Multicenter assessment of the Brain Injury Guidelines and a proposal of guideline modifications

Abstract

BackgroundThe Brain Injury Guidelines provide an algorithm fortreating patients with traumatic brain injury (TBI) and intracranial hemorrhage(ICH) that does not mandate hospital admission, repeat head CT, orneurosurgical consult for all patients. The purposes of this study are toreview the guidelines’ safety, to assess resource utilization, and to proposeguideline modifications that improve patient safety and widespreadreproducibility.MethodsA multi-institutional review of TBI patients was conducted. Patients with ICH on CT were classified as BIG 1, 2, or 3 based on the guidelines. BIG 3 patients were excluded. Variables collected included demographics, Injury Severity Score (ISS), hospital length of stay (LOS), intensive care unit LOS, number of head CTs, type of injury, progression of injury, and neurosurgical interventions performed.Results269 patients met inclusion criteria. 98 were classifiedas BIG 1 and 171 as BIG 2. The median length of stay (LOS) was 2 (2,4)days and the ICU LOS was 1 (0,2) days. Most patients had a neurosurgeryconsultation (95.9%) and all patients included had a repeat head CT. 370repeat head CT scans were performed, representing 1.38 repeat scans perpatient. 11.2% of BIG 1 and 11.1% of BIG 2 patients demonstratedworsening on repeat head CT. Patients who progressed exhibited a higherISS (14 vs. 10, p=0.040), and had a longer length of stay (4 vs. 2 days;p=0.015). After adjusting for other variables, the presence of epiduralhematoma (EDH) and intraparenchymal hematoma were independent predictors ofprogression. Two BIG 2 patients with EDH had clinical deteriorationrequiring intervention.DiscussionThe Brain Injury Guidelines may improve resourceallocation if utilized, but alterations are required to ensure patientsafety. The modified Brain Injury Guidelines refine the originalguidelines to enhance reproducibility and patient safety while continuing toprovide improved resource utilization in TBI management.

Impact of Repeat Head Computed Tomography on Mild Traumatic Brain Injury Patients With Abbreviated Injury Score 1-2 Injuries

“…7,8,13,14 Over time, these guidelines have evolved, with some modifications, to a mainstay in the management of acute TBI patients, particularly in non-trauma centers. 15 Analysis of BIG by outside institutions has found statistically significant increased rate of progression in BIG 1 and 2 groups who have EDH or IPH. Other risk factors for radiologic progression of ICH were found to be alcohol consumption, age greater than 65, skull fractures, and usage of anticoagulants (for age over 65).…”

A multicenter validation of the modified brain injury guidelines: Are they safe and effective?

“…A multicenter retrospective assessment found that improvements were needed to ensure patient safety and to clarify several aspects of the BIG to allow them to be consistently reproduced. 4 The mBIGs were created to accomplish both of these tasks. In order to improve patient safety, all EDHs are characterized as mBIG 3 under the modified guidelines.…”

“…The BIG are not perfect, however. A multicenter retrospective assessment found that improvements were needed to ensure patient safety and to clarify several aspects of the BIG to allow them to be consistently reproduced 4 . The mBIGs were created to accomplish both of these tasks.…”

Validation of Quality Indicators Targeting Low-Value Trauma Care

“…Examples of changes made over iterations include refining comorbidity codes for preexisting anemia and coronary disease for red blood cell (RBC) transfusion and refining Abbreviated Injury Scale codes for Brain Injury Guidelines criteria for mild complicated traumatic brain injury (TBI). 33…”