Survey of resources available to implement severe pediatric traumatic brain injury management guidelines in low and middle-income countries

Rehabilitation models of care for children and youth with traumatic brain and/or spinal cord injuries: A focus on service structure, service organization, and the barriers and facilitators of rehabilitation service provision

To understand the systems underlying current rehabilitation models of care used with children and youth (0-21years) who sustain traumatic brain and/or spinal cord injuries. This study gathered qualitative data on service structures, service organization, and the barriers and facilitators of service provision in selected medical rehabilitation service(s) (MRS) and community-based rehabilitation service(s) (CBRS). Informants from 11 rehabilitation services were interviewed using a semi-structured interview guide. Interviews were analysed in NVivo using content analysis method. Experiences shared by the service representatives indicated that most services supported children and youth with brain injury, with a limited number also specializing in spinal cord injuries. MRS often delivered care in inpatient or outpatient settings, while CBRS offered home/community-based services. Care planning often started either prior to or shortly after admission from acute care settings, using either multidisciplinary or interdisciplinary teamwork models. Strengths of the services included innovation and provision of family-centred care; while challenges experienced included difficulty translating evidence into practice and poor team communication. Models of care were similar across services, with a focus on providing family-centred care. Several shared challenges were described, and service representatives expressed interest in forming partnerships and collaborations to address these challenges through innovative initiatives.

The Use of Prehospital Intensive Care Units in Emergencies-A Scoping Review

BACKGROUND

Amidst a rising tide of trauma-related emergencies, emergency departments worldwide grapple with the challenges of overcrowding and prolonged patient wait times. Addressing these challenges, the integration of prehospital intensive care units has appeared as a promising solution, streamlining trauma care and enhancing patient safety. Nevertheless, the feasibility of such an initiative becomes murky when considered globally. This review delves into the intricacies of prehospital intensive care units' deployment for trauma care, scrutinizing their configurations, operational practices, and the inherent challenges and research priorities.

METHODS

A scoping review was performed for eligible studies. The result was uploaded to the RAYYAN research platform, facilitating simultaneous evaluation of the studies by all researchers.

RESULTS

A total of 42 studies were initially selected. Four studies were duplicates, and 25 studies were unanimously removed as irrelevant. The remaining studies (n = 13) were included in the review, and the outcomes were categorized into diverse subgroups.

CONCLUSIONS

A country's emergency medical services must achieve specific milestones in education, competency, resource availability, and performance to effectively harness the potential of a prehospital intensive care unit. While certain nations are equipped, others lag, highlighting a global disparity in readiness for such advanced care modalities.

Assessment of the Neurosurgical Capacity in Ghana: Challenges and Opportunities

BACKGROUND

Low- and middle-income countries experience numerous challenges in the provision of neurosurgical care. However, limited information exists on the neurosurgical workforce and the constraints under which care is delivered in Ghana, West Africa.

METHODS

A 19-item survey assessing neurosurgical workforce, infrastructure, and education was administered to Ghanaian consultant neurosurgeons and neurosurgeon trainees between November 8, 2021, and January 20, 2022. The data were analyzed using summary descriptions, and qualitative data were categorized into themes.

RESULTS

There were 25 consultant neurosurgeons and 8 neurosurgical trainees (from 2 training centers) identified at 11 hospitals in Ghana totaling a workforce density of 1 neurosurgeon per 1,240,000. Most neurosurgical centers were located in Accra, the capital city. Almost half of the population did not have access to a hospital with a neurosurgeon in their region. Of hospitals, 82% had in-house computed tomography and/or magnetic resonance imaging scanners. In the operating room, most neurosurgeons had access to a high-speed drill (91%) but lacked microscopes and endoscopic sets (only 64% and 36% had these tools, respectively). There were no neurointensivists or neurological intensive care units in the entire country, and there was a paucity of neurovascular surgeries and functional neurosurgical procedures.

CONCLUSIONS

The provision of neurosurgical care in Ghana has come a long way since the 1960s. However, the neurosurgical community continues to face significant challenges. Alleviating these barriers to care will call for systems-level changes that allow for the prioritization of neurosurgical care within the Ghanaian health care system.

The Next Frontier in Neurocritical Care in Resource-Constrained Settings

Neurocritical care (NCC) is an emerging field within critical care medicine, reflecting the widespread prevalence of neurologic injury in critically ill patients. Morbidity and mortality from neurocritical illness (NCI) have been reduced substantially in resource-rich settings (RRS), owing to the development of advanced technologies, neuro-specific units, and subspecialized medical training. Despite shouldering much of the burden of NCI worldwide, resource-limited settings (RLS) face immense hurdles when implementing guidelines generated in RRS. This review summarizes the current epidemiology, management, and outcomes of the most common NCIs in RLS and offers commentary on future directions in NCC practiced in RLS.

Racial and Socioeconomic Disparities in Neurotrauma: Research Priorities in the New York Metropolitan Area through a Global Neurosurgery Paradigm

The New York Neurotrauma Consortium (NYNC) is a nascent multidisciplinary research and advocacy organization based in the New York Metropolitan Area (NYMA). It aims to advance health equity and optimize outcomes for traumatic brain and spine injury patients. Given the extensive racial, ethnic, and socioeconomic diversity of the NYMA, global health frameworks aimed at eliminating disparities in neurotrauma may provide a relevant and useful model for the informing research agendas of consortia like the NYNC. In this review, we present a comparative analysis of key health disparities in traumatic brain injury (TBI) that persist in the NYMA as well as in low- and middle-income countries (LMIC). Examples include: (a) inequitable access to quality care due to fragmentation of healthcare systems, (b) barriers to effective prehospital care for TBI, and (c) socioeconomic challenges faced by patients and their families during the subacute and chronic post-injury phases of TBI care. This review presents strategies to address each area of health disparity based on previous studies conducted in both LMIC and high-income country (HIC) settings. Increased awareness of healthcare disparities, education of healthcare professionals, effective policy advocacy for systemic changes, and fostering racial diversity of the trauma care workforce can guide the development of trauma care systems in the NYMA that are free of racial and related healthcare disparities.

Machine Learning for Predicting In-Hospital Mortality After Traumatic Brain Injury in Both High-Income and Low- and Middle-Income Countries

BACKGROUND

Machine learning (ML) holds promise as a tool to guide clinical decision making by predicting in-hospital mortality for patients with traumatic brain injury (TBI). Previous models such as the international mission for prognosis and clinical trials in TBI (IMPACT) and the corticosteroid randomization after significant head injury (CRASH) prognosis calculators can potentially be improved with expanded clinical features and newer ML approaches.

OBJECTIVE

To develop ML models to predict in-hospital mortality for both the high-income country (HIC) and the low- and middle-income country (LMIC) settings.

METHODS

We used the Duke University Medical Center National Trauma Data Bank and Mulago National Referral Hospital (MNRH) registry to predict in-hospital mortality for the HIC and LMIC settings, respectively. Six ML models were built on each data set, and the best model was chosen through nested cross-validation. The CRASH and IMPACT models were externally validated on the MNRH database.

RESULTS

ML models built on National Trauma Data Bank (n = 5393, 84 predictors) demonstrated an area under the receiver operating curve (AUROC) of 0.91 (95% CI: 0.85-0.97) while models constructed on MNRH (n = 877, 31 predictors) demonstrated an AUROC of 0.89 (95% CI: 0.81-0.97). Direct comparison with CRASH and IMPACT models showed significant improvement of the proposed LMIC models regarding AUROC (P = .038).

CONCLUSION

We developed high-performing well-calibrated ML models for predicting in-hospital mortality for both the HIC and LMIC settings that have the potential to influence clinical management and traumatic brain injury patient trajectories.

Pediatric traumatic brain injury prehospital guidelines: a systematic review and appraisal

BACKGROUND

Traumatic brain injury (TBI) disproportionately affects children within low- and middle-income countries (LMICs). Prehospital emergency care can mitigate secondary brain injury and improve outcomes. Here, we systematically review clinical practice guidelines (CPGs) for pediatric TBI with the goal to inform LMICs prehospital care.

METHODS

A systematic search was conducted in PubMed/Medline, Embase, and Web of Science databases. We appraised evidence-based CPGs addressing prehospital management of pediatric TBI using the Appraisal of Guidelines for Research & Evaluation (AGREE) tool. CPGs were rated as high-quality if ≥ 5 (out of 6) AGREE domains scored > 60%.

RESULTS

Of the 326 articles identified, 10 CPGs were included in analysis. All 10 were developed in HICs, and 4 were rated as high-quality. A total of 154 pediatric prehospital recommendations were grouped into three subcategories, initial assessment (35.7%), prehospital treatment (38.3%), and triage (26.0%). Of these, 79 (51.3%) were evidence-based with grading, and 31 (20.1%) were consensus-based without direct evidence.

CONCLUSION

Currently available CPGs for prehospital pediatric TBI management were all developed in HICs. Four CPGs have high-quality, and recommendations from these can serve as frameworks for LMICs or resource-limited settings. Context-specific evaluation and implementation of evidence-based recommendations allow LMIC settings to respond to the public health crisis of pediatric TBI and address gaps in trauma care systems.

An exploratory assessment of the management of pediatric traumatic brain injury in three centers in Africa

PURPOSE

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in low- and middle-income countries (LMICs). Hospital care practices of pediatric TBI patients in LMICs are unknown. Our objective was to report on hospital management and outcomes of children with TBI in three centers in LMICs.

METHODS

We completed a secondary analysis of a prospective observational study in children (<18 years) over a 4-week period. Outcome was determined by Pediatric Cerebral Performance Category (PCPC) score; an unfavorable score was defined as PCPC > 2 or an increase of two points from baseline. Data were compared using Chi-square and Wilcoxon rank sum tests.

RESULTS

Fifty-six children presented with TBI (age 0-17 y), most commonly due to falls (43%, n = 24). Emergency department Glasgow Coma Scale scores were ≤ 8 in 21% (n = 12). Head computed tomography was performed in 79% (n = 44) of patients. Forty (71%) children were admitted to the hospital, 25 (63%) of whom were treated for suspected intracranial hypertension. Intracranial pressure monitoring was unavailable. Five (9%, n = 5) children died and 10 (28%, n = 36) inpatient survivors had a newly diagnosed unfavorable outcome on discharge.

CONCLUSION

Inpatient management and monitoring capability of pediatric TBI patients in 3 LMIC-based tertiary hospitals was varied. Results support the need for prospective studies to inform development of evidence-based TBI management guidelines tailored to the unique needs and resources in LMICs.

A Review of Implementation Concepts and Strategies Surrounding Traumatic Brain Injury Clinical Care Guidelines

Despite considerable efforts to advance the science surrounding traumatic brain injury (TBI), formal efforts supporting the current and future implementation of scientific findings within clinical practice and healthcare policy are limited. While many and varied guidelines inform the clinical management of TBI across the spectrum, clinicians and healthcare systems are not broadly adopting, implementing, and/or adhering to them. As part of the Brain Trauma Blueprint TBI State of the Science, an expert workgroup was assembled to guide this review article, which describes: (1) possible etiologies of inadequate adoption and implementation; (2) enablers to successful implementation strategies; and (3) strategies to mitigate the barriers to adoption and implementation of future research.

A 3-Country Assessment of Traumatic Brain Injury Practices and Capacity

BACKGROUND

The World Health Organization predicts a striking rise in the burden of traumatic brain injury (TBI) burden in the next decades. A disproportionately large increase is predicted in low- and middle-income countries, which have brain injury rates 3 times higher than high-income countries. The aim of this study was to identify current TBI practices and treatment capacity in 3 low- and middle-income countries: Republic of Armenia, Georgia, and Republic of Moldova.

METHODS

After a national inventory of hospitals treating TBI, a situational analysis was conducted in the highest volume adult and pediatric hospital in each country. The situational analysis included key informant interviews with content analysis and a quantitative checklist of treatment resources.

RESULTS

All 3 countries follow international, national, and hospital protocols for TBI treatment, and the in-hospital management of patients with TBI is similar to international standards in all 3 countries. Although health care specialists were well trained, however, lack of proper equipment, a scant number of hospitals outside the capital region, lack of specialized personnel in regional areas, and lack of rehabilitation services were mentioned as difficulties in interviews from all 3 countries.

CONCLUSIONS

Particular gaps were found in pre-hospital and rehabilitative care, as well as national leadership and data collection. Surveillance and standardized data collection are important measures to fill treatment gaps and reduce the burden of TBI.

Addressing Key Clinical Care and Clinical Research Needs in Severe Pediatric Traumatic Brain Injury: Perspectives From a Focused International Conference

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children and adolescents. Survivors of severe TBI are more prone to functional deficits, resulting in poorer school performance, poor health-related quality of life (HRQoL), and increased risk of mental health problems. Critical gaps in knowledge of pathophysiological differences between children and adults concerning TBI outcomes, the paucity of pediatric trials and prognostic models and the uncertain extrapolation of adult data to pediatrics pose significant challenges and demand global efforts. Here, we explore the clinical and research unmet needs focusing on severe pediatric TBI to identify best practices in pathways of care and optimize both inpatient and outpatient management of children following TBI.