Improving hospital quality and costs in nonoperative traumatic brain injury the role of acute care surgeons

IMPORTANCE The role of acute care surgeons is evolving; however, no guidelines exist for the selective treatment of patients with traumatic brain injury (TBI) exclusively by acute care surgeons.We implemented the Brain Injury Guidelines (BIG) for managing TBI at our institution on March 1, 2012. OBJECTIVE To compare the outcomes in patients with TBI before and after implementation of the BIG protocol. DESIGN, SETTING, AND PARTICIPANTS We conducted a 2-year analysis of our prospectively maintained database of all patients with TBI (findings of skull fracture and/or intracranial hemorrhage on an initial computed tomographic scan of the head) who presented to our level I trauma center. The pre-BIG group included patients with TBI from March 1, 2011, through February 29, 2012, and the post-BIG group included patients from July 1, 2012, through June 30, 2013. MAIN OUTCOMES AND MEASURES The primary outcome measureswere patients with repeated computed tomography of the head and neurosurgical consultations. Secondary outcome measures were findings of progression of intracranial hemorrhage on repeated computed tomographic scans, neurosurgical intervention, hospital admission, intensive care unit admission, hospital and intensive care unit length of stay, 30-day readmission rate, and hospital costs per patient. RESULTS A total of 796 patients (415 in the pre-BIG group and 381 in the post-BIG group)were included. Therewas a significant reduction (19.0%) in the rate of neurosurgical consultation (post-BIG group, 273 patients [71.7%]; pre-BIG group, 376 [90.6%]; P < .001), repeated computed tomography of the head (post-BIG group, 255 patients [66.9%]; pre-BIG group, 381 patients [91.8%]; P < .001), hospital (post-BIG group, 330 [86.6%]; pre-BIG group, 398 [95.9%]; P < .001) and intensive care unit admission (post-BIG group, 202 [53.0%]; pre-BIG group, 257 [61.9%]; P = .01), hospital length of stay (post-BIG group, 5.4 [4.5] days; pre-BIG group, 6.1 [4.8] days; P = .03), and hospital costs per patient ($4772 per patient; P = .03) with implementation of BIG. Therewas no difference in the in-hospital mortality rate (post-BIG group, 62 patients [16.3%]; pre-BIG group, 69 patients [16.6%]; P = .89), progression of intracranial hemorrhage on repeated scans (post-BIG group, 41 patients [10.8%]; pre-BIG group, 59 patients [14.2%]; P = .14), neurosurgical intervention (post-BIG group, 61 patients [16.0%]; pre-BIG group, 59 patients [14.2%]; P = .48), and 30-day readmission rate (post-BIG group, 31 patients [8.1%]; pre-BIG group, 37 patients [8.9%]; P = .69) after implementation of BIG. CONCLUSIONS AND RELEVANCE Implementation of BIG is safe and cost-effective. BIG defines the management of TBI without the need for neurosurgical consultation and unnecessary imaging. Establishing a national, multi-institutional study implementing the BIG protocol is warranted.