Impact of ICU Structure and Processes of Care on Outcomes After Severe Traumatic Brain Injury: A Multicenter Cohort Study

Objectives: It is uncertain whether dedicated neurocritical care units are associated with improved outcomes for critically ill neurologically injured patients in the era of collaborative protocol-driven care. We examined the association between dedicated neurocritical care units and mortality and the effects of standardized management protocols for severe traumatic brain injury. Design: We surveyed trauma medical directors from centers participating in the American College of Surgeons Trauma Quality Improvement Program to obtain information about ICU structure and processes of care. Survey data were then linked to the Trauma Quality Improvement Program registry, and random-intercept hierarchical multivariable modeling was used to evaluate the association between dedicated neurocritical care units, the presence of standardized management protocols and mortality. Setting: Trauma centers in North America participating in Trauma Quality Improvement Program. Patients: Data were analyzed from 9,773 adult patients with isolated severe traumatic brain injury admitted to 134 Trauma Quality Improvement Program centers between 2011 and 2013. Interventions: None. Measurements and Main Results: Only 50 ICUs (37%) were dedicated neurocritical care units, whereas 84 (63%) were general ICUs. Rates of standardized management protocols were similar comparing dedicated neurocritical care units and general ICUs. Among severe TBI patients admitted to trauma centers enrolled in Trauma Quality Improvement Program, care in a dedicated neurocritical care unit did not improve risk-adjusted in-hospital survival (odds ratio, 0.97; 95% CI, 0.80–1.19; p = 0.79). However, the presence of a standardized management protocol for these patients was associated with lower risk-adjusted in-hospital mortality (odds ratio, 0.77; 95% CI, 0.63–0.93; p = 0.009). Conclusions: Compared with dedicated neurocritical care models, standardized management protocols for severe traumatic brain injured patients are process-targeted intervention strategies that may improve clinical outcomes. The opinions, results, and conclusions reported in this article are those of the authors and are independent of funding sources. Dr. McCredie contributed to the literature search, study design, data analysis, data interpretation, writing, and critical revision. Drs. Alali, Scales, Rubenfeld, and Cuthbertson contributed to the study design, data interpretation, and critical revision. Dr. Nathens contributed to the study design, data analysis, data interpretation, and critical revision. Supplemental digital content is available for this article. Direct URL ­citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/29S62lw). Supported, in part, by a de Souza Chair in Trauma Research. Dr. Nathens received other support from a de Souza Chair in Trauma Research. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: Victoria.McCredie@uhn.ca Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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