External validation of the updated Brain Injury Guidelines for complicated mild traumatic brain injuries: a retrospective cohort study

Abstract

OBJECTIVE Approximately 10% of patients with mild traumatic brain injury (mTBI) have intracranial bleeding (complicated mTBI) and 3.5% eventually require neurosurgical intervention, which is mostly available at centers with a higher level of trauma care designation and often requires interhospital transfer. In 2018, the Brain Injury Guidelines (BIG) were updated in the United States to guide emergency department care and patient disposition for complicated mild to moderate TBI. The aim of this study was to validate the sensitivity and specificity of the updated BIG (uBIG) for predicting the need for interhospital transfer in Canadian patients with complicated mTBI. METHODS This study took place at three level I trauma centers. Consecutive medical records of patients with complicated mTBI (Glasgow Coma Scale score 13–15) who were aged ≥ 16 years and presented between September 2016 and December 2017 were retrospectively reviewed. Patients with a penetrating trauma and those who had a documented cerebral tumor or aneurysm were excluded. The primary outcome was a combination of neurosurgical intervention and/or mTBI-related death. Sensitivity and specificity analyses were performed. RESULTS A total of 477 patients were included, of whom 8.4% received neurosurgical intervention and 3% died as a result of their mTBI. Forty patients (8%) were classified as uBIG-1, 168 (35%) as uBIG-2, and 269 (56%) as uBIG-3. No patients in uBIG-1 underwent neurosurgical intervention or died as a result of their injury. This translates into a sensitivity for predicting the need for a transfer of 100% (95% CI 93.2%–100%) and a specificity of 9.4% (95% CI 6.8%–12.6%). Using the uBIG could potentially reduce the number of transfers by 6% to 25%. CONCLUSIONS The patients in uBIG-1 could be safely managed at their initial center without the need for transfer to a center with a higher level of neurotrauma care. Although the uBIG could decrease the number of transfers, further refinement of the criteria could improve its specificity.

Reducing low-value interhospital transfers for mild traumatic brain injury

“…This study demonstrates that the mBIG algorithm 5 provides a safe framework to assess patient risk for progression of TBI in this patient population, and therefore, resources can, and should, be assigned accordingly. Several validation studies 6–9 support this. In their prospective analysis using a slight algorithmic variation of the original BIG, 3 Ross et al 7 found that no BIG 1 or BIG 2 patients demonstrated a clinical decline or required any further NSG intervention.…”

“…Of those ICU admissions, most (n = 45, 65.2%) were downgraded in less than 48 hours. For mBIG2 patients, the median hospital LOS was 5 (IQR, [4][5][6][7][8][9] with the majority initially admitted to the ICU (n = 54, 88.5%). Again, most (n = 38, 62.3%) were in the ICU for less than 48 hours (Table 3).…”

“…From a resource utilization perspective, a consequential application for mBIG is in the potential for reducing unnecessary, "lowvalue" interhospital transfers for mild TBI. In recent years, several validation studies [5][6][7][8][9] have assessed the safety and reproducibility of BIG and its adaptations. However, the clinical and financial impact of these guidelines on interhospital patient transfer protocols remains poorly defined, especially in large metropolitan areas, where transport time between healthcare facilities may be rapid.…”

Clinical Best Practice Integration (cBPI): A Dynamic Model for Increasing Adherence to Evidence-Based Practice

“…To satisfy requirements of this phase of the cBPI pipeline, the team reviewed a decade of studies from different hospital systems totaling over 9000 patients. This research shows that adherence to BIG provides high-quality, safe care for patients 4–7. Waste is reduced by eliminating unnecessary transfers, follow-up imaging, and neurosurgery consults.…”

“…This research shows that adherence to BIG provides high-quality, safe care for patients. [4][5][6][7] Waste is reduced by eliminating unnecessary transfers, follow-up imaging, and neurosurgery consults. Simultaneously, value is increased by flagging those injuries most likely to need intervention.…”