Evaluation of the effect of intensity of care on mortality after traumatic brain injury

Abstract

Objectives-To evaluate the effect of age on intensity of care provided to traumatically braininjured adults and to determine the influence of intensity of care on mortality at discharge and 12 months postinjury, controlling for injury severity.Design-Cohort study using the National Study on the Costs and Outcomes of Trauma (NSCOT) database. Risk ratio and Poisson regression analyses were performed using data weighted according to the population of eligible patients.Setting and Patients-A total of 18 level 1 and 51 level 2 non-trauma centers located in 14 states in the United States and 1,776 adults aged 25−84 yrs with a diagnosis of traumatic brain injury. Measurements-Injury severity was determined by the motor component of the Glasgow ComaScale score, the Injury Severity Score, pupillary reactivity, and presence of midline shift. Factors evaluated as contributing to intensity of care included: admission to the intensive care unit, mechanical ventilation, placement of an intracranial pressure monitor, placement of a jugular bulb catheter, placement of a pulmonary artery catheter, critical care consultation, the number of specialty care consultations, mannitol use, treatment with barbiturate coma, decompressive craniectomy, number of nonneurosurgical procedures performed, the presence of a do-not-resuscitate order, and withdrawal of therapy.Main Results-Controlling for injury-related factors, sex, and comorbidity, as age increased, the overall likelihood of receiving various interventions decreased. After controlling for injury severity, sex, and comorbidity, factors associated with higher risk of in-hospital death were: being aged 75 −84 yrs (relative risk [RR] 1.32, 95% confidence interval [CI] 1.13, 1.55), pulmonary artery catheter use (RR 1.56, 95% CI 1.30, 1.86), intubation (RR 4.17, 95% CI 2.28, 7.61), the presence of a donot-resuscitate order (RR 3.21, 95% CI 2.21, 4.65), and withdrawal of therapy (RR 2.33, 95% CI 1.69, 3.23). In contrast, a higher number of specialty care consultations (surgical consults: RR 0.63, 95% CI 0.54, 0.74; medical consults: RR 0.87, 95% CI 0.79, 0.95; and other consults: RR 0.43, 95% CI 0.26, 0.69) were associated with decreased risk of death. The results were similar for factors associated with death at 12 months, with the exception that the number of medical consultations was not significant, whereas the number of nonneurosurgical procedures performed was associated with lower risk of death (RR 0.96, 95% CI 0.92, 0.99), as was obtaining critical care consultation services (RR 0.84, 95% CI 0.71, 1.0).Conclusions-There is a lower intensity of care provided to older adults with traumatic brain injury. Although the specific contributions of specialists to patient management are unknown, theirThe authors have not disclosed any potential conflicts of interest.Work for this study was performed at the University of Washington, Seattle, WA. By the year 2030, the number of Americans aged ≥65 will exceed 70 million, doubling current figures (1). Along with this increase in the...

External Validation and Recalibration of Risk Prediction Models for Acute Traumatic Brain Injury among Critically Ill Adult Patients in the United Kingdom

“…Of the 23 full text papers reviewed, 13 were excluded either because they were not studies that had developed or evaluated risk prediction models for TBI or because the models included predictors measured outside of the hospital, leaving 10 studies published since 2006 (reporting 78 models) meeting the Perel and colleagues inclusion criteria. 22,27,30,[35][36][37]39,40,42,43 Of these 10 studies, eight did not fulfil the RAIN Study eligibility criteria-because the models had been developed in pediatric populations (n = 3), were based on samples of fewer than 500 patients (n = 6), adjusted for care received within hospital (n = 1), or had been conducted in a single-center, non-UK setting (n = 6)-resulting in two eligible studies (reporting 14 models). 35,40 Additionally including the two studies reporting the most clinically useful models from the original systematic review resulted in four studies (reporting 17 models) for review by the RAIN Study Steering Group-the models of Signorini and colleagues (1999), The RAIN Study Steering Group did not identify any further studies, either published or ongoing, that would be potentially eligible for the RAIN Study (date of meeting, April 17, 2009).…”

Happy Birthday, Mom; Your Card Is Not in the Mail

“…Older adults experience undertriage, undertreatment, and even therapeutic nihilism (Ausman, 2008;Chang, Bass, Cornwell, & MacKenzie, 2008;Fairhead & Rothwell, 2006;Luker & Grimmer-Somers, 2008;Scheetz, 2004;Stalnikowicz, Mahamid, Kaspi, & Brezis, 2005;Thompson et al, 2008). Further, while much of our research focus has been placed on reducing health disparities, there are few published studies to date about how to specifically address ageism.…”

Treatment withdrawal and acute brain injury: an integral part of care

“…G. R. Dunstan, Professor of Moral and Social Theology, 1995 [1] Critical care medicine has evolved rapidly over the last two decades, with therapeutic and technological advances leading to improved outcome in a wide variety of life-threatening conditions. This is particularly true for acute brain injury where improved understanding of pathophysiology, in association with advances in monitoring and imaging techniques, has led to the introduction of more effective and individualised treatment strategies that have translated into improved outcomes [2][3][4]. Acute brain injury can occur from a variety of causes including trauma, subarachnoid and intracerebral haemorrhage, and acute ischaemic stroke.…”

“…Acute brain injury can occur from a variety of causes including trauma, subarachnoid and intracerebral haemorrhage, and acute ischaemic stroke. Patients who were previously deemed to be unsalvageable are now being admitted to intensive care units, allowing many to recover beyond initial expectations [4,5]. Others will have a poor outcome despite maximal intervention and it is essential that early aggressive treatment is linked to a timely switch to compassionate end-of-life care if a satisfactory degree of neurological recovery is not possible.…”

“…In anaesthetic practice they have been reported for monitoring neuromuscular function [4], measuring 15-degree tilt in obstetric patients [5] and as an aid during resuscitation [6]. The rise in the use of mobile phones, from concern over their use near sensitive medical devices [7] to their ubiquitous presence in all clinical areas [8], and now their use as medical devices themselves, is extraordinary.…”