title: Guideline Adherence and Outcomes in Severe Adult Traumatic Brain Injury for the CHIRAG (Collaborative Head Injury and Guidelines) Study.
abstract: We examined the effect of early intensive care unit (ICU) adherence to 2007 Brain Trauma Foundation Guideline indicators after traumatic brain injury (TBI) on inpatient mortality at a level 1 trauma center in India (Jay Prakash Narayan Apex Trauma Center [JPNATC]) and Harborview Medical Center (HMC) in U.S. among adults older than 18 years with severe TBI. At each site, ICU Guideline adherence in first 72 hours for 17 indicators was determined and expressed as a percentage. Outcomes were in-hospital mortality and Glasgow Outcome Scale (GOS) scores at 3, 6, and 12 months after discharge. JPNATC and HMC Guideline adherence rates were 74.9% [11.0] and 71.6 % (SD ±10.4), and overall in-hospital mortality was 24% and 27%, respectively. At JPNATC, less than 65% ICU Guideline adherence was associated with higher inpatient mortality (adjusted relative risk [aRR], 1.92; 95% confidence interval [CI], 1.11-3.33) and an increase in ICU Guideline adherence rate by 1% was associated with a 3% lower in-hospital mortality (aRR, 0.97; 95% CI, 0.95-0.99). Among patients discharged with a GOS score of 2-4 at JPNATC, 67% improved at 12 months (R(2) = 0.991; P < 0.01; 99% follow-up rate) compared with discharge, but 35%, 25%, and 14% of patients discharged with a GOS score of 3-5 deteriorated at 3, 6, and 12 months to a lower GOS at home. Achieving early ICU adherence to guideline indicators was feasible and associated with significantly lower in-hospital mortality at JPNATC. Although the intracranial pressure (ICP) monitoring rates varied, in-hospitals deaths were similar between the two institutions. Although long-term outcomes generally improved, patients discharged with favorable GOS score often deteriorated at home.
authors.affiliation: Department of Neurosurgery, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Deepak
authors.initials: D
authors.lastname: Gupta
authors.affiliation: Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA; Department of Neurological Surgery, University of Washington, Seattle, Washington, USA.
authors.forename: Deepak
authors.initials: D
authors.lastname: Sharma
authors.affiliation: Department of Epidemiology, University of Washington, Seattle, Washington, USA.
authors.forename: Nithya
authors.initials: N
authors.lastname: Kannan
authors.affiliation: Department of Neurosurgery, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Suchada
authors.initials: S
authors.lastname: Prapruettham
authors.affiliation: Department of Epidemiology, University of Washington, Seattle, Washington, USA; Department of Surgery, University of Washington, Seattle, Washington, USA.
authors.forename: Charles
authors.initials: C
authors.lastname: Mock
authors.affiliation: Department of Pediatrics, University of Washington, Seattle, Washington, USA.
authors.forename: Jin
authors.initials: J
authors.lastname: Wang
authors.affiliation: Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA.
authors.forename: Qian
authors.initials: Q
authors.lastname: Qiu
authors.affiliation: Department of Biostatistics and Epidemiology Unit, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Ravindra M
authors.initials: RM
authors.lastname: Pandey
authors.affiliation: Department of Neurosurgery, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Ashok
authors.initials: A
authors.lastname: Mahapatra
authors.affiliation: Department of Anesthesiology, Fortis Memorial Research Institute, Gurgaon, India.
authors.forename: Hari Har
authors.initials: HH
authors.lastname: Dash
authors.affiliation: Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA.
authors.forename: James G
authors.initials: JG
authors.lastname: Hecker
authors.affiliation: Department of Epidemiology, University of Washington, Seattle, Washington, USA; Department of Pediatrics, University of Washington, Seattle, Washington, USA.
authors.forename: Frederick P
authors.initials: FP
authors.lastname: Rivara
authors.affiliation: Department of Epidemiology, University of Washington, Seattle, Washington, USA.
authors.forename: Ali
authors.initials: A
authors.lastname: Rowhani-Rahbar
authors.affiliation: Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA; Department of Neurological Surgery, University of Washington, Seattle, Washington, USA; Department of Pediatrics, University of Washington, Seattle, Washington, USA. Electronic address: vavilala@u.washington.edu.
authors.forename: Monica S
authors.initials: MS
authors.lastname: Vavilala
mesh_terms: D000328:Adult; D000070642:Brain Injuries, Traumatic / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D005260:Female; D023261:Glasgow Outcome Scale; D019983:Guideline Adherence; D017052:Hospital Mortality; D006801:Humans; D007194:India; D007362:Intensive Care Units; D007427:Intracranial Pressure; D008297:Male; D010351:Patient Discharge; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D012189:Retrospective Studies; D012306:Risk; D014193:Trauma Centers; D016896:Treatment Outcome; D014861:Washington
keywords: Guidelines; Outcomes; Traumatic brain injury