Moving from “optimal resources” to “optimal care” at trauma centers

Clinical practice guideline recommendations for the management of challenging behaviours after traumatic brain injury in acute hospital and inpatient rehabilitation settings: a systematic review

PURPOSE

Clinical practice guideline (CPG) recommendations for the management of challenging behaviours after traumatic brain injury (TBI) in hospital and inpatient rehabilitation settings are sparse. This systematic review aims to identify and appraise CPGs, and report high-quality recommendations for challenging behaviours after TBI in hospital and rehabilitation settings.

MATERIALS AND METHODS

A three-step search strategy was conducted to identify CPGs that met inclusion criteria. Two reviewers independently scored the AGREE II domains. Guideline quality was assessed based on CPGs adequately addressing four out of the six AGREE II domains. Data extraction was performed with a compilation of high-quality CPG recommendations.

RESULTS

Seven CPGs out of 408 identified records met the inclusion criteria. Two CPGs were deemed high-quality. High-quality CPG recommendations with the strongest supporting evidence include behaviour management plans; beta-blockers for the treatment of aggression; selective serotonin reuptake inhibitors for moderate agitation; adamantanes for impaired arousal/attention in agitation; specialised, multi-disciplinary TBI behaviour management services.

CONCLUSIONS

This systematic review identified and appraised the quality of CPGs relating to the management of challenging behaviours after TBI in acute hospital and rehabilitation settings. Further research to rigorously evaluate TBI behaviour management programs, investigation of evidence-practice gaps, and implementation strategies for adopting CPG recommendations into practice is needed.Implications for rehabilitationTwo clinical practice guidelines appraised as high-quality outline recommendations for the management of challenging behaviours after traumatic brain injury in hospital and inpatient rehabilitation settings.High-quality guideline recommendations with the strongest supporting evidence for non-pharmacological treatment include behaviour management plans considering precipitating factors, antecedents, and reinforcing events.High-quality guideline recommendations with the strongest supporting evidence for pharmacological management include beta blockers for aggression in traumatic brain injury.Few guidelines provide comprehensive detail on the implementation of recommendations into clinical care which may limit adoption.

Quality of Reporting on Guideline, Protocol, or Algorithm Implementation in Adult Trauma Centers: A Systematic Review

OBJECTIVE

To appraise the quality of reporting on guideline, protocol, and algorithm implementations in adult trauma settings according to the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0).

BACKGROUND

At present we do not know if published reports of guideline implementations in trauma settings are of sufficient quality to facilitate replication by other centers wishing to implement the same or similar guidelines.

METHODS

A systematic review of the literature was conducted. Articles were identified through electronic databases and hand searching relevant trauma journals. Studies meeting inclusion criteria focused on a guideline, protocol, or algorithm that targeted adult trauma patients ≥18 years and/or trauma patient care providers, and evaluated the effectiveness of guideline, protocol, or algorithm implementation in terms of change in clinical practice or patient outcomes. Each included study was assessed in duplicate for adherence to the 18-item SQUIRE 2.0 criteria. The primary endpoint was the proportion of studies meeting at least 80% (score ≥15) of SQUIRE 2.0.

RESULTS

Of 7368 screened studies, 74 met inclusion criteria. Thirty-nine percent of studies scored ≥80% on SQUIRE 2.0. Criteria that were met most frequently were abstract (93%), problem description (93%), and specific aims (89%). The lowest scores appeared in the funding (28%), context (47%), and results (54%) criteria. No study indicated using SQUIRE 2.0 as a guideline to writing the report.

CONCLUSIONS

Significant opportunity exists to improve the utility of guideline implementation reports in adult trauma settings, particularly in the domains of study context and the implications of context for study outcomes.

Adherence to Guidelines in Adult Patients with Traumatic Brain Injury: A Living Systematic Review

Guidelines aim to improve the quality of medical care and reduce treatment variation. The extent to which guidelines are adhered to in the field of traumatic brain injury (TBI) is unknown. The objectives of this systematic review were to (1) quantify adherence to guidelines in adult patients with TBI, (2) examine factors influencing adherence, and (3) study associations of adherence to clinical guidelines and outcome. We searched EMBASE, MEDLINE, Cochrane Central, PubMed, Web of Science, PsycINFO, SCOPUS, CINAHL, and grey literature in October 2014. We included studies of evidence-based (inter)national guidelines that examined the acute treatment of adult patients with TBI. Methodological quality was assessed using the Research Triangle Institute item bank and Quality in Prognostic Studies Risk of Bias Assessment Instrument. Twenty-two retrospective and prospective observational cohort studies, reported in 25 publications, were included, describing adherence to 13 guideline recommendations. Guideline adherence varied considerably between studies (range 18-100%) and was higher in guideline recommendations based on strong evidence compared with those based on lower evidence, and lower in recommendations of relatively more invasive procedures such as craniotomy. A number of patient-related factors, including age, Glasgow Coma Scale, and intracranial pathology, were associated with greater guideline adherence. Guideline adherence to Brain Trauma Foundation guidelines seemed to be associated with lower mortality. Guideline adherence in TBI is suboptimal, and wide variation exists between studies. Guideline adherence may be improved through the development of strong evidence for guidelines. Further research specifying hospital and management characteristics that explain variation in guideline adherence is warranted.

Implementation of an algorithm for chest imaging in blunt trauma decreases use of CT-scan: Resource management in a middle-income country

PURPOSE

Due to the low sensitivity of chest radiography, chest CT-scan is usually recommended for the evaluation of high-risk blunt trauma patients. Considering the radiation exposure and costs accompanying routine CT-scan, the aim of this study was to design and implement an evidence-based institutional algorithm for selective chest imaging in high energy blunt trauma patients and evaluate its effect on patient outcome and resource utilization.

METHODS

For this field trial, an institutional evidence-based algorithm for chest trauma imaging was designed according to existing data and expert panel. After final consent and ethic committee approval, the algorithm was integrated in the diagnostic flow sheet in the emergency department and patient data were collected from the pre- and post-implementation period.

RESULTS

One-hundred and sixty-five patients before algorithm implementation and 158 patients after that were included. Chest CT-scan was requested for 93% of patients in the pre-implementation group and for 73% in the post-implementation group (P<0.001). Length of stay in hospital was slightly shorter in the post-implementation group (p = 0.036), however, duration of stay in emergency room and ICU, pulmonary complications and mortality showed no significant difference.

CONCLUSION

Implementation of an algorithm for limiting chest CT-scan to a subgroup of patients with a higher risk of chest injuries can reduce radiation exposure and more useful distribution of resources without harming the patients. Each institution should use institutional guidelines and algorithms with respect to patient load, available resources and desired sensitivity for injury detection.

What is the quality of reporting on guideline, protocol or algorithm implementation in adult trauma centres? Protocol for a systematic review

INTRODUCTION

Quality improvement (QI) is mandatory in trauma centres but there is no prescription for doing successful QI. Considerable variation in implementation strategies and inconsistent use of evidence-based protocols therefore exist across centres. The quality of reporting on these strategies may limit the transferability of successful initiatives across centres. This systematic review will assess the quality of reporting on guideline, protocol or algorithm implementation within a trauma centre in terms of the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0).

METHODS AND ANALYSIS

We will search for English language articles published after 2010 in EMBASE, MEDLINE, CINAHL electronic databases and the Cochrane Central Register of Controlled Trials. The database search will be supplemented by searching trial registries and grey literature online. Included studies will evaluate the effectiveness of guideline implementation in terms of change in clinical practice or improvement in patient outcomes. The primary outcome will be a global score reporting the proportion of studies respecting at least 80% of the SQUIRE 2.0 criteria and will be obtained based on the 18-items identified in the SQUIRE 2.0 guidelines. Secondary outcome will be the risk of bias assessed with the Risk Of Bias In Non-randomised Studies- of Interventions tool for observational cohort studies and with the Cochrane Collaboration tool for randomised controlled trials. Meta-analyses will be conducted in randomised controlled trials to estimate the effectiveness of guideline implementation if studies are not heterogeneous. If meta-analyses are conducted, we will combine studies according to the risk of bias (low, moderate or high/unclear) in subgroup analyses. All study titles, abstracts and full-text screening will be completed independently and in duplicate by the review team members. Data extraction and risk of bias assessment will also be done independently and in duplicate.

ETHICS AND DISSEMINATION

Results will be disseminated through scientific publication and conferences.

PROSPERO REGISTRATION NUMBER

CRD42018084273.

The National Trauma Research Repository: Ushering in a New ERA of trauma research (Commentary)

Despite being the leading cause of death in the United States for individuals 46 years and younger and the primary cause of death among military service members, trauma care research has been underfunded for the last 50 years. Sustained federal funding for a coordinated national trauma clinical research program is required to advance the science of caring for the injured. The Department of Defense is committed to funding studies with military relevance; therefore, it cannot fund pediatric or geriatric trauma clinical trials. Currently, trauma clinical trials are often performed within a single site or a small group of trauma hospitals, and research data are not available for secondary analysis or sharing across studies. Data-sharing platforms encourage transfer of research data and knowledge between civilian and military researchers, reduce redundancy, and maximize limited research funding. In collaboration with the Department of Defense, trauma researchers formed the Coalition for National Trauma Research (CNTR) in 2014 to advance trauma research in a coordinated effort. CNTR's member organizations are the American Association for the Surgery of Trauma (AAST), the American College of Surgeons Committee on Trauma (ACS COT), the Eastern Association for the Surgery of Trauma (EAST), the Western Trauma Association (WTA), and the National Trauma Institute (NTI). CNTR advocates for sustained federal funding for a multidisciplinary national trauma research program to be conducted through a large clinical trials network and a national trauma research repository. The initial advocacy and research activities underway to accomplish these goals are presented.

Process for developing rehabilitation practice recommendations for individuals with traumatic brain injury

Background

Attempts at measuring quality of rehabilitation care are hampered by a gap in knowledge translation of evidence-based approaches and lack of consensus on best practices. However, adoption of evidence-based best practices is needed to minimize variations and improve quality of care. Therefore, the objective of this project was to describe a process for assessing the quality of evidence of clinical practices in traumatic brain injury (TBI) rehabilitative care.

Methods

A multidisciplinary team of clinicians developed discipline-specific clinical questions using the Population, Intervention, Control, Outcome process. A systematic review of the literature was conducted for each question using Pubmed, CINAHL, PsychInfo, and Allied Health Evidence databases. Team members assessed the quality, level, and applicability of evidence utilizing a modified Oxford scale, the Agency for Healthcare Research and Quality Methods Guide, and a modified version of the Grading of Recommendations, Assessment, Development, and Evaluation scale.

Results

Draft recommendations for best-practice were formulated and shared with a Delphi panel of clinical representatives and stakeholders to obtain consensus.

Conclusion

Evidence-based practice guidelines are essential to improve the quality of TBI rehabilitation care. By using a modified quality of evidence assessment tool, we established a process to gain consensus on practice recommendations for individuals with TBI undergoing rehabilitation.

"Delay to operating room" fails to identify adverse outcomes at a Level I trauma center

BACKGROUND

The American College of Surgeons Committee on Trauma devised process audit filters to identify opportunities for improvement (OFI), prevent adverse outcomes, and improve quality. Delay to the operating room for primary trauma laparotomy is a process audit filter that has not been definitively associated with improved outcomes. We sought to evaluate the effectiveness of delay to the operating room of greater than 2 hours (DOR) to independently identify an adverse outcome or an OFI at our Level I trauma center.

METHODS

Trauma patients who underwent primary exploratory laparotomy from July 2006 to March 2015 were reviewed. Those with DOR were identified and compared with those without DOR. To analyze the ability of DOR to independently identify an adverse outcome or an OFI, DOR patients were further divided into those with isolated DOR and those with DOR in conjunction with one or more other process audit filter. Primary outcome was the presence of a complication. Secondary outcome was an identified OFI. Medical records of patients with either outcome were reviewed to determine if the outcome resulted directly from DOR.

RESULTS

Of 472 patients, 109 (23%) had DOR and 363 (77%) did not. There were no significant differences in age, sex, or injury severity between the two groups. The rates of complications among DOR patients and those without DOR were not significantly different (35% vs. 38%, p = 0.59). The DOR was the only process audit filter flagged in 31(28%) patients in the DOR group. This subgroup had no identified complications but incurred two OFIs; neither OFI was associated with an adverse outcome.

CONCLUSION

In trauma patients undergoing primary exploratory laparotomy, DOR fails to independently identify adverse outcomes. These findings suggest that DOR, as a routinely collected process audit filter, is not an effective indicator of suboptimal care or adverse outcomes at a Level I trauma center.

LEVEL OF EVIDENCE

Therapeutic study, level IV; prognostic study, level III.

The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition

BACKGROUND

Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013.

RESULTS

The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome.

CONCLUSIONS

A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.

Validation of Complications Selected by Consensus to Evaluate the Acute Phase of Adult Trauma Care: A Multicenter Cohort Study

OBJECTIVE

Evaluate the predictive validity of complications derived using expert consensus methodology to monitor the quality of trauma care. Secondary objectives were to assess the predictive validity of complications not selected by consensus and identify determinants of complications.

BACKGROUND

A list of complications to monitor the quality of trauma care has recently been derived using Delphi consensus methodology. However, the predictive validity of consensus complications has not yet been demonstrated.

METHODS

We conducted a multicenter cohort study of adults admitted to the 57 adult trauma centers of a Canadian integrated trauma system (2007-2012; n = 84,216). Multiple generalized linear models were used to assess the influence of complications on mortality and acute care length of stay (LOS) and to identify determinants of consensus complications.

RESULTS

The presence of at least 1 consensus complication was associated with a 2.7-fold [95% confidence interval (CI): 2.45-2.90] and 2.2-fold (95% CI: 2.11-2.19) increase in the odds of mortality and mean LOS, respectively. Nonselected complications were associated with no increase in mortality (odds ratio = 0.90, 95% CI: 0.80-1.01) and a 60% increase in LOS (geometric mean ratio = 1.60, 95% CI: 1.57-1.62). Patient-related factors and factors related to treatment explained 66% and 34% of the variation in complication rates, respectively.

CONCLUSIONS

In addition to the face and content validity ensured by consensus methodology, this study suggests that consensus complications have good predictive validity. Monitoring these complications as part of quality improvement activities would provide an opportunity to improve outcome and resource use for injury admissions.

System-level planning, coordination, and communication: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement

BACKGROUND

System-level planning involves uniting hospitals and health systems, local/regional government agencies, emergency medical services, and other health-care entities involved in coordinating and enabling care in a major disaster. We reviewed the literature and sought expert opinions concerning system-level planning and engagement for mass critical care due to disasters or pandemics and offer suggestions for system-planning, coordination, communication, and response. The suggestions in this chapter are important for all of those involved in a pandemic or disaster with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials.

METHODS

The American College of Chest Physicians (CHEST) consensus statement development process was followed in developing suggestions. Task Force members met in person to develop nine key questions believed to be most relevant for system-planning, coordination, and communication. A systematic literature review was then performed for relevant articles and documents, reports, and other publications reported since 1993. No studies of sufficient quality were identified upon which to make evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process.

RESULTS

Suggestions were developed and grouped according to the following thematic elements: (1) national government support of health-care coalitions/regional health authorities (HC/RHAs), (2) teamwork within HC/RHAs, (3) system-level communication, (4) system-level surge capacity and capability, (5) pediatric patients and special populations, (6) HC/RHAs and networks, (7) models of advanced regional care systems, and (8) the use of simulation for preparedness and planning.

CONCLUSIONS

System-level planning is essential to provide care for large numbers of critically ill patients because of disaster or pandemic. It also entails a departure from the routine, independent system and involves all levels from health-care institutions to regional health authorities. National government support is critical, as are robust communication systems and advanced planning supported by realistic exercises.

Complications to evaluate adult trauma care: An expert consensus study

BACKGROUND

Complications affect up to 37% of patients hospitalized for injury and increase mortality, morbidity, and costs. One of the keys to controlling complications for injury admissions is to monitor in-hospital complication rates. However, there is no consensus on which complications should be used to evaluate the quality of trauma care. The objective of this study was to develop a consensus-based list of complications that can be used to assess the acute phase of adult trauma care.

METHODS

We used a three-round Web-based Delphi survey among experts in the field of trauma care quality with a broad range of clinical expertise and geographic diversity. The main outcome measure was median importance rating on a 5-point Likert scale (very low to very high); complications with a median of 4 or greater and no disagreement were retained. A secondary measure was the perceived quality of information on each complication available in patient files.

RESULTS

Of 19 experts invited to participate, 17 completed the first (brainstorming) round and 16 (84%) completed all rounds. Of 73 complications generated in Round 1, a total of 25 were retained including adult respiratory distress syndrome, hospital-acquired pneumonia, sepsis, acute renal failure, deep vein thrombosis, pulmonary embolism, wound infection, decubitus ulcers, and delirium. Of these, 19 (76%) were perceived to have high-quality or very high-quality information in patient files by more than 50% of the panel members.

CONCLUSION

This study proposes a consensus-based list of 25 complications that can be used to evaluate the quality of acute adult trauma care. These complications can be used to develop an informative and actionable quality indicator to evaluate trauma care with the goal of decreasing rates of hospital complications and thus improving patient outcomes and resource use. DRG International Classification of Diseases codes are provided.

Suboptimal compliance with evidence-based guidelines in patients with traumatic brain injuries

OBJECT

Evidence-based management (EBM) guidelines for severe traumatic brain injuries (TBIs) were promulgated decades ago. However, the extent of their adoption into bedside clinical practices is not known. The purpose of this study was to measure compliance with EBM guidelines for management of severe TBI and its impact on patient outcome.

METHODS

This was a retrospective study of blunt TBI (11 Level I trauma centers, study period 2008-2009, n = 2056 patients). Inclusion criteria were an admission Glasgow Coma Scale score ≤ 8 and a CT scan showing TBI, excluding patients with nonsurvivable injuries-that is, head Abbreviated Injury Scale score of 6. The authors measured compliance with 6 nonoperative EBM processes (endotracheal intubation, resuscitation, correction of coagulopathy, intracranial pressure monitoring, maintaining cerebral perfusion pressure ≥ 50 cm H2O, and discharge to rehabilitation). Compliance rates were calculated for each center using multivariate regression to adjust for patient demographics, physiology, injury severity, and TBI severity.

RESULTS

The overall compliance rate was 73%, and there was wide variation among centers. Only 3 centers achieved a compliance rate exceeding 80%. Risk-adjusted compliance was worse than average at 2 centers, better than average at 1, and the remainder were average. Multivariate analysis showed that increased adoption of EBM was associated with a reduced mortality rate (OR 0.88; 95% CI 0.81-0.96, p < 0.005).

CONCLUSIONS

Despite widespread dissemination of EBM guidelines, patients with severe TBI continue to receive inconsistent care. Barriers to adoption of EBM need to be identified and mitigated to improve patient outcomes.

American College of Surgeons trauma center verification versus state designation: are Level II centers slipping through the cracks?

BACKGROUND

Single-center experience has shown that American College of Surgeons (ACS) trauma verification can improve outcomes. The current objective was to compare mortality between ACS-verified and state-designated centers in a national sample.

METHODS

Subjects 16 years or older from ACS-verified or state-designated Level I and II centers were identified in the National Trauma Databank 2007 to 2008. A predictive mortality model was constructed using Trauma Quality Improvement Project methodology. Imputation was used for missing data. Probability of mortality in the model determined expected deaths. Observed-to-expected (O/E) mortality ratios with 90% confidence interval (CI) and outliers (90% CI more than or less than 1.0) were compared across ACS and state Level I and II centers. The mortality model was repeated with ACS versus state included.

RESULTS

There were 900,274 subjects. The model had an area under the curve of 0.92 to predict death. Level I ACS centers had a lower median O/E ratio compared with state centers (0.95 [interquartile range, 0.82-1.05] vs. 1.02 [interquartile range, 0.87-1.15]; p < 0.01), with no difference in Level II centers. Level II state centers had more high O/E outliers. ACS verification was an independent predictor of survival in Level II centers (odds ratio, 1.26; 95% CI, 1.20-1.32; p < 0.01) but not in Level I centers (p = 0.84).

CONCLUSION

Level II centers have a disproportionate number of high mortality outliers, and ACS verification is a predictor of survival. Level I ACS centers have lower O/E ratios overall, but no difference in outliers. ACS verification seems beneficial. These data suggest that Level II centers benefit most, and promoting Level II ACS verification may be an opportunity for improved outcomes.

LEVEL OF EVIDENCE

Prognostic study, level III.

Frequency of adoption of practice management guidelines at trauma centers

Evidence-based management guidelines have been shown to improve patient outcomes, yet their utilization by trauma centers remains unknown. This study measured adoption of practice management guidelines or protocols by trauma centers. A survey of 228 trauma centers was conducted over 1 year; 55 completed the survey. Centers were classified into three groups: noncompliant, partially compliant, and compliant with adoption of management protocols. Characteristics of compliant centers were compared with those of the other two groups. Most centers were Level I (58%) not-for-profit (67%) teaching hospitals (84%) with a surgical residency (74%). One-third of centers had an accredited fellowship in surgical critical care (37%). Only one center was compliant with all 32 management protocols. Half of the centers were compliant with 14 of 32 protocols studied (range, 4 to 32). Of the 21 trauma center characteristics studied, only two were independently associated with compliant centers: use of physician extenders and daily attending rounds (both P < .0001). Adoption of management guidelines by trauma centers is inconsistent, with wide variations in practices across centers.