Variation in Structure and Process of Care in Traumatic Brain Injury: Provider Profiles of European Neurotrauma Centers Participating in the CENTER-TBI Study.

INTRODUCTION: The strength of evidence underpinning care and treatment recommendations in traumatic brain injury (TBI) is low. Comparative effectiveness research (CER) has been proposed as a framework to provide evidence for optimal care for TBI patients. The first step in CER is to map the existing variation. The aim of current study is to quantify variation in general structural and process characteristics among centers participating in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. METHODS: We designed a set of 11 provider profiling questionnaires with 321 questions about various aspects of TBI care, chosen based on literature and expert opinion. After pilot testing, questionnaires were disseminated to 71 centers from 20 countries participating in the CENTER-TBI study. Reliability of questionnaires was estimated by calculating a concordance rate among 5% duplicate questions. RESULTS: All 71 centers completed the questionnaires. Median concordance rate among duplicate questions was 0.85. The majority of centers were academic hospitals (n = 65, 92%), designated as a level I trauma center (n = 48, 68%) and situated in an urban location (n = 70, 99%). The availability of facilities for neuro-trauma care varied across centers; e.g. 40 (57%) had a dedicated neuro-intensive care unit (ICU), 36 (51%) had an in-hospital rehabilitation unit and the organization of the ICU was closed in 64% (n = 45) of the centers. In addition, we found wide variation in processes of care, such as the ICU admission policy and intracranial pressure monitoring policy among centers. CONCLUSION: Even among high-volume, specialized neurotrauma centers there is substantial variation in structures and processes of TBI care. This variation provides an opportunity to study effectiveness of specific aspects of TBI care and to identify best practices with CER approaches

Variation in neurosurgical management of traumatic brain injury

Background: Neurosurgical management of traumatic brain injury (TBI) is challenging, with only low-quality evidence. We aimed to explore differences in neurosurgical strategies for TBI across Europe. Methods: A survey was sent to 68 centers participating in the Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. The questionnaire contained 21 questions, including the decision when to operate (or not) on traumatic acute subdural hematoma (ASDH) and intracerebral hematoma (ICH), and when to perform a decompressive craniectomy (DC) in raised intracranial pressure (ICP). Results: The survey was completed by 68 centers (100%). On average, 10 neurosurgeons work in each trauma center. In all centers, a neurosurgeon was available within 30 min. Forty percent of responders reported a thickness or volume threshold for evacuation of an ASDH. Most responders (78%) decide on a primary DC in evacuating an ASDH during the operation, when swelling is present. For ICH, 3% would perform an evacuation directly to prevent secondary deterioration and 66% only in case of clinical deterioration. Most respondents (91%) reported to consider a DC for refractory high ICP. The reported cut-off ICP for DC in refractory high ICP, however, differed: 60% uses 25 mmHg, 18% 30 mmHg, and 17% 20 mmHg. Treatment strategies varied substantially between regions, specifically for the threshold for ASDH surgery and DC for refractory raised ICP. Also within center variation was present: 31% reported variation within the hospital for inserting an ICP monitor and 43% for evacuating mass lesions. Conclusion: Despite a homogeneous organization, considerable practice variation exists of neurosurgical strategies for TBI in Europe. These results provide an incentive for comparative effectiveness research to determine elements of effective neurosurgical care

Toimintaohjeet sairaanhoitajille tehohoitopotilaan suunhoitoon

Opinnäytetyö on osa Metropolia Ammattikorkeakoulussa vuonna 2007 alkanutta ”Työikäisen sydänpotilaan ja hänen perheensä sekä hoidonantajan ohjaaminen” -hanketta. Opinnäytetyö toteutettiin yhteistyössä Metropolia Ammattikorkeakoulun suuhygienistiopiskelijoiden ja Helsingin seudun yliopistollisen keskussairaalan (HYKS) teho-osasto 20 kanssa. Toiminnallisen opinnäytetyön tarkoituksena on lisätä teho-osastolla työskentelevien sairaanhoitajien suun terveydenhoidon osaamista. Tavoitteena on ohjata sairaanhoitajat arvioimaan potilaan suun terveydentilaa. Teoriatietoa hankittiin käyttämällä eri tiedonhakukantoja, joita olivat Cinahl, Cochrane, EBSCO, Google Scholar, Helka, Medline ja PudMed. Hakusanat kohdennettiin vuosien 2006–2013 suomen- ja englanninkielisiin tietokantoihin. Hakusanoina käytettiin esimerkiksi CPAP, health promotion, intensive care, oral health, oral care, prevention, VAP prevention, ventilated patients, tehohoito, ohjaus, oppiminen ja terveyden edistäminen. Teoreettista taustaa ohjasi tutkimustieto suun bakteeriston ja verenkiertoelimistön yhteydestä. Yleisin komplikaatio hengityslaitehoidossa on intubaatioon ja hengityslaiteisiin liittyvä keuhkokuume eli VAP (Ventilator Associated Pneumonia). Viimeaikaisissa tutkimuksissa on korostettu suunhoidon tärkeyttä keuhkokuumeen ehkäisyssä hengitysavusteisilla potilailla. Opinnäytetyön toiminnallinen osuus toteutettiin syksyllä 2012. Sairaanhoitajille järjestettiin ohjaustilanteita, joissa näytettiin suunhoidon toteutus tehohoitopotilaalle käytännössä. Sairaanhoitajia ohjattiin myös omien vastuupotilaiden suunhoidossa. Tulosten perusteella voidaan tehdä johtopäätös, että suunhoidon ohjeistukset ja käytännöt tulee yhtenäistää. Sairaanhoitajien koulutukseen tulee sisällyttää enemmän suunhoidon opetusta.This final project is a part of “The guidance of working-age heart patients, their families and nurses” project started in 2007 by the Helsinki Metropolia University of Applied Sciences. The final project was carried out in cooperation between Dental Hygienist students of Helsinki Metropolia University and Helsinki University Central Hospital intensive care unit 20. The purpose of this final project is to help nurses working in intensive care unit to increase their knowledge of the oral health. The aim is to guide the nurses in patients’ oral health evaluation and oral care implementation and as consequence to promote the ICU patients’ oral health. Data for this final project were collected from different electronic information sources, such as Cinahl, Cochrane, EBSCO, Google Scholar, Helka and PubMed. Only articled published between the years 2006-2013 were used. The search was made by using the following keywords: CPAP (Continuous Positive Airway Pressure), health promotion, intensive care, oral health, oral care, prevention of VAP (Ventilator Associated Pneumonia), ventilated patients, prevention, treatment, control and learning. The information from medical researches about direct connection between oral bacteria and the cardiovascular system has formed the basic of this final project. The most common complication the mechanically ventilated patients develop is VAP (Ventilator Associated Pneumonia). Recent studies have highlighted the importance of oral care in the prevention of pneumonia in ICU patients. The practical part of the final project was carried out in the autumn 2012. A few counseling situations were organized where the ICU nurses were shown the oral care implementation of an intensive care patient. In addition, the nurses had an opportunity to participate in the oral care of ICU patients. Based on the results of this final project, it can be argued that ICU patients’ oral care guidance and practices should be unified. Nurses' education program should include more in-formation about oral health and oral care training

Traumatic brain injury : integrated approaches to improve prevention, clinical care, and research

Rahul Raj on työryhmän InTBIR Participants Investigators jäsen.Peer reviewe