Sylvain Palmer

The Impact on Outcomes in a Community Hospital Setting of Using the Aans Traumatic Brain Injury Guidelines

BACKGROUND Traumatic brain injury poses a serious public health challenge. Treatment paradigms have dramatically shifted with the introduction of the American Association of Neurologic Surgeons (AANS) Guidelines for the Management of Severe Head Injury. Implementation of the AANS guidelines positively affects patient outcomes and can be successfully introduced in a community hospital setting. METHODS Data were collected both retrospectively and prospectively from the records of all trauma patients between 1994 and 1999. A cohort of 93 patients was selected. Thirty-seven patients were treated before the implementation of the AANS guidelines, and these were statistically compared with 56 patients treated after the implementation of the guidelines. RESULTS Implementation of the recommendations in the AANS guidelines in a standardized protocol resulted in a 9.13 times higher odds ratio of a good outcome relative to the odds of a poor outcome or death compared with a group managed before the practice change. A Glasgow Coma Scale (GCS) admission score > 8 was associated with a 6.58 times higher odds ratio of a good outcome compared with a GCS admission score < or = 8. Odds ratio of a good outcome decreased by a factor of 0.92 for each year increase in age of patients starting at age 9. A dedicated neurotrauma team and comprehensive treatment algorithms are critical elements to this success. Hospital charges increased by more than

Brain tissue oxygenation in brain death

97,000 per patient, but are justifiable in the face of significantly improved outcomes. CONCLUSION Implementation of a traumatic brain injury protocol in a community hospital setting is practical and efficacious. Appropriate invasive monitoring of systemic and cerebral parameters guides care decisions. The protocol results in an increase in resource usage, but it also results in statistically improved outcomes justifying the increase in expenditures.

Refractory Increased Intracranial Pressure in Severe Traumatic Brain Injury Barbiturate Coma and Bispectral Index Monitoring

Introduction: The value of brain tissue oxygenation (PbtO2) measurements in determining brain death is unknown.Methods: Eleven of 72 patients who had brain tissue oxygen monitors placed experienced brain death. Admission diagnoses included six severe traumatic brain injuries, one multiple trauma with cardiac arrest, one brain tumor, one subarachnoid hemorrhage, one intracerebral hemorrhage, and one cerebral stroke. Eleven males and zero females were studied, with an average age of 26 years (range: 20–70 years). Nine patients had Glasgow Coma Scores (GCS) of 3 on admission, one patient had a GCS of 5, and one patient had a GCS of 15.Results: Time from admission to declaration of brain death varied from 5 hours to 7 days; the most common interval was 1 or 2 days. Cerebral perfusion pressure (CPP) fell to 0 in eight patients, which indicated primary failure of cerebral perfusion. CPP stayed above 60 mmHg in three patients, indicating primary tissue failure, possibly of the cerebral microvasculature. PbtO2 fell to 0 in all patients who experienced brain death, and all patients with PbtO2 of 0 experienced brain death. None of the 61 patients who did not experience brain death had confirmed PbtO2 readings of 0.Conclusion: PbtO2 can be successfully and accurately used as a bedside adjunctive test for brain death. The use of PbtO2 as a sole confirmatory test for brain death in the setting of an appropriate clinical examination will require the evaluation of a larger number of patients to assess its sensitivity and specificity.

Using a FOCUS-PDCA quality improvement model for applying the severe traumatic brain injury guidelines to practice: process and outcomes

Patients with severe traumatic brain injury resulting in increased intracranial pressure refractory to first-tier interventions challenge the critical care team. After exhausting these initial interventions, critical care practitioners may utilize barbiturate-induced coma in an attempt to reduce the intracranial pressure. Titrating appropriate levels of barbiturate is imperative. Underdosing the drug may fail to control the intracranial pressure, whereas overdosing may lead to untoward effects such as hypotension and cardiac compromise. Monitoring for a therapeutic level of barbiturate coma includes targeting drug levels and using continuous electroencephalogram monitoring, considered the gold standard. New technology, the Bispectral Index monitor, utilizes electroencephalogram principles to monitor the level of sedation and hypnosis in the critical care environment. This technology is now being considered for targeting appropriate levels of barbiturate coma.

What’s the “Hyper” in Hyperacute Stroke? Strategies to Improve Outcomes in Ischemic Stroke Patients Presenting Within 6 Hours

Trauma teams strive to provide care based on best practice. Exploring the clinical outcomes of patients sustaining severe traumatic brain injury (TBI) at our trauma centre from 1994–97 we found that the outcomes were marginal at best: 43% of our patients expired and 30% suffered severe disability. These results were consistent with those of some studies on TBI published in the 1980s. Researchers in the past decade have used new technology for monitoring the effects of secondary brain injury and examined the effects of various treatment modalities on the outcomes of patients with TBI. In 1995, the American Association of Neurological Surgeons (AANS) evidence-based clinical guidelines for managing severe TBI were published.1 The guidelines recommended changes in the care of patients with TBI and challenged caregivers to evaluate their practices and examine the clinical outcomes of this high risk group. Motivated by the new practice recommendations and the potential for greatly affecting patient outcomes, Mission Hospital Regional Medical Center’s (MHRMC) multidisciplinary neurotrauma team convened in 1997 to begin performance improvement. Current practice was examined and new hospital based clinical guidelines were developed. Numerous changes were recommended as the team dismantled current practice patterns and constructed new care priorities. The result was a series of algorithms with established outcomes at every phase of the patient’s hospital course. Four years after integrating the changes in practice, the team evaluated prospectively collected data to determine outcomes for patients with severe TBI. Current outcomes (2001 data) indicated that 72.8% of patients had a good outcome (no disability to moderate disability), 13.6% had severe disability to persistent vegetative state, and 13.6% died. We will present a FOCUS-PDCA performance improvement approach to show the processes used to apply national scientific guidelines to the clinical setting. Statistical analysis using an ordinal regression model will show outcome …

Keeping the Brain in the Zone: Applying the Severe Head Injury Guidelines to Practice

Ischemic stroke patients presenting to acute care hospitals require an organized response from multiple disciplines and clinical areas. Patients presenting within 6 hours of stroke onset constitute a category of stroke patient known as the “hyperacute stroke patient.” This category of stroke patients is eligible for treatment using intravenous recombinant tissue plasminogen activator when treated within 3 hours, or interventional treatment options when treated within 6 hours of stroke onset. Guidelines have been established identifying critical elements for hospitals in order to be designated as primary or comprehensive stroke centers. Research studies exploring treatment options for stroke, as well as general care priorities exist in the scientific literature but must be integrated into hospital-based protocols. Recommended interventions are highlighted to assist critical care practitioners in the delivery of care for stroke patients. Coordinated teams using an evidence-based approach can optimize the outcomes of the stroke patient population.

The Adam Williams Initiative: Collaborating With Community Resources to Improve Care for Traumatic Brain Injury

Providing care to the TBI patient population with severe injuries requires an integrated multidisciplinary approach. The team in clinical practice must be willing to examine its own practice, seek out the latest information on TBI, and critically analyze the information. Members must be open to changing their own practice when the data presented support change. Interventions based on scientific evidence provide a strong foundation for delivering care. The standardization of these interventions into protocols facilitates team communication and coordination. Measuring outcomes is imperative for evaluating the effectiveness of current treatment algorithms. Changes in treatment practice should be based on the measured outcomes and advances in the scientific literature.

Cerebral Oxygen Desaturation with Normal ICP and CPP in Severe TBI

BACKGROUND The Brain Trauma Foundation has developed treatment guidelines for the care of patients with acute traumatic brain injury. However, a method to provide broad acceptance and application of these guidelines has not been published. OBJECTIVE To describe methods for the development, funding, and continued educational efforts of the Adam Williams Initiative; the experiences from the first 10 years may serve as a template for hospitals and nurses that seek to engage in long-term quality improvement collaborations with foundations and/or industry. METHODS In 2004, the nonprofit Adam Williams Initiative was established with the goal of providing education and resources that would encourage hospitals across the United States to incorporate the Brain Trauma Foundations guidelines into practice. RESULTS Between 2004 and 2014, 37 hospitals have been funded by the Adam Williams Initiative and have had staff members participate in an immersion experience at Mission Hospital (Mission Viejo, California) during which team members received both didactic and hands-on education in the care of traumatic brain injury. CONCLUSIONS Carefully cultivated relationships and relentless teamwork have contributed to successful implementation of the Brain Trauma Foundations guidelines in US hospitals.

Using a FOCUS‐PDCA Quality Improvement Model for Applying the Severe Traumatic Brain Injury Guidelines to Practice: Process and Outcomes

Introduction: Standard monitoring of severe traumatic brain injury patients (TBI) by intracranial pressure (ICP) and cerebral perfusion pressure (CPP) monitoring fails to recognize episodes of cerebral oxygen desaturation. We found and characterized frequent episodes of desaturation of jugular venous oxygen (SjO2) in the face of normal ICP and CPP. Methods: Fifty six patients with severe TBI had SjO2 and ICP monitors placed. The charts were retrospectively reviewed and all episodes of desaturation were recorded and characterized. Results: Nineteen patients had episodes of desaturation with normal ICP and CPP. The average GCS score was 5.8. 63% of desaturations occurred in the first 24 hours, 17% of desaturations occurred in 24-48 hours, and 20% occurred in 48-72 hours. The depth of desaturation was 50-54% in 50% of instances, 45-49% in 37% of instances, and 40-44% in 13% of in- stances. The duration of the desaturation episodes was less than 10 minutes in 47%, 10-30 minutes in 17%, 30-60 minutes in 23%, and greater than 50 minutes in 13%. Treatment of the desaturation was elevation of FIO2 in all patients, elevation of pCO2 in 15 patients, volume expansion in 9 patients, pressors in 9 patients, and Propofol in 5 patients. Conclusions: The monitoring of severe TBI patients with ICP and CPP alone is insufficient to recognize cerebral oxygen de- saturation episodes in 34% of patients. The monitoring of SjO2 facilitates the recognition and treatment of these episodes.