Association of Statewide Implementation of the Prehospital Traumatic Brain Injury Treatment Guidelines With Patient Survival Following Traumatic Brain Injury: The Excellence in Prehospital Injury Care (EPIC) Study.

TitleAssociation of Statewide Implementation of the Prehospital Traumatic Brain Injury Treatment Guidelines With Patient Survival Following Traumatic Brain Injury: The Excellence in Prehospital Injury Care (EPIC) Study.
Publication TypeJournal Article
Year of Publication2019
AuthorsSpaite DW, Bobrow BJ, Keim SM, Barnhart B, Chikani V, Gaither JB, Sherrill D, Denninghoff KR, Mullins T, P Adelson D, Rice AD, Viscusi C, Hu C
JournalJAMA Surg
Volume154
Issue7
Paginatione191152
Date Published2019 07 01
ISSN Number2168-6262
KeywordsAdult, Brain Injuries, Traumatic, Emergency Medical Services, Female, Glasgow Coma Scale, Guideline Adherence, Humans, Male, Middle Aged, Survival Rate, Treatment Outcome, United States, Young Adult
Abstract

<p><b>Importance: </b>Traumatic brain injury (TBI) is a massive public health problem. While evidence-based guidelines directing the prehospital treatment of TBI have been promulgated, to our knowledge, no studies have assessed their association with survival.</p>

<p><b>Objective: </b>To evaluate the association of implementing the nationally vetted, evidence-based, prehospital treatment guidelines with outcomes in moderate, severe, and critical TBI.</p>

<p><b>Design, Setting, and Participants: </b>The Excellence in Prehospital Injury Care (EPIC) Study included more than 130 emergency medical services systems/agencies throughout Arizona. This was a statewide, multisystem, intention-to-treat study using a before/after controlled design with patients with moderate to critically severe TBI (US Centers for Disease Control and Prevention Barell Matrix-Type 1 and/or Abbreviated Injury Scale Head region severity &ge;3) transported to trauma centers between January 1, 2007, and June 30, 2015. Data were analyzed between October 25, 2017, and February 22, 2019.</p>

<p><b>Interventions: </b>Implementation of the prehospital TBI guidelines emphasizing avoidance/treatment of hypoxia, prevention/correction of hyperventilation, and avoidance/treatment of hypotension.</p>

<p><b>Main Outcomes and Measures: </b>Primary: survival to hospital discharge; secondary: survival to hospital admission.</p>

<p><b>Results: </b>Of the included patients, the median age was 45 years, 14 666 (67.1%) were men, 7181 (32.9%) were women; 16 408 (75.1% ) were white, 1400 (6.4%) were Native American, 743 (3.4% ) were Black, 237 (1.1%) were Asian, and 2791 (12.8%) were other race/ethnicity. Of the included patients, 21 852 met inclusion criteria for analysis (preimplementation phase [P1]: 15 228; postimplementation [P3]: 6624). The primary analysis (P3 vs P1) revealed an adjusted odds ratio (aOR) of 1.06 (95% CI, 0.93-1.21; P&thinsp;=&thinsp;.40) for survival to hospital discharge. The aOR was 1.70 (95% CI, 1.38-2.09; P&thinsp;&lt;&thinsp;.001) for survival to hospital admission. Among the severe injury cohorts (but not moderate or critical), guideline implementation was significantly associated with survival to discharge (Regional Severity Score-Head 3-4: aOR, 2.03; 95% CI, 1.52-2.72; P&thinsp;&lt;&thinsp;.001; Injury Severity Score 16-24: aOR, 1.61; 95% CI, 1.07-2.48; P&thinsp;=&thinsp;.02). This was also true for survival to discharge among the severe, intubated subgroups (Regional Severity Score-Head 3-4: aOR, 3.14; 95% CI, 1.65-5.98; P&thinsp;&lt;&thinsp;.001; Injury Severity Score 16-24: aOR, 3.28; 95% CI, 1.19-11.34; P&thinsp;=&thinsp;.02).</p>

<p><b>Conclusions and Relevance: </b>Statewide implementation of the prehospital TBI guidelines was not associated with significant improvement in overall survival to hospital discharge (across the entire, combined moderate to critical injury spectrum). However, adjusted survival doubled among patients with severe TBI and tripled in the severe, intubated cohort. Furthermore, guideline implementation was significantly associated with survival to hospital admission. These findings support the widespread implementation of the prehospital TBI treatment guidelines.</p>

<p><b>Trial Registration: </b>ClinicalTrials.gov identifier: NCT01339702.</p>

DOI10.1001/jamasurg.2019.1152
Alternate JournalJAMA Surg
PubMed ID31066879
PubMed Central IDPMC6506902
Grant ListR01 NS071049 / NS / NINDS NIH HHS / United States
Faculty Reference: 
Kurt Denninghoff, MD
Joshua B. Gaither, MD, FACEP
Samuel M. Keim, MD, MSc
Amber Rice, MD
Daniel W. Spaite, MD
Chad Viscusi, MD
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