The effectiveness of specialist neuroscience care in severe traumatic brain injury: a systematic review

Advanced Trauma Life Support/Advanced Trauma Care for Nurses: A systematic review concerning the knowledge and skills of emergency nurse related to trauma triage in a community

BACKGROUND

In the trauma triage procedure, nurses with good knowledge and skills can start initial treatment immediately pending doctors availability, and before a final diagnosis is made. The Advanced Trauma Life Support/ Advanced Trauma Care for Nurses is one of the most important trauma education programmes to enhance the knowledge and skills of emergency nurses. This systematic review of the literature attempts to investigate the implications of introducing an Advanced Trauma Life Support/Advanced Trauma Care for Nurses' knowledge and skills related to trauma triage.

METHODS

A systematic review was carried out using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The included sites and databases are Web of Science, Scopus, PubMed, ScienceDirect, Cochrane Library, and Bielefeld Academic Search Engine (BASE) from 1994 to 2019. The quality of the selected studies was evaluated using a standard quality rating tool (SQRT). The quality of the criteria for inclusion and exclusion was independently reviewed by three researchers.

RESULTS

This study evaluated 5266 records in the identification stage. In the included stage, only four studies were included in this review. In the standard quality assessment, none of the included studies were evaluated as being a strong study, none used an experimental design at three points in time (pre, post and follow-up), and all showed a moderate to high risk of bias. There is a lack of knowledge and skills related to trauma triage among emergency nurses in the included studies.

CONCLUSION

A lack of knowledge and skills concerning trauma triage among emergency nurses could potentially have an adverse effect on the outcomes of the patients in trauma cases.

A comparison of patients managed in specialist versus non-specialist inpatient rehabilitation units in Australia

Aim: To compare the rehabilitation of patients with brain and spinal cord injury in specialist rehabilitation units and non-specialist rehabilitation units in Australia over a 10-year period.Method: A retrospective cohort study design was used. Epidemiological descriptive analysis was used to examine inpatient rehabilitation data held in the Australasian Rehabilitation Outcomes Centre Registry Database at four discrete time points: 2007, 2010, 2013 and 2016. Data sets included patient demographics, length of stay and the Functional Independence Measure. Data sets were examined for differences between specialist and non-specialist rehabilitation units.Results: Over the 10-year study period, compared to patients admitted to non-specialist rehabilitation units patients admitted to specialist rehabilitation units: (1) were younger and more likely to be male; (2) had a longer time between onset of illness/injury and rehabilitation admission; (3) had a longer median rehabilitation length of stay; (4) had a higher burden of care on admission to rehabilitation; however (5) had a greater functional gain. Patients in specialist rehabilitation units had a lower relative functional efficiency per day of rehabilitation, but higher percentage of Functional Independence Measure gain. In 2016, 66% of brain injury and 51% of spinal cord injury patients were not rehabilitated in specialist rehabilitation units.Conclusion: There are differences in the characteristics of patients admitted to specialist versus non-specialist rehabilitation units. Patients admitted to specialist rehabilitation units have greater functional gain. A noteworthy proportion of brain and spinal cord injury patients are not being rehabilitated in specialist rehabilitation units, particularly patients with non-traumatic injuries.Implications for rehabilitationPatients with a brain or spinal cord injury rehabilitated in specialist rehabilitation units achieve a greater functional gain than those in non-specialist units.Development of best practice admission guidelines would better enable the right care for the right patient in the right setting at the right time.There is a need for longitudinal examination of patient outcomes to better understand the long-term benefits of being rehabilitated in specialist rehabilitation units compared to non-specialist rehabilitation units.

The currency, completeness and quality of systematic reviews of acute management of moderate to severe traumatic brain injury: A comprehensive evidence map

OBJECTIVE

To appraise the currency, completeness and quality of evidence from systematic reviews (SRs) of acute management of moderate to severe traumatic brain injury (TBI).

METHODS

We conducted comprehensive searches to March 2016 for published, English-language SRs and RCTs of acute management of moderate to severe TBI. Systematic reviews and RCTs were grouped under 12 broad intervention categories. For each review, we mapped the included and non-included RCTs, noting the reasons why RCTs were omitted. An SR was judged as 'current' when it included the most recently published RCT we found on their topic, and 'complete' when it included every RCT we found that met its inclusion criteria, taking account of when the review was conducted. Quality was assessed using the AMSTAR checklist (trichotomised into low, moderate and high quality).

FINDINGS

We included 85 SRs and 213 RCTs examining the effectiveness of treatments for acute management of moderate to severe TBI. The most frequently reviewed interventions were hypothermia (n = 17, 14.2%), hypertonic saline and/or mannitol (n = 9, 7.5%) and surgery (n = 8, 6.7%). Of the 80 single-intervention SRs, approximately half (n = 44, 55%) were judged as current and two-thirds (n = 52, 65.0%) as complete. When considering only the most recently published review on each intervention (n = 25), currency increased to 72.0% (n = 18). Less than half of the 85 SRs were judged as high quality (n = 38, 44.7%), and nearly 20% were low quality (n = 16, 18.8%). Only 16 (20.0%) of the single-intervention reviews (and none of the five multi-intervention reviews) were judged as current, complete and high-quality. These included reviews of red blood cell transfusion, hypothermia, management guided by intracranial pressure, pharmacological agents (various) and prehospital intubation. Over three-quarters (n = 167, 78.4%) of the 213 RCTs were included in one or more SR. Of the remainder, 17 (8.0%) RCTs post-dated or were out of scope of existing SRs, and 29 (13.6%) were on interventions that have not been assessed in SRs.

CONCLUSION

A substantial number of SRs in acute management of moderate to severe TBI lack currency, completeness and quality. We have identified both potential evidence gaps and also substantial research waste. Novel review methods, such as Living Systematic Reviews, may ameliorate these shortcomings and enhance utility and reliability of the evidence underpinning clinical care.

Criteria for Intensive Care admission and monitoring after elective craniotomy

PURPOSE OF REVIEW

The current article revises the recent evidence on ICU admission criteria and postoperative neuromonitoring for patients undergoing elective craniotomy.

RECENT FINDINGS

Only a small proportion of elective postoperative neurosurgical patients require specific medical interventions and invasive monitoring. Among these, patients undergoing elective craniotomy are frequently admitted to neuro-ICU, specialist postanaesthesia care units or intermediate-level care unit in the postoperative period.Craniotomy patients have a high risk of neurological complications in the immediate postoperative period and might require advanced neuromonitoring, especially if sedation is continued in the ICU.Furthermore, the concept of enhanced recovery after surgery with the goal of improving functional capacity after surgery and decreasing morbidity has expanded to encompass neurosurgery.Postoperative clinical examination and neurological scores, bispectral index and simplified electroencephalography, and morning discharge huddles are the most used strategies in this context.

SUMMARY

After elective craniotomy, ICU admission should be warranted to patients who show new neurological deficits, especially when these include reduced consciousness or deficits of the lower cranial nerves, or have surgical indication for delayed extubation. Currently, evidence does not allow defining standardized protocol to guide ICU admission and postoperative neuromonitoring.

Management of severe traumatic brain injury (first 24hours)

The latest French Guidelines for the management in the first 24hours of patients with severe traumatic brain injury (TBI) were published in 1998. Due to recent changes (intracerebral monitoring, cerebral perfusion pressure management, treatment of raised intracranial pressure), an update was required. Our objective has been to specify the significant developments since 1998. These guidelines were conducted by a group of experts for the French Society of Anesthesia and Intensive Care Medicine (Société francaise d'anesthésie et de réanimation [SFAR]) in partnership with the Association de neuro-anesthésie-réanimation de langue française (ANARLF), The French Society of Emergency Medicine (Société française de médecine d'urgence (SFMU), the Société française de neurochirurgie (SFN), the Groupe francophone de réanimation et d'urgences pédiatriques (GFRUP) and the Association des anesthésistes-réanimateurs pédiatriques d'expression française (ADARPEF). The method used to elaborate these guidelines was the Grade^® method. After two Delphi rounds, 32 recommendations were formally developed by the experts focusing on the evaluation the initial severity of traumatic brain injury, the modalities of prehospital management, imaging strategies, indications for neurosurgical interventions, sedation and analgesia, indications and modalities of cerebral monitoring, medical management of raised intracranial pressure, management of multiple trauma with severe traumatic brain injury, detection and prevention of post-traumatic epilepsia, biological homeostasis (osmolarity, glycaemia, adrenal axis) and paediatric specificities.

Bypassing nearest hospital for more distant neuroscience care in head-injured adults with suspected traumatic brain injury: findings of the head injury transportation straight to neurosurgery (HITS-NS) pilot cluster randomised trial

OBJECTIVE

Reconfiguration of trauma services, with direct transport of patients with traumatic brain injury (TBI) to specialist neuroscience centres (SNCs)-bypassing non-specialist acute hospitals (NSAHs), could improve outcomes. However, delays in stabilisation of airway, breathing and circulation (ABC) may worsen outcomes when compared with selective secondary transfer from nearest NSAH to SNC. We conducted a pilot cluster randomised controlled trial to determine the feasibility and plausibility of bypassing suspected patients with TBI -directly into SNCs-producing a measurable effect.

SETTING

Two English Ambulance Services.

PARTICIPANTS

74 clusters (ambulance stations) were randomised within pairs after matching for important characteristics. Clusters enrolled head-injured adults-injured nearest to an NSAH-with internationally accepted TBI risk factors and stable ABC. We excluded participants attended by Helicopter Emergency Medical Services or who were injured more than 1 hour by road from nearest SNC.

INTERVENTIONS

Intervention cluster participants were transported directly to an SNC bypassing nearest NSAH; control cluster participants were transported to nearest NSAH with selective secondary transfer to SNC.

OUTCOMES

Trial recruitment rate (target n=700 per annum) and percentage with TBI on CT scan (target 80%) were the primary feasibility outcomes. 30-day mortality, 6-month Extended Glasgow Outcome Scale and quality of life were secondary outcomes.

RESULTS

56 ambulance station clusters recruited 293 patients in 12 months. The trial arms were similar in terms of age, conscious level and injury severity. Less than 25% of recruited patients had TBI on CT (n=70) with 7% (n=20) requiring neurosurgery. Complete case analysis showed similar 30-day mortality in the two trial arms (control=8.8 (2.7-14.0)% vs intervention=9.4(2.3-14.0)%).

CONCLUSION

Bypassing patients with suspected TBI to SNCs gives an overtriage (false positive) ratio of 13:1 for neurosurgical intervention and 4:1 for TBI. A measurable effect from a full trial of early neuroscience care following bypass is therefore unlikely.

TRIAL REGISTRATION NUMBER

ISRCTN68087745.

Out-of-Hospital Triage of Older Adults With Head Injury: A Retrospective Study of the Effect of Adding "Anticoagulation or Antiplatelet Medication Use" as a Criterion

STUDY OBJECTIVE

Field triage guidelines recommend that emergency medical services (EMS) providers consider transport of head-injured older adults with anticoagulation use to trauma centers. However, the triage patterns and the incidence of intracranial hemorrhage or neurosurgery in these patients are unknown. Our objective is to describe the characteristics and outcomes of older adults with head trauma who are transported by EMS, particularly for patients who do not meet physiologic, anatomic, or mechanism-of-injury (steps 1 to 3) field triage criteria but are receiving anticoagulant or antiplatelet medications.

METHODS

This was a retrospective study at 5 EMS agencies and 11 hospitals (4 trauma centers, 7 nontrauma centers). Patients aged 55 years or older with head trauma who were transported by EMS were included. The primary outcome was the presence of intracranial hemorrhage. The secondary outcome was a composite measure of inhospital death or neurosurgery.

RESULTS

Of the 2,110 patients included, 131 (6%) had intracranial hemorrhage and 41 (2%) had inhospital death or neurosurgery. There were 162 patients (8%) with steps 1 to 3 criteria. Of the remaining 1,948 patients without steps 1 to 3 criteria, 566 (29%) had anticoagulant or antiplatelet use. Of these patients, 52 (9%) had traumatic intracranial hemorrhage and 15 (3%) died or had neurosurgery. The sensitivity (adjusted for clustering by EMS agency) of steps 1 to 3 criteria was 19.8% (26/131; 95% confidence interval [CI] 5.5% to 51.2%) for identifying traumatic intracranial hemorrhage and 34.1% (14/41; 95% CI 9.9% to 70.1%) for death or neurosurgery. The additional criterion of anticoagulant or antiplatelet use improved the sensitivity for intracranial hemorrhage (78/131; 59.5%; 95% CI 42.9% to 74.2%) and death or neurosurgery (29/41; 70.7%; 95% CI 61.0% to 78.9%).

CONCLUSION

Relatively few patients met steps 1 to 3 triage criteria. For individuals who did not have steps 1 to 3 criteria, nearly 30% had anticoagulant or antiplatelet use. A relatively high proportion of these patients had intracranial hemorrhage, but a much smaller proportion died or had neurosurgery during hospitalization. Use of steps 1 to 3 triage criteria alone is not sufficient in identifying intracranial hemorrhage and death or neurosurgery in this patient population. The additional criterion of anticoagulant or antiplatelet use improves the sensitivity of the instrument, with only a modest decrease in specificity.

The Head Injury Transportation Straight to Neurosurgery (HITS-NS) randomised trial: a feasibility study

BACKGROUND

Reconfiguration of trauma services, with direct transport of traumatic brain injury (TBI) patients to neuroscience centres (NCs), bypassing non-specialist acute hospitals (NSAHs), could potentially improve outcomes. However, delays in stabilisation of airway, breathing and circulation (ABC) and the difficulties in reliably identifying TBI at scene may make this practice deleterious compared with selective secondary transfer from nearest NSAH to NC. National Institute for Health and Care Excellence guidance and systematic reviews suggested equipoise and poor-quality evidence - with regard to 'early neurosurgery' in this cohort - which we sought to address.

METHODS

Pilot cluster randomised controlled trial of bypass to NC conducted in two ambulance services with the ambulance station (n = 74) as unit of cluster [Lancashire/Cumbria in the North West Ambulance Service (NWAS) and the North East Ambulance Service (NEAS)]. Adult patients with signs of isolated TBI [Glasgow Coma Scale (GCS) score of < 13 in NWAS, GCS score of < 14 in NEAS] and stable ABC, injured nearest to a NSAH were transported either to that hospital (control clusters) or bypassed to the nearest NC (intervention clusters).

PRIMARY OUTCOMES

recruitment rate, protocol compliance, selection bias as a result of non-compliance, accuracy of paramedic TBI identification (overtriage of study inclusion criteria) and pathway acceptability to patients, families and staff. 'Open-label' secondary outcomes: 30-day mortality, 6-month Extended Glasgow Outcome Scale (GOSE) and European Quality of Life-5 Dimensions.

RESULTS

Overall, 56 clusters recruited 293 (169 intervention, 124 control) patients in 12 months, demonstrating cluster randomised pre-hospital trials as viable for heath service evaluations. Overall compliance was 62%, but 90% was achieved in the control arm and when face-to-face paramedic training was possible. Non-compliance appeared to be driven by proximity of the nearest hospital and perceptions of injury severity and so occurred more frequently in the intervention arm, in which the perceived time to the NC was greater and severity of injury was lower. Fewer than 25% of recruited patients had TBI on computed tomography scan (n = 70), with 7% (n = 20) requiring neurosurgery (craniotomy, craniectomy or intracranial pressure monitoring) but a further 18 requiring admission to an intensive care unit. An intention-to-treat analysis revealed the two trial arms to be equivalent in terms of age, GCS and severity of injury. No significant 30-day mortality differences were found (8.8% vs. 9.1/%; p > 0.05) in the 273 (159/113) patients with data available. There were no apparent differences in staff and patient preferences for either pathway, with satisfaction high with both. Very low responses to invitations to consent for follow-up in the large number of mild head injury-enrolled patients meant that only 20% of patients had 6-month outcomes. The trial-based economic evaluation could not focus on early neurosurgery because of these low numbers but instead investigated the comparative cost-effectiveness of bypass compared with selective secondary transfer for eligible patients at the scene of injury.

CONCLUSIONS

Current NHS England practice of bypassing patients with suspected TBI to neuroscience centres gives overtriage ratios of 13 : 1 for neurosurgery and 4 : 1 for TBI. This important finding makes studying the impact of bypass to facilitate early neurosurgery not plausible using this study design. Future research should explore an efficient comparative effectiveness design for evaluating 'early neurosurgery through bypass' and address the challenge of reliable TBI diagnosis at the scene of injury.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN68087745.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 1. See the NIHR Journals Library website for further project information.

Functional and long-term outcomes in severe traumatic brain injury following regionalization of a trauma system

BACKGROUND

We previously demonstrated that regionalization of trauma (RT) significantly reduced in-hospital mortality from 19% to 14% in patients with severe traumatic brain injury (sTBI). However, functional and long-term outcomes had not been assessed. We hypothesized that RT would be associated with improved functional and long-term outcomes in sTBI patients.

METHODS

All TBI patients older than 14 years with a head Abbreviated Injury Scale (AIS) score of 3 or greater were identified from the RT database and matched to the state death index and the regional TBI rehabilitation (TBIr) database. Data from 2008 through 2012 were analyzed before and after RT in 2010. For patients discharged to the TBIr unit, overall Functional Independence Measure (FIM) scores and FIM score gains were compared before and after RT.

RESULTS

A total of 3,496 patients with sTBI were identified in the RT database, 1,359 in the pre-RT and 2,137 in the post-RT period. The mortality rate after discharge decreased significantly after RT from 21% to 16% (p < 0.0001) at 30 days and from 24% to 20% (p = 0.004) at 6 months. Multivariable logistic regression demonstrated RT to be an independent predictor against mortality at 30 days (odds ratio, 0.74; 95% confidence interval, 0.60-0.91; C statistic, 0.84) and 6 months (odds ratio, 0.82; 95% confidence interval, 0.67-0.99; C statistic, 0.82). Discharges to the TBIr unit increased from 117 (9%) in the pre-RT to 297 (14%) in the post-RT period (p < 0.0001), while discharges to home and non-TBIr units remained similar. Injury Severity Score (ISS) and Glasgow Coma Scale (GCS) score for all discharged patients remained similar. FIM admission scores were similar in the pre-RT (median, 54; interquartile range [IQR], 30-65) and post-RT period (median, 48; IQR, 31-61) (p = 0.2) and remained similar at discharge in the pre-RT (median, 92; IQR, 75-102) and post-RT period (median, 89; IQR, 73-100) (p = 0.1). TBIr patients showed similar FIM score gains in the pre-RT (median, 37; IQR, 26-46) and post-RT period (median, 36; IQR, 24-49) (p = 0.6).

CONCLUSION

RT was associated with reduced long-term mortality, increased TBIr admissions, and similar FIM score improvements for patients with sTBI.

LEVEL OF EVIDENCE

Therapeutic/care management study, level IV.

Save the patient a trip. Outcome difference between conservatively treated patients with traumatic brain injury in a nonspecialized intensive care unit vs a specialized neurosurgical intensive care unit in the Sultanate of Oman

Traumatic brain injury (TBI) continues to be the main cause of death among trauma patients. Accurate diagnosis and timely surgical interventions are critical steps in reducing the mortality from this disease. For patients who have no surgically reversible head injury pathology, the decision to transfer to a dedicated neurosurgical unit is usually controversial.

OBJECTIVE

To compare the outcome of patients with severe TBI treated conservatively in a specialized neurosurgical intensive care unit (ICU) and those treated conservatively at a general ICU in the Sultanate of Oman.

DESIGN

Retrospective cohort study.

METHODS

This is a retrospective study of patients with severe TBI admitted to Khoula Hospital ICU (specialized neurosurgical ICU) and Nizwa Hospital ICU (general ICU) in Oman in 2013. Surgically treated patients were excluded. Data extracted included demographics, injury details, interventions, and outcomes. The outcome variables included mortality, length of stay, length of ICU days, and ventilated days.

RESULTS

There were 100 patients with severe TBI treated conservatively at Khoula Hospital compared with 74 patients at Nizwa Hospital. Basic demographics were similar between the 2 groups. No significant difference was found in mortality, length of stay, ICU days, and ventilation days.

CONCLUSION

There is no difference in outcome between patients with TBI treated conservatively in a specialized neurosurgical ICU and those treated in a general nonspecialized ICU in Oman in 2013. Therefore, unless neurosurgical intervention is warranted or expected, patients with TBI may be managed in a general ICU, saving the risk and expense of a transfer to a specialized neurosurgical ICU.