Complications following hospital admission for traumatic brain injury: A multicenter cohort study.

PURPOSE: To evaluate the incidence, determinants and impact on outcome of in-hospital complications in adults with traumatic brain injury (TBI). MATERIALS AND METHODS: We conducted a multicenter cohort study of TBI patients admitted between 2007 and 2012 in an inclusive Canadian trauma system. Risk ratios of complications, odds ratios of mortality and geometric mean ratios of length of stay (LOS) were calculated using generalized linear models with adjustment for prognostic indicators and hospital cluster effects. RESULTS: Of 12,887 patients, 3.2% had at least one neurological complication and 22.6% a non-neurological complication. Mechanical ventilation, head injury severity, blood transfusion and neurosurgical intervention had the strongest correlation with neurological complications. Mechanical ventilation, the Glasgow Coma Scale, blood transfusion and concomitant injuries had the strongest correlation with non-neurological complications. Neurological and non-neurological complications were associated with a 85% and 53% increase in the odds of mortality, and a 60% and two-fold increases in LOS, respectively. CONCLUSIONS: More than 20% of patients with TBI developed a complication. Many of these complications were associated with increased mortality and LOS. Results highlight the importance of prevention strategies adapted to treatment decisions and underline the need to improve knowledge on the underuse and overuse of clinical interventions.

Impact of trauma centre designation level on outcomes following hemorrhagic shock: a multicentre cohort study.

BACKGROUND: Hemorrhagic shock is responsible for 45% of injury fatalities in North America, and 50% of these occur within 2 h of injury. There is currently a lack of evidence regarding the trajectories of patients in hemorrhagic shock and the potential benefit of level I/II care for these patients. We aimed to compare mortality across trauma centre designation levels for patients in hemorrhagic shock. Secondary objectives were to compare surgical delays, complications and hospital length of stay (LOS). METHODS: We performed a retrospective cohort study based on a Canadian inclusive trauma system (1999-2012), including adults with systolic blood pressure (SBP) < 90 mm Hg on arrival who required urgent surgical care (< 6 h). Logistic regression was used to examine the influence of trauma centre designation level on risk-adjusted surgical delays, mortality and complications. Linear regression was used to examine LOS. RESULTS: Compared with level I centres, adjusted odds ratios (and 95% confidence intervals [CI]) of mortality for level III and IV centres were 1.71 (1.03-2.85) and 2.25 (1.08-4.73), respectively. Surgical delays did not vary across designation levels, but mean LOS and complications were lower in level II-IV centres than level I centres. CONCLUSION: Level I/II centres may offer a survival advantage over level III/IV centres for patients requiring emergency intervention for hemorrhagic shock. Further research with larger sample sizes is required to confirm these results and to identify optimal transport time thresholds for bypassing level III/IV centres in favour of level I/II centres.

CONTEXTE: Le choc hémorragique est responsable de 45 % des décès chez les polytraumatisés en Amérique du Nord, et 50 % de ces décès surviennent dans les 2 h suivant le traumatisme. On ne dispose pas actuellement de données concernant la trajectoire des patients en état de choc hémorragique et les bénéfices potentiels de soins de niveaux I/II pour ces patients. Nous avons voulu comparer la mortalité selon les niveaux de désignation des centres de traumatologie pour les patients en état de choc hémorragique. Les objectifs secondaires étaient de comparer les délais d'accès à la chirurgie, les complications et la durée des séjours hospitaliers. MÉTHODES: Nous avons procédé à une étude de cohorte rétrospective basée sur un système de traumatologie inclusif au Canada (1999-2012), incluant des adultes dont la tension artérielle systolique (TAS) était < 90 mm Hg à l'arrivée et qui nécessitaient un traitement chirurgical urgent (< 6 h). La régression logistique a été utilisée pour analyser l'influence du niveau de désignation du centre de traumatologie sur le délai d'accès à la chirurgie, la mortalité et les complications ajustés selon le risque. La régression linéaire a été utilisée pour analyser la durée du séjour hospitalier. RÉSTULATS: Comparativement aux centres de niveau I, les rapports des cotes ajustés (et les intervalles de confiance [IC] de 95 %) de mortalité pour les centres de niveaux III et IV ont été 1,71 (1,03-2,85) et 2,25 (1,08-4,73), respectivement. Les délais d'accès à la chirurgie n'ont pas varié en fonction des niveaux de désignation, mais la durée moyenne du séjour hospitalier et les complications étaient moindres dans les centres de niveaux II et IV comparativement aux centres de niveau I. CONCLUSION: Les centres de niveaux I/II peuvent offrir des avantages au plan de la survie comparativement aux centres de niveaux III/IV pour les patients en état de choc hémorragique qui ont besoin d'une intervention d'urgence. Il faudra approfondir la recherche auprès d'échantillons de plus grande taille pour confirmer ces résultats et établir les seuils optimaux en termes de temps de transport permettant de passer outre les centres de niveaux III/IV en faveur des centres de niveaux I/II.

Hospital length of stay following admission for traumatic brain injury in a Canadian integrated trauma system: A retrospective multicenter cohort study.

BACKGROUND: Traumatic brain injury (TBI) is the leading cause of disability in children and young adults and costs CAD$3 billion annually in Canada. Stakeholders have expressed the urgent need to obtain information on resource use for TBI to improve the quality and efficiency of acute care in this patient population. We aimed to assess the components and determinants of hospital and ICU LOS for TBI admissions. METHODS: We performed a retrospective multicenter cohort study on 11,199 adults admitted for TBI between 2007 and 2012 in an inclusive Canadian trauma system. Our primary outcome measure was index hospital LOS (admission to the hospital with the highest designation level). Index LOS was compared to total LOS (all consecutive admissions related to the injury). Expected LOS was calculated by matching TBI admissions to all-diagnosis hospital admissions by age, gender, and year of admission. LOS determinants were identified using multilevel linear regression. RESULTS: Geometric mean total LOS was 1day longer than geometric mean index LOS (12.6 versus 11.7 days). Observed index and ICU LOS were respectively 4.2days and 2.5days longer than that expected according to all-diagnosis admissions. The six most important determinants of LOS were discharge destination, severity of concomitant injuries, extracranial complications, GCS, TBI severity, and mechanical ventilation, accounting for 80% of explained variation. CONCLUSIONS: Results of this multicenter retrospective cohort study suggest that hospital and ICU LOS for TBI admissions are 56% and 119% longer than expected according to all-diagnosis admissions, respectively. In addition, hospital LOS is underestimated when only the index visit is considered and is largely influenced by discharge destination and extracranial complications, suggesting that improvements could be achieved with better discharge planning and interventions targeting prevention of in-hospital complications. This study highlights the importance of considering TBI patients as a distinct population when allocating resources or planning quality improvement interventions.