Factors influencing intracranial pressure monitoring guideline compliance and outcome after severe traumatic brain injury*

Biersteker, Heleen A. R.; Andriessen, Teuntje M. J. C.; Horn, Janneke; Franschman, Gaby; Naalt, Joukje van der; Hoedemaekers, Cornelia; Lingsma, Hester F.; Haitsma, Iain; Vos, Pieter E.

doi:10.1097/ccm.0b013e3182474bde

Cited by 46 publications

(52 citation statements)

References 54 publications

(57 reference statements)

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“…The overall rate of ICP monitoring was low in this study at 26.8%, which is similar to other pediatric studies [13, 25]. There is a paucity of high-quality evidence supporting ICP monitor placement, as summarized by the pediatric guidelines for the management of children with sTBI, with a level 3 recommendation that ICP monitoring “may be considered in children with sTBI” similar to the adult BTF level 2b recommendation [2, 3].…”

Section: Discussionsupporting

confidence: 58%

“…There is a paucity of high-quality evidence supporting ICP monitor placement, as summarized by the pediatric guidelines for the management of children with sTBI, with a level 3 recommendation that ICP monitoring “may be considered in children with sTBI” similar to the adult BTF level 2b recommendation [2, 3]. This also attests to the heterogeneity of the TBI population and variations in factors on the level of both the patient and the hospital that affect the use of ICP monitoring, as reported in other studies [13]. The mortality rate of 24% for the whole sTBI cohort, after excluding those who died within 24 h, is similar to the mortality in other studies of pediatric sTBI which used patient data from the National Trauma Data Bank, a large multi-institutional database similar to VPS [11, 12].…”

Section: Discussionmentioning

confidence: 73%

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

et al. 2018

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Background: Severe traumatic brain injury (sTBI) is the leading cause of morbidity and mortality from trauma. Brain Trauma Foundation guidelines recommend intracranial pressure (ICP) monitoring in sTBI. We hypothesized that early ICP monitor placement was associated with better outcomes in children. Methods: This was a retrospective study of children with sTBI admitted to the participating pediatric intensive care units (PICUs) and entered into the Virtual Pediatric Systems (VPS), LLC, database between 1 January 2010 and 31 December 2015. We compared outcomes of patients who had an ICP monitor placed early (≤6 h from PICU admission) to those with later placement (> 6 to < 72 h). We collected demographics, diagnoses, procedure data, illness severity scores, outcomes, and site data. Multivariable regression analysis was used to identify variables independently associated with outcomes. Results: Twenty-seven percent of 3,608 patients with sTBI underwent ICP monitoring, 355 in the early and 156 in the later ICP monitoring groups, respectively. A higher proportion of patients in the early ICP monitoring group had worse markers of illness/injury severity; unadjusted analysis showed higher mortality in this group (31.3 vs. 21.8%, p = 0.029). Multivariable regression analysis showed that ICP monitoring was not independently associated with any of the outcomes. Conclusion: Time to ICP monitoring was not associated with outcomes after pediatric sTBI.

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Section: Discussionsupporting

confidence: 58%

Section: Discussionmentioning

confidence: 73%

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

et al. 2018

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“…This inconsistency among previous studies might explain the wide variability in ICP monitoring utilization across different hospitals. 22 Our findings agree with a number of previous studies that support the value of ICP monitoring in TBI, 22,39 but contrast with several studies that either failed to show an association between ICP monitoring and better outcomes, 14,15,17,19,40,41 or showed an association between ICP monitoring and higher mortality. 18 However, previous observational studies in this area have generally suffered from several limitations, including small sample size, a lack of or inadequate adjustment for multiple important confounders, and selection bias.…”

Section: Discussioncontrasting

confidence: 51%

“…20 The increasing number of studies that challenge the benefit of invasive ICP monitoring and the limited confidence in its utility might explain the reported wide variability in the utilization of ICP monitoring across centers. 14,21,22 Further, this variability might, in part, account for wide differences in institutional TBI-related mortality. [23][24][25] In this context, we conducted a retrospective cohort study using data derived from the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP).…”

Section: Introductionmentioning

confidence: 99%

“…9,12 Moreover, several recent studies examining the relationship between utilization of ICP monitors and outcome have questioned the benefit of ICP monitors in severe TBI. [14][15][16][17][18][19] In practice, there appears to be a low level of confidence among clinicians that ICP monitoring confers a benefit to TBI patients. According to a survey of practicing neurosurgeons in Canada, only 20% are highly confident that the routine use of ICP in severe TBI improves outcome.…”

Section: Introductionmentioning

confidence: 99%

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

Alali

Fowler

Mainprize

et al. 2013

Journal of Neurotrauma

185

145

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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.

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Compliance With Evidence-Based Guidelines and Interhospital Variation in Mortality for Patients With Severe Traumatic Brain Injury

et al. 2015

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IMPORTANCECompliance with evidence-based guidelines in traumatic brain injury (TBI) has been proposed as a marker of hospital quality. However, the association between hospital-level compliance rates and risk-adjusted clinical outcomes for patients with TBI remains poorly understood.OBJECTIVE To examine whether hospital-level compliance with the Brain Trauma Foundation guidelines for intracranial pressure monitoring and craniotomy is associated with risk-adjusted mortality rates for patients with severe TBI. DESIGN, SETTING, AND PARTICIPANTS All adult patients (N = 734) who presented to a regional consortium of 14 hospitals from January 1, 2009, through December 31, 2010, with severe TBI (ie, blunt head trauma, Glasgow Coma Scale score of <9, and abnormal intracranial findings from computed tomography of the head). Data analysis took place from December 2013 through January 2015. We used hierarchical mixed-effects models to assess the association between hospital-level compliance with Brain Trauma Foundation guidelines and mortality rates after adjusting for patient-level demographics, severity of trauma (eg, mechanism of injury and Injury Severity Score), and TBI-specific variables (eg, cranial nerve reflexes and findings from computed tomography of the head). MAIN OUTCOMES AND MEASURESHospital-level risk-adjusted inpatient mortality rate and hospital-level compliance with Brain Trauma Foundation guidelines for intracranial pressure monitoring and craniotomy.RESULTS Unadjusted mortality rates varied by site from 20.0% to 50.0% (median, 42.6; interquartile range, 35.5-46.2); risk-adjusted rates varied from 24.3% to 56.7% (median, 41.1; interquartile range, 36.4-47.8). Overall, only 338 of 734 patients (46.1%) with an appropriate indication underwent placement of an intracranial pressure monitor and only 134 of 335 (45.6%) underwent craniotomy. Hospital-level compliance ranged from 9.6% to 65.2% for intracranial pressure monitoring and 6.7% to 76.2% for craniotomy. Despite widespread variation in compliance across hospitals, we found no association between hospital-level compliance rates and risk-adjusted patient outcomes (Spearman ρ = 0.030 [P = .92] for ICP monitoring and Spearman ρ = −0.066 [P = .83] for craniotomy). CONCLUSIONS AND RELEVANCEHospital-level compliance with evidence-based guidelines has minimal association with risk-adjusted outcomes in patients with severe TBI. Our results suggest that caution should be taken before using compliance with these measures as independent quality metrics. Given the complexity of TBI care, outcomes-based metrics, including functional recovery, may be more accurate than current process measures at determining hospital quality.

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Factors influencing intracranial pressure monitoring guideline compliance and outcome after severe traumatic brain injury*

Cited by 46 publications

References 54 publications

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

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

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

Compliance With Evidence-Based Guidelines and Interhospital Variation in Mortality for Patients With Severe Traumatic Brain Injury

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