Portland, Ore.
Three peer-reviewed journals simultaneously publish the guidelines
For the first time, health care providers around the world now have scientific guidelines for the best way to treat children who have suffered traumatic brain injuries (TBI). Researchers from Oregon Health & Science University joined forces with other national experts to create the most effective guidelines based on the review of more than 700 peer-reviewed journal articles. In an unusual cooperative effort, three journals -- Pediatric Critical Care Medicine, Critical Care Medicine and the Journal of Trauma -- will be simultaneously publishing "Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescents" on June 6 as special supplements. This unique tri-publication will put the guidelines in the hands of more than 30,000 health care experts across multiple disciplines.
"There's an enormous amount of information out there about what works and what doesn't in treating pediatric brain injury," said Randy Chesnut, M.D., associate professor of neurological surgery in the OHSU School of Medicine and the principal investigator on the guidelines project. "We not only want to publish guidelines that bring together all the best practices, we want to remove obstacles to putting those guidelines to work saving lives."
In the past, a child's treatment for a brain injury could vary depending on what country they lived in, how they got to the hospital, what hospital they went to and what kind of equipment was there, who her/his doctor was and dozens of other variables. And if his/her injury was severe, variations in any of these factors could make the difference between full recovery, a lifetime of disability or death. These new guidelines will allow all hospitals and clinicians, no matter where you take your child, to consistently provide the best treatment available.
"For parents sitting in ED waiting rooms this means that if that hospital is following the new guidelines, the physicians will be using the best evidence to treat their child as opposed to looking at the adult guidelines and trying to translate that to treat a child or relying only on their own clinical experience," said Nancy Carney, Ph.D., assistant professor of medical informatics and clinical epidemiology in the OHSU School of Medicine and a fellow investigator on the guidelines.
Each year, more than 1.5 million people sustain brain injuries in the United States, ranging from mild to severe trauma and 50,000 die, according to the Centers for Disease Control and Prevention. The majority of those are children and young adults.
Chesnut convened a group of investigators to help develop the guidelines that included neurosurgery, emergency medicine and pediatrics experts from schools of medicine at OHSU, University of Pittsburgh, the University of Michigan and Emory University.
In 1996 Chesnut led another multidisciplinary team that published the first comprehensive guidelines for treating adult brain injury. In several countries in Eastern Europe such as Poland, Hungary and the Czech Republic, socialized health care systems adopted the guidelines nationwide all at once. In those countries, documented adult deaths from traumatic brain injury have dropped by as much as 50 percent in the past five years. Chesnut and his OHSU team have helped develop all seven sets of treatment guidelines for TBI, including the adult guidelines.
"It was natural for us to look next at developing pediatric guidelines," said Chesnut. "But it's not as easy as just applying the adult guidelines to children. Children are still growing and there are some important developmental issues to which you have to pay attention in treating brain injury."
The team started the project in March 2000. They reviewed thousands of abstracts and more than 700 journal articles, thanks to the administrative management of this project by OHSU's Evidence Based Practice Center. The resulting pediatric guidelines cover 18 topic areas (compared with 14 in the adult guidelines) ranging from managing a patient's airway on the way to the hospital to monitoring brain pressure in the hospital to surgical options and nutrition.
In addition to the three scientific journals publishing the guidelines nationwide, several professional societies have reviewed and endorsed the document, including the American Association for the Surgery of Trauma, International Society for Pediatric Neurosurgery, World Federation of Pediatric Intensive and Critical Care Societies, Society of Critical Care Medicine, Child Neurology Society, and International Trauma Anesthesia and Critical Care Society
"All this speaks to the widespread recognition of the importance of this work," said Carney. "People are willing to cross boundaries in order to accomplish the widest possible dissemination of these guidelines."
They're also willing to cross borders. Rather than simply publishing the guidelines and hoping clinicians use them, the OHSU team will follow their progress in the United States and abroad for years, continually adjusting them based on how they work in the real world. The U.S. researchers will team up with Cuba's Ministry of Public Health and the Argentine Society for Intensive Therapy to observe different implementation systems.
In Cuba, with its socialized (and relatively sophisticated) health system, the researchers will study how outcomes for young brain injury patients change before and after adoption of the guidelines in a country where the guidelines can be implemented nationwide.
"It's a great opportunity to conduct a well-controlled, population-based implementation study that could not be carried out in the U.S.," said Carney.
In Argentina, the focus will be on how to implement the guidelines in a country where many hospitals have limited technology and where post-hospital rehabilitation is almost nonexistent.
"Here in the U.S., the biggest obstacle to implementation isn't technology, it's that our health care delivery system is so scattered," said Chesnut. "In Argentina critical care physicians are willing to help implement the guidelines nationwide. But many hospitals there don't have equipment called for in the guidelines, such as intracranial pressure monitors or CT scanners." So the researchers will work with local facilities to recraft the guidelines based on locally available technology and expertise. In addition, because setting up elaborate rehabilitation programs simply isn't feasible, the research in Argentina will involve enlisting family members to be the main rehabilitation "team" for their injured loved ones.
Synthes Corporation has provided $30,000 in unrestricted funds to support meeting and administrative costs for the study; The International Brain Injury Association, a multidisciplinary professional organization focused on translating scientific discoveries in brain injury research into lifesaving clinical practices, contributed more than $40,000 to support development of the guidelines; and two members of the National Institutes of Health provided $63,000 to cover the costs of publishing the guidelines in special supplements.
Another benefit of this evidence-based review was the discovery of the need to further research many areas of pediatric TBI treatment. Ongoing research in these areas will help the guidelines to improve as additional treatment options are shown to be effective.
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