Resource utilization in the management of traumatic brain injury patients in a critical care unit: An audit from rural setup of a developing country.

INTRODUCTION: Traumatic brain injuries (TBI) are steadily increasing and are a major cause of mortality and morbidity, particularly in the young population, leading to the loss of life and productivity in the developing countries. Providing critical care to these patients with TBI is a challenge even in well-advanced centers in major cities of India. In the present study, we describe our experience of resource utilization in the management of TBI in a critical care unit (CCU) from a rural setup.
MATERIALS AND METHODS: All consecutive patients who were admitted from January 2007 to December 2009 in the CCU for the management of traumatic brain injury were included in the study. The case records of the patients were reviewed retrospectively, and data were collected on age, gender, severity of head injury, associated injuries, total CCU stay, total hospital stay, and outcome.
RESULTS: The total duration (days) of hospital stay was 8.96±6.16 days and a median of 8 days, and CCU stay was 3.77±6.34 days with a median of 2 days. No deaths occurred with mild head injury. A total of 73 (19.16%) deaths occurred in 381 admitted subjects in CCU. The risk of death among both the sexes is not significantly different, that is, odds ratio (OR) 1.032 [95% confidence interval (CI) 0.351-3.03], so also the risk of death among the different age groups is also not significant having OR, 0.978 (95% CI, 0.954-1.00). The severity of head injury (mild, moderate, and severe) and CCU stay parameters had significant difference with risk of death [OR, 3.22 (95% CI, 2.49-4.16) and OR, 2.50 (95% CI, 1.9-3.2)].
CONCLUSIONS: Apparently it seems possible to use the existing health care structures in rural areas to improve trauma care. It becomes particularly relevant in poor resource, developing countries, where health care facilities and access to specialized care units are still far below the acceptable standard, there is a need to compare with the reference group to further support the evidence.

INTRODUCTION

Traumatic brain injuries (TBI) is steadily increasing and is a major cause of mortality and morbidity, particularly in the young population, leading to the loss of life and productivity in the developing countries.[1-4] Providing critical care to these patients with TBI is a challenge even in well-advanced centers in major cities of India.[4-8] In the present study, we describe our experience of critical care unit (CCU) resource utilization in the management of TBI from a rural setup.

MATERIALS AND METHODS

The present study was a retrospective review performed at Acharya Binova Bhave Rural Hospital (AVBRH), Sawangi (Meghe). AVBRH is a 900 bedded teaching hospital cum tertiary referral center situated in rural area of central India. The period of study was from January 2007 to December 2009. All consecutive patients who were admitted in the CCU for the management of traumatic brain injury were included in the study. The case records of the patients were reviewed retrospectively, and data were collected on age, gender, severity of head injury, associated injuries, total CCU stay, total hospital stay, and outcome. The biochemical investigations were performed only where and when necessary. Computerized tomography (CT) was performed in all the cases. Based on the neurologic status and status of the associated injuries, patients were managed conservatively and all the patients were managed as per the standard protocol and maximally aggressive therapy aimed at diminishing intracranial pressure and elevating cerebral perfusion pressure was pursued in every case. We did not have facility for the intracranial pressure monitoring. Indications for surgery were operable lesions on CT scan. Based on Glasgow Coma Scale (GCS), the severity of head injury was defined as mild (GCS: 13–15), moderate (GCS: 9–12), and severe (GCS: 3–8).[9]

All the patients with a GCS score of 8 or less, respiratory distress, or shock were intubated, ventilated, and sedated as necessary. Tracheostomy was performed where there was poor neurological status, prolonged intubation, ventilation, and facial injuries. Prophylactic anticonvulsant (pheytoin) was used in all high-risk cases. We do not use corticosteroids in head injury patients routinely. All patients were provided with supportive care and received regular physiotherapy for their physical disability and respiratory problems. The condition was noted at discharge and outcome was analyzed according to the GCS.[10]

Statistical analyses

All statistical analyses were carried out using SPSS software version 11.0 (SPSS Inc., Chicago IL). Continuous variables were expressed as mean ± SD. Chi-square test was used to compare categorical variables. Statistical significance was set at P < 0.05. Logistic regression analysis was used to identify risk factors associated with CCU mortality at various day and times of admission.

RESULTS

During the study period, a total 381 patients were admitted to the intensive care unit for the management of head injury. There were total 303 males and 78 females [Figure 1]. The majority of the patients were in their 3rd, 4th, and 5th decade [Figure 2]. The mean age of the subjects was 37.78±16.99 years and median age was 36 years. The most common cause of the TBI was road traffic accidents (67%). The total duration (days) of hospital stay was 8.96±6.16 days and median of 8 days, CCU stay was 3.77±6.34 days with median of 2 days [Table 1]. The pattern of injuries is shown in Table 2. It was evident that majority of the death in Severe GCS was in less than 24 h, that is, 44 (100%), whereas those subjects who were in CCU for 2–7 days among them 14 (21.21%) died, whereas only 4 (11.43%) died in CCU who stayed for 8–14 days, out of the 62 deaths, which occurred among the severe GCS. No deaths occurred in CCU subjects who stayed for more than 15 days [Table 3]. The deaths which occurred in Moderate GCS were within 24 h among 11 (5.50%) subjects of the 200 subjects. No deaths occurred in Mild GCS subjects. A total 73 (19.16%) deaths occurred in 381 admitted subjects in CCU. The risk of death among both the sexes is not significantly different, that is, OR, 1.032 (95% CI, 0.351–3.03), so also the risk of death among the different age groups is also not significant having OR, 0.978 (95% CI, 0.954–1.00). While, the GCS (mild, moderate, and severe) and CCU stay parameters were having significant difference with risk of death having OR, 3.22 (95% CI, 2.49–4.16) and OR, 2.50 (95% CI, 1.9–3.2) [Table 4].

Figure 1

Sex distribution

Figure 2

Age distribution

Table 1

Demographic profile of study population

Table 2

Pattern of injuries in patients admitted to CCU clinical traumatic brain injury (n=381)

Table 3

Duration of stay in ICU, severity of head injury and outcome

Table 4

Multiple logistic regression of outcome with sex, age, and duration of stay

DISCUSSION

As in any other injuries, the majority of victims of traumatic brain injury patients are male and in younger age groups;[11] and is explained by the fact that during this age, people, especially males are more mobile, go out for work and take risks, while elderly people, females, and children usually stay at home. Initial GCS and severity of brain injury was used to match TBI patients and lower initial GCS can be due to greater severity of brain injury and also possible because of decreased brain perfusion (perhaps reflecting inadequate resuscitation).[12] It has been concluded that the GCS score may be used to stratify and predict mortality risk in intensive care patients, but it may lack sensitivity.[13] Resource limitation in developing countries restricts the routine use of aggressive pre- and inhospital management strategies, such as intracranial pressure monitoring for patients with head injury, and many strategies have been developed to overcome these limitations and also to improve outcome in resource constrained environment.[4] Despite the limitations of our trauma care system and resource limitations, mortality among traumatic brain injury patients can be reduced if every caregiver, from the site of injury to the CCU, maintains hemodynamic stability (diastolic blood pressure > 70 mmHg and systolic BP > 90 mmHg) at all times.[4] As in the present study, prolonged CCU lengths of stay can have increased survival rates, acceptable mortality rates, and quality of life despite significant costs.[14-16] One of the limitations of this present study is that we do not know about patients who were injured and did not reach hospital[17] and those with nonfatal severe injuries in the city received hospital care.[18]

CONCLUSION

Apparently it seems possible to use existing health care structures in rural areas to improve trauma care[19] and it becomes particularly relevant in poor resource, developing countries, where health care facilities and access to specialized care units are still far below the acceptable standard,[20] there is a need to compare with the reference group to further support the evidence. Although the present article may not change the way critical care is provided, we believe that it will give clinicians and their associates a fair idea of what to expect (and possibly to prepare families/survivors for) regarding the prognosis and path of critical care in the time to come, particularly in rural areas where the resources are limited.