Author Year

Country

Research Design

PEDro

Sample Size

Methods

Outcomes

Sorinola et al.

(2018)

Hungary

PCT

N= 7230

Population:  severe TBI Group (N= 7230): Mean Age= 60.89yr; Gender: Male=72%, Female=28%.

Intervention: Health records of TBI individuals were examined of at hospitals in Hungary. Authors investigated the impact of a TBI guideline introduction. Authors classified the 8 institutions that provided over 50% of the care as ‘centers’ and the remaining 49 as ‘secondary institutions’.

Outcomes: Case Fatality Ratios (CFR).

1.        Pre-guideline introduction saw CFRs of 23.4%, 37.7%, and 47% at 1wk, 1mo, and 6mos, respectively at the centers.

2.        Post-guideline introduction saw CFRs of 22.1%, 39.1%, and 50% at 1wk, 1mo, and 6mo, respectively at the centers.

3.        Pre-guideline introduction saw CFRs of 21.5%, 39.1%, and 50% at 1wk, 1mo, and 6mo, respectively at the secondary institutions.

4.        Post-guideline introduction saw CFRs of 21.9%, 37%, and 48.9% one week, one month, and 6 months, respectively at the secondary institutions.

5.        The center and secondary institution CFRs showed no significant change when comparing the pre and post guideline periods.

Tarapore et al.

(2016)

The Netherlands

Cohort

N=832

1.        The percentage of early TBI deaths (<24hr) were 59% lower in the Joint Commission-certified TBI program cohort as compared to the historical control cohort.

2.        The percentage of observed deaths 6mo after the Joint Commission-certified TBI program was instituted was 22% lower as compared to the historical cohort.

Kesinger et al.

 (2014)

USA

Case Control

N=108

Population: TBI; Pre-Standard Trauma Protocols (STP; n=68): Mean Age=37.1yr; Gender: Male=63, Female=5. Post-STP (n=40): Mean Age=38.6yr; Gender: Male=31, Female=9.

Intervention: Chart reviews were conducted comparing hospital records pre and post implementation of STPs. These protocols were based on best practices and damage control resuscitation (e.g., small volume resuscitation, requiring a physician’s presence in intra-hospital transportation of severely injured patients, etc.).

Outcome Measure: Glasgow Coma Scale (GCS), Medical Interventions, Mortality Rates.

1.        In the emergency department, after STPs were implemented, there was an increase in resuscitation with 7.5% hypertonic saline (p=0.014), use of catheters (p=0.015), administration of tetanus vaccinations (p=0.034), and earlier use of blood transfusions (p=0.008).

2.        Post STP, hospital mortality decreased from 38% to 18% (p=0.024) and GCS scores improved from a median of 10 to a median of 14 (p=0.034).

Kramer & Zygun (2013)

Canada

Cohort

N=4,097

Population: TBI=1604, Anoxic BI=552, Subarachnoid Hemorrhage=449, Intracerebral Hemorrhage= 398, Stroke=444, Central Nervous System Infection=242, Status Epilepticus=605; Gender: Male=2581, Female=1516.

Intervention: Patient data was extracted from an Intensive Care Unit (ICU) database over four time periods based on when new protocols were developed and introduced. New protocols included: Neurocritical Care Consult Service (September 2003), Temperature Regulation Protocol (September 2004), Mutual Neurocritical Care/Neurosurgery Rounds (July 2005), TBI Protocol (August 2008), and Clustering of Neurocritical Care Patients (June 2010).

Outcome Measure: Hospital Mortality, Discharge Home Without Support.

1.        Hospital mortality improved significantly after implementation of a Neurocritical Care Consult Service (p=0.03; Odds ratio=0.81), Mutual Neurocritical Care/Neurosurgery Rounds (p=0.008; Odds ratio=0.80), TBI Protocol (p=0.04; Odds ratio=0.84), and Clustering of Neurocritical Care Patients (p=0.02; Odds ratio=0.76) and improved non-significantly after implementation of the Temperature Regulation Protocol (p=0.07; Odds ratio=0.85).

2.        Discharge without home support improved significantly after implementation of a Neurocritical Care Consult Service (p=0.04; Odds ratio=1.27), Mutual Neurocritical Care/Neurosurgery Rounds (p=0.0002; Odds ratio=1.39), Clustering of Neurocritical Care Patients (p=0.01; Odds ratio=1.31), and implementation of the Temperature Regulation Protocol (p=0.0009; Odds ratio=1.38), and improved non-significantly after TBI Protocol implementation (p=0.06; Odds ratio=1.17).

Myburgh et al.

(2008)

Australia/NZ

Cohort

N=635

Population: TBI; Mean Age=41.6yr; Gender: Male=471, Female=164; Severity: Mild=159, Moderate=114, Severe=362.

Intervention: Data was obtained prospectively for patients cared for after the publication of new Brain Trauma Foundation guidelines, and compared to retrospective control data (pre-guidelines). Follow-up telephone interviews were conducted at 6mo and 12mo post-injury.

Outcome Measure: Glasgow Outcome Scale Extended (GOSE), Mortality.

1.        Favourable outcomes on the GOSE were found in 58.8% of all patients, and 48.5% of patients with severe TBI.

2.        Mortality was reported in 26.9% of all patients and 35.1% for patients with a severe TBI.

3.        Although concordance with guideline management was generally seen; mortality and favorable neurological outcomes were similar to previous studies before the advent of evidence-based guidelines.

Fakhry et al. (2004)

USA

Case Control

N=830

Population: TBI; Group 1 (n=219): Mean Age=33.8yr; Gender: Male=161, Female=58; Mean GCS=4. Group 2 (n=188): Mean Age=33.9yr; Gender: Male=133, Female=55; Mean GCS=3.5. Group 3 (n=423): Mean Age=35.6yr; Gender: Male=327, Female=96; Mean GCS=3.5.

Intervention: Patients were retrospectively divided into 3 groups: Group 1, 1991-1994 (pre-guidelines); Group 2, 1995-1996 (post-guidelines low compliance); and Group 3, 1997-2000 (post-guidelines high compliance). Data was extracted from hospital trauma registries and from chart reviews.

Outcome Measure: Mortality, length of stay, total charges, Rancho Los Amigos Levels of Cognitive Functioning Scale (RLAS), and Glasgow Outcome Scale (GOS).

1.        Significant differences were seen between groups, with group 2 achieving higher GOS scores at discharge (p<0.001), a decrease in length of stay in hospital (p=0.001) and a decrease in total charges per patient (p=0.002).

2.        A significant drop in mortality was seen in the Group 3 compared to Group 1 (p=0.047).

3.        Appropriate responses on the RLAS significantly improved over time from 43.9% in Group 1, 44% in Group 2 and 56.6% in Group 3 (p=0.004).

Palmer et al.

(2001)

USA

Case Control

N=93

Population: TBI; Group 1 (n=37): Mean Age=41.35yr; Mean GCS=6.43. Group 2 (n=56): Mean Age=38.10yr; Mean GCS=6.88.

Intervention: Data was collected from the medical records of patients with TBI treated pre- (group 1) and post- (group 2) guideline implementation.

Outcome Measure: Glasgow Outcome Score (GOS) and cost.

1.        Patients in group 2 were more likely to demonstrate significant gains on GOS (p<0.005) compared to group 1.

2.        Guideline implementation resulted in a 9.13 times higher odds ratio of good outcome relative to poor outcome or death pre-implementation.

3.        Hospital charges increased by $97,000 per patient.

Mackay et al.

(1992)

USA

Case Control

N=38

Population: TBI; Group 1 (n=17): Mean Age=29.1yr; Gender: Male=12, Female=5; Mean GCS=5.18. Group 2 (n=21): Mean Age=30yr; Gender: Male=19, Female=2; Mean GCS=5.80.

Treatment: Chart reviews were completed on patients treated in hospital.  Patients in Group 1 received a formalized early intervention program and were compared with patients in Group 2 who were treated at hospitals without a formalized early intervention program.

Outcome Measure: Length of coma, length of stay, Rancho Los Amigos Scale of Cognitive Functioning and Injury Severity Score.

1.        Patients in Group 1 experienced shorter comas (p=0.033), lengths of stay (p=0.026) and had a greater likelihood of being discharged to home (94% versus 57%).

2.        Patients in Group 1 demonstrated significantly greater functional improvements at discharge in cognitive/language levels (p=0.018), motor/physical abilities (p=0.032) and perceptual/sensory skills (p=0.025) compared with Group 2.