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Citation
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McCredie VA, Alali AS, Xiong W, Rubenfeld GD, Cuthbertson BH, Scales DC, Nathens AB. J. Trauma Acute Care Surg. 2015; 80(3): 484-491. |
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Affiliation
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1Department of Critical Care Medicine, Sunnybrook Health Sciences Center, Toronto, Canada M4N 3M5 2Sunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto, Canada M4N 3M5 3Department of Surgery, Sunnybrook Health Sciences Center and the University of Toronto, Toronto, Canada 4Department of Anesthesia, University of Toronto, Toronto, Canada. |
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Abstract
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BACKGROUND: The care of patients with severe traumatic brain injury (TBI) is complex and confounded by uncertainty in prognoses. Studies have demonstrated significant unexplained variation in mortality between centers. Possible explanations include differences in the quality and intensity of care across centers, including the appropriateness and timing of withdrawal of life-sustaining therapies. We postulated that centers with a preponderance of early deaths might have a more pessimistic approach to the TBI patient, which would be reflected in an increased hospital TBI-related mortality.
METHODS: This is a retrospective cohort study. Time to death was used as a proxy for time to withdrawal of life-sustaining therapies. Centers were classified as early or late based on when the majority (75 percentile) of their TBI-related deaths occurred. We evaluated the association between adjusted mortality and center classification using a hierarchical multivariable model. Two hundred trauma centers contributing data to the American College of Surgeons Trauma Quality Improvement Program from 2010 through 2013. The cohort included 17,505 patients with severe isolated TBI.
RESULTS: One hundred and eight centers were classified as early centers. The 75 percentile for time to death was 4 days among early centers versus 7 days in late centers. Mortality was 34% and 33%, respectively. After adjustment for case mix, care in an early center was not associated with increased odds of death (adjusted OR 0.95; 95% CI 0.83-1.09). Higher odds of death were independently associated with age, Glasgow Coma Scale score, head Abbreviated Injury Score, multiple comorbidities, traumatic subarachnoid hemorrhage, intracerebral mass lesions, brainstem lesions and signs of compressed or absent basal cisterns.
CONCLUSION: Centers rendering early decisions related to withdrawal of life-sustaining therapies in TBI patients, as measured by time until death, do not have worse outcomes than those making later decisions. How and when these decisions are made requires further exploration to balance an opportunity for clinical improvement with appropriate resource utilization. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.
Language: en |