Acute Management

 

 

The most severe consequences of an ABI are often not due to the initial trauma itself. Secondary brain injury can result in edema, ischemia, elevated intracranial pressure and inadequate cerebral perfusion pressure, as well as a cellular cascade resulting in calcium imbalances, excitatory amino acid release and free radical production; all of which can lead to cell death (Zasler et al. 2007). For this reason, the speed and intensity with which patients are cared for is of the utmost importance. Assessments of how to acutely treat patients with ABI generally fall into one of four categories: pre-hospital care, hospital facility type, adherence to acute care guidelines, and discharge destination. Each of these areas presents a unique challenge. Chapter 16 of this systematic review reports the current evidence for acute treatment of ABI. Here we have attempted to highlight concerns and elucidate attempts being made to improve the current system of care.

Pre-hospital care can be the difference between life and death. The time from injury to intervention is perhaps the most obvious component of pre-hospital care but debate has also arisen regarding the types of treatments that are suitable prior to hospital arrival. In 2000, the BTF released guidelines for pre-hospital management of patients with ABI. An Emergency Medical Service task force developed a consensus based algorithm (Gabriel et al. 2002). The guidelines were then updated in 2007 (Badjatia et al. 2007). Nevertheless, the variability in the way in which care is delivered in the US is still fairly unknown (Bulger et al. 2007). This has also shown to be true of other countries that have begun to examine protocols for out-of-hospital care (Baethmann et al. 1999; Harrington et al. 2005). Research has been conducted regarding the efficiency of transfer and access to trauma centers in general (Bulger et al. 2007) but little to no research has been performed specifically for brain Injury.

Facility type is also of prime interest relative to the specific needs of the patient. Trauma care facilities have proven to be superior to general care facilities for emergency medical care. MacKenzie et al. (2007) noted patients with head injuries, Abbreviated Injury Scale score ≥3, showed a 90% survival rate at 12-month follow up in trauma centers compared to 64.3% in non-trauma centers. The availability of trauma centers tends to be dictated by local needs and resources. In the absence of such a facility, local centers must be able to handle ABI effectively and transport them when necessary to a properly equipped center.

As mentioned earlier, guidelines have been established by organizations such as the BTF and the European Brain Injury Consortium to standardize treatment and to aid in the dissemination of information. Audits of guideline implementation can help to ensure that a proper level of care is provided in all types of medical centers. A study by Griesdale et al. (2015) revealed that adherence to BTF guidelines regarding cerebral perfusion pressure was low with recommended pressure ranges occurring only 31.6% of the time. In addition, Talving et al. (2013) also reported that compliance of BTF guidelines for monitoring intracranial pressure (ICP) was at 46.8%, resulting in signficantly higher mortality and brain herniation among patients not receiving ICP monitoring (Talving et al. 2013). Despite these figures, Shafi et al. (2014) revealed a mean compliance rate of 73% to the BTF guidelines, with 3 of 11 level-1 trauma centres achieving rates of over 80%, thus indicating improvements of clinicians and health professionals transitioning into new methods of practice.  In the US alone, it is estimated that a modest improvement to 50% adherence of BTF guidelines from 33% would result in 989 lives saved annually (Faul et al. 2007). Adherence to guidelines is a continuous process, and has a direct impact on patient care.   

The final stage of acute care involves the transition to post-acute care. Once patients are medically stable they are transferred to one of three places: home, long term care or a rehabilitation unit. Rehabilitation units for patients with ABI can consist of hospital-based inpatient rehabilitation centers or specialized rehabilitation units that often focus on behavioural issues. How and by whom this decision is made may greatly affect the type of care that is received by patients. Several factors, such as availability of rehabilitation spaces, the patient’s support needs and the patient’s financial situation may play a role in this decision. In the US, Medicaid patients were 68% and Health Maintenance Organization patients were 23% more likely to be discharged to a skilled nursing facility than those on a fee-for-service plan (Chan et al. 2001). In Canada, patients injured in a motor vehicle accident were 1.6 times more likely to be discharged home with support services than those who were injured in a fall (Kim et al. 2006), likely due to the greater availability of resources accompanying the former injury. 

Table: Individual Studies of Models for Acute ABI Management

Discussion

Guideline adherence was the most highly analyzed component of acute ABI care. In a survey by Rusnak et al. (2007) only adherence to the recommendations regarding blood pressure, oxygenation resuscitation, and cerebral perfusion pressure maintenance were seen to be significantly related to ICU survival in Austria. Similarly, Myburgh et al. (2008) reported that concordance with BTF guidelines was frequently observed with supportive measures for thromboprophylaxis, head elevation, gastric ulcer prophylaxis and nutrition. However, less than half of patients with severe TBI were monitored for ICP, indicating a much-needed area for improvement. In the USA, Level I centers were significantly more likely to adhere to most American Association of Neurological Surgeons guideline recommendations (Hesdorffer & Ghajar 2007). The study found that increased adherence resulted in a decreased use of contraindicated treatments, such as corticosteroids. In a pre-post study, when BTF guidelines were followed, patients had a 9.13 times greater odds ratio in favor of “good outcome” in six-month Glasgow Outcome Scale (GOS) scores (Palmer et al. 2001). Although adherence to best practice recommendations is the goal, deviations from these protocols are frequent with a TBI population due to the complexity of their injuries (Schirmer-Mikalsen et al. 2013). There was an associated increase in acute care costs with guideline adherence; however, the cost may be justifiable based on the improved patient outcomes (Palmer et al. 2001). Others have argued that the National Institute for Health and Clinical Excellence guidelines in the UK do not support cost effective care (Goodacre 2008).

Another prominent concern in acute care is death; reducing mortality rates is thus a primary goal for all trauma centers and ICUs. Tobi and Azeez (2016) found no significant difference in mortality rates between TBI and non-TBI patients admitted to the ICU. Among patients with TBI, Godbolt et al. (2015) noted a survival rate of 88% in a cohort of 100 patients, with 56% having a favorable outcomes. Furthermore, Myburgh et al. (2008) reported no changes in mortality rate after new guideline and protocol implementation; many studies have proven the contrary. Fakhry et al. (2004) found that patients treated according to the BTF guidelines not only showed improvements in mortality rates but also GOS scores, LOS and cost per patient. Standard Trauma Protocol implementation was investigated by Kesinger et al. (2014), it was found that mortality rates were halved, with severe TBI mortality four times less likely after these guideline protocols were introduced. Mejaddam et al. (2013) determined that longer emergency department LOS significantly increased the survival rates in ICU patients, but not in patients requiring an operation.

Bulger et al. (2002) identified ICP management as an indicator of the aggressiveness of acute care management. Centers adhering to an “aggressive” protocol were significantly more likely to administer ICP monitoring, provide neurosurgical consultation, use osmotic agents and perform head CT scans. While the aggressive centers reported decreased mortality rates, the division of centers was rather arbitrary and further study into potential confounding factors is necessary. Patients cared for in a Level I trauma center also showed decreased mortality rates, fewer complications, and were less likely to experience progression of neurological insult relative to patients cared for in a Level II trauma center (DuBose et al. 2008). These results were maintained even after adjusting for patient severity. These findings may be explained through Ghajar et al. (1995) who found Level I trauma centers monitor ICP more frequently than Level II or III centers.

The final stage of acute ABI is the discharge of patients who are medically stable. Guideline adherence is also influential in this realm, with a study by Kramer and Zygun (2013) showing that a series of practice modifications implemented over an 11 year span, resulted in a greater number of individuals being discharged home. Discharge destination varies significantly based on regional differences. Factors such as the health care system, regional funding, rehabilitation facility availability, and the patient’s specific needs can all play a role in the final decision. In a cohort of 100 patients Godbolt et al. (2015) noted that 85% of participants were discharge to inpatient rehabilitation within one year, whereas de Koning et al. (2015), in a retrospective analysis of 330 patients found an initial discharge destination of 36% to inpatient and 45% to home/nursing home, with 94% of participants returning home after one year. Chan et al. (2001) showed that patients in the US with Medicaid health insurance were significantly more likely to go to a skilled nursing facility than those who were covered by Healthcare Maintenance Organizations or fee-for-service plans. However, Esselman et al. (2004) found that there were no difference in referral rates to rehabilitation or skilled nursing facilities between those injured violently and non-violently, despite that patients who were violently injured were more likely to be funded by Medicaid. In Canada, universal health care is designed to allow for equal access to healthcare resources but there is variability based on different provincial health care plans and the availability of additional third-party insurance funding. For example, patients injured in a motor vehicle accident were 1.6 times more likely to be discharged home without support services than those injured in falls with similar injuries (Kim et al. 2006). This suggests that insurance supplementation can influence resource access. Finally, Foster et al. (2000) found Australian patients who were younger and treated in a designated brain injury rehabilitation unit were more likely to be referred for inpatient rehabilitation. Jourdan et al. (2013) found that approximately 64% of patients were admitted to a rehabilitation program. Orthopedic injuries, CT Marshall scan score and a longer stay in ICU were all significant predictors of discharge to rehabilitation ( Jourdan et al. 2013).

Three of the studies identified made reference to pre-hospital care of patients with ABI (Baethmann et al. 1999; Citerio et al. 2003; Myburgh et al. 2008). Baethmann et al. (1999) was the only study to specifically focus on pre-hospital and early hospital care and had medical students act as observers during primarily helicopter rescues of patients suspected to have sustained a brain injury. In 75% of cases, the rescue team arrived at the accident scene in less than 11 minutes after dispatch center alarm, intubation was made within 37 minutes, hospital admission was within 74 minutes, and completion of the CT scan was within 120 minutes. The use of helicopter rescue with an on-board emergency physician made transfers more efficient, as well as referrals to neurotrauma centers more accurate. Citerio et al. (2003) found patients admitted directly from the accident site to a neurotrauma center in Italy took 79 minutes to reach the first emergency room. For patients indirectly admitted, it took 59 minutes to reach the first emergency room but averaged 300 minutes before reaching the neurotrauma center. Finally Myburgh et al. (2008) reported the mean time to admission at the first hospital was 63 minutes and 56.4% of these patients were admitted directly to a tertiary trauma center. The time of arrival to a trauma center versus a non-trauma center was comparable.

Conclusions

There is Level 2 evidence that patients cared for in a Level I trauma center experience fewer complications, have a lower likelihood of progression of the neurological insult, and reduced mortality rates compared to patients cared for in a Level II center.

There is Level 2 evidence suggesting that reduction in the time spent in acute care and in rehabilitation does not have a negative impact on overall patient outcomes. 

There is Level 2 evidence indicating the overall cost of care is directly related to injury severity.

There is Level 2 evidence that guideline adherence in acute care results in improved functional outcomes.

There is Level 2 evidence that standardized trauma protocols result in decreased mortality rates and improved outcomes for patients with TBI.

There is Level 4 evidence that adherence to Brain Trauma Foundation guidelines for acute care results in improved outcomes and decreased mortality. 

 

 

Patients cared for in a Level I trauma center had better outcomes compared to individuals cared for in a Level II center.

Reducing the time spent in acute care and rehabilitation does not have a negative effect on patient outcomes; although, it can place a greater burden on the family and outpatient rehab services.

Adherence to Brain Trauma Foundation acute care guidelines results in improved patient outcomes and decreased mortality.

Level of injury impacts the total cost of care.

TBI survivors in acute care are as likely to experience medical complications, but less likely to experience neurological complications, when compared to TBI non-survivors.