Unpicking the Gordian knot: a systems approach to traumatic brain injury care in low-income and middle-income countries

Bashford, Tom; Clarkson, PJ; Menon, David; Hutchinson, Peter J.

doi:10.1136/bmjgh-2018-000768

Cited by 13 publications

(8 citation statements)

References 40 publications

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“…43 Such efforts should be mindful that a holistic approach across the entire health system (including prevention, pre-hospital care, surgery, intensive care, and rehabilitation) is likely to be required to truly address the complexity of improving care for TBI, surgical or otherwise, worldwide. 33,44 The main strength of the study is the geographical and socioeconomic diversity of the patient population, with approximately half being from medium HDI or low HDI countries, and 57% originating from the South Asia, sub-Saharan Africa, or Latin American and Caribbean regions. Moreover, despite limited resources, we showed excellent case ascertainment and completeness of data collection.…”

Section: Median Admission Gcsmentioning

confidence: 99%

Casemix, management, and mortality of patients receiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study

Clark

Joannides

Bajamal

et al. 2022

The Lancet Neurology

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Section: Median Admission Gcsmentioning

confidence: 99%

Casemix, management, and mortality of patients receiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study

Clark

Joannides

Bajamal

et al. 2022

The Lancet Neurology

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“…Patients are younger, with a history of clear traumatic precipitants [22,23] and lower rates of anticoagulation [24] than is seen in high-income country series [2]. The challenges of improving outcomes for patients with other forms of traumatic brain injury in low and middle-income country settings are well documented [25], with delayed presentation a clear problem in the care of chronic SDH [24,26].…”

Section: Methodsmentioning

confidence: 99%

Chronic subdural haematoma: the role of peri‐operative medicine in a common form of reversible brain injury

2022

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Epidemiological studies project a significant rise in cases of chronic subdural haematoma over the next 20 years. Patients with this condition are frequently older and medically complex, with baseline characteristics that may increase peri-operative risk. The intra-operative period is only a small portion of a patient's total hospital stay, with a majority of patients in the United Kingdom transferred between institutions for their surgical and rehabilitative care. Definitive management remains surgical, but peri-operative challenges exist which resonate with other surgical cohorts where multidisciplinary working has become the gold standard. These include shared decision-making, medical optimisation, the management of peri-operative anticoagulation and the identification of key points of equipoise for examination in the future trials. In this narrative review, we use a stereotyped patient journey to provide context to the recent literature, highlighting where multidisciplinary expertise may be required to optimise patient care and maximise the benefits of surgical management. We discuss the triage, pre-operative optimisation, intra-operative management and immediate postoperative care of patients undergoing surgery for a chronic subdural haematoma. We also discuss where adjunctive medical management may be indicated. In so doing, we present the current and emerging evidence base for the role of an integrated peri-operative medicine team in the care of patients with a chronic subdural haematoma.

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“…1 The management of TBI is complex and difficult to characterise. 4 While epidemiological studies have been conducted to explore the global picture, mapping practice at the level of the institution to drive service improvement remains a challenge. 5 This is exacerbated in settings which have low levels of routine data collection, or a lack of established clinical and organisational protocols and care pathways.…”

Section: Strengths and Limitations Of This Studymentioning

confidence: 99%

Systems approach to improving traumatic brain injury care in Myanmar: a mixed-methods study from lived experience to discrete event simulation

et al. 2022

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ObjectivesTraumatic brain injury (TBI) is a global health problem, whose management in low-resource settings is hampered by fragile health systems and lack of access to specialist services. Improvement is complex, given the interaction of multiple people, processes and institutions. We aimed to develop a mixed-method approach to understand the TBI pathway based on the lived experience of local people, supported by quantitative methodologies and to determine potential improvement targets.DesignWe describe a systems approach based on narrative exploration, participatory diagramming, data collection and discrete event simulation (DES), conducted by an international research collaborative.SettingThe study is set in the tertiary neurotrauma centre in Yangon General Hospital, Myanmar, in 2019–2020 (prior to the SARS-CoV2 pandemic).ParticipantsThe qualitative work involved 40 workshop participants and 64 interviewees to explore the views of a wide range of stakeholders including staff, patients and relatives. The 1-month retrospective admission snapshot covered 85 surgical neurotrauma admissions.ResultsThe TBI pathway was outlined, with system boundaries defined around the management of TBI once admitted to the neurosurgical unit. Retrospective data showed 18% mortality, 71% discharge to home and an 11% referral rate. DES was used to investigate the system, showing its vulnerability to small surges in patient numbers, with critical points being CT scanning and observation ward beds. This explorative model indicated that a modest expansion of observation ward beds to 30 would remove the flow-limitations and indicated possible consequences of changes.ConclusionsA systems approach to improving TBI care in resource-poor settings may be supported by simulation and informed by qualitative work to ground it in the direct experience of those involved. Narrative interviews, participatory diagramming and DES represent one possible suite of methods deliverable within an international partnership. Findings can support targeted improvement investments despite coexisting resource limitations while indicating concomitant risks.

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Unpicking the Gordian knot: a systems approach to traumatic brain injury care in low-income and middle-income countries

Cited by 13 publications

References 40 publications

Casemix, management, and mortality of patients receiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study

Casemix, management, and mortality of patients receiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study

Chronic subdural haematoma: the role of peri‐operative medicine in a common form of reversible brain injury

Systems approach to improving traumatic brain injury care in Myanmar: a mixed-methods study from lived experience to discrete event simulation

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