title: Establishing a Traumatic Brain Injury Program of Care: Benchmarking Outcomes after Institutional Adoption of Evidence-Based Guidelines.
abstract: Traumatic brain injury (TBI) is a widespread global disease, often with widely varying outcomes. Standardization of care and adherence to established guidelines are central to the effort to improve outcomes. At our level I urban trauma center, we developed and implemented a Joint Commission-certified TBI Program of Care in 2011 and compared our post-implementation patient data set with historical controls, using the International Mission for Prognosis and Analysis of Clinical Trials (IMPACT) prognostic model. Historical controls were drawn from the San Francisco General Hospital Traumatic Coma Data Bank (SFGH/TCDB) from 1987 to 1996. Recent era patients were drawn from the NeuroTracker database, a customized electronic medical record used in our clinical practice. Descriptive statistics were calculated. Adherence to four quality-of-care metrics on the clinical service was tracked for 2011-2013. The IMPACT prognostic model was used to calculate expected versus observed mortality for current and historical patient groups. In the historical control group, 832 patients were identified and 6-month mortality was available for 592. Observed 6-month mortality was 49%. In the recent era patient group, 211 patients were identified and 6-month mortality was 38%. The IMPACT prognostic model was applied to each patient group. Areas under the curve for each analysis were >0.85 and goodness of fit was satisfactory, indicating good performance of the IMPACT model. Comparison of observed versus expected deaths in the recent versus the control patient sets revealed a drop of 59% in early mortality. The greatest reductions in mortality were observed in the group of patients with IMPACT-predicted mortality ≤50%. Significant progress has been made in reducing the percentage of unexpected deaths in TBI patients. It is likely that major factors include more aggressive management and tracking of compliance with the implementation of guidelines for the management of TBI patients.
authors.affiliation: 1 Department of Neurological Surgery, University of California San Francisco , San Francisco, California.|2 Brain and Spinal Injury Center, San Francisco General Hospital , San Francisco, California.
authors.forename: Phiroz E
authors.initials: PE
authors.lastname: Tarapore
authors.affiliation: 1 Department of Neurological Surgery, University of California San Francisco , San Francisco, California.|2 Brain and Spinal Injury Center, San Francisco General Hospital , San Francisco, California.
authors.forename: Mary J
authors.initials: MJ
authors.lastname: Vassar
authors.affiliation: 2 Brain and Spinal Injury Center, San Francisco General Hospital , San Francisco, California.
authors.forename: Shelly
authors.initials: S
authors.lastname: Cooper
authors.affiliation: 2 Brain and Spinal Injury Center, San Francisco General Hospital , San Francisco, California.
authors.forename: Twyila
authors.initials: T
authors.lastname: Lay
authors.affiliation: 2 Brain and Spinal Injury Center, San Francisco General Hospital , San Francisco, California.|3 School of Nursing, University of California San Francisco , San Francisco, California.
authors.forename: Julia
authors.initials: J
authors.lastname: Galletly
authors.affiliation: 1 Department of Neurological Surgery, University of California San Francisco , San Francisco, California.|2 Brain and Spinal Injury Center, San Francisco General Hospital , San Francisco, California.
authors.forename: Geoffrey T
authors.initials: GT
authors.lastname: Manley
authors.affiliation: 1 Department of Neurological Surgery, University of California San Francisco , San Francisco, California.|2 Brain and Spinal Injury Center, San Francisco General Hospital , San Francisco, California.
authors.forename: Michael C
authors.initials: MC
authors.lastname: Huang
mesh_terms: D000328:Adult; D000368:Aged; D019985:Benchmarking / Q000379:methods / Q000592:standards* / Q000639:trends; D000070642:Brain Injuries, Traumatic / Q000175:diagnosis / Q000401:mortality*; D015331:Cohort Studies; D019317:Evidence-Based Medicine / Q000379:methods / Q000592:standards* / Q000639:trends; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009026:Mortality / Q000639:trends; D017410:Practice Guidelines as Topic / Q000592:standards*; D016730:Program Development / Q000379:methods / Q000592:standards*; D016896:Treatment Outcome
keywords: IMPACT model; TBI; TBI guidelines; TBI outcomes; traumatic brain injury