Table 3.
Finally proposed set of clinical quality indicators in traumatic brain injury at the ICU
| Domain | Indicators |
|---|---|
| Protocol | |
| 1. Structure: The existence of a protocol including specific guidelines (like the BTF guidelines or institutional guidelines) for traumatic brain injury patients (yes/no) | |
| 2. Structure: The presence of (some form of) regular audits to check guideline adherence in general at the intensive care unit (ICU) (yes/no) Extra: Audits do not have to be specific for TBI | |
| 3. Structure: The presence of a dedicated person(s) to oversee guidelines development and maintenance, including those for patients with TBI, at the ICU (yes/no) | |
| Intensive care unit | |
| 4. Structure: The presence of a step-down unit where patients can still be monitored 24/7, but less intensively than at the ICU (yes/no) Extra: A facility in-between ICU and ward. It is often used for patients who improved at the intensive care and no longer need the intensity of ICU care, but are also not well enough to be cared for at the ward. The care provided in step down beds is less intensive than the care provided at the ICU but more intensive than ward care |
|
| 5. Structure: Does your hospital have a dedicated/specialized neurocritical care unit? (yes/no) | |
| 6. Structure: The availability of operating rooms 24 h per day (yes/no) | |
| 7. Process: Median accident-to-ICU-admission time (process) Extra: Time of the accident/injury to ICU-door-time | |
| Staff | |
| 8. Structure: A daily meeting between intensivist and neurosurgeon to discuss patients with TBI at the ICU (yes/no) | |
| 9. Structure: Availability of a neurosurgeon (staff) 24/7 within 30 min after the call (yes/no) | |
| 10. Structure: Total number of disciplines (i.e., neurologist, physiotherapy, occupational therapy) involved during ICU stay | |
| 11. Structure: Certified intensivist present in person 7 days a week during at least day-time (yes/no) | |
| 12. Structure: Intensivist to ICU bed ratio | |
| 13. Structure: ICU nurse to ICU bed ratio | |
| 14. Process: Number of visits by a neurosurgeon/ total number of ICU days in patients with TBI | |
| CT scanning | |
| 15. Structure: 24/7 availability of a CT scan and radiologist review (yes/no) | |
| ICP monitoring | |
| 16. Structure: 24/7 availability of a certified person at your center that can insert an ICP monitor within 2 h after admission at the ICU (yes/no) | |
| 17. Process: Number of severe (GCS 3–8) TBI patients with ICP monitoring/number of severe TBI patients at the ICU | |
| 18. Outcome: Number of EVD infections in patients with TBI/total number of patients with TBI at the ICU with an EVD inserted Extra: Only for centers that use ventricular catheters | |
| Deep venous thrombosis (DVT) | |
| 19. Process: Number of patients with TBI that receive any DVT prophylaxis/total number of patients with TBI at the ICU Extra: Timing (application of prophylaxis in days from the injury) and type of DVT prophylaxis (mechanical and/or pharmaceutical) can be registered as well |
|
| 20. Process: Number of patients that receive pharmaceutical prophylaxis with low molecular weight heparins/total number of TBI patients admitted to the ICU Extra: This QI is about the choice of prophylaxis (low molecular weight heparin), not about timing | |
| 21. Process: Number of patients with TBI that receive mechanical DVT prophylaxis (e.g., stockings) initiated within 6 h/total number of patients with TBI at the ICU with the possibility to receive stockings Extra: Exclude patients with leg fractures | |
| Glucose and nutrition | |
| 22. Structure: Do you have a protocol for glucose management available for patients with TBI at your ICU? yes/no | |
| 23. Process: Number of TBI patients with basal full caloric replacement within 5 to 7 days post-injury/number of TBI patients at the ICU | |
| 24. Process: Number of TBI patients with start of (early) enteral nutrition within 72 h/number of patients with enteral feeding during ICU stay | |
| 25. Outcome: Number of TBI patients with any blood glucose above 10 mmol/L (180 mg/dL, hyperglycemia)/total number of patients with TBI at the ICU Extra: Other values are not necessarily good, only detection of extreme cases | |
| 26. Outcome: Number of TBI patients with any blood glucose below 4 mmol/L (hypoglycemia)/total number of patients with TBI at the ICU Extra: Other values are not necessarily good, only detection of extreme cases | |
| Surgery | |
| 27. Structure: The presence of a protocol/institutional guideline that provide indications for surgery with SDH an EDH (yes/no) | |
| 28. Process: Median door-to-operation time for acute operation of SDH and EDH with surgical indication | |
| Allied health professional | |
| 29. Process: Number of patients with a support plan (e.g., rehabilitation) after ICU discharge/number of patients discharged from the ICU Extra: plan consists of physio-, speech-, and occupational therapist goals during hospital stay |
|
| 30. Process: Number of patients with TBI visited daily by a physiotherapist during ICU stay/total number of patients with TBI at the ICU | |
| Assessment scales at the ICU | |
| 31. Structure: Information on prognosis is discussed with family by one of the treating physicians (ICU physician or neurosurgical physician) at least once during ICU stay | |
| 32. Process: Number of assessments of motor scores of the GCS/total number of ICU days in patients with TBI | |
| 33. Process: Number of assessments of pupillary responses/total number of ICU days in patients with TBI | |
| 34. Process: Number of assessments of delirium presence with validated screening tool in conscious TBI patients/total number of ICU days in conscious TBI patients | |
| In-hospital outcomes | |
| 35. Outcome: Number of ICU-deaths among patients with TBI/total number of ICU-admitted patients with TBI | |
| 36. Outcome: Incidence of ventilator-associated pneumonia (VAP) in patients with TBI/total number of TBI patients with mechanical ventilation at the ICU Extra: Pneumonia defined as “the presence of new lung infiltrate plus clinical evidence that the infiltrate is of an infectious origin, which includes the new onset of fever, purulent sputum, leukocytosis, and a decline in oxygenation,”. VAP is defined as pneumonia occurring > 48 h after endotracheal intubation [46] | |
| 37. Outcome: Number of TBI patients with decubitus grade 2 or higher at the ICU/number of TBI patients at the ICU Extra (also register the grade): Grade 1: Pressure zone with redness that does not blanch with fingertip pressure, with the skin still intact Grade 2: Decubitus ulcer (pressure sore) with skin erosion, blister, partial loss of the epidermis and/or dermis, or skin loss Grade 3: Decubitus ulcer (pressure sore) with loss of all skin layers and damage or necrosis of the subcutaneous tissue, which may extend down to the underlying fascia Grade 4: Decubitus ulcer (pressure sore) with necrosis of the muscle, bone, or supportive structures such as tendons or joint capsules | |
| 38. Outcome: Number of patients with TBI with severe sepsis or septic shock/total number of patients with TBI at the ICU Extra: Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. For clinical operationalization, organ dysfunction can be represented by an increase in the Sequential [sepsis-related] Organ Failure Assessment (SOFA) score of 2 points or more, which is associated with an in-hospital mortality greater than 10%. The septic shock should be defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone. Patients with septic shock can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mmHg or greater and serum lactate level greater than 2 mmol/L (> 18 mg/dL) in the absence of hypovolemia [47] | |
| After discharge or follow-up outcomes | |
| 39. Process: Number of patients with TBI receiving follow-up by a specialist within 2 months after discharge/total number of patients with TBI discharged (not in rehab clinic) | |
| 40. Process: Number of patients with neuropsychological testing at hospital discharge/number of patients with TBI discharged from the hospital | |
| Outcome scales at 6 months | |
| 41. Outcome: The median score of the GOSE from all patients with TBI at 6 months/number of patients with TBI discharged from the ICU and alive at 6 months | |
| 42. Outcome: The median score of the SF-36 from all patients with TBI at 6 months/number of patients with TBI discharged from the ICU and alive at 6 months | |
The final set of indicators after the Delphi rounds per domain. All outcome indicators will be adjusted for case-mix
EDH epidural hematoma, GCS Glasgow Coma Scale, GOSE Glasgow Coma Scale – Extended, ICU intensive care unit SDH subdural hematoma, SF-36 36-item short form survey