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

Daniel W Spaite, Bentley J Bobrow, Samuel M Keim, Bruce Barnhart, Vatsal Chikani, Joshua B Gaither, Duane L Sherrill, Kurt R Denninghoff, Terry Mullins, P. David Adelson, Amber D. Rice, Chad D Viscusi, Chengcheng Hu

Research output: Contribution to journalArticle

Abstract

Importance: 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. Objective: To evaluate the association of implementing the nationally vetted, evidence-based, prehospital treatment guidelines with outcomes in moderate, severe, and critical TBI. Design, Setting, and Participants: 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 ≥3) transported to trauma centers between January 1, 2007, and June 30, 2015. Data were analyzed between October 25, 2017, and February 22, 2019. Interventions: Implementation of the prehospital TBI guidelines emphasizing avoidance/treatment of hypoxia, prevention/correction of hyperventilation, and avoidance/treatment of hypotension. Main Outcomes and Measures: Primary: survival to hospital discharge; secondary: survival to hospital admission. Results: Of the included patients, the median age was 45 years, 14666 (67.1%) were men, 7181 (32.9%) were women; 16408 (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, 21852 met inclusion criteria for analysis (preimplementation phase [P1]: 15228; 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 =.40) for survival to hospital discharge. The aOR was 1.70 (95% CI, 1.38-2.09; P <.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 <.001; Injury Severity Score 16-24: aOR, 1.61; 95% CI, 1.07-2.48; P =.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 <.001; Injury Severity Score 16-24: aOR, 3.28; 95% CI, 1.19-11.34; P =.02). Conclusions and Relevance: 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. Trial Registration: ClinicalTrials.gov: NCT01339702.

Original languageEnglish (US)
JournalJAMA Surgery
DOIs
StatePublished - Jan 1 2019

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Guidelines
Survival
Wounds and Injuries
Odds Ratio
Therapeutics
Injury Severity Score
Head
Abbreviated Injury Scale
Traumatic Brain Injury
Hyperventilation
North American Indians
Trauma Centers
Emergency Medical Services
Centers for Disease Control and Prevention (U.S.)
Hypotension
Public Health
Outcome Assessment (Health Care)

ASJC Scopus subject areas

  • Surgery

Cite this

@article{b5193b3033c1420dbd213c7892a09f23,
title = "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",
abstract = "Importance: 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. Objective: To evaluate the association of implementing the nationally vetted, evidence-based, prehospital treatment guidelines with outcomes in moderate, severe, and critical TBI. Design, Setting, and Participants: 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 ≥3) transported to trauma centers between January 1, 2007, and June 30, 2015. Data were analyzed between October 25, 2017, and February 22, 2019. Interventions: Implementation of the prehospital TBI guidelines emphasizing avoidance/treatment of hypoxia, prevention/correction of hyperventilation, and avoidance/treatment of hypotension. Main Outcomes and Measures: Primary: survival to hospital discharge; secondary: survival to hospital admission. Results: Of the included patients, the median age was 45 years, 14666 (67.1{\%}) were men, 7181 (32.9{\%}) were women; 16408 (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, 21852 met inclusion criteria for analysis (preimplementation phase [P1]: 15228; 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 =.40) for survival to hospital discharge. The aOR was 1.70 (95{\%} CI, 1.38-2.09; P <.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 <.001; Injury Severity Score 16-24: aOR, 1.61; 95{\%} CI, 1.07-2.48; P =.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 <.001; Injury Severity Score 16-24: aOR, 3.28; 95{\%} CI, 1.19-11.34; P =.02). Conclusions and Relevance: 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. Trial Registration: ClinicalTrials.gov: NCT01339702.",
author = "Spaite, {Daniel W} and Bobrow, {Bentley J} and Keim, {Samuel M} and Bruce Barnhart and Vatsal Chikani and Gaither, {Joshua B} and Sherrill, {Duane L} and Denninghoff, {Kurt R} and Terry Mullins and Adelson, {P. David} and Rice, {Amber D.} and Viscusi, {Chad D} and Chengcheng Hu",
year = "2019",
month = "1",
day = "1",
doi = "10.1001/jamasurg.2019.1152",
language = "English (US)",
journal = "JAMA Surgery",
issn = "2168-6254",
publisher = "American Medical Association",

}

TY - JOUR

T1 - Association of Statewide Implementation of the Prehospital Traumatic Brain Injury Treatment Guidelines with Patient Survival Following Traumatic Brain Injury

T2 - The Excellence in Prehospital Injury Care (EPIC) Study

AU - Spaite, Daniel W

AU - Bobrow, Bentley J

AU - Keim, Samuel M

AU - Barnhart, Bruce

AU - Chikani, Vatsal

AU - Gaither, Joshua B

AU - Sherrill, Duane L

AU - Denninghoff, Kurt R

AU - Mullins, Terry

AU - Adelson, P. David

AU - Rice, Amber D.

AU - Viscusi, Chad D

AU - Hu, Chengcheng

PY - 2019/1/1

Y1 - 2019/1/1

N2 - Importance: 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. Objective: To evaluate the association of implementing the nationally vetted, evidence-based, prehospital treatment guidelines with outcomes in moderate, severe, and critical TBI. Design, Setting, and Participants: 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 ≥3) transported to trauma centers between January 1, 2007, and June 30, 2015. Data were analyzed between October 25, 2017, and February 22, 2019. Interventions: Implementation of the prehospital TBI guidelines emphasizing avoidance/treatment of hypoxia, prevention/correction of hyperventilation, and avoidance/treatment of hypotension. Main Outcomes and Measures: Primary: survival to hospital discharge; secondary: survival to hospital admission. Results: Of the included patients, the median age was 45 years, 14666 (67.1%) were men, 7181 (32.9%) were women; 16408 (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, 21852 met inclusion criteria for analysis (preimplementation phase [P1]: 15228; 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 =.40) for survival to hospital discharge. The aOR was 1.70 (95% CI, 1.38-2.09; P <.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 <.001; Injury Severity Score 16-24: aOR, 1.61; 95% CI, 1.07-2.48; P =.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 <.001; Injury Severity Score 16-24: aOR, 3.28; 95% CI, 1.19-11.34; P =.02). Conclusions and Relevance: 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. Trial Registration: ClinicalTrials.gov: NCT01339702.

AB - Importance: 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. Objective: To evaluate the association of implementing the nationally vetted, evidence-based, prehospital treatment guidelines with outcomes in moderate, severe, and critical TBI. Design, Setting, and Participants: 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 ≥3) transported to trauma centers between January 1, 2007, and June 30, 2015. Data were analyzed between October 25, 2017, and February 22, 2019. Interventions: Implementation of the prehospital TBI guidelines emphasizing avoidance/treatment of hypoxia, prevention/correction of hyperventilation, and avoidance/treatment of hypotension. Main Outcomes and Measures: Primary: survival to hospital discharge; secondary: survival to hospital admission. Results: Of the included patients, the median age was 45 years, 14666 (67.1%) were men, 7181 (32.9%) were women; 16408 (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, 21852 met inclusion criteria for analysis (preimplementation phase [P1]: 15228; 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 =.40) for survival to hospital discharge. The aOR was 1.70 (95% CI, 1.38-2.09; P <.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 <.001; Injury Severity Score 16-24: aOR, 1.61; 95% CI, 1.07-2.48; P =.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 <.001; Injury Severity Score 16-24: aOR, 3.28; 95% CI, 1.19-11.34; P =.02). Conclusions and Relevance: 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. Trial Registration: ClinicalTrials.gov: NCT01339702.

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