Adherence to Guidelines in Adult Patients with Traumatic Brain Injury: A Living Systematic Review

Cnossen, Maryse C.; Scholten, Annemieke C.; Lingsma, Hester F.; Synnot, Anneliese; Tavender, Emma; Gantner, Dashiell; Lecky, Fiona; Steyerberg, Ewout W.; Polinder, Suzanne

doi:10.1089/neu.2015.4121

Cited by 68 publications

(53 citation statements)

References 57 publications

(143 reference statements)

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“…Our study confirms that, in the TBI field, paucity of evidence often results in low adherence to guidelines . This was confirmed by observing large variations between countries and centres.…”

Section: Discussionsupporting

confidence: 88%

Variation in the practice of tracheal intubation in Europe after traumatic brain injury: a prospective cohort study

Gravesteijn¹,

Sewalt

Ercole

et al. 2019

Anaesthesia

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Summary Traumatic brain injury patients frequently undergo tracheal intubation. We aimed to assess current intubation practice in Europe and identify variation in practice. We analysed data from patients with traumatic brain injury included in the prospective cohort study collaborative European neurotrauma effectiveness research in traumatic brain injury (CENTER‐TBI) in 45 centres in 16 European countries. We included patients who were transported to hospital by emergency medical services. We used mixed‐effects multinomial regression to quantify the effects on pre‐hospital or in‐hospital tracheal intubation of the following: patient characteristics; injury characteristics; centre; and trauma system characteristics. A total of 3843 patients were included. Of these, 1322 (34%) had their tracheas intubated; 839 (22%) pre‐hospital and 483 (13%) in‐hospital. The fit of the model with only patient characteristics predicting intubation was good (Nagelkerke R2 64%). The probability of tracheal intubation increased with the following: younger age; lower pre‐hospital or emergency department GCS; higher abbreviated injury scale scores (head and neck, thorax and chest, face or abdomen abbreviated injury score); and one or more unreactive pupils. The adjusted median odds ratio for intubation between two randomly chosen centres was 3.1 (95%CI 2.1–4.3) for pre‐hospital intubation, and 2.7 (95%CI 1.9–3.5) for in‐hospital intubation. Furthermore, the presence of an anaesthetist was independently associated with more pre‐hospital intubation (OR 2.9, 95%CI 1.3–6.6), in contrast to the presence of ambulance personnel who are allowed to intubate (OR 0.5, 95%CI 0.3–0.8). In conclusion, patient and injury characteristics are key drivers of tracheal intubation. Between‐centre differences were also substantial. Further studies are needed to improve the evidence base supporting recommendations for tracheal intubation.

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Section: Discussionsupporting

confidence: 88%

Variation in the practice of tracheal intubation in Europe after traumatic brain injury: a prospective cohort study

Gravesteijn¹,

Sewalt

Ercole

et al. 2019

Anaesthesia

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“…Adherence to the NICE CT-scan guidance was highest, reaching 70-100% in the ve studies referenced. 16 Despite high compliance, this study does not prove that the NICE guideline is always clinically safe. In a larger study 17 2.4% of patients with a positive CT scan did not meet NICE criteria.…”

Section: Discussionmentioning

confidence: 70%

“…This implies the guideline is relevant, valid and its clinical application is supported by ED doctors. A systematic review 16 investigating the adherence to guidelines in TBI showed that internationally compliance was quite variable between 18-100%. Adherence was highest in centres using guidelines based on strong evidence.…”

Section: Discussionmentioning

confidence: 99%

Acute traumatic brain injury presentations and the use of head CT scans in the Emergency Department

Rogan¹,

Patel²,

Birdling³

et al. 2020

Preprint

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Objective: The use of CT head scanning for traumatic brain injury (TBI) is a vital diagnostic tool, guided by risk stratification tools. This study aims to review the use of CT head scans for TBI in two Australasian Emergency Departments (ED) in New Zealand.Methods: Retrospective observational design of patients referred for head CT from ED to exclude a significant intracranial injury between 1st September 2018 and 31st August 2019. Clinical data were collected regarding presenting patterns, identification of injuries on CT scan and adherence to CT guidelines.Results: Out of 425 cases reviewed, a clinically significant injury was identified in 41 (10%) patients. Patients who reported loss (32% vs 20% p < 0.05) or possible loss of consciousness (34% vs 22% p < 0.05) and had GCS < 13 (17% vs 8%, p < 0.05) or focal neurology (10% vs 3%, p < 0.05) were more likely to have a significantly intracranial injury on CT. Interestingly, 17 (41%) patients with significant injury were GCS 15 with no focal neurology. NICE guidelines were adhered to in 364 (86%) patients. In the 14% of cases that did not meet guideline criteria, all CT head scans were negative.Conclusion: CT head scans are a valuable tool in TBI and guidelines successfully identify those with significant intracranial injuries. However, the rate of significant injury for the total population requiring head CT remains low, with over 90% of head CTs in the population normal, despite high guideline compliance perhaps identifying a role for novel objective tests in ED guidelines internationally.

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“…Current evidence-based guidelines for the treatment of TBI were generated from studies conducted in developed countries. [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32]39 It is estimated that 80% of the global population live in developing economies 40 in which access to resources required for optimum treatment is limited. There are few guidelines focused on the management of TBI in low and middle income countries with organized international methodology.…”

Section: Discussionmentioning

confidence: 99%

“…8,34 Most of these guidelines, developed in high and low-middle income countries do not fill the gaps of different scenarios in real-life situations due to the methodology itself, attached to the evidence-based methodological science. [40][41][42][43][44] In real circumstances, not all the resources are always available on time, especially in LMICs. 45 The present effort is focused on filling these gaps with a mixed methods approach combining evidence-based recommendations and expert opinion where there is no evidence-based medicine to develop helpful recommendations for real-life situations in different context with resources level variation.…”

Section: Discussionmentioning

confidence: 99%

Recommendations of the Colombian Consensus Committee for the Management of Traumatic Brain Injury in Prehospital, Emergency Department, Surgery, and Intensive Care (Beyond One Option for Treatment of Traumatic Brain Injury: A Stratified Protocol [BOOTStraP])

Rubiano

Vera

Montenegro³

et al. 2020

J Neurosci Rural Pract

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Abstract Background Traumatic brain injury (TBI) is a global public health problem. In Colombia, it is estimated that 70% of deaths from violence and 90% of deaths from road traffic accidents are TBI related. In the year 2014, the Ministry of Health of Colombia funded the development of a clinical practice guideline (CPG) for the diagnosis and treatment of adult patients with severe TBI. A critical barrier to the widespread implementation was identified—that is, the lack of a specific protocol that spans various levels of resources and complexity across the four treatment phases. The objective of this article is to present the process and recommendations for the management of patients with TBI in various resource environments, across the treatment phases of prehospital care, emergency department (ED), surgery, and intensive care unit. Methods Using the Delphi methodology, a consensus of 20 experts in emergency medicine, neurosurgery, prehospital care, and intensive care nationwide developed recommendations based on 13 questions for the management of patients with TBI in Colombia. Discussion It is estimated that 80% of the global population live in developing economies where access to resources required for optimum treatment is limited. There is limitation for applications of CPGs recommendations in areas where there is low availability or absence of resources for integral care. Development of mixed methods consensus, including evidence review and expertise points of good clinical practices can fill gaps in application of CPGs. BOOTStraP (Beyond One Option for Treatment of Traumatic Brain Injury: A Stratified Protocol) is intended to be a practical handbook for care providers to use to treat TBI patients with whatever resources are available. Results Stratification of recommendations for interventions according to the availability of the resources on different stages of integral care is a proposed method for filling gaps in actual evidence, to organize a better strategy for interventions in different real-life scenarios. We develop 10 algorithms of management for building TBI protocols based on expert consensus to articulate treatment options in prehospital care, EDs, neurological surgery, and intensive care, independent of the level of availability of resources for care.

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Adherence to Guidelines in Adult Patients with Traumatic Brain Injury: A Living Systematic Review

Cited by 68 publications

References 57 publications

Variation in the practice of tracheal intubation in Europe after traumatic brain injury: a prospective cohort study

Variation in the practice of tracheal intubation in Europe after traumatic brain injury: a prospective cohort study

Acute traumatic brain injury presentations and the use of head CT scans in the Emergency Department

Recommendations of the Colombian Consensus Committee for the Management of Traumatic Brain Injury in Prehospital, Emergency Department, Surgery, and Intensive Care (Beyond One Option for Treatment of Traumatic Brain Injury: A Stratified Protocol [BOOTStraP])

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