Intracranial Pressure Monitoring in Severe Traumatic Brain Injury: Results from the American College of Surgeons Trauma Quality Improvement Program

Abstract

Although existing guidelines support the utilization of intracranial pressure (ICP) monitoring in patients with traumatic brain injury (TBI), the evidence suggesting benefit is limited. To evaluate the impact on outcome, we determined the relationship between ICP monitoring and mortality in centers participating in the American College of Surgeons Trauma Quality Improvement Program (TQIP). Data on 10,628 adults with severe TBI were derived from 155 TQIP centers over 2009-2011. Random-intercept multilevel modeling was used to evaluate the association between ICP monitoring and mortality after adjusting for important confounders. We evaluated this relationship at the patient level and at the institutional level. Overall mortality (n = 3769) was 35%. Only 1874 (17.6%) patients underwent ICP monitoring, with a mortality of 32%. The adjusted odds ratio (OR) for mortality was 0.44 [95% confidence interval (CI), 0.31-0.63], when comparing patients with ICP monitoring to those without. It is plausible that patients receiving ICP monitoring were selected because of an anticipated favorable outcome. To overcome this limitation, we stratified hospitals into quartiles based on ICP monitoring utilization. Hospitals with higher rates of ICP monitoring use were associated with lower mortality: The adjusted OR of death was 0.52 (95% CI, 0.35-0.78) in the quartile of hospitals with highest use, compared to the lowest. ICP monitoring utilization rates explained only 9.9% of variation in mortality across centers. Results were comparable irrespective of the method of case-mix adjustment. In this observational study, ICP monitoring utilization was associated with lower mortality. However, variability in ICP monitoring rates contributed only modestly to variability in institutional mortality rates. Identifying other institutional practices that impact on mortality is an important area for future research.

Impact of the Timing of Placement of an Intracranial Pressure Monitor on Outcomes in Children with Severe Traumatic Brain Injury

“…Several studies evaluating the impact of ICP monitoring on the outcomes of sTBI have yielded varying results [7-16]. The BEST-TRIP trial was published in 2012 and was based on cases in several ICUs in South America.…”

“…Intracranial pressure (ICP) monitoring is a key component of the guidelines, and management recommendations in each subsequent update are tailored towards treating intracranial hypertension (ICH) [2, 3]. Although this has biologic plausibility, the results of various studies examining the impact of ICP monitoring on the outcomes of sTBI patients have been conflicting [7-16]. It is also plausible that early identification of elevated ICP and management of ICH would improve outcomes in these patients.…”

Moderately Elevated Intracranial Pressure after Diffuse Traumatic Brain Injury is Associated with Exacerbated Neuronal Pathology and Behavioral Morbidity in the Rat

“…10,11 These approaches have proven to have limited success in overcoming the predisposition for negative outcomes associated with elevated ICP after TBI 45,46 sparking debate over the efficacy of such ICP/CPP strategies and the cost benefit of invasive ICP monitoring. [13][14][15]30,[47][48][49] The current study, however, suggests that global ischemia is not the only threat of elevated ICP contributing to morbidity after TBI and speaks to a need for additional basic research exploring the pathologies exacerbated by elevated ICP after TBI.…”

Reduction in Venous Thromboembolism Events: Trauma Performance Improvement and Loop Closure Through Participation in a State-Wide Quality Collaborative

“…This has been illustrated by 2 recent publications citing NSQIP data. 16,17 It is not really a surprise because the "report" has very little to do with the heavy lifting required to successfully implement performance improvement. Donald Berwick stated, in his editorial comments to these 2 articles, that capturing local individual stories and withinorganization trends is as important as calculating p values for relative differences between groups.…”