbourne LH, Haider AH. Guidelines for the Treatment of Severe Traumatic Brain InjuryAre They Used?. JAMA Surg. 2015;150(10):1013-1015. doi:10.1001/jamasurg.2015.1838
Persons with severe traumatic brain injury (STBI) are frequently admitted to the neurologic intensive care unit. Each year, an estimated 1.4 million people in the United States have a TBI, resulting in 235 000 hospitalizations, 50 000 deaths, and $56.3 million in direct/indirect costs. Evidence-based guidelines for the management of patients with STBI have been available from the Brain Trauma Foundation (BTF) since 1995.1 Current recommendations, particularly those related to intracranial pressure (ICP),1 remain controversial owing to the questions raised by single-center studies and international trials about the benefit2- 4 and feasibility5 of implementation. Based on a national assessment of US trauma medical directors (TMDs), the objective of our study was to determine the extent to which BTF guidelines are used.
Our study was conducted as part of a larger project assessing the military-to-civilian translation of battlefield innovations in surgical trauma care, the methods of which have been previously described.6 The TMDs provided written informed consent and completed an anonymous, uncompensated electronic survey designed to collected data on trauma center demographics and on use of BTF guidelines. The survey was designed using a modified Delphi technique involving multiple consultations with an expert physician/surgeon panel. Pilot testing was conducted among a group of 12 trauma-section chiefs. Descriptive statistics compared differences in trauma center level (levels I-III). The institutional review board of the Johns Hopkins University School of Medicine approved our study.
A total of 245 TMDs—representing nearly 40% of trauma centers (ie, 245 of 630 centers) in the United States—completed the survey (Table). Fourteen TMDs (5.7%) indicated that they do not have policies in place reflecting BTF guidelines; an additional 204 TMDs (83.3%) indicated that, although policies reflecting BTF guidelines are in place, these guidelines are completely followed in less than 75% of STBI cases. Use of the BTF guidelines varied by trauma center level. For example, while only 3 of 108 level I centers (2.8%) indicated a lack of institutional policies reflecting guideline use, 6 of 65 level III centers (9.2%) indicated the same (P < .001). Compliance with recommendation-specific guidelines1 was moderately high (>50%) with 2 exceptions: ICP and hypotonic saline. The majority of level I centers (ie, 69 of 108 [63.9%]) reported ICP use in more than 60% of STBI cases, while 45 of 65 of level III centers (69.2%) acknowledged use in less than 20% of cases (P < .001). Comparable results were observed for hypotonic saline, with 66.0% of level I centers using hypotonic saline in more than 60% of STBI cases and 78.5% of level III centers using it in less than 20% of cases.
Following published reports of battlefield efficacy during the Iraq and Afghanistan wars and publication of the most recent BTF guidelines in 2007,1 93 of 245 TMDs (38.0%) indicated resurgences in the use of decompressive craniectomy for patients with medically refractory intracranial hypertension between 2001 and 2011. An additional 105 TMDs (42.9%) indicated increases in the procedure for patients with acute STBI (excluding epidural hematomas). Reported increases were most common in level III centers (P < .001) (Table).
Mixed evidence surrounding the use of BTF guidelines created controversy about the appropriateness of and need for implementation in a civilian population1- 5; single-center studies point to both positive2 and neutral5 effects. The more widely recognized studies include a 2008-2011 trial of ICP conducted among 324 patients in Bolivia and Ecuador by Chesnut et al,3 who found no difference in a composite measure of functional/cognitive status comparing patients with TBI managed using ICP with those managed using imaging/clinical-examination modalities.3 How generalizable the findings are to other contexts, such as the United States, and how the results may have changed in more recent years since publication of the most recent BTF guidelines remain topics of debate.3,4
Our findings assessing the extent of policies reflecting the use of BTF guidelines among US trauma centers point to a similar trend. While the majority of TMDs reported institutional policies and perceived use consistent with overall use of BTF guidelines, use of more specific contentious recommendations, such as ICP monitoring, varied. Of 245 TMDs, 150 (61.2%) stated that ICP policies were implemented in less than 60% of STBI cases. Study limitations, including the potentially subjective nature of the TMDs’ reports, need to be taken into account.6
Corresponding Author: Adil H. Haider, MD, MPH, Department of Surgery, Brigham and Women’s Hospital, 1620 Tremont St, One Brigham Circle, Ste 4-020, Boston, MA 02120 (firstname.lastname@example.org).
Published Online: August 12, 2015. doi:10.1001/jamasurg.2015.1838.
Author Contributions: Drs Haider and Piper had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Zogg, Schneider, Orman, Rasmussen, Blackbourne, Haider.
Acquisition, analysis, or interpretation of data: Piper, Zogg, Haider.
Drafting of the manuscript: Piper, Zogg.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Zogg.
Administrative, technical, or material support: Zogg, Orman, Rasmussen, Blackbourne, Haider.
Study supervision: Zogg, Schneider, Rasmussen, Haider.
Conflict of Interest Disclosures: None reported.
Previous Presentation: This paper was presented at the 86th Annual Meeting of the Pacific Coast Surgical Association; February 20, 2015; Monterey, California.
Additional Contributions: We would like to extend our deepest gratitude to Frank K. Butler, MD (Department of Military and Emergency Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland); Robert T. Gerhardt, MD, MPH (Department of Emergency Medicine, Brooke Army Medical Center, Joint Base San Antonio–Fort Sam Houston, Texas); Elliot R. Haut, MD, PhD (Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland); Jacques P. Mather, MD, MPH (Department of General Surgery, University of Miami/Jackson Memorial Medical Center, Miami, Florida); Ellen J. MacKenzie, PhD (Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland); Diane A. Schwartz, MD (Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland); David W. Geyer, MD (Department of Anesthesiology, Reading Health System, West Reading, Pennsylvania); and Joseph J. DuBose, MD (Department of Surgery, University of Maryland School of Medicine, Baltimore), all of whom contributed significantly to the design and conduct of this study and the interpretation of the data.