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Traumatic Brain Injury in Mumbai: A Survey of Providers along the Care Continuum.

ABSTRACT: Introduction:Traumatic brain injury (TBI) represents a significant burden of a global disease, especially in low- and middle-income countries (LMICs) such as India. Efforts to curb the impact of TBI require an appreciation of local factors related to this disease and its treatment. Methods:Semi-structured qualitative interviews were administered to paramedics, anesthesiologists, general surgeons, and neurosurgeons in locations throughout Mumbai from April to May 2018. A thematic analysis with an iterative coding was used to analyze the data. The primary objective was to identify provider-perceived themes related to TBI care in Mumbai. Results:A total of 50 participants were interviewed, including 17 paramedics, 15 anesthesiologists, 9 general surgeons, and 9 neurosurgeons who were involved in caring for TBI patients. The majority of physicians interviewed discussed their experiences in public sector hospitals (82%), while 12% discussed private sector hospitals and 6% discussed both. Four major themes emerged: Workforce, equipment, financing care, and the family and public role. These themes were often discussed in the context of their effects on increasing or decreasing complications and delays. Participants developed adaptations when managing shortcomings in these thematic areas. These adaptations included teamwork during workforce shortages and resource allocation when equipment was limited among others. Conclusions:Workforce, equipment, financing care, and the family and public role were identified as major themes in the care for TBI in Mumbai. These thematic elements provide a framework to evaluate and improve care along the care spectrum for TBI. Similar frameworks should be adapted to local contexts in urbanizing cities in LMICs.

SUBMITTER: Gupta S

PROVIDER: S-EPMC7591204 | biostudies-literature | 2020 Jul-Sep

REPOSITORIES: biostudies-literature

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Traumatic Brain Injury in Mumbai: A Survey of Providers along the Care Continuum.

Gupta Saksham S Khajanchi Monty M Solomon Harris H Raykar Nakul P NP Alkire Blake C BC Roy Nobhojit N Park Kee B KB Kumar Vineet V

Asian journal of neurosurgery 20200701 3

<h4>Introduction</h4>Traumatic brain injury (TBI) represents a significant burden of a global disease, especially in low- and middle-income countries (LMICs) such as India. Efforts to curb the impact of TBI require an appreciation of local factors related to this disease and its treatment.<h4>Methods</h4>Semi-structured qualitative interviews were administered to paramedics, anesthesiologists, general surgeons, and neurosurgeons in locations throughout Mumbai from April to May 2018. A thematic a ...[more]

PMID: 33145217

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Project description:BACKGROUND:General supportive and preventive measures in the intensive care management of traumatic brain injury (TBI) aim to prevent or limit secondary brain injury and optimize recovery. The aim of this survey was to assess and quantify variation in perceptions on intensive care unit (ICU) management of patients with TBI in European neurotrauma centers. METHODS:We performed a survey as part of the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. We analyzed 23 questions focused on: 1) circulatory and respiratory management; 2) fever control; 3) use of corticosteroids; 4) nutrition and glucose management; and 5) seizure prophylaxis and treatment. RESULTS:The survey was completed predominantly by intensivists (n?=?33, 50%) and neurosurgeons (n?=?23, 35%) from 66 centers (97% response rate). The most common cerebral perfusion pressure (CPP) target was >?60 mmHg (n?=?39, 60%) and/or an individualized target (n?=?25, 38%). To support CPP, crystalloid fluid loading (n?=?60, 91%) was generally preferred over albumin (n?=?15, 23%), and vasopressors (n?=?63, 96%) over inotropes (n?=?29, 44%). The most commonly reported target of partial pressure of carbon dioxide in arterial blood (PaCO2) was 36-40 mmHg (4.8-5.3 kPa) in case of controlled intracranial pressure (ICP) <?20 mmHg (n?=?45, 69%) and PaCO2 target of 30-35 mmHg (4-4.7 kPa) in case of raised ICP (n?=?40, 62%). Almost all respondents indicated to generally treat fever (n?=?65, 98%) with paracetamol (n?=?61, 92%) and/or external cooling (n?=?49, 74%). Conventional glucose management (n?=?43, 66%) was preferred over tight glycemic control (n?=?18, 28%). More than half of the respondents indicated to aim for full caloric replacement within 7 days (n?=?43, 66%) using enteral nutrition (n?=?60, 92%). Indications for and duration of seizure prophylaxis varied, and levetiracetam was mostly reported as the agent of choice for both seizure prophylaxis (n?=?32, 49%) and treatment (n?=?40, 61%). CONCLUSIONS:Practice preferences vary substantially regarding general supportive and preventive measures in TBI patients at ICUs of European neurotrauma centers. These results provide an opportunity for future comparative effectiveness research, since a more evidence-based uniformity in good practices in general ICU management could have a major impact on TBI outcome.

Project description:Importance:Traumatic brain injury (TBI) is a massive public health problem. While evidence-based guidelines directing the prehospital treatment of TBI have been promulgated, to our knowledge, no studies have assessed their association with survival. Objective:To evaluate the association of implementing the nationally vetted, evidence-based, prehospital treatment guidelines with outcomes in moderate, severe, and critical TBI. Design, Setting, and Participants:The Excellence in Prehospital Injury Care (EPIC) Study included more than 130 emergency medical services systems/agencies throughout Arizona. This was a statewide, multisystem, intention-to-treat study using a before/after controlled design with patients with moderate to critically severe TBI (US Centers for Disease Control and Prevention Barell Matrix-Type 1 and/or Abbreviated Injury Scale Head region severity ?3) transported to trauma centers between January 1, 2007, and June 30, 2015. Data were analyzed between October 25, 2017, and February 22, 2019. Interventions:Implementation of the prehospital TBI guidelines emphasizing avoidance/treatment of hypoxia, prevention/correction of hyperventilation, and avoidance/treatment of hypotension. Main Outcomes and Measures:Primary: survival to hospital discharge; secondary: survival to hospital admission. Results:Of the included patients, the median age was 45 years, 14?666 (67.1%) were men, 7181 (32.9%) were women; 16?408 (75.1% ) were white, 1400 (6.4%) were Native American, 743 (3.4% ) were Black, 237 (1.1%) were Asian, and 2791 (12.8%) were other race/ethnicity. Of the included patients, 21?852 met inclusion criteria for analysis (preimplementation phase [P1]: 15?228; postimplementation [P3]: 6624). The primary analysis (P3 vs P1) revealed an adjusted odds ratio (aOR) of 1.06 (95% CI, 0.93-1.21; P?=?.40) for survival to hospital discharge. The aOR was 1.70 (95% CI, 1.38-2.09; P?<?.001) for survival to hospital admission. Among the severe injury cohorts (but not moderate or critical), guideline implementation was significantly associated with survival to discharge (Regional Severity Score-Head 3-4: aOR, 2.03; 95% CI, 1.52-2.72; P?<?.001; Injury Severity Score 16-24: aOR, 1.61; 95% CI, 1.07-2.48; P?=?.02). This was also true for survival to discharge among the severe, intubated subgroups (Regional Severity Score-Head 3-4: aOR, 3.14; 95% CI, 1.65-5.98; P?<?.001; Injury Severity Score 16-24: aOR, 3.28; 95% CI, 1.19-11.34; P?=?.02). Conclusions and Relevance:Statewide implementation of the prehospital TBI guidelines was not associated with significant improvement in overall survival to hospital discharge (across the entire, combined moderate to critical injury spectrum). However, adjusted survival doubled among patients with severe TBI and tripled in the severe, intubated cohort. Furthermore, guideline implementation was significantly associated with survival to hospital admission. These findings support the widespread implementation of the prehospital TBI treatment guidelines. Trial Registration:ClinicalTrials.gov identifier: NCT01339702.

Dataset Information

Traumatic Brain Injury in Mumbai: A Survey of Providers along the Care Continuum.

Publications

Traumatic Brain Injury in Mumbai: A Survey of Providers along the Care Continuum.

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