The objective of this study was to examine the effect of implementing a clinical practice
guidelines-based management protocol on the outcome of patients with severe traumatic
brain injury (TBI).
We carried out a pre-post guideline implementation study using previously collected
data in the Intensive Care Unit (ICU). All patients older than 12 years with severe
TBI, defined as a Glasgow Coma Scale score of 8 or less, from March 1999 to January
2001 (control group) and from February 2001 to December 2006 (protocol group) were
identified and included in this study. Patients in the protocol group were managed
using a clinical practice guidelines-based management protocol, derived from the guidelines
published by the Brain Trauma Foundation. Primary outcome was hospital mortality,
whereas the secondary outcome was ICU mortality. To assess whether the ICU protocol
might have led to an increase in the number of surviving patients with severe disability,
we examined the association of the protocol use and the need for tracheostomies, mechanical
ventilation duration, and ICU and hospital length of stay (LOS) among survivors.
During the study period, a total of 434 patients met the inclusion criteria. After
adjustment for several prognostic factors, the use of protocol was independently associated
with a significant reduction in hospital and ICU mortality (odds ratio, 0.45; 95%
confidence interval, 0.24-0.86; and odds ratio, 0.47; 95% confidence interval, 0.23-0.96,
respectively). The use of the protocol was not associated with an increase in the
need for tracheostomies, mechanical ventilation duration, ICU LOS, and hospital LOS.
The protocol implementation was associated with a reduction in hospital and ICU mortality.
This improvement was not associated with an increase in the frequency of tracheostomies
and in ICU or hospital LOS, suggesting that the improved survival was not associated
with the increased number of surviving patients with severe disability and that the
functional status might have also improved.
Copyright (c) 2010 Elsevier Inc. All rights reserved.