Harborview Injury Prevention Research Center, Harborview Medical Center, Seattle, WA, USA.
Department of Neurological Surgery, University of Washington, Seattle, WA, USA.
Neurocrit Care. 2019 Feb;30(1):157-170. doi: 10.1007/s12028-018-0590-0.
Patients with mild traumatic brain injury (TBI) are frequently admitted to an intensive care unit (ICU), but routine ICU use may be unnecessary. It is not clear to what extent this practice varies between hospitals.
We conducted a retrospective cohort study using the National Trauma Data Bank. Patients with at least one TBI ICD-9-CM diagnosis code, a head abbreviated injury score (AIS) ≤ 4, and Glasgow coma scale (GCS) ≥ 13 were included; individuals with only a concussion and those with a non-head AIS > 2 were excluded. Primary outcomes were ICU admission and "overtriage" to the ICU, defined by: ICU stay ≤ 1 day; hospital stay ≤ 2 days; no intubation; no neurosurgery; and discharged to home. Mixed effects multivariable models were used to identify patient and facility characteristics associated with these outcomes.
A total of 595,171 patients were included, 44.7% of whom were admitted to an ICU; 17.3% of these met the criteria for overtriage. Compared with adults, children < 2 years were more likely to be admitted to an ICU (RR 1.21, 95% CI 1.16-1.26) and to be overtriaged (RR 2.06, 95% CI 1.88-2.25). Similarly, patients with isolated subarachnoid hemorrhage were at greater risk of both ICU admission (RR 2.36, 95% CI 2.31-2.41) and overtriage (RR 1.22, 95% CI 1.17-1.28). The probabilities of ICU admission and overtriage varied as much as 16- and 11-fold across hospitals, respectively; median risk ratios were 1.67 and 1.53, respectively. The likelihood of these outcomes did not vary substantially with the characteristics of the treating facility.
There is considerable variability in ICU admission practices for mild TBI across the USA, and some of these patients may not require ICU-level care. Refined ICU use in mild TBI may allow for reduced resource utilization without jeopardizing patient outcomes.
轻度创伤性脑损伤（TBI）患者经常被收入重症监护病房（ICU），但常规 ICU 应用可能并非必要。目前尚不清楚这种做法在各医院之间的差异程度。
我们使用国家创伤数据库进行了一项回顾性队列研究。纳入至少有一个 TBI ICD-9-CM 诊断代码、头部简明损伤评分（AIS）≤4 和格拉斯哥昏迷评分（GCS）≥13 的患者；排除仅为脑震荡且非头部 AIS＞2 的患者。主要结局为 ICU 收治和 ICU“过度收治”，定义为：ICU 住院时间≤1 天；住院时间≤2 天；无需插管；无需神经外科手术；出院回家。采用混合效应多变量模型确定与这些结局相关的患者和医院特征。
共纳入 595171 例患者，其中 44.7%的患者收入 ICU；其中 17.3%符合过度收治标准。与成人相比，＜2 岁的儿童更有可能被收入 ICU（RR 1.21，95%CI 1.16-1.26）和过度收治（RR 2.06，95%CI 1.88-2.25）。同样，单纯蛛网膜下腔出血的患者 ICU 收治（RR 2.36，95%CI 2.31-2.41）和过度收治（RR 1.22，95%CI 1.17-1.28）的风险也更高。各医院 ICU 收治和过度收治的概率差异高达 16 倍和 11 倍；中位数风险比分别为 1.67 和 1.53。这些结局的发生可能性与治疗医院的特征并无显著差异。
美国对轻度 TBI 的 ICU 收治实践存在相当大的差异，其中一些患者可能不需要 ICU 级别的护理。在轻度 TBI 中更精细地使用 ICU 可能会减少资源利用，而不会危及患者的结局。
