Hospital-Level Variation in Early Tracheostomy and Withdrawal of Life-Sustaining Treatment in Severe Traumatic Brain Injury: A Nationwide Analysis

OBJECTIVES: Early tracheostomy (ET) in severe traumatic brain injury (TBI) is often considered during periods of prognostic uncertainty and evolving goals of care. We aimed to evaluate the association between hospital-level tendency for ET and the frequency of withdrawal of life-sustaining treatment (WLST) following tracheostomy in patients with severe TBI. DESIGN: Retrospective cohort study. SETTING: Trauma centers participating in the American College of Surgeons Trauma Quality Improvement Program (2016-2021). PATIENTS: Adult patients 20-89 years old with severe TBI (head Abbreviated Injury Scale: 3-5 and Glasgow Coma Scale: 3-8), who received mechanical ventilation and underwent tracheostomy. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A mixed-effects logistic regression model was developed to estimate each hospital's unique risk-adjusted odds ratio (AOR) for ET (≤ 7 d after injury), and hospitals were stratified into low-, medium-, and high-tendency groups based on the AOR for ET. The association between hospital-level tendency for ET and WLST post-tracheostomy was assessed. Among 22,156 patients with severe TBI treated at 417 hospitals, the ET rates were 16.8%, 30.1%, and 47.7% in the low-, medium-, and high-tendency hospitals, respectively. WLST following tracheostomy occurred in 2.6%, 4.8%, and 9.6% of patients 20-39, 40-59, and 60-89 years old, respectively. After multilevel case-mix adjustments, a high hospital-level tendency for ET was associated with increased odds of WLST post-tracheostomy (AOR, 1.35; 95% CI, 1.10-1.66; p = 0.004), with the highest point estimate observed among patients 40-59 years old (AOR, 1.39; 95% CI, 1.01-1.91). CONCLUSIONS: Hospitals with a higher tendency to perform ET had a greater likelihood of WLST following tracheostomy. These findings highlight practice variability in tracheostomy timing that may occur in the setting of prognostic uncertainty early after severe TBI and may influence downstream care pathways.