Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Observational Study
. 2020 May;46(5):995-1004.
doi: 10.1007/s00134-020-05965-z. Epub 2020 Feb 25.

Changing care pathways and between-center practice variations in intensive care for traumatic brain injury across Europe: a CENTER-TBI analysis

Jilske A Huijben  1 , Eveline J A Wiegers  2 , Hester F Lingsma  2 , Giuseppe Citerio  3   4 , Andrew I R Maas  5 , David K Menon  6 , Ari Ercole  6 , David Nelson  7 , Mathieu van der Jagt  8 , Ewout W Steyerberg  2   9 , Raimund Helbok  10 , Fiona Lecky  11 , Wilco Peul  12 , Tatiana Birg  13 , Tommaso Zoerle  13 , Marco Carbonara  13 , Nino Stocchetti  13   14 ; CENTER-TBI investigators and participants
Collaborators, Affiliations
Observational Study

Changing care pathways and between-center practice variations in intensive care for traumatic brain injury across Europe: a CENTER-TBI analysis

Jilske A Huijben et al. Intensive Care Med. 2020 May.

Abstract

Purpose: To describe ICU stay, selected management aspects, and outcome of Intensive Care Unit (ICU) patients with traumatic brain injury (TBI) in Europe, and to quantify variation across centers.

Methods: This is a prospective observational multicenter study conducted across 18 countries in Europe and Israel. Admission characteristics, clinical data, and outcome were described at patient- and center levels. Between-center variation in the total ICU population was quantified with the median odds ratio (MOR), with correction for case-mix and random variation between centers.

Results: A total of 2138 patients were admitted to the ICU, with median age of 49 years; 36% of which were mild TBI (Glasgow Coma Scale; GCS 13-15). Within, 72 h 636 (30%) were discharged and 128 (6%) died. Early deaths and long-stay patients (> 72 h) had more severe injuries based on the GCS and neuroimaging characteristics, compared with short-stay patients. Long-stay patients received more monitoring and were treated at higher intensity, and experienced worse 6-month outcome compared to short-stay patients. Between-center variations were prominent in the proportion of short-stay patients (MOR = 2.3, p < 0.001), use of intracranial pressure (ICP) monitoring (MOR = 2.5, p < 0.001) and aggressive treatments (MOR = 2.9, p < 0.001); and smaller in 6-month outcome (MOR = 1.2, p = 0.01).

Conclusions: Half of contemporary TBI patients at the ICU have mild to moderate head injury. Substantial between-center variations exist in ICU stay and treatment policies, and less so in outcome. It remains unclear whether admission of short-stay patients represents appropriate prudence or inappropriate use of clinical resources.

Keywords: Intensive care unit; Intracranial pressure; Outcome; Traumatic brain injury.

PubMed Disclaimer

Conflict of interest statement

AIRM declares consulting fees from PresSura Neuro, Integra Life Sciences, and NeuroTrauma Sciences. DKM reports grants from the UK National Institute for Health Research, during the conduct of the study; grants, personal fees, and non-financial support from GlaxoSmithKline; personal fees from Neurotrauma Sciences, Lantmaanen AB, Pressura, and Pfizer, outside of the submitted work. WP reports grants from the Netherlands Brain Foundation. ES reports personal fees from Springer, during the conduct of the study. All other authors declare no competing interests.

Figures

Fig. 1
Fig. 1
ICU patient flow over time. a Plot of the dynamic states of patients with TBI that were admitted to the ICU during the first seven days after ICU admission. The y-axis represents the probability to be in one of the possible states (i.e., alive or dead or discharged from ICU) at each time point from ICU admission. *Died after ICU discharge. b Plot of the dynamic states of patients with TBI that were admitted to the ICU during the first 6 months after ICU admission. The y-axis represents the probability to be in one of the possible states (i.e., alive or dead or discharged from ICU) at each point from ICU admission. *Still in ICU
Fig. 2
Fig. 2
Flowchart of ICU patients. This figure shows the flow of patients at the ICU, based on their length of stay. *Patients who died within 72 h at the ICU
Fig. 3
Fig. 3
Six-month Glasgow outcome scale extended. This figure shows the distribution of the functional outcomes at the GOSE after 6 months for all ICU patients, short-stay patients, and long-stay patients
Fig. 4
Fig. 4
Between-center differences in ICU policies and outcome. This panel shows the adjusted differences (adjusted for case-mix with the IMPACT prognostic model) between centers by considering. a The proportion of patients with a short stay (≤ 72 h in the ICU) versus long stay (> 72 h) and early deaths (≤ 72 h); long stay and early deaths were treated as one group, since they resemble more severe patients and we aimed to study the proportion in each center of short-stay patients that were discharged alive within 72 h. b GOSE at 6 months for total ICU population. c ICP monitoring. d Aggressive therapy (any use of decompressive craniectomy, metabolic suppression, hypothermia therapy or intensive hypocapnia during ICU stay). A random-effect regression model was used to correct for random variation and adjusted for case-mix severity using the IMPACT variables and the presence of any major extracranial injury. The MOR reflects the between-center variation; a MOR equal to 1 represents no variation, the larger the MOR, the larger the variation. Significant differences (p value < 0.001) are present for data shown in a, c, and d for b (p = 0.01). GOSE Glasgow Outcome Scale extended, ICP intracranial pressure, MOR median odds ratio
See this image and copyright information in PMC

References

    1. Majdan M, Plancikova D, Brazinova A, Rusnak M, Nieboer D, Feigin V, Maas A. Epidemiology of traumatic brain injuries in Europe: a cross-sectional analysis. Lancet Public Health. 2016;1:e76–e83. doi: 10.1016/S2468-2667(16)30017-2. - DOI - PubMed
    1. Stocchetti N, Carbonara M, Citerio G, Ercole A, Skrifvars MB, Smielewski P, Zoerle T, Menon DK. Severe traumatic brain injury: targeted management in the intensive care unit. Lancet Neurol. 2017;16:452–464. doi: 10.1016/S1474-4422(17)30118-7. - DOI - PubMed
    1. Kalil AC, Metersky ML, Klompas M, Muscedere J, Sweeney DA, Palmer LB, Napolitano LM, O’Grady NP, Bartlett JG, Carratala J, El Solh AA, Ewig S, Fey PD, File TM, Jr, Restrepo MI, Roberts JA, Waterer GW, Cruse P, Knight SL, Brozek JL. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016;63:e61–e111. doi: 10.1093/cid/ciw353. - DOI - PMC - PubMed
    1. Steyerberg EW, Wiegers E, Sewalt C, Buki A, Citerio G, De Keyser V, Ercole A, Kunzmann K, Lanyon L, Lecky F, Lingsma H, Manley G, Nelson D, Peul W, Stocchetti N, von Steinbuchel N, Vande Vyvere T, Verheyden J, Wilson L, Maas AIR, Menon DK, Participants C-T, Investigators Case-mix, care pathways, and outcomes in patients with traumatic brain injury in CENTER-TBI: a European prospective, multicentre, longitudinal, cohort study. Lancet Neurol. 2019;18:923–934. doi: 10.1016/S1474-4422(19)30232-7. - DOI - PubMed
    1. Volovici V, Ercole A, Citerio G, Stocchetti N, Haitsma IK, Huijben JA, Dirven CMF, van der Jagt M, Steyerberg EW, Nelson D, Cnossen MC, Maas AIR, Polinder S, Menon DK, Lingsma HF. Intensive care admission criteria for traumatic brain injury patients across Europe. J Crit Care. 2019;49:158–161. doi: 10.1016/j.jcrc.2018.11.002. - DOI - PubMed

Publication types