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Introduction of the Uppsala Traumatic Brain Injury register for regular surveillance of patient characteristics and neurointensive care management including secondary insult quantification and clinical outcome
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurosurgery.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurosurgery.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurosurgery.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Neurosurgery.
2013 (English)In: Upsala Journal of Medical Sciences, ISSN 0300-9734, E-ISSN 2000-1967, Vol. 118, no 3, 169-180 p.Article in journal (Refereed) Published
Abstract [en]

Background. To improve neurointensive care (NIC) and outcome for traumatic brain injury (TBI) patients it is crucial to define and monitor indexes of the quality of patient care. With this purpose we established the web-based Uppsala TBI register in 2008. In this study we will describe and analyze the data collected during the first three years of this project. Methods. Data from the medical charts were organized in three columns containing: 1) Admission data; 2) Data from the NIC period including neurosurgery, type of monitoring, treatment, complications, neurological condition at discharge, and the amount of secondary insults; 3) Outcome six months after injury. Indexes of the quality of care implemented include: 1) Index of improvement; 2) Index of change; 3) The percentages of 'Talk and die' and `Talk and deteriorate' patients. Results. Altogether 314 patients were included 2008-2010: 66 women and 248 men aged 0-86 years. Automatic reports showed that the proportion of patients improving during NIC varied between 80% and 60%. The percentage of deteriorated patients was less than 10%. The percentage of Talk and die/Talk and deteriorate cases was <1%. The mean Glasgow Coma Score (Motor) improved from 5.04 to 5.68 during the NIC unit stay. The occurrences of secondary insults were less than 5% of good monitoring time for intracranial pressure (ICP) >25 mmHg, cerebral perfusion pressure (CPP) <50 mmHg, and systolic blood pressure <100 mmHg. Favorable outcome was achieved by 64% of adults. Conclusion. The Uppsala TBI register enables the routine monitoring of NIC quality indexes.

Place, publisher, year, edition, pages
2013. Vol. 118, no 3, 169-180 p.
Keyword [en]
Database, neurointensive care, outcome, quality register, secondary insults, traumatic brain injury
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:uu:diva-204853DOI: 10.3109/03009734.2013.806616ISI: 000321587100004OAI: oai:DiVA.org:uu-204853DiVA: diva2:640136
Available from: 2013-08-12 Created: 2013-08-12 Last updated: 2017-12-06Bibliographically approved
In thesis
1. Quality systems to avoid secondary brain injury in neurointensive care
Open this publication in new window or tab >>Quality systems to avoid secondary brain injury in neurointensive care
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Outcome after traumatic brain injury (TBI) depends on the extent of primary cell death and on the development of secondary brain injury. The general aim of this thesis was to find strategies and quality systems to minimize the extent of secondary insults in neurointensive care (NIC).

An established standardized management protocol system, multimodality monitoring and computerized data collection, and analysis systems were used.

The Uppsala TBI register was established for regular monitoring of NIC quality indexes. For 2008-2010 the proportion of patients improving during NIC was 60-80%, whereas 10% deteriorated. The percentage of ‘talk and die’ cases was < 1%. The occurrences of secondary insults were less than 5% of good monitoring time (GMT) for intracranial pressure (ICP) > 25 mmHg, cerebral perfusion pressure (CPP) < 50 mmHg and systolic blood pressure < 100 mmHg. Favorable outcome was achieved by 64% of adults.

Nurse checklists of secondary insult occurrence were introduced. Evaluation of the use of nursing checklists showed that the nurses documented their assessments in 84-85% of the shifts and duration of monitoring time at insult level was significantly longer when secondary insults were reported regarding ICP, CPP and temperature. The use of nurse checklist was found to be feasible and accurate.

 A clinical tool to avoid secondary insults related to nursing interventions was developed. Secondary brain insults occurred in about 10% of nursing interventions. There were substantial variations between patients. The risk ratios of developing an ICP insult were 4.7 when baseline ICP ≥ 15 mmHg, 2.9 when ICP amplitude ≥ 6 mmHg and 1.7 when pressure autoregulation ≥ 0.3.

Hyperthermia, which is a known frequent secondary insult, was studied. Hyperthermia was most common on Day 7 after admission and 90% of the TBI patients had hyperthermia during the first 10 days at the NIC unit. The effects of hyperthermia on intracranial dynamics (ICP, brain energy metabolism and BtipO2) were small but individual differences were observed. Hyperthermia increased ICP slightly more when temperature increased in the groups with low compliance and impaired pressure autoregulation. Ischemic pattern was never observed in the microdialysis samples. The treatment of hyperthermia may be individualized and guided by multimodality monitoring. 

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2015. 89 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1113
Keyword
Traumatic brain injury, Subarachnoid hemorrhage, Intracranial pressure, Quality register, Checklist, Nursing interventions, Pressure autoregulation, Intracranial compliance, Hyperthermia, Cerebral energy metabolism, Microdialysis and Brain tissue oxygenation.
National Category
Anesthesiology and Intensive Care
Research subject
Neurosurgery
Identifiers
urn:nbn:se:uu:diva-253005 (URN)978-91-554-9270-0 (ISBN)
Public defence
2015-09-10, Grönwallsalen, Akademiska sjukhuset. Ing 70, Uppsala, 09:15 (Swedish)
Opponent
Supervisors
Available from: 2015-06-10 Created: 2015-05-18 Last updated: 2015-07-07Bibliographically approved

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Nyholm, LenaEnblad, PerLewen, Anders

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