Thank you for attending this SCCM Congress presentation on Go Big or Go Home, How the Brain Injury Guidelines Will Impact Your ICU. I have no disclosures. We will discuss soon-to-be-published research on how we have utilized the brain injury guidelines in the areas of traumatic intracranial hemorrhage, as well as, if needed, how to incorporate the non-traumatic cranial hemorrhage guidelines to add synergy to the management and improve the care and impact of ICU capacity. These are the objectives we will cover today. Understanding how the brain injury guidelines can improve the under- and over-utilization of resources within your region, discuss the solutions to barriers in the development and integration of the brain injury guidelines within a large healthcare system, and reveal how the brain injury guidelines can impact standards of care and capacity improvement throughout a region. This is one of many of Dr. Joseph's publications on how to adjust the brain injury guidelines to add standards around brain injury management and impact resources at a level one trauma center. In this retrospective study of over 3,800 patients with blunt trauma over four years, based on anticoagulation, intoxicants, and CT findings, and they developed guidelines based on the individual baseline needs for hospitalization, a repeat head CT, or neurosurgery consultation. Out of the 3,800 patients, 132 had abnormal head CTs. The authors developed brain injury guidelines showing three categories of big one, requiring no intervention, big two, had radiographic worsening, and big three, requiring neurosurgical consultation. These categories have been validated in surgical centers and allow majority of brain injury patients to be managed by acute care surgeons without overtaxing the neurosurgical resources. This is an example of Dr. Joseph's published guideline. It classifies the three categories based on the type of injury, the location, and its size of the injury, as well as the therapeutic plan, hospitalization, and the potential need for either a repeat head CT and the possible need for neurosurgical consultation. We looked at adopting the brain injury guidelines at our large American College of Surgeons Committee on Trauma Verified Level I Trauma Center. We have several trauma admissions a year with over 500 non-traumatic intracranial hemorrhage transfers and over 2,000 traumatic brain injuries a year. We are a healthcare system of over 40 hospitals and eight non-system referral hospitals in the region. We wanted to reduce the neurosurgical consultations and the hospital unnecessary transfers. We realized that we would have to adapt some of these guidelines based on our referral hospitals carrying resources at some of the system hospitals. Some things sound worse than they actually are. Most brain hemorrhages, regardless of type, do not require surgical procedures nor supportive specialty care. Yet for many years, many trauma centers advertised to send all of the brain injuries to the Level I Trauma Center. Most referring hospitals had this transfer consult culture embedded into the process and did not have the robust education nor the resources to really manage the less severe traumatic brain injuries. We had several goals when we started this initiative, knowing that non-traumatic intracranial hemorrhage and traumatic brain injury patients needed to be at the right place within the system at the right time and with the right care. We wanted to also reduce avoidable transfers while monitoring for any unintended outcomes, readmissions, or care delays. We also wanted to create an environment that supported and empowered our hospitals that did not have any dedicated neuro-specialist. As mentioned, we have a very large healthcare system with hospitals of different sizes, resources, and comfort levels in managing brain injury. So we really had to adapt those guidelines before we adopted them for the system. In 2008, with the growth of the stroke standardization, we actually merged the parallel work with the non-traumatic intracranial hemorrhage along with the traumatic brain injury guidelines and looked at standardizing across the system. But first we had to look at the individual hospitals and we had adapted within the changes of the system and laying the foundation for the process to work. We had to identify and improve all of the local resources at the varying hospitals, develop and educate the personnel. We had to develop an electronic medical record power plan for monitoring and documentation, strengthening the actual transfer process. If needed, we had to standardize the radiographic template for the intracranial hemorrhage and brain injury guidelines CT scans with varying radiologic resources at the different institutions. We developed and adapted the expanding national guidelines to work in a complex healthcare system, standardizing and anti-coagulation and reversal guidelines to make sure resources were present and obtaining the full credentials and adjusting the bylaws at each of the system hospitals to provide the neurointensivist telemedicine potential consultation. Intracranial hemorrhage guidelines were created using most up-to-date literature and research with similar format to the brain injury guidelines. We had separate but aligned work streams for both non-traumatic intracranial hemorrhage and traumatic brain injury. Each of the work groups identified similar key stakeholders at the different institutions and met separately, but created synergies in the development and implementation, especially where all the different disciplines came together. Knowing the National Traumatic Brain Injury Guidelines and our own healthcare systems needs, we addressed the question, do all TBI patients need neurosurgical consultation or even transfer to a trauma center? Knowing that there were resource limitations and varying levels of comfort in management of these patients, we adapted the brain injury guidelines to identify the patients that did not necessitate that higher level of care, especially around the use of specific anti-coagulants, anti-platelets and the available reversal agents and their availability at our local and referral hospitals. As you see, we adjusted the big two category into a two and a 2A to address our specific systems needs to help the patients be managed locally when appropriate. We learned that streamlining guidelines for ease of adherence and documentation was key in safely managing all of the brain hemorrhages. The non-traumatic intracranial hemorrhage guidelines were developed in a similar manner as the traumatic brain injury guidelines with similar therapeutic and consultation plans so as to eliminate confusion, as well as to further adapt the standards around all bleeds. They were created with most of the up-to-date literature and research possible and organized into a similar format as the brain injury guidelines, but the stratified risk, the extremes either stable or devastating were different than the mild TBI. And we had to incorporate the considerations of anti-coagulation, which drove the category development in the non-traumatic intracranial hemorrhage guidelines. We trialed these guidelines and the processes surrounding them at one of our American College of Surgeons committee on trauma verified level three centers and had a very successful trial run. In doing so, we developed a Power BI data dashboard for tracking transfers. We also developed an electronic health record tool, which we'll show later and optimize the transfer communication processes. This slide shows the data collection results with the Power BI database. And it shows the visualization of the volume and disposition of patients falling within the identified ICD-10 diagnoses. And it shows that during our trial run, we were really successful at making an impact, decreasing unnecessary transfers 2017 through 2019. The number of brain injury guideline patients that were successfully kept locally and discharged home increased 300% over and through the system in a very short period of time in 2019 compared to 2017. After our trial run, looking at the post PDSA improvement process, we realized that we needed to increase comfort in managing the non-traumatic and traumatic brain injured patients. This included providers and nursing. So education was provided to nursing staff, as well as seeing the stroke certified centers from eight to even more. There were concerns around nursing workload changes. So we'd led discussions with facility leadership to help alleviate those concerns, needs and resources. We created a ICH TBI management SharePoint site with evidence-based workflow and clinical guidelines so that the low volume centers could assess and access those resources to assist in the clinical comfort. And knowing that the opportunity for standardization and clinical decision support in minor TBI patients, we created a minor TBI power plan available for outlining that standard of care for those minor TBI patients. We initiated a process within the neurosurgical leadership called Access Neurosurgery. It was a 24 seven, 365 day image review and triage decision-making support for the local management of TBI and ICH patients. There were templated notes that were created to document critical clinical components for emergency medicine and hospitalist providers. We showed a reduction in avoidable transfers by 22 in the first month. More than half weren't part of the original feedback pilot process, but many of them were 80 plus years of age. Six were known to be DNR status prior to transfer. Two patients with devastating intracranial hemorrhage were converted to copy access neurosurgery evaluation. We identified two key variables for the transfer assessment, standardizing the process around patients living in skilled nursing facilities and documentation of the communication of preexisting DNR status. Then the pandemic started. Capacity issues worsened and this process had not yet started at all the referral facilities. There was an urgent need to rapidly adopt processes to identify those patients that could be kept locally when able to and prevent unnecessary transfers. This is an example of an electronic medical record power form that we developed using the Cerner electronic medical record. It automatically calculates information, pulls it into the note as the ER physician completes it. It calculates the brain injury guideline categories with therapeutic recommendations. The score is then ready for any discussion as needed with neurosurgery or the hospitalist as indicated. Working with radiology leadership at the system hospital levels, as well as other radiology groups, we developed a standardized radiology reporting and all of the radiologists agreed to use it for all of the brain injury patients. And this template when completed feeds into the electronic medical record power form. We did utilize a post-implementation improvement process with hospitalists and emergency medicine groups at the different facilities. This was to evaluate for any process improvement needs as well as to identify any potential patients that may have had worsened outcomes. Data from the Power BI dashboard documented patients with a primary diagnosis of traumatic brain injury or non-traumatic intracranial hemorrhage that had been evaluated in the non-tertiary facilities. When we looked at the full 12 months of the 2021 data comparing to the 2017 data on transfer volumes by the diagnoses, we showed a decrease in transfer rates for non-traumatic intracranial hemorrhage of 17%, as well as a decrease in traumatic brain injury transfer rates of 17%. When we looked at access neurosurgery services for urgent neurosurgical e-consultation intervention data, we were able to show significant cost efficiencies that were gained through transfer avoidance with the avoidance of 278 transfers and an additional 12 activations from receiving facilities requesting additional consultation on the same patients. There were a total of 524 activations during this time period with 1,259 bed days avoided by non-transferring to trauma centers. Implementing the adapted traumatic brain injury and non-traumatic intracranial hemorrhage guidelines have had several immediate benefits. Improved standards of care at the local facilities, avoided transfer cost, capacity creation at the referral trauma center, and patient and family benefits of the right care, right place. When you look at the same time period, we had reduced air transport costs of almost a half million dollars. And adjusting for avoidable bed days during the year of use, the savings were over $2.3 million. This slide shows our successes, what we have learned and what the next steps to utilize to sustain these gains. We need better documentation and communication of the DNR-DNI status prior to consultation and or transfer. We need to standardize that information of patients coming from different skilled nursing facilities. And we need to possibly expand to other initiatives such as spine fractures or multi-trauma cases. These adapted guidelines have impacted our trauma center, not just changing who admits a patient at the trauma center, though it is important not to burden a service such as neurosurgery, but we have reduced the unnecessary neurosurgical consultation and reducing unnecessary patient transfers to our trauma center. This has improved TBI standards of care, improves the ICH non-traumatic standards of care amid the stroke verification strategies, have improved the communication of our electronic medical record, radiology and transfer protocols, and has reinforced all of the education for providers. We've also been able to streamline and improve the documentation and communication for DNR-DNI plus adjust for capacity during a pandemic. I am listing references for further understanding for non-traumatic intracranial hemorrhage guideline development, as well as for traumatic brain injury guideline development, should you want further information. We thank you for attending this session on how the brain injury guidelines could impact your ICU, as well as thank you for attending the Society of Critical Care Medicine 2022 Congress.

brain injury guidelines

traumatic intracranial hemorrhage

non-traumatic cranial hemorrhage guidelines

ICU care

resource utilization