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

BACKGROUND

Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development.

METHODS

We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital's 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)-a composite of life expectancy, education, and income measures-into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation.

FINDINGS

Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24-51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34-69) and the youngest in the low HDI tier (median 28 years, IQR 20-38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6-32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55-5·2) and high HDI tier (2·26, 1·23-4·15), but not the low HDI tier (1·66, 0·61-4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17-2·49).

INTERPRETATION

Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices.

FUNDING

National Institute for Health Research Global Health Research Group.

The persistent breach between evidence and practice in the prevention of surgical site infection. Qualitative study

BACKGROUND

Despite the dissemination of guidelines for surgical site infection (SSI) prevention, a gap between the theoretical measures and their compliance persists. Accurate estimates of the implementation of preventative measures is crucial before planning dissemination strategies.

METHODS

A web-based survey was distributed to members of 11 Associations of operative nurses and surgeons. Questions aimed to determine their awareness of evidence, personal beliefs and actual use of the main preventative measures.

RESULTS

Of 1105 responders, 50.5% receive no feed-back of their SSI rate. Responders show a moderate rate of awareness of the recommendations about not removing hair, hair clipping, skin antisepsis with alcoholic solutions, and normothermia. Antibiotic prophylaxis is given for more than 24 h by 18.8% of respondents. Screening for S. aureus is performed by 27.6%. Hair removal by shaving is used by 16.6% of responders. The most common antiseptic solutions are alcoholic chlorhexidine (57.2%) and aqueous povidone (23.3%). 62.8% of surgeons allow the solution to air dry before applying surgical drapes. Adhesive drapes in the surgical field are used routinely in 33.4% of cases. Perioperative normothermia, glucose control and hyperoxia are used in 84.3%, 65.9% and 23.3% of cases. Antimicrobial sutures and negative pressure therapy are used by 20.2% and 43.5% of teams, respectively. Prior to closing the incision, 83.9% replace surgical instruments always or selectively. Wound irrigation before closing is used in 78.1% of cases, mostly with saline. Check-lists, standardized orders, surveillance, feed-back and educational programs were rated most highly by respondents as a means to improve compliance with preventative guidelines, but few of these strategies were in place at their institutions.

CONCLUSION

Gaps in the translation of evidence into practice remain in the prevention of SSI among different surgical specialities. Several areas for improvement have been identified, as some core prevention measures are not in common use.