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1. The aggressiveness of neurotrauma practitioners and the influence of the IMPACT prognostic calculator.

Author

Joshua Letsinger, Casey Rommel, Ryan Hirschi, Raminder Nirula, and Gregory W J Hawryluk

Subjects
Medicine, Science
Abstract

Published guidelines have helped to standardize the care of patients with traumatic brain injury; however, there remains substantial variation in the decision to pursue or withhold aggressive care. The International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) prognostic calculator offers the opportunity to study and decrease variability in physician aggressiveness. The authors wish to understand how IMPACT's prognostic calculations currently influence patient care and to better understand physician aggressiveness. The authors conducted an anonymous international, multidisciplinary survey of practitioners who provide care to patients with traumatic brain injury. Questions were designed to determine current use rates of the IMPACT prognostic calculator and thresholds of age and risk for death or poor outcome that might cause practitioners to consider withholding aggressive care. Correlations between physician aggressiveness, putative predictors of aggressiveness, and demographics were examined. One hundred fifty-four responses were received, half of which were from physicians who were familiar with the IMPACT calculator. The most frequent use of the calculator was to improve communication with patients and their families. On average, respondents indicated that in patients older than 76 years or those with a >85% chance of death or poor outcome it might be reasonable to pursue non-aggressive care. These thresholds were robust and were not influenced by provider or institutional characteristics. This study demonstrates the need to educate physicians about the IMPACT prognostic calculator. The consensus values for age and prognosis identified in our study may be explored in future studies aimed at reducing variability in physician aggressiveness and should not serve as a basis for withdrawing care.

Published
2017
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2. Brain Trauma Foundation Guideline Compliance: Results of a Multidisciplinary, International Survey

Author

Ryan Hirschi, Raminder Nirula, Gregory W.J. Hawryluk, Joshua Letsinger, and Casey Rommel

Subjects
Male, medicine.medical_specialty, Internationality, Intracranial Pressure, Traumatic brain injury, Best practice, Specialty, 03 medical and health sciences, 0302 clinical medicine, Multidisciplinary approach, Physicians, Surveys and Questionnaires, Brain Injuries, Traumatic, medicine, Humans, Intracranial pressure, business.industry, Foundation (evidence), 030208 emergency & critical care medicine, medicine.disease, Family medicine, Practice Guidelines as Topic, Respondent, Intracranial pressure monitoring, Female, Surgery, Guideline Adherence, Neurology (clinical), business, 030217 neurology & neurosurgery, Foundations
Abstract

Brain Trauma Foundation (BTF) guidelines reflect evidence-based best practices in management of traumatic brain injury. The aim of this study was to examine self-reported physician compliance and predictors of compliance related to BTF guidelines.We conducted an international, multidisciplinary survey examining self-reported adherence to BTF guidelines and multiple factors potentially affecting adherence. We also surveyed intracranial pressure monitoring practices.Of 154 physician respondents, 15.9% reported their institutions "always" follow BTF guidelines and 72.2% reported that they follow them "most of the time." Personal volume of traumatic brain injury cases and years in practice were not significantly related to adherence. Reported adherence varied significantly in association with respondent's institutional trauma level (P = 0.0010): 17.3% of practitioners at level I, 13.0% at level II, and 0% at level III trauma centers reported "always" following guidelines. Reported adherence to guidelines also varied significantly in association with provider specialty (P = 0.015) and institutional volume of severe traumatic brain injury cases (P = 0.008). Regarding intracranial pressure monitoring practices, 52% of respondents used external ventricular drains, 21% used intraparenchymal monitors, and 27% had no preference (P0.001). Of respondents not routinely using external ventricular drains, 36% claimed to "always" follow guidelines. There was no apparent association between type of intracranial pressure monitoring used and reported guideline adherence.Few respondents reported their institutions "always" follow BTF guidelines. General surgeons and providers at high-volume level I trauma centers were more likely to comply with guidelines. Differences in survey responses based on provider and institutional characteristics may help target educational efforts.

Published
2018
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