Variation in capability, organisational structure, and treatment processes for critically ill adults with moderate-to-severe traumatic brain injury in Australia and New Zealand

Jonathon D Taylor; Camila R Battistuzzo; Chien Y Kow; James Moore; Lydia Shim; Judith Bellapart; Toby Betteridge; Robert S Bevan; Deepak Bhonagiri; Andrew Chow; Oliver Flower; Timothy P Haydon; Toby Jeffcote; Wei-Yun Mak; Robert McNamara; Ravi N Mistry; Idunn S Morris; Siva Senthuran; Krishnaswamy Sundararajan; Stephen Warrillow; Mark Weeden; Paul J Young; Alisa M Higgins; Colin J McArthur; Andrew A Udy

doi:10.1016/j.ccrj.2026.100219

. 2026 Sep 23;28(4):100219. doi: 10.1016/j.ccrj.2026.100219

Variation in capability, organisational structure, and treatment processes for critically ill adults with moderate-to-severe traumatic brain injury in Australia and New Zealand

Jonathon D Taylor ^a,^b, Camila R Battistuzzo ^b, Chien Y Kow ^c, James Moore ^d,^e, Lydia Shim ^a, Judith Bellapart ^f,^g, Toby Betteridge ^h, Robert S Bevan ^a, Deepak Bhonagiri ^i,^j,^k,^l,^m, Andrew Chow ⁿ, Oliver Flower ^o, Timothy P Haydon ^p, Toby Jeffcote ^b,^q, Wei-Yun Mak ^r, Robert McNamara ^s,^t, Ravi N Mistry ^u, Idunn S Morris ^v,^w, Siva Senthuran ^x,^y, Krishnaswamy Sundararajan ^z,^aa, Stephen Warrillow ^ab, Mark Weeden ^ac, Paul J Young ^b,^d,^e,^ad, Alisa M Higgins ^b, Colin J McArthur ^a,^b, Andrew A Udy ^b,^q,^⁎

^aDepartment of Critical Care Medicine, Auckland City Hospital, 2 Park Road, Grafton, Auckland 1023, New Zealand

^bAustralian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Level 3, 553 St Kilda Road, Melbourne, Victoria 3004, Australia

^cNeurosurgical Department, Auckland City Hospital, 2 Park Road, Grafton, Auckland 1023, New Zealand

^dIntensive Care Unit, Wellington Hospital, 39 Riddiford Street, Newtown, Wellington 6021, New Zealand

^eMedical Research Institute of New Zealand, Level 7, CSB Building, Wellington Hospital, Riddiford Street, Newtown, Wellington 6021, New Zealand

^fIntensive Care Unit, Royal Brisbane and Women's Hospital, Corner Butterfield Street and Bowen Bridge Road, Herston, Queensland 4029, Australia

^gMedical School, The University of Queensland, Level 2, Mayne Medical Building, 288 Herston Road, Herston, Queensland 4006, Australia

^hIntensive Care Unit, Christchurch Hospital, 2 Riccarton Avenue, Christchurch Central, Christchurch 8011, New Zealand

ⁱIntensive Care Unit, Liverpool Hospital, Corner Elizabeth and Goulburn Streets, Liverpool, New South Wales 2170, Australia

^jCampbelltown Hospital, 1 Therry Road, Campbelltown, New South Wales 2560, Australia

^kMacquarie University Hospital, 3 Technology Place, Macquarie University, New South Wales 2109, Australia

^lUniversity of New South Wales, High Street, Kensington, New South Wales 2052, Australia

^mWestern Sydney University, Locked Bag 1797, Penrith, New South Wales 2751, Australia

ⁿIntensive Care Unit, John Hunter Hospital, Lookout Road, New Lambton Heights, New South Wales 2305, Australia

^oIntensive Care Unit, Royal North Shore Hospital, Reserve Road, St Leonards, New South Wales 2065, Australia

^pIntensive Care Unit, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, Victoria 3065, Australia

^qDepartment of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004, Australia

^rIntensive Care Unit, Monash Medical Centre, 246 Clayton Road, Clayton, Victoria 3168, Australia

^sIntensive Care Unit, Royal Perth Hospital, 197 Wellington Street, Perth, Western Australia 6000, Australia

^tSchool of Medicine, Curtin University, Kent Street, Bentley, Western Australia 6102, Australia

^uIntensive Care Unit, Gold Coast University Hospital, 1 Hospital Boulevard, Southport, Queensland 4215, Australia

^vDepartment of Critical Care, Nepean Clinical School, Faculty of Medicine and Health, The University of Sydney, 62 Derby Street, Kingswood, New South Wales 2747, Australia

^wIntensive Care Unit, Nepean Hospital, Derby Street, Kingswood, New South Wales 2747, Australia

^xIntensive Care Unit, Townsville University Hospital, 100 Angus Smith Drive, Douglas, Queensland 4814, Australia

^yCollege of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Douglas, Queensland 4811, Australia

^zDepartment of Intensive Care Medicine, Royal Adelaide Hospital, Port Road, Adelaide, South Australia 5000, Australia

^aaThe University of Adelaide, North Terrace, Adelaide, South Australia 5005, Australia

^abIntensive Care Unit, Austin Hospital, 145 Studley Road, Heidelberg, Victoria 3084, Australia

^acIntensive Care Unit, St George Hospital, Gray Street, Kogarah, New South Wales 2217, Australia

^adDepartment of Critical Care, School of Medicine, The University of Melbourne, Grattan Street, Parkville, Victoria 3010, Australia

^⁎

Corresponding author at: Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia. Tel.: +61 438 755 568. andrew@udy.com

PMCID: PMC13633861 PMID: 42830737

Abstract

Objective

To characterise between-centre variation in capability, organisational structure, and treatment processes for adults with moderate-to-severe traumatic brain injury (msTBI) admitted to intensive care (ICU) in Australia and New Zealand (ANZ).

Design

Cross-sectional questionnaire supplemented by linked Australian and New Zealand Intensive Care Society CORE Critical Care Resources Registry descriptors.

Setting

ANZ ICUs treating adults with msTBI, October–December 2025.

Main outcome measures

Variation in organisational structure and capability, ICU treatment processes, neuroprognostication, withholding or withdrawal of life-sustaining therapy, and fulfilment of selected Australian TBI Quality Indicator Set elements. Heterogeneity was assessed using the index of qualitative variation (IQV) for nominal items and Leik’s dispersion for ordinal items; values <0.3 were considered low, 0.3–0.7 moderate, and >0.7 substantial.

Results

Moderate or substantial heterogeneity was observed in 39 of 74 measured items (53%). Substantial heterogeneity included neurocritical care subspecialty expertise (IQV 1.00), perceived devastating traumatic brain injury management (IQV 0.99), cerebrospinal fluid drainage timing (IQV 0.93), withholding or withdrawal of life-sustaining therapy decision-making processes (IQV 0.86), arterial transducer zero level for cerebral perfusion pressure calculation (IQV 0.82), haemoglobin targets (Leik’s dispersion 0.81), and post-ICU follow-up interval (IQV 0.81). Low heterogeneity in several advanced neuromonitoring and neuroprognostication modalities reflected consistent non-use or unavailability. Fulfilment of the six measured Australian TBI Quality Indicator Set indicators ranged from 2/6 to 5/6 across centres.

Conclusions

Among ANZ ICUs providing care for adults with msTBI, moderate or substantial variation was evident in over half of measured organisational and clinical aspects of care. These findings identify targets for research and quality improvement and highlight centre variation as a potential modifier of patient outcomes.

Keywords: Traumatic brain injury, Intensive care, Neurocritical care, Centre variation, Quality improvement

1. Introduction

Traumatic brain injury (TBI) remains a major cause of death and disability in Australia and New Zealand (ANZ), and outcomes for patients admitted to an intensive care unit (ICU) have remained largely unchanged over the last decade.¹^,² Despite numerous randomised clinical trials evaluating potential therapies, effective treatments remain elusive.³^,⁴ Contemporary management of critically ill patients with moderate-to-severe traumatic brain injury (msTBI) (Glasgow Coma Scale score ≤12) is therefore informed by limited high-quality evidence.⁴^,⁵ Many key management decisions remain discretionary and threshold based, including escalation of therapy for intracranial hypertension, use of late-tier interventions, and decisions regarding withholding or withdrawal of life-sustaining therapy (WLST).[5], [6], [7], [8] While such decisions are influenced by individual patient and clinician factors, they may also be shaped by centre practice norms, organisational structure, and capability.[8], [9], [10], [11], [12] Conceptually, centre characteristics may therefore independently influence treatment selection, therapy timing and intensity, exposure to secondary cerebral insults, and functional neurological outcome, beyond patient, clinician, or injury characteristics (Fig. S1).

Exploring centre variation in msTBI care has important implications for research, quality improvement, and clinical trial design.⁸^,¹⁰^,¹³^,¹⁴ It may identify heterogeneous elements of care as priorities for investigation or quality improvement initiatives.⁸^,¹⁰^,¹⁴ For clinical trials, understanding variation can inform site selection, clarify assumptions about usual care, highlight potential effect modifiers, and inform strategies to manage heterogeneity of treatment effect.[15], [16], [17], [18] Furthermore, it can provide a framework for outcome-linked analyses, incorporating both theory-based and data-driven approaches to centre-level phenotyping, to identify organisational or practice characteristics associated with improved patient outcomes.⁴^,¹⁰^,¹³

Prior studies have described between-centre variation in TBI care internationally.⁷^,⁸^,¹⁰^,¹⁹^,²⁰ However, contemporary data describing such variation in ANZ are limited, despite broadly comparable healthcare systems across jurisdictions, shared training and accreditation standards, and access to a high-quality binational registry.²¹^,²² To our knowledge, no contemporary study has described centre-level variation in adult msTBI ICU care across ANZ or related reported practice to the Australian TBI Quality Indicator Set (ATBI QIS) framework. Therefore, we conducted a provider profiling study to: (1) characterise between-centre variation in capability, organisational structure, and treatment processes for adults with msTBI admitted to ICU in ANZ; (2) quantify centre fulfilment of the six measured ATBI QIS elements, and (3) identify elements demonstrating heterogeneity across centres, to inform future research and generate hypotheses for outcome-linked analyses.²³

2. Methods

2.1. Development of the provider profiling questionnaire

A multidisciplinary steering committee comprising clinicians and researchers involved in multiple stages of the TBI care pathway in ANZ developed the provider-profiling questionnaire (Table S1). Study domains and component elements were selected based on relevance to contemporary adult msTBI management, existing guidelines, the overarching aims of the study, and measurability using centre-level data (Table 1).³^,⁵^,[23], [24], [25] Items were reviewed for feasibility, face validity, and relevance, and the questionnaire as a whole was reviewed for content validity to ensure adequate coverage of all domains. To balance coverage with respondent burden, the final questionnaire comprised 23 questions (Document S1). Pilot testing assessed clarity, interpretability, response burden, and whether respondents could answer questions at the centre level. This resulted in minor wording revisions but no substantive changes to questionnaire construct.

Table 1.

Study domains and component elements.

Domains	Domain elements
Hospital and ICU organisational structure and capability^a	• Hospital classification • Hospital trauma level designation • Functional ICU level • ICU staffing: SMO FTE, RN FTE, physio FTE, and nurse-to-patient ratio • Capacity: hospital beds, available ICU beds, and ICU occupancy • Neurocritical care subspecialty training • Access to specialist inpatient TBI rehabilitation
ICU treatment processes^a	• Presence, maintenance, and audit of ICU TBI guidelines • Cohorting of TBI patients admitted to ICU • Physiotherapy review following TBI • Neurosurgical specialist attendance • ICP monitoring and targets • Multimodality neuromonitoring utilisation • Cerebral perfusion pressure targets and monitoring • Management of refractory intracranial hypertension • Timing and method of CSF drainage for ICP control • Fever treatment threshold following TBI • Haemoglobin targets following TBI • Follow-up after discharge from ICU with TBI
Neuroprognostication capability and processes^a	• Modalities used to inform neuroprognostic assessment • Management of perceived devastating TBI
Withholding or withdrawal of life-sustaining therapy processes^a	• WLST decision-making process • Participants in WLST decisions • Patient factors informing WLST decisions • Therapies withdrawn at end of life

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ICU, intensive care unit; SMO, senior medical officer; FTE, full-time equivalent; RN, registered nurse; TBI, traumatic brain injury; ICP, intracranial pressure; CSF, cerebrospinal fluid; WLST, withholding or withdrawal of life-sustaining therapy.

Capability and organisational structure refer to the conditions under which patient care is provided, including the number of beds, hospital facilities, and staffing. Process refers to activities that constitute patient care, including general hospital or department policies.

Questionnaire variables were defined according to the wording and response categories provided in the questionnaire (Document S1). Perceived devastating TBI was defined as a TBI that was assessed at the time of hospital admission as an immediate threat to life despite treatment, or incompatible with acceptable functional recovery, AND where early limitation or withdrawal of therapy was being considered.²⁶ Adult specialist brain injury rehabilitation was defined as inpatient rehabilitation for adults who are medically stable and require a high level of care, have had a severe or very severe brain injury, and may still be in a state of confusion or posttraumatic amnesia.²⁷ Rescue decompressive craniectomy was defined as a decompressive craniectomy used as a specific last-tier intervention when the intracranial pressure remains elevated, despite all other reasonable measures.²⁸

Respondents were asked to describe not what they would do personally, but how the majority of patients would usually be treated in their centre/hospital. This wording was intended to capture reported predominant centre practice, including practices that may not be specified in a formal guideline or protocol. Responses therefore reflect stated usual practice at the centre level and should not be interpreted as indicating uniform management of individual patients. We did not attempt to assess patient-level adherence or interindividual variation in practice. Questionnaires required completion of all applicable answers before submission, ensuring no partial responses.

2.2. Study sample and questionnaire distribution

The questionnaire was administered using the Monash University–hosted Research Electronic Data Capture Platform (REDCap) and a single copy of the questionnaire was sent electronically to the clinical director, or nominated representative, of all ICUs in ANZ that contribute to the ANZ Trauma Registry and/or have accreditation as a neurosurgical ICU training unit with the College of Intensive Care Medicine. To identify centres providing definitive acute msTBI care, respondents first confirmed that their ICU managed adults with msTBI without routine transfer to another specialised centre. The questionnaire was open from October to December 2025.

2.3. Data linkage

Where centres provided permission, additional information describing general hospital and ICU organisational structure and capability was obtained from the most contemporary available Australian and New Zealand Intensive Care Society (ANZICS) CORE Critical Care Resources (CCR) registry record and linked to questionnaire responses. The CCR collects annual survey data on the provision and utilisation of CCR from approximately 80% of ICUs across ANZ and was used to extend the completeness of centre-level descriptors.

2.4. Ethics approval

The Monash University Human Research Ethics Committee approved the study, with consent implied by questionnaire completion (MUHREC 48300).

2.5. Statistical analysis

Categorical variables are reported as number and percentage. Continuous variables are summarised as mean (SD) or median (interquartile range [IQR]), as appropriate.

Heterogeneity in responses was assessed for each individual questionnaire item using the index of qualitative variation (IQV) for nominal items and Leik’s ordinal dispersion for ordinal items, normalised to the number of selected options for each item. Where multiple items represented a subdomain, the mean heterogeneity across those items was calculated as a subdomain level summary. “Don't know” answers were excluded from both the numerator and the denominator. Both metrics range from 0 (uniform practice) to 1 (maximum dispersion of reported practice). For descriptive interpretation, we used prespecified heuristic categories: <0.3 low, 0.3–0.7 moderate, and >0.7 substantial heterogeneity. These metrics describe the extent to which stated centre practices were dispersed across categories. They were not intended to measure clinical importance, appropriateness of care, or unwarranted variation and were interpreted alongside item content, denominators, and response distributions. As an exploratory analysis, questionnaire responses were summarised descriptively by country. Formal statistical comparisons between Australian and New Zealand centres were not performed because of the small and unequal number of centres within each country.

Data analysis was undertaken on the Monash University Secure e-Research Platform using RStudio (R version 4.4.2).

3. Results

3.1. Questionnaire completion

Thirty-three ICUs met screening criteria and were invited to participate; responses were received from 31 ICUs (94%). Three centres reported that they did not provide definitive care for adult msTBI patients and were excluded. Twenty-eight eligible centres completed the questionnaire (Fig. S2). Twenty-seven centres (96%) provided permission to link questionnaire responses with Australian and New Zealand Intensive Care Society (ANZICS) CORE CCR data. Responding centres were geographically distributed across New Zealand, and all states and territories of Australia, except Tasmania (Table S2). Across the four study domains, 39 of 74 measured items (53%) demonstrated moderate or substantial heterogeneity (Table 2, Table 3, Table 4, Table 5 and Tables S3–S6; Figs. S3–S6).

Table 2.

Hospital and ICU organisational structure and capability.

Characteristic/element or subdomain	N completed	Results	Heterogeneity^b
Hospital classification	27	Tertiary 26/27 (96%); metropolitan 1/27 (4%).	–
Hospital trauma level designation	27	Level 1: 21/27 (78%); Level 2: 2/27 (7%); other: 4/27 (15%).	–
ICU level	27	Level 3: 27/27 (100%).	–
Senior medical officer staffing	27	1.5 FTE per 1000 funded bed-days (IQR 1.2–1.7).	–
Permanent registered nurse staffing	27	20.9 FTE per 1000 funded bed-days (IQR 18.1–23.4).	–
Physiotherapy staffing	24	4.3 FTE (IQR: 3.0–6.0).	–
Hospital beds	25	593 beds (IQR: 525–673).	–
Available ICU capacity	27	26 beds (IQR: 19–37).	–
ICU occupancy	27	83% (IQR: 79–93%).	–
Neurocritical care subspecialty training	28	Senior ICU clinician with subspecialty neurocritical care training: yes 13/28 (46%); no 14/28 (50%); don’t know 1/28 (4%).	Substantial (1.00)
Access to specialist inpatient TBI rehabilitation^a	28	Yes 27/28 (96%); no 1/28 (4%).	Low (0.14)

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ICU, intensive care unit; FTE, full-time equivalent; IQR, interquartile range; TBI, traumatic brain injury.

Data are n/N (%) or median (IQR), as appropriate. Linked Australian and New Zealand Intensive Care Society CORE Critical Care Resources (ANZICS CORE CCR) data were available for 27 of 28 centres; missingness is shown by N completed. Percentages may not total 100% due to rounding.

Complete response distributions are provided in Table S3 and Fig. S3.

Adult specialist brain injury inpatient rehabilitation for adults who are medically stable and require a high level of care, have had a severe or very severe brain injury, and may still be in a state of confusion (posttraumatic amnesia).

Heterogeneity represents the normalised index of qualitative variation (IQV) for nominal items and Leik’s ordinal dispersion for ordinal items. “Don’t know” responses were excluded from calculation of heterogeneity. Heterogeneity was not calculated for linked registry descriptors.

Table 3.

ICU treatment processes.

Characteristic/element or subdomain	N completed	Results^a	Heterogeneity^d
Presence of ICU TBI guideline	28	TBI guideline used in 23/28 (82%); no guideline used in 5/28 (18%).	Moderate (0.59)
Frequency of TBI guideline adherence audit	23	ICU TBI guideline adherence audited several times per year 1/23 (4%); less than once per year 7/23 (30%); not within the preceding five years 13/23 (57%); don’t know 2/23 (9%).	Substantial (0.76)
Cohorting of patients with TBI	28	Not routinely cohorted 22/28 (79%); single ICU pod 4/28 (14%); separate ICU 2/28 (7%).	Moderate (0.54)
Physiotherapy review	28	Daily physiotherapy review once clinically appropriate 28/28 (100%).	Low (0.00)
Neurosurgical specialist attendance	28	Daily 6/28 (21%); less than daily 21/28 (75%); never 1/28 (4%).	Moderate (0.59)
Initial ICP monitoring device	28	Parenchymal monitor alone 15/28 (54%); EVD alone 9/28 (32%); simultaneous parenchymal ICP monitor and EVD 1/28 (4%); EVD with integrated ICP sensor 1/28 (4%); subdural monitor alone 1/28 (4%); invasive ICP monitoring not routine 1/28 (4%).	Substantial (0.73)
Initial ICP treatment threshold	28	Initial ICP treatment thresholds were concentrated at >20 mmHg in 15/28 centres (54%) and >22 mmHg in 11/28 (39%). Therefore, 26/28 centres (93%) selected one of the two adjacent fixed thresholds. No centre reported an individualised initial threshold.	Substantial (0.83)
Multimodal neuromonitoring utilisation	28	Always/frequently used for routine clinical care: advanced ICP waveform analysis, 4/28 (14%); intermittent EEG, 9/28 (32%); continuous EEG, 1/28 (4%); processed EEG, 0/28 (0%); PbtO₂, 0/28 (0%); jugular bulb oximetry, 0/28 (0%); near-infrared spectroscopy, 2/28 (7%); transcranial Doppler, 0/28 (0%); cerebral microdialysis, 0/28 (0%); invasive cerebral blood-flow monitoring, 0/28 (0%).	Low (0.15)^e
Initial CPP target	28	60–70 mmHg 24/28 (86%); 50–60 mmHg 3/28 (11%); individualised 1/28 (4%).	Moderate (0.38)
Arterial transducer zero level for CPP calculation	28	Foramen of Monro 20/28 (71%); phlebostatic axis/right atrium 8/28 (29%).	Substantial (0.82)
Refractory^b intracranial hypertension management	28	Always/frequently used during routine clinical care: mild hypothermia, 6/28 (21%); moderate hypothermia, 1/28 (4%); intensive hyperventilation, 4/28 (14%); moderate-/high-dose barbiturates, 11/28 (39%); rescue decompressive craniectomy, 17/28 (61%).	Moderate (0.30)^e
ICP threshold for rescue decompressive craniectomy^c	25	Individualised 15/25 (60%); >25 mmHg 7/25 (28%); >22 mmHg 2/25 (8%); >20 mmHg 1/25 (4%).	Substantial (0.74)
Timing of therapeutic CSF drainage	28	Early-tier therapy 12/28 (43%); later-tier therapy 7/28 (25%); hydrocephalus only 6/28 (21%); not routinely undertaken 3/28 (11%).	Substantial (0.93)
Method of CSF drainage among centres using an EVD for ICP control	25	EVD open to drain most of the time 17/25 (68%); predominantly intermittent drainage 8/25 (32%).	Substantial (0.87)
Fever treatment threshold	28	37.0 °C 2/28 (7%); 37.5 °C 13/28 (46%); 38.0 °C 10/28 (36%); 38.5 °C, 39.0 °C and individualised threshold each 1/28 (4%).	Substantial (0.78)
Minimum haemoglobin target	28	>70 g/L 10/28 (36%); >80 g/L 3/28 (11%); >90 g/L 12/28 (43%); >95 g/L, >100 g/L and individualised target each 1/28 (4%).	Substantial (0.81)
Post-ICU outcome follow-up interval	28	Six months postinjury 2/28 (7%); other follow-up interval 6/28 (21%); no follow-up undertaken 12/28 (43%); don’t know 8/28 (29%).	Substantial (0.81)
Routine comparison of observed with predicted outcomes among centres providing follow-up	8	No 7/8 (88%); don’t know 1/8 (13%); no centre reported routine comparison.	Low (0.00)

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ICU, intensive care unit; TBI, traumatic brain injury; ICP, intracranial pressure; EVD, external ventricular drain; EEG, electroencephalography; PbtO₂, brain tissue oxygen tension; CPP, cerebral perfusion pressure; CSF, cerebrospinal fluid.

Complete response distributions are provided in Table S4 and Fig. S4.

Data are n/N (%). Percentages may not total 100% due to rounding.

Refractory is defined as recurrent increase of intracranial pressure above the upper limit of the ICP threshold for a sustained period of time (10–15 min), despite conventional therapies, such as osmotic therapy, cerebrospinal fluid drainage, and mild hyperventilation.

Rescue decompressive craniectomy defined as a decompressive craniectomy used as a specific last-tier intervention when the intracranial pressure remains elevated, despite all other reasonable measures.

Heterogeneity represents the normalised index of qualitative variation (IQV) for nominal items and Leik’s ordinal dispersion for ordinal items. “Don't know” responses were excluded from calculation of heterogeneity.

Subdomain heterogeneity represents the mean heterogeneity across component items.

Table 4.

Neuroprognostication capability and processes.

Characteristic/element or subdomain	N completed	Results^a	Heterogeneity^b
Modalities used to inform neuroprognostic assessment in patients with a prolonged disorder of consciousness	28	Always/frequently used: clinical examination, 28/28 (100%); CT, 28/28 (100%); conventional MRI, 26/28 (93%); EEG, 20/28 (71%); ICP dose/burden, 17/28 (61%); SSEP N20, 6/28 (21%); prognostic scores, 3/28 (11%); blood biomarkers, 2/28 (7%); functional MRI, 1/28 (4%); MRI tractography, 0/28 (0%).	Low (0.27)^c
Management of perceived devastating^d TBI	28	Admission solely for palliation or consideration of organ donation 15/28 (54%); admission for physiological stabilisation and observation 13/28 (46%).	Substantial (0.99)

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CT, computed tomography; MRI, magnetic resonance imaging; EEG, electroencephalography; ICP, intracranial pressure; SSEP N20, somatosensory evoked potential N20 response; TBI, traumatic brain injury.

Complete response distributions are provided in Table S5 and Fig. S5.

Data are n/N (%). Percentages may not total 100% due to rounding.

Heterogeneity represents the normalised index of qualitative variation (IQV) for nominal items and Leik’s ordinal dispersion for ordinal items.

Subdomain heterogeneity represents the mean heterogeneity across component items.

Devastating is defined as any TBI that is assessed at the time of hospital admission as an immediate threat to life despite treatment, or incompatible with acceptable functional recovery, AND where early limitation or withdrawal of therapy is being considered.

Table 5.

Withholding or withdrawal of life-sustaining therapies.

Characteristic/element or subdomain	N completed	Results^a	Heterogeneity^b
WLST decision-making process	28	Unanimous multidisciplinary consensus 13/28 (46%); majority multidisciplinary agreement 6/28 (21%); one physician after multidisciplinary discussion 6/28 (21%); one physician without multidisciplinary discussion 1/28 (4%); other multidisciplinary process 2/28 (7%).	Substantial (0.86)
Participants in WLST decisions	28	Always/frequently involved: intensivist, 28/28 (100%); patient’s family or surrogate decision-maker, 28/28 (100%); neurosurgeon, 27/28 (96%); patient’s nurse, 9/28 (32%); neurologist, 2/28 (7%); clinical ethics committee, 0/28 (0%).	Low (0.21)^c
Patient factors informing WLST decisions	28	Always/frequently considered: probability of survival, 28/28 (100%); long-term neurological prognosis, 28/28 (100%); patient wishes, 28/28 (100%); premorbid physical function, 28/28 (100%); frailty, 27/28 (96%); premorbid cognitive function, 26/28 (93%); specific comorbidities, 26/28 (93%); age, 26/28 (93%); cultural preferences, 14/28 (50%); religious preferences, 11/28 (39%); social supports, 6/28 (21%); socioeconomic status, 3/28 (11%).	Low (0.29)^c
Therapies withdrawn at end of life	28	Vasoactive medications, 26/28 (93%); invasive mechanical ventilation, 27/28 (96%); renal replacement therapy, 27/28 (96%); intravenous fluids, 16/28 (57%); nasogastric feeding, 18/28 (64%); endotracheal tube, 27/28 (96%); external ventricular drain, 22/28 (79%).	Moderate (0.46)^c

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WLST, withholding or withdrawal of life-sustaining therapy.

Complete response distributions are provided in Table S6 and Fig. S6.

Data are n/N (%). Percentages may not total 100% due to rounding.

Subdomain heterogeneity represents the mean heterogeneity across component items.

3.2. Hospital and ICU organisational structure and capability

Linked CCR data described predominantly tertiary hospitals (26/27, 96%), with 21 of 27 (78%) designated level 1 trauma centres and all classified as level 3 ICUs. Median hospital size was 593 beds (IQR 525–673), available ICU capacity 26 beds (IQR 19–37), and ICU occupancy 83% (IQR 79–93%). Neurocritical care subspecialty training demonstrated substantial heterogeneity (IQV 1.00), with 13 of 28 centres (46%) reporting a senior ICU clinician with subspecialty training, while access to specialist inpatient brain injury rehabilitation was near-universal (27/28, 96%) (Table 2 and Table S3; Fig. S3).

3.3. ICU treatment processes

Twenty-three centres (82%) reported a specific TBI management guideline, although 13 of 23 (57%) had not audited adherence within the preceding 5 y. Parenchymal monitoring alone was the most common initial intracranial pressure (ICP) device (15/28, 54%), followed by external ventricular drain (EVD) alone (9/28, 32%). Initial ICP treatment thresholds were predominantly >20 mmHg (15/28, 54%) or >22 mmHg (11/28, 39%), and 24 of 28 centres (86%) targeted an initial cerebral perfusion pressure (CPP) of 60–70 mmHg. In contrast, arterial transducer zero level demonstrated substantial heterogeneity (IQV 0.82), with 20 of 28 centres (71%) referencing the foramen of Monro and 8/28 (29%) the phlebostatic axis/right atrium. Multimodal neuromonitoring, including ICP waveform analysis, intermittent, continuous, or processed electroencephalography, brain tissue oxygen tension (PbtO₂₎ monitoring, jugular bulb oximetry, near-infrared spectroscopy, transcranial Doppler, cerebral microdialysis, and intracranial blood flow monitoring, was generally unavailable or infrequently used during routine clinical care (Table 3 and Table S4; Fig. S4).

Management of refractory intracranial hypertension also varied. Seventeen of 28 centres (61%) reported always or frequently using rescue decompressive craniectomy. Corresponding proportions were lower for mild hypothermia (>34 to <36 °C), moderate hypothermia (≤34 °C), intensive hyperventilation, and moderate- or high-dose barbiturates, reported by 6 of 28 (21%), 1 of 28 (4%), 4 of 28 (14%), and 11 of 28 centres (39%), respectively. Among the 25 centres reporting an ICP threshold for rescue decompressive craniectomy, 15 of 25 (60%) reported that the threshold was individualised. Timing of therapeutic cerebrospinal fluid (CSF) drainage demonstrated substantial heterogeneity (IQV 0.93), with drainage used as an early-tier intervention at 12 of 28 centres (43%), later-tier at 7 of 28 (25%), and only for hydrocephalus at 6 of 28 (21%). When EVD drainage was used, 17 of 25 centres (68%) reported predominantly continuous drainage. Haemoglobin targets were also heterogeneous (Leik’s dispersion 0.81), most commonly >90 g/L (12/28, 43%) or >70 g/L (10/28, 36%). Post-ICU follow-up demonstrated substantial heterogeneity (IQV 0.81), eight centres (29%) reported routine follow-up, 12 (43%) reported no routine follow-up, and 8 (29%) selected “don't know” (Table 3 and Table S4; Fig. S4).

3.4. Neuroprognostication

Clinical examination was always used to inform neuroprognostication at all centres. Computed tomography, conventional magnetic resonance imaging (MRI), and electroencephalography were always or frequently used at 28 of 28 (100%), 26 of 28 (93%), and 20 of 28 centres (71%), respectively. Use of prognostic scores was uncommon, with only 3 of 28 centres (11%) reporting frequent use, while somatosensory evoked potential N20 responses were always or frequently used at 6/28 centres (21%). Blood biomarkers were frequently used at 2 of 28 centres (7%) and were unavailable at 18 of 28 centres (64%). Functional MRI and MRI tractography were unavailable at 17 of 28 (61%) and 22 of 28 centres (79%), respectively. Management of perceived devastating TBI demonstrated substantial heterogeneity (IQV 0.99). Fifteen of 28 centres (54%) reported admission solely for palliation or consideration of organ donation, whereas 13 of 28 (46%) reported admission for physiological stabilisation and observation. Among the latter, observation duration was determined by patient characteristics at 10 of 13 centres (77%) and clinician judgement at 3 of 13 (23%), respectively (Table 4 and Table S5; Fig. S5).

3.5. Withholding or withdrawal of life-sustaining therapies

WLST decision-making processes demonstrated substantial heterogeneity (IQV 0.86). Thirteen centres (46%) reported unanimous multidisciplinary consensus, 6 of 28 (21%) majority agreement, and 6 of 28 (21%) physician-led decision-making following multidisciplinary discussion. Intensivists, neurosurgeons, and family or surrogate decision-makers were reported as always or frequently involved at almost all centres, whereas neurologists and clinical ethics committees were rarely or never involved. Probability of survival, long-term neurological prognosis, patient wishes, and premorbid physical function were always or frequently considered at all centres, while socioeconomic status was never considered at 21 of 28 centres (75%) (Table 5 and Table S6; Fig. S6).

3.6. Fulfilment of selected ATBI QIS indicators

Fulfilment of the six measured ATBI QIS indicators varied between centres, ranging from 2/6 indicators (33%) to 5/6 indicators (83%), with a median fulfilment of 4/6 indicators (67%; IQR 50–83%; Fig. 1).²³

Fig. 1 — **Fulfilment of selected Australian TBI Quality Indicator Set elements**. ATBI QIS elements: ¹Daily visit by a physiotherapist during ICU stay. ²The existence of a protocol for ICU management of TBI including specific guidelines for ICU management of TBI. ³The presence of a dedicated person(s) to oversee TBI guideline development and maintenance. ⁴The presence of regular audits to check TBI guideline adherence. ⁵Observed versus predicted (e.g. IMPACT score) outcome assessment. ⁶Access to specialist acute brain injury rehabilitation unit. ATBI QIS, Australian Traumatic Brain Injury Quality Indicator Set; TBI, Traumatic brain injury; ICU, Intensive care unit; IMPACT, International Mission for Prognosis and Analysis of Clinical Trials in TBI.

3.7. Between-country comparison

Twenty-three participating centres were from Australia and five were from New Zealand. Descriptive comparison demonstrated broadly similar patterns of practice, with some differences in reported ICP monitoring and thresholds, advanced neuromonitoring, and management of perceived devastating TBI, although interpretation was limited by the small number of New Zealand centres (Table S7).

4. Discussion

In this binational provider-profiling study of ANZ ICUs providing definitive care for critically ill adults with msTBI, variation was observed across all study domains. Moderate or substantial heterogeneity was present in more than half of measured items, including organisational capability, ICP-monitoring and CPP-measurement practices, CSF-drainage strategies, physiological treatment thresholds, neuroprognostication processes, management pathways for perceived devastating TBI, and WLST decision-making. Fulfilment of the six measured ATBI QIS elements also varied between centres. Descriptive differences between Australian and New Zealand centres were observed for some study elements, although the small number of New Zealand centres precluded conclusions regarding systematic differences between the two countries.

4.1. Comparison with previous studies

Although methodological differences preclude direct comparison, our findings are consistent with international evidence of substantial between-centre variation in the organisation and delivery of TBI care.⁷^,⁸^,¹⁰^,¹¹^,¹⁹^,²⁰^,²⁹ In a CENTER-TBI provider-profiling survey of ICP-monitoring and treatment policies across 66 European neurotrauma centres, the availability, selection, and use of ICP-monitoring devices and treatments for intracranial hypertension varied across centres.⁸^,¹⁹ For example, ICP-device strategies varied: 21 of 64 centres (33%) reported using only parenchymal monitors, 5 (8%) only ventricular catheters, and 38 (59%) had both available, with parenchymal monitoring typically used when both were available.⁸ Although question construct differed, initial device choice also varied in our study, where a parenchymal monitor alone was used in 15 of 28 centres (54%) and an EVD alone in 9 (32%).

Variation in the arterial pressure reference used to calculate CPP was also clinically relevant, with 8 of 28 centres (29%) using the phlebostatic axis/right atrium rather than the tragus/foramen of Monro. In a 2013 survey of neurosurgical ICUs in Great Britain and Ireland, 58% levelled the arterial transducer at the right atrium and 42% at the tragus.³⁰ A subsequent joint position statement from the Neuro Anaesthesia & Critical Care Society of Great Britain and Ireland and the Society of British Neurological Surgeons recommended levelling the arterial transducer at the tragus for calculating CPP.³⁰ However, a recent review concluded that the optimal reference level remains uncertain, with limited guideline consensus and inconsistent clinical practice.³¹

CSF-drainage practices were similarly heterogeneous. In CENTER-TBI, CSF drainage was included among first-tier treatments by 27% of centres and among second-tier treatments by 33%. Among centres reporting a drainage strategy, continuous and intermittent drainage were used with similar frequency.⁸ In our study, CSF drainage was used as an early-tier therapy in 12 of 28 centres (43%), as a later-tier therapy in 7 (25%), only for hydrocephalus in 6 (21%), and not routinely in 3 (11%). Among centres using an EVD, 17 of 25 (68%) favoured continuous drainage. Recent World Federation of Neurosurgical Societies consensus recommendations support early ventriculostomy when CSF drainage is indicated, although the optimal timing and drainage strategy remain uncertain.⁶^,³² Both our study and the CENTER-TBI provider-profiling work also identified variation in the reported use of barbiturates, hyperventilation, hypothermia, and decompressive craniectomy.⁸^,¹⁹ These comparisons indicate that variation concerns not only whether interventions are available, but also when and how they are incorporated into treatment pathways.

Patient-level studies provide complementary evidence that delivered care differs across centres. Among 2138 patients admitted to an ICU in CENTER-TBI, the adjusted between-centre median odds ratio was 2.5 for the use of invasive ICP monitoring.¹⁰ In SYNAPSE-ICU, which included 2395 patients with acute brain injury from 146 ICUs in 42 countries, including 1287 patients (54%) with TBI, the adjusted between-centre median odds ratio for the use of invasive ICP monitoring was 4.5; treatment intensity also varied across centres.²⁰^,²⁹ Centre-level variation is not confined to monitoring and active treatment but also extends to end-of-life care. In CENTER-TBI, 86% of ICU deaths followed withdrawal of life-sustaining measures, with proportions ranging from 0 to 96% across European regions.⁷ In a six-centre Canadian cohort, the proportion of deaths associated with withdrawal of life-sustaining therapy ranged from 45.0 to 86.8%, and hospital mortality differed among centres after adjustment for patient characteristics.¹¹

4.2. Individualised decision-making

A notable pattern was the distinction between fixed and individualised decision-making. Twenty-six of 28 centres (93%) used initial ICP treatment thresholds of 20 or 22 mmHg, and no centre reported an individualised initial threshold. Thus, although there was categorical dispersion in the initial ICP threshold, there was consistency in the use of a fixed and clinically similar treatment threshold. Initial CPP targets were similarly concentrated, with 24 of 28 centres (86%) targeting 60–70 mmHg. In contrast, 15 of 25 centres (60%) individualised the ICP threshold for rescue decompressive craniectomy. Individualisation was also evident in other context-dependent decisions. Among centres admitting patients with perceived devastating TBI for stabilisation and observation, the duration of observation was determined by patient characteristics at 10 of 13 centres, while multiple patient-specific factors informed WLST decisions. These findings suggest that individualisation is applied selectively and that the drivers and clinical significance of variation differ according to the decision being considered. In a field characterised by heterogeneous patients and limited high-certainty evidence, some variation may reflect appropriate adaptation to patient circumstances or local context. Other variation may reflect differences in local practice norms, access to resources, or inconsistent implementation of recommended processes. The aim should therefore be reliable delivery of processes for which consistency is desirable, alongside appropriate personalisation where the balance of benefits and harms differs among patients.

4.3. Limitations

Most data are centre-level and self-reported and therefore may not fully reflect actual bedside practice. Reporting and social desirability biases are therefore also possible. Questionnaire responses were provided by the clinical director or a nominated representative and were intended to describe reported centre-level practice rather than the practice of individual clinicians or the management of individual patients. Accordingly, the questionnaire did not permit assessment of adherence to stated practice, within-centre or interclinician variation and did not include prehospital or early-hospital phases of care, which may also influence outcome following TBI. Although the response rate was high and participating centres were geographically diverse, participating centres were limited to those providing definitive care for adult msTBI and contributing to the ANZ Trauma Registry or holding College of Intensive Care Medicine neurosurgical ICU training accreditation at the time of questionnaire development, which may limit generalisability.

The heterogeneity metrics describe dispersion in reported centre practice but cannot distinguish unwarranted from appropriate variation related to local context, nor consistent best practice from widespread underuse of appropriate interventions. Study domain elements were informed by expert consensus, existing guidelines, and the ATBI QIS, and although all selected elements were clinically and organisationally relevant, their association with patient outcomes remains hypothesised rather than proven. The ATBI QIS was developed in Australia, and its applicability as a quality framework for New Zealand centres has not been established. Furthermore, some domain elements, particularly those relating to neuroprognostication and WLST processes, are complex and often context-dependent, and our questionnaire may have failed to capture all essential aspects. Additionally, this study did not examine whether regional, demographic, socioeconomic, or cultural factors influenced centre-level treatment decisions. Accordingly, this study should be interpreted as a descriptive analysis of centre-level variation intended to inform hypotheses, benchmarking, and future outcome-linked work, rather than as evidence of direct causal relationships between individual domain elements and patient outcomes.

5. Implications for clinical practice, research, and quality improvement

These findings identify priorities for clinical practice, quality improvement, and research. Patient-level linkage could determine whether reported centre practices correspond to differences in treatment exposure and whether these differences are associated with mortality, functional outcomes, or resource use after adjustment for patient and injury characteristics. Differences in reported fulfilment of ATBI QIS elements identify candidate items for further evaluation and, where variation reflects inconsistent implementation of agreed care processes, potential for improvement through standardised pathways or care bundles. Neuroprognostication and WLST processes warrant particular evaluation because treatment-limitation practices may influence observed outcomes and complicate comparisons between centres. Differences in access to biomarkers, multimodal neuromonitoring, and advanced imaging may represent system-level barriers to implementing emerging approaches to TBI classification, treatment, and prognostication.³^,[33], [34], [35] Characterising variation in usual care may also inform multicentre trial design by identifying differences in background care, potential effect modifiers, and site-level practices that influence treatment exposure or outcomes.

6. Conclusion

This binational provider-profiling study identified between-centre variation across multiple elements of reported hospital and ICU organisational structure, capability, treatment processes, neuroprognostication, and WLST practices for critically ill adults with msTBI in ANZ. These findings provide a contemporary description of organisational characteristics and clinical practices, identify potential targets for quality improvement, highlight priorities for further research, and emphasise the importance of accounting for centre-level variation in the design, conduct, and interpretation of observational research and multicentre clinical trials.

CRediT authorship contribution statement

JDT: Conceptualisation, Methodology, Formal analysis, Investigation, Data curation, Writing – original draft, Visualization, Project administration. CRB, CYK, JM, LS: Conceptualisation, Methodology, Writing – review and editing. JB, TB, RSB, DB, AC, OF, TPH, TJ, WYM, RMcN, RNM, ISM, SS, KS, SW, MW, PJY: Investigation, Writing – review and editing. AMH, CJM, AAU: Conceptualisation, Methodology, Investigation, Supervision, Writing – review and editing.

Data sharing statement

The data underlying this study are not publicly available because they contain confidential information provided by participating sites and are subject to institutional, registry, and ethics restrictions. Data access requests may be directed to the corresponding author and will be considered subject to appropriate approvals and data-use agreements.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. JDT is the recipient of an Australian Government Research Training Program (RTP) Scholarship. AMH is supported by a National Health and Medical Research Council Investigator Grant (#2008447).

Conflict of interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Alisa M. Higgins reports a relationship with National Health and Medical Research Council Investigator Grant that includes: funding grants. Jonathon D. Taylor reports a relationship with an Australian Government Research Training Program (RTP) Scholarship that includes: funding grants. Paul Young, Andrew Udy, and Alisa Higgins are members of the Critical Care and Resuscitation editorial team. All other authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgements

The authors would like to thank Drs Liam Byrne, Christopher Joyce and Markus Renner for their contribution through completion of the questionnaire.

This research was supported by Monash eResearch capabilities, including the Secure eResearch Platform and REDCap. The authors and the ANZICS CORE Management Committee thank the clinicians, data collectors, and researchers at all contributing sites in Australia and New Zealand, particularly those who have supported research using the ANZICS CORE Registry.

Footnotes

Supplementary data to this article can be found online at https://doi.org/10.1016/j.ccrj.2026.100219.

Appendix A. Supplementary data

The following are the Supplementary data to this article:

Multimedia component 1

mmc1.docx^{(1.7MB, docx)}

Multimedia component 2

mmc2.pdf^{(9.9MB, pdf)}

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Associated Data

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Supplementary Materials

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PERMALINK

Variation in capability, organisational structure, and treatment processes for critically ill adults with moderate-to-severe traumatic brain injury in Australia and New Zealand

Jonathon D Taylor, FCICM, MSc

Camila R Battistuzzo, PhD, Bs (PT)

Chien Y Kow, MBBS, FRACS(Neuro)

James Moore, MBChB, MSc, FANZCA, FCICM

Lydia Shim, BN, RN

Judith Bellapart, FCICM, PhD

Toby Betteridge, MBChB, FANZCA, FCICM

Robert S Bevan, FRACP, FCICM

Deepak Bhonagiri, MBBS, MD, FCICM

Andrew Chow, FCICM, MBBS

Oliver Flower, MBBS, BMedSci, FCICM

Timothy P Haydon, MBBS, FRACP, FCICM, FANZCA, MBioethics

Toby Jeffcote, FCICM, PhD

Wei-Yun Mak, FACEM, FCICM

Robert McNamara, BMBS, FCICM

Ravi N Mistry, FANZCA, FCICM

Idunn S Morris, MBChB, FRCA, FCICM

Siva Senthuran, MBBS, FRCA, FCICM, FANZCA

Krishnaswamy Sundararajan, MBBS, MPH, FCICM

Stephen Warrillow, MBBS, PhD, FRACP, FCICM

Mark Weeden, MBBS, FCICM

Paul J Young, MBChB, FCICM, PhD

Alisa M Higgins, BPhysio(Hons), GDipBiostat, MPH, PhD

Colin J McArthur, FCICM, MBChB

Andrew A Udy, BHB, MBChB, FCICM, PhD

Abstract

Objective

Design

Setting

Main outcome measures

Results

Conclusions

1. Introduction

2. Methods

2.1. Development of the provider profiling questionnaire

Table 1.

2.2. Study sample and questionnaire distribution

2.3. Data linkage

2.4. Ethics approval

2.5. Statistical analysis

3. Results

3.1. Questionnaire completion

Table 2.

Table 3.

Table 4.

Table 5.

3.2. Hospital and ICU organisational structure and capability

3.3. ICU treatment processes

3.4. Neuroprognostication

3.5. Withholding or withdrawal of life-sustaining therapies

3.6. Fulfilment of selected ATBI QIS indicators

Fig. 1.

3.7. Between-country comparison

4. Discussion

4.1. Comparison with previous studies

4.2. Individualised decision-making

4.3. Limitations

5. Implications for clinical practice, research, and quality improvement

6. Conclusion

CRediT authorship contribution statement

Data sharing statement

Funding

Conflict of interest

Acknowledgements

Footnotes

Appendix A. Supplementary data

References

Associated Data

Supplementary Materials

ACTIONS

PERMALINK

RESOURCES

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