Table 1.
Characteristics of the Included Studies (n = 22)
| Study ID | Objective | Study design & setting | Patients | Guideline and topic | Strength of recommendation* | Adherence operationalization | Adherence (% (n adherent /n total)) |
|---|---|---|---|---|---|---|---|
| Alali (2013) |
1,2,3 |
Retrospective cohort (US, Canada) in 155 centers |
Severe TBI, age ≥16 |
BTF (2007) – ICP monitoring |
M/W |
ICP monitor inserted |
18% (1874/10628) |
| Andriessen (2011) |
1A |
Same dataset as Biersteker (2012) |
Severe TBI, age ≥16 |
BTF (2007) – Pre-hospital intubation |
M/W |
Pre-hospital intubation performed |
69% (234/339) |
| Biersteker (2012) |
1,2,3 |
Prospective cohort (The Netherlands) in 5 centers |
Severe TBI, age ≥16, intracranial pathology or 2/3 criteria: age >40, ED motor score ≤3 or systolic blood pressure <90 mmHg |
BTF (2007) – ICP monitoring |
M/W |
ICP monitor inserted |
46% (123/265) |
| Bulger (2002) |
1,3 |
Retrospective cohort (US) in 33 centers |
Severe TBI, multitrauma, age ≥18. ICP monitoring: abnormal head CT |
BTF (1995) – Pre-hospital intubation and ICP monitoring |
M/W |
Pre-hospital intubation performed |
43% (79/182) |
| ICP monitor inserted |
58% (105/182) |
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| Fakhry (2004) |
1,3 |
Prospective cohort with historical control group (US) |
Severe TBI, age >14 |
BTF (1995) – ICU management of severe TBI patientsB |
M/W |
Following ICU protocol*** |
76% (466/611) |
| Farahvar (2012) Gerber (2013) |
1,2,3 |
Retrospective analysis of prospectively collected database (US) in 22 centers |
Severe TBI, intracranial pathology or 2/3 criteria: age >40, hypotension or GCS motor score ≤3; ICP lowering treatment on first 2 days |
BTF (2000) – ICP monitoring |
M/W |
ICP monitor inserted |
83% (1084/1307) |
| Franschman (2012) Franschman (2009) |
1 |
Retrospective cohort (The Netherlands) in 3 centers |
Severe, CT scan confirmed TBI, age >10 |
BTF (2000) – prehospital intubation |
M/W |
Pre-hospital intubation performed |
88% (NR/372) |
| Griesdale (2010) |
1,2,3 |
Retrospective cohort (Canada) |
Severe TBI, intracranial pathology |
BTF (2000) – ICP monitoring |
M/W |
ICP monitoring with EVD inserted |
61% (98/161)C |
| Harr (2011) Heskestad (2012) |
1,2 |
Retrospective cohort (Norway) |
ICD-10 diagnosis head injury, age ≥15 years |
Scandinavian guidelines (2000) – CT scanning & hospital admission |
M/W |
CT scanning and hospital admission according to algorithm |
61% (520/860) |
| Härtl (2006) |
1,2,3 |
Same dataset as Farahvar (2012) |
Severe TBI |
BTF (2000) – Direct transport |
M/W |
Direct transfer to trauma center |
77% (864/1118) |
| Haydon (2013) |
1 |
Retrospective cohort (UK) |
Head injury, age ≥16, received a CT scan |
NICE CG 56 (2007) – CT scanning |
S |
Documentation of ≥1 CT scan requirements |
84% (129/153) |
| Performing CT scan ≤1 h of request for all but three of indications |
86% (93/108) |
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| Performing CT scan ≤8 h in three other risk factors |
100% (21/21) |
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| Heskestad (2008) |
1,2 |
Prospective cohort (Norway) |
ICD-10 diagnosis head injury |
Scandinavian guidelines (2000) – CT scanning & hospital admission |
M/W |
CT scanning and hospital admission according to algorithm |
51% (259/508) |
| Mauritz (2008) |
1,2,3 |
Prospective cohort in 13 tertiary care centers (Austria, Slovakia, Bosnia, and Macedonia) |
Severe TBI |
BTF (1995) – Pre-hospital intubation, direct transport, steroid use |
M/W |
Following BTF guidelines for: |
|
| M/W |
Pre-hospital intubation |
58% (673/1172) |
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| M/W |
Direct transfer |
72 (534/746) |
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| S |
Steroids not used |
83% (468/564) |
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| Mooney (2011) |
1 |
Retrospective cohort (UK) in 2 centers |
Head injury |
NICE CG56 (2007) – CT scanning |
S |
CT performed according to criteria |
97 (741/762) |
| Prowse (2009) |
1 |
Retrospective cohort (UK) |
Isolated head injury |
NICE CG56 (2007) – CT scanning |
S |
NICE criteria reported in patients who had a CT scan performed |
70% (23/33) |
| Ravindran (2007) |
1 |
Retrospective cohort (UK) |
Head injury |
NICE CG4 (2003) – CT scanning |
S |
NICE criteria reported in patients who had a CT scan performed out of hours |
100% (27/27) |
| Rognas (2013) |
1 |
Prospective cohort (Denmark) |
Severe TBI |
BTF (2007) and Scandinavian Guidelines on pre-hospital management of TBI (2008) – pre-hospital intubation |
M/W |
Pre-hospital intubation performed |
93% (50/54) |
| Rusnak (2007) |
1,3 |
Prospective cohort (Austria) in 5 centers |
Severe TBI |
BTF (1995) – Various recommendations |
|
Following BTF guidelines (see Rusnak (2007) Table 2) for: |
|
| M/W |
Resuscitation of BP & O2 |
79% (217/274) |
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| M/W |
Indications for ICP monitoring |
68% (283/415) |
|||||
| M/W |
Hyperventilation |
92% (363/393) |
|||||
| M/W |
Barbiturates |
83% (269/326) |
|||||
| S |
Steroids |
89% (362/409) |
|||||
| M/W |
Antiseizure prophylaxis |
89% (360/407) |
|||||
| Shafi (2014) |
1,2,3 |
Retrospective cohort (US) in 11 centers |
Severe TBI patients, age <99, intracranial pathology |
BTF (2007) – various recommendations |
|
Following BTF guidelines (see Shafi (2014) Table 1): |
|
| M/W |
Endotracheal intubation |
92% (1890/2056) |
|||||
| M/W |
Resuscitation |
75% (48/64) |
|||||
| M/W |
ICP monitoring |
52% (818/1569) |
|||||
| M/W |
ICP directed therapy |
76% (742/978) |
|||||
| Shafi (2014b) |
1 |
Retrospective cohort (US) in 5 hospitals |
Severe TBI, age ≥16 |
BTF – various recommendations |
M/W |
Pre-hospital intubation performed |
94% (468/497) |
| M/W |
Intracranial pressure monitoring in trauma patients with a GCS ≤8 and intracranial bleed on head CT and endotracheal intubation |
39% (100/257) |
|||||
| M/W |
Craniotomy in patients with GCS ≤8 and intracranial bleed on head CT |
20% (66/326) |
|||||
| Shravat (2006) |
1 |
Retrospective cohort (UK) |
Head injury |
NICE CG56 (2007) – CT scanning |
S |
Whether CT had been requested within existing NICE criteria |
100% (472/472) |
| Talving (2013) | 1,2,3 | Prospective cohort (US) | Severe TBI, age >18, meeting BTF criteria for ICP monitoring | BTF (2007) – ICP monitoring | M/W | ICP monitor inserted | 47% (101/216) |
S = strong recommendation, the guideline recommendation was based on good quality randomized controlled trials; M/W = strong/weak recommendation, the guideline recommendation was based on lower level evidence.
= Because of multiple publications, only the amount of intubation adherence is assessed from Andriessen. For ICP monitoring, see Biersteker (2012).
= See appendix Fakhry (2004) for the ICU protocol.
= Authors stated that 98 of 171 patients got an ICP monitor placed. They also stated that 10 of the patients who got no ICP monitor placed did not had an indication. We therefore recalculated the percentage adherence without those 10 patients.
TBI, traumatic brain injury; NR, not reported; AIS, Abbreviated Injury Scale; BTF, Brain Trauma Foundation; ICP, intracranial pressure; LOS, length of stay; GCS, Glasgow Coma Scale; ED, emergency department; GOSE, Glasgow Outcome Scale Extended; US, United States of America; CT, computed tomography; ICU, intensive care unit; RLAS = Rancho Los Amigos Scale; ISS, Injury Severity Score; EVD, external ventricular drainage; ICD, International Classification of Diseases; HI, head injury; NICE, National Institute of Health and Clinical Excellence; HIC, high income country; UMIC, upper middle income country; LMIC, lower middle income country; BP, blood pressure; O2, oxygen; RBC, red blood cell; SBP, systolic blood pressure; CPP, cerebral perfusion pressure.
Definition: severe TBI = GCS <9.