title: Management of severe head injury: institutional variations in care and effect on outcome.
abstract: OBJECTIVE
  The purpose of this study was three-fold: a) to examine variations in care of patients with severe head injury in academic trauma centers across the United States; b) to determine the proportion of patients who received care according to the Brain Trauma Foundation guidelines; and c) to correlate the outcome from severe traumatic brain injury with the care received.
  
  
  METHODS
  Retrospective data collection for consecutive patients with closed head injury and long bone fracture admitted over an 8-month period.
  
  
  METHODS
  Thirty-four academic trauma centers in the United States
  
  
  METHODS
  All patients admitted with a presenting Glasgow Coma Scale score < or = 8.
  
  
  RESULTS
  Variations in care were assessed, including prehospital intubation, intracranial pressure monitoring, use of osmotic agents, hyperventilation, and computed tomography scan utilization. Aggressive centers were defined as those placing intracranial pressure monitors in >50% of patients meeting the Brain Trauma Foundation criteria for intracranial pressure monitoring. The primary outcome variables were mortality, functional status at discharge, and length of stay. Kaplan-Meier survival analysis was performed for aggressive vs. nonaggressive centers. A Cox proportional hazard model was used to evaluate the association between type of center and mortality rate. Length of stay was evaluated by using linear regression.
  
  
  RESULTS
  There was considerable variation in the rates of prehospital intubation, intracranial pressure monitoring, intracranial pressure-directed therapy, and head computed tomography scan utilization across centers. Management at an aggressive center was associated with a significant reduction in the risk of mortality (hazard ratio, 0.43; 95% confidence interval, 0.27-0.66). There was no statistically significant difference in functional status at the time of discharge for survivors. Adjusted length of stay for survivors at aggressive centers was shorter, compared with the length of stay at nonaggressive centers: -6 days (95% confidence interval, -14 to 2 days).
  
  
  CONCLUSIONS
  Considerable national variation in the care of severely head-injured patients persists. An "aggressive" management strategy is associated with decreased mortality rate for patients with severe head injury, with no significant difference in functional status at discharge among survivors.
authors.affiliation: Department of Surgery, University of Washington, Seattle, WA, USA.
authors.forename: Eileen M
authors.initials: EM
authors.lastname: Bulger
authors.forename: Avery B
authors.initials: AB
authors.lastname: Nathens
authors.forename: Frederick P
authors.initials: FP
authors.lastname: Rivara
authors.forename: Maria
authors.initials: M
authors.lastname: Moore
authors.forename: Ellen J
authors.initials: EJ
authors.lastname: MacKenzie
authors.forename: Gregory J
authors.initials: GJ
authors.lastname: Jurkovich
mesh_terms: D000328:Adult; D015331:Cohort Studies; D006259:Craniocerebral Trauma / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D015601:Injury Severity Score; D007427:Intracranial Pressure / Q000502:physiology; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D015588:Observer Variation; D017063:Outcome Assessment, Health Care; D012189:Retrospective Studies; D016019:Survival Analysis; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology