Quality management in traumatic brain injury (TBI) Lessons from the prospective study in 6.800 patients after acute TBI in respect of neurorehabilitation

Summary

Preliminary results on epidemiology, acute hospital care, and neurorehabilitation of TBI are presented of the first ever prospective controlled German study to analyse the use of regional structures and quality management as provided by the German social healthcare system. The sum of inhabitants in Hannover and Münster area was 2,114 million. Within an area of 100 kilometres diameter each. 6.783 acute TBI (58% male) were admitted for acute treatment from March 2000 to 2001. Definition of acute TBI was according to the ICD 10 S-02, S-04, S-06, S-07, S-09 in combination with dizziness or vomiting; retrograde or anterograde amnesia, impaired consciousness, skull fracture, and/or focal neurological impairment. The incidence was 321/100.000 population. Cause of TBI was traffic accident in 26%, during leisure time 35%, at home 30% and at work 15%. Initial GCS (emergency room) was only assessed in 3.731 TBI (=55%). Out of those 3.395 = 90,9% were mild, 145 = 3,9% were moderate, and 191 = 5,2% severe TBI. 28% of 6.783 patients were <1 to 15 years, 18% > 65 years of age. The number admitted to hospital treatment is 5.221 = 77%, of whom 72 patients (=1,4%) died caused by TBI. One year follow-up in 4.307 TBI patients (=63.5%) revealed that only 258 patients (=3,8%) received neurorehabilitation (73% male), but 68% within one month of injury. Five percent of these patients were <16 years of age, 25% > 65 years. Early rehabilitation “B” was performed in 100 patients (=39%), 19% within one week following TBI. The management of frequent complications in 148 patients (=57%) and the high number of one or more different consultations (n = 196) confirmed the author’s concept for early neurosurgical rehabilitation in TBI when rehabilitation centres were compared regarding GCS and GOS: Early GOS 1 = 4%; GOS 2 = 2,7%, GOS 3 = 37,3%, GOS 4 = 26,7%, GOS 5 = 29,3%, final GOS scores were 1 = 1,2%, 2 = 1,7%, 3 = 21,8%, 4 = 36,2%, and 5 = 39,1% of all patients at the end of rehabilitation. Mean duration for both “B” and “C” was 41 days compared to 80 days for “D” and “E”. An assessment of both GCS and GOS was insufficient (Fig. 1).

Advisory board

W. J. Bock, Prof. emeritus Dr. med., former Director of the Neurochirurgische Universitätsklinik, Düsseldorf, W. Gobiet, Dr. med., former Head of the Neurological Clinic, Hessisch Oldendorf, U. Lehmann, Priv. Doz. Dr. med., Senior Registrar at the Department of Accident, Hand, and Restorative Surgery of the Saarland University, Homburg, Saar, K. Mayer, Prof. emeritus. Dr. med., Industrial Cooperative Compensation Fund Accident Clinic, Tübingen, E. Rickels, Prof. Dr. med., Former Senior Registrar Neurosurgical Clinic of the Medical University, Hannover (MHH), Now Head Dept. Neurosurgery Clinic of Med. University Ulm, Dr. B. Sens, Head of the Centre for Quality Management in Healthcare, Physicians’ Chamber of Lower Saxony, Hannover, H. D. Wassmann, Prof. Dr., Director of the Neurosurgical University Clinic UKM, Muünster, P. Wenzlaff, Medical statistician, Centre for Quality Management in Healthcare Physicians’ Chamber of Lower Saxonian Hannover, R. Wiechers, Managing Director of the Curatorium CNS for Accident Victims with Injuries of the Central Nervous System and of the Hannelore Kohl Foundation, Bonn, K. R. H. von Wild, Prof. Dr. med., Prof. of Neurosurgery, Münster and Former Head of the Neurosurgical Department and the Unit for Posttraumatic Early Neurorehabilitation, Münster.