Therapy Intensity Level Scale for Traumatic Brain Injury: Clinimetric Assessment on Neuro-Monitored Patients Across 52 European Intensive Care Units

Abstract

Intracranial pressure (ICP) data from traumatic brain injury (TBI) patients in the intensive care unit (ICU) cannot be interpreted appropriately without accounting for the effect of administered therapy intensity level (TIL) on ICP. A 15-point scale was originally proposed in 1987 to quantify the hourly intensity of ICP-targeted treatment. This scale was subsequently modified—through expert consensus—during the development of TBI Common Data Elements to address statistical limitations and improve usability. The latest 38-point scale (hereafter referred to as TIL) permits integrated scoring for a 24-h period and has a five-category, condensed version (TIL (Basic) ) based on qualitative assessment. Here, we perform a total- and component-score analysis of TIL and TIL (Basic) to: 1) validate the scales across the wide variation in contemporary ICP management; 2) compare their performance against that of predecessors; and 3) derive guidelines for proper scale use. From the observational Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study, we extract clinical data from a prospective cohort of ICP-monitored TBI patients ( n = 873) from 52 ICUs across 19 countries. We calculate daily TIL and TIL (Basic) scores (TIL 24 and TIL (Basic) 24 , respectively) from each patient's first week of ICU stay. We also calculate summary TIL and TIL (Basic) scores by taking the first-week maximum (TIL max and TIL (Basic) max ) and first-week median (TIL median and TIL (Basic) median ) of TIL 24 and TIL (Basic) 24 scores for each patient. We find that, across all measures of construct and criterion validity, the latest TIL scale performs significantly greater than or similarly to all alternative scales (including TIL (Basic) ) and integrates the widest range of modern ICP treatments. TIL median outperforms both TIL max and summarized ICP values in detecting refractory intracranial hypertension (RICH) during ICU stay. The RICH detection thresholds which maximize the sum of sensitivity and specificity are TIL median ≥ 7.5 and TIL max ≥ 14. The TIL 24 threshold which maximizes the sum of sensitivity and specificity in the detection of surgical ICP control is TIL 24 ≥ 9. The median scores of each TIL component therapy over increasing TIL 24 reflect a credible staircase approach to treatment intensity escalation, from head positioning to surgical ICP control, as well as considerable variability in the use of cerebrospinal fluid drainage and decompressive craniectomy. Since TIL ...

TILTomorrow today: dynamic factors predicting changes in intracranial pressure treatment intensity after traumatic brain injury

“…incidence of decompressive craniectomy) or clinician-impression (e.g., reason for decompressive craniectomy) variables, and (2) focusing only on variables that occur at least a day before a change in TIL (Basic) . Since daily use of TIL (Basic) was prospectively validated, 7 we calculate the TIL (Basic) score over each available calendar day of a patient's ICU stay. For the CENTER-TBI study, information pertaining to the TIL (Basic) treatments (Table 1) was recorded on days 1-7, 10, 14, 21, and 28 of ICU stay.…”

“…For instance, administering head elevation, low-volume cerebrospinal fluid drainage, and low-dose mannitol is numerically 'equivalent' to performing a last-resort decompressive craniectomy. 7 On the contrary, changes in TIL (Basic) correspond to transitions across specific, interpretable bands of treatment intensity (Table 1). The TIL (Basic) scale was developed by Maas et al 8 and prospectively validated by Bhattacharyay et al 7 The TIL (Basic)…”

“…7 On the contrary, changes in TIL (Basic) correspond to transitions across specific, interpretable bands of treatment intensity (Table 1). The TIL (Basic) scale was developed by Maas et al 8 and prospectively validated by Bhattacharyay et al 7 The TIL (Basic)…”

“…2,3 Therefore, consensus-based guidelines 4,5 encourage a precautionary, stepwise approach 6 to ICP management, in which therapeutic intensity -defined by the perceived risk and complexity of each treatment plan -is incrementally escalated until adequate ICP control is achieved. The overall intensity of a patient's ICP management can be measured on the latest Therapy Intensity Level (TIL) scale, 7 which was developed by the interagency TBI Common Data Elements (CDE) scheme 8 and prospectively validated thereafter. 7,9 An analysis of high-TIL treatment administration across 52 ICUs participating in the Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study 10,11 revealed frequent deviation from the recommended stepwise approach, even with ICP monitoring.…”

“…The overall intensity of a patient's ICP management can be measured on the latest Therapy Intensity Level (TIL) scale, 7 which was developed by the interagency TBI Common Data Elements (CDE) scheme 8 and prospectively validated thereafter. 7,9 An analysis of high-TIL treatment administration across 52 ICUs participating in the Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study 10,11 revealed frequent deviation from the recommended stepwise approach, even with ICP monitoring. 12 In fact, there was substantial between-centre variation in ICP management (according to TIL) without commensurate variation in six-month functional outcome on the Glasgow Outcome Scale -Extended (GOSE).…”