Benefits of protocolization in improving neurotrauma care: from evidence gaps to structured implementation

The practice of neurotrauma management involves integrating a large number of individual treatment decisions into an overall treatment approach. This is rendered very difficult when the evidentiary support for individual decisions is not strong and there is almost no validated data on how they should be combined. The Brain Trauma Foundation’s Guidelines for the Management of Severe Traumatic Brain Injury in Adults have served as the source evidence report in severe traumatic brain injury (sTBI) management, improving in methodology over the four editions, albeit in the absence of marked incremental improvements in the quality of the evidence. However, evidence reports focusing on individual treatment questions do not provide the integrated management schemata required at the bedside. Studies of the possible impact on outcomes and process variables of implementation of the Guidelines have frequently demonstrated associated benefits but it has been difficult to differentiate the influence of the Guidelines from a parallel independent impact of protocolization of care. Recent prospective investigations into the influence on outcome of the management protocols from the BEST TRIP trial have strongly suggested that protocolization per se has strong benefits, at least partially independent of the actual algorithm adopted. The discussion here presents the foundation of such a conclusion and strongly supports protocolization of care by the composite neurotrauma team at all levels of care as being of likely benefit to sTBI management. Adoption of existing consensus-based algorithms or adaptation based on local situational variables, concomitant with development of QA process to track effectiveness and the impact of protocol changes, is highly recommended. It is concluded that such an approach creates a management structure that mitigates the impact of current evidentiary shortcomings while accommodating future improvements in the rigor of our investigations.