Quality indicators for patients with traumatic brain injury in European intensive care units: a CENTER-TBI study

Abstract

Background: The aim of this study is to validate a previously published consensus-based quality indicator set for the management of patients with traumatic brain injury (TBI) at intensive care units (ICUs) in Europe and to study its potential for quality measurement and improvement.Methods: Our analysis was based on 2006 adult patients admitted to 54 ICUs between 2014 and 2018, enrolled in the CENTER-TBI study. Indicator scores were calculated as percentage adherence for structure and process indicators and as event rates or median scores for outcome indicators. Feasibility was quantified by the completeness of the variables. Discriminability was determined by the between-centre variation, estimated with a random effect regression model adjusted for case-mix severity and quantified by the median odds ratio (MOR). Statistical uncertainty of outcome indicators was determined by the median number of events per centre, using a cut-off of 10.Results: A total of 26/42 indicators could be calculated from the CENTER-TBI database. Most quality indicators proved feasible to obtain with more than 70% completeness. Sub-optimal adherence was found for most quality indicators, ranging from 26 to 93% and 20 to 99% for structure and process indicators. Significant (p < 0.001) between-centre variation was found in seven process and five outcome indicators with MORs ranging from 1.51 to 4.14. Statistical uncertainty of outcome indicators was generally high; five out of seven had less than 10 events per centre. Conclusions: Overall, nine structures, five processes, but none of the outcome indicators showed potential for quality improvement purposes for TBI patients in the ICU. Future research should focus on implementation efforts and continuous reevaluation of quality indicators. Trial registration: The core study was registered with ClinicalTrials.gov, number NCT02210221, registered on August 06, 2014, with Resource Identification Portal (RRID: SCR_015582).

An international survey of the structure and process of care for traumatic spinal cord injury in acute and rehabilitation facilities: lessons learned from a pilot study

“…In TBI, a survey on structure and processes of care among centers in the CENTER-TBI study revealed substantial variation in care [ 25 ], on which the development of a set of quality indicators was based, together with international guidelines and clinical expertise [ 24 ]. Testing the indicator set in over fifty intensive care units for its potential for quality measurement and improvement suggested that the indicators with high between-center variation and suboptimal adherence rates could be useful for benchmarking and improving quality of care [ 26 ]. The empirical evidence supporting the successful implementation of quality improvement initiatives in TBI [ 26 ] corroborates that a similar approach is sustainable for SCI.…”

“…Testing the indicator set in over fifty intensive care units for its potential for quality measurement and improvement suggested that the indicators with high between-center variation and suboptimal adherence rates could be useful for benchmarking and improving quality of care [ 26 ]. The empirical evidence supporting the successful implementation of quality improvement initiatives in TBI [ 26 ] corroborates that a similar approach is sustainable for SCI. In this regard, surveying facilities at regular intervals would quantify the progress (e.g., improvement of practice and adoption of guidelines) and enable economic evaluations.…”

The faster the better? Time to first CT scan after admission in moderate-to-severe traumatic brain injury and its association with mortality

“…A 24/7 availability of a CT scan with radiological assessment is required. This should be performed within 20-30 min after admission of the patient in order to be able to provide early surgical therapy in case of intracranial hematoma to lower intracranial pressure and minimize secondary brain damages [2,10,17]. Surprisingly, very little data has been published on this topic so far, making this study driven from the TR-DGU one of the largest investigations of the impact of the duration from admission to first computer tomography scan in moderate-tosevere traumatic brain injury.…”

“…Another notable finding of the study is that emergency room staff obviously pays attention to the admission status of the pupils as the rate of patients with anisocoric or bilaterally fixed and dilated pupils was associated with faster acquisitions of the CT. Overall, adherence to guidelines and recommendations can demonstrably lead to an improvement in care in patients with TBI and offer the opportunity for quality improvements, especially in process management [2,5,6,10]. The strength of the study is, on the one hand, the relatively high number of cases and, on the other hand, the multicenter approach through the use of data from the TR-DGU which allows a uniform and standardized collection of time data.…”

“…To confirm a clinically suspected TBI, it is deemed necessary to carry out an imaging diagnostic, in most cases a computed tomography (CT), which represents the "gold standard" [18]. This fact is reflected by the CENTER-TBI consortium that regards a 24/7 availability of CT scan and radiologist review as a quality indicator in the treatment of TBI patients [10]. Timely access to computed tomography (CT) has been defined as a major prerequisite for the participation of trauma centers within the TraumaNetzwerk DGU® [3].…”