The Austrian Traumatic Brain Injury Project

The project, supported by the Open Society Institute grant, focused on the implementation of scientific evidence-based treatment guidelines for the management of traumatic brain injury (TBI) and documented the efficacy of these protocols through an analysis of outcomes. The project started in Hungary, Slovakia, Croatia and Slovenia. In year two it was expanded to the Czech Republic, Estonia, Latvia and Lithuania. Education and training of local physicians was followed by collaboration using electronic means, mostly an interactive, internet database. INRO followed the performance of each center closely and provided them with a monthly summary of their progress as well as with a list of specific areas in need of attention or improvement. As a teaching tool the database, workshops and symposium increased scientific “guidelines” compliance from less than 10% to 93%, resulting in significant reduction in mortality as well as severe disability.

Based on experiences gained through the previous years, INRO decided to develop a new database for patients with brain trauma (“International Traumatic Coma Project” – ITCP). The purpose of this new database is to track and evaluate the treatment process and outcome of patients with severe TBI. The database is web-based and copies of collected data are kept at cooperating local trauma centers. The project has a significant educational potential as well. The database is running since April 2002.

There is a consensus among Austrian trauma surgeons, neurosurgeons and intensive care physicians, that it is desirable and timely to develop national guidelines and to build a national database for all trauma patients. Recognizing this consensus, INRO developed the technical means to address this opportunity. It was done through a three-year project, in six regional trauma hospitals throughout Austria. In the first year the hospitals were introduced to the concept of evidence-based care through the TBI Guidelines and then compliance with their TBI patients was tracked through the use of a patient database. The data collected were analyzed and provided basic epidemiological and quality of care information. The project resulted in publication of 6 original papers in the Wiener Klinische Wochenschrift (February 2007).

The number of deaths from injuries in Bosnia-Hercegovina, Macedonia and Croatia as reported by the WHO in 1998 is very high. Injuries rank as the number one, number two and number three killers in the younger population of the region (ages 5 to 44). The broad objectives of RESEARCH-TREAT-TBI was to save the lives of TBI victims and to improve the quality of life of survivors through research in factors determining health outcomes of hospital care and through changing current clinical practices to provide better care. The project built up on experiences with the research in determinants of health outcomes and in implementation of scientific based guidelines for good clinical practice. The Project focused on the research into factors determining the quality of care for victims of severe Traumatic Brain Injuries (TBI) (Glasgow Coma Scale less then 9), accentuating the quality of life after recovery. State-of-the-art knowledge on quality care of Traumatic Brain Injury patients was disseminated; practical and participative implementing programs for the introduction into clinical care procedures of Scientific Evidence Based Guidelines were conducted (elaborating protocols, practice modification taking local conditions fully into consideration, behavioral change of the staff involved, collecting data on patients in order to monitor the progress so that participants can see the results of their work, and can check and revisit the assumptions on best clinical practice). The implementation of Scientific Evidence Based procedures was followed by research in efficacy of changed medical practice. This was facilitated by developing a guidelines compliance measurement tool, which evaluates how closely the guidelines are followed in the treatment of individual case. When evaluating the compliance and when discussing the guidelines implementation one of the major problems surfaced was the lack of support from the management of hospitals. A draft of a policy to deal with the situation was delineated. One of the goals of the endeavor was to help the countries in preserving and developing their research excellence in the field of public health. This has materialized in visits and presentations given by project participants at meetings, conferences, symposia and in individual departments. Joint publications were submitted to national and international conferences and symposia. Several PhD studies were initiated.

ASDI collects data from 43 Austrian ICUs; it has now more than 80.000 patients from the years 2000 – 2006 in the database. The INRO team analyzed the subset of patients with TBI (approx. 4000 data sets), and investigated factors determining the outcomes of the TBI patients. The study (published in “Intensive Care Medicine” in 2008) proved that there is a significant “center effect” – patients treated at experienced centers (defined as treatment of >30 cases of severe TBI/year) had a significantly lower mortality.

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In a pilot project (65 patients) the course of ICP and other variables (cerebral perfusion pressure, glucose, hyperventilation, etc) was reconstructed as closely as possible. Over the course of the first 10 treatment days hourly values for these variables have been transferred to a database (sets of up to 240 values for each parameter and patient!). The course of ICP (and possibly other parameters) might be related to the short- and long-term outcome of the patients. Data collection was finished by October 2007; as soon as further funding is available the data will be analysed.

In 2006 IGEH has participated in the international project supervised by DG Sanco of the European Commission and implemented by Kuratorium für Verkehrssicherheit, Austria. In 2007 we have summarized our participation and developed the final report.