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Original Investigation
May 8, 2019

Association of Statewide Implementation of the Prehospital Traumatic Brain Injury Treatment Guidelines With Patient Survival Following Traumatic Brain Injury: The Excellence in Prehospital Injury Care (EPIC) Study

Author Affiliations
  • 1Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Phoenix
  • 2Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
  • 3Arizona Department of Health Services, Bureau of EMS, Phoenix, Arizona
  • 4Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson
  • 5Barrow Neurological Institute at Phoenix Children’s Hospital, Department of Child Health/Neurosurgery, College of Medicine, The University of Arizona, Phoenix
JAMA Surg. Published online May 8, 2019. doi:10.1001/jamasurg.2019.1152
Key Points

Question  Is implementation of prehospital TBI treatment guidelines in demographically diverse emergency medical services systems associated with survival in patients with major traumatic brain injury (TBI)?

Findings  In this cohort study, among 21 852 patients with moderate, severe, or critical TBI (15 228 preimplementation and 6624 postimplementation), guideline implementation was not associated with improved adjusted survival. However, it was associated with improved outcome in the severe and severe, intubated subgroups.

Meaning  Statewide implementation of the prehospital TBI guidelines was independently associated with improvement in survival among patients with severe TBI and in the severe, intubated group; these findings support the widespread implementation of the prehospital TBI treatment guidelines.

Abstract

Importance  Traumatic brain injury (TBI) is a massive public health problem. While evidence-based guidelines directing the prehospital treatment of TBI have been promulgated, to our knowledge, no studies have assessed their association with survival.

Objective  To evaluate the association of implementing the nationally vetted, evidence-based, prehospital treatment guidelines with outcomes in moderate, severe, and critical TBI.

Design, Setting, and Participants  The Excellence in Prehospital Injury Care (EPIC) Study included more than 130 emergency medical services systems/agencies throughout Arizona. This was a statewide, multisystem, intention-to-treat study using a before/after controlled design with patients with moderate to critically severe TBI (US Centers for Disease Control and Prevention Barell Matrix-Type 1 and/or Abbreviated Injury Scale Head region severity ≥3) transported to trauma centers between January 1, 2007, and June 30, 2015. Data were analyzed between October 25, 2017, and February 22, 2019.

Interventions  Implementation of the prehospital TBI guidelines emphasizing avoidance/treatment of hypoxia, prevention/correction of hyperventilation, and avoidance/treatment of hypotension.

Main Outcomes and Measures  Primary: survival to hospital discharge; secondary: survival to hospital admission.

Results  Of the included patients, the median age was 45 years, 14 666 (67.1%) were men, 7181 (32.9%) were women; 16 408 (75.1% ) were white, 1400 (6.4%) were Native American, 743 (3.4% ) were Black, 237 (1.1%) were Asian, and 2791 (12.8%) were other race/ethnicity. Of the included patients, 21 852 met inclusion criteria for analysis (preimplementation phase [P1]: 15 228; postimplementation [P3]: 6624). The primary analysis (P3 vs P1) revealed an adjusted odds ratio (aOR) of 1.06 (95% CI, 0.93-1.21; P = .40) for survival to hospital discharge. The aOR was 1.70 (95% CI, 1.38-2.09; P < .001) for survival to hospital admission. Among the severe injury cohorts (but not moderate or critical), guideline implementation was significantly associated with survival to discharge (Regional Severity Score–Head 3-4: aOR, 2.03; 95% CI, 1.52-2.72; P < .001; Injury Severity Score 16-24: aOR, 1.61; 95% CI, 1.07-2.48; P = .02). This was also true for survival to discharge among the severe, intubated subgroups (Regional Severity Score–Head 3-4: aOR, 3.14; 95% CI, 1.65-5.98; P < .001; Injury Severity Score 16-24: aOR, 3.28; 95% CI, 1.19-11.34; P = .02).

Conclusions and Relevance  Statewide implementation of the prehospital TBI guidelines was not associated with significant improvement in overall survival to hospital discharge (across the entire, combined moderate to critical injury spectrum). However, adjusted survival doubled among patients with severe TBI and tripled in the severe, intubated cohort. Furthermore, guideline implementation was significantly associated with survival to hospital admission. These findings support the widespread implementation of the prehospital TBI treatment guidelines.

Trial Registration  ClinicalTrials.gov: NCT01339702

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