The Earlier the Better - Do Centers That Adopt an Early Tracheostomy Approach in TBI Patients Have Improved Outcomes?

Introduction: Significant evidence advocates early tracheostomy for severe traumatic brain injury (TBI), but individual and center-level practices vary. Most studies have analyzed tracheostomy timing at the patient level, with no prior studies examining the association of hospital-level tracheostomy practices with resource utilization and patient outcomes.

Methods: The Trauma Quality Improvement Program database was queried for adults with severe TBI, defined as Head Abbreviated Injury Score (AIS) >3, undergoing tracheostomy 2017-2021. Early tracheostomy centers (ETC) had the highest tertile percent of early tracheostomy (≤7 days) performed, with late tracheostomy centers (LTC) performing most beyond 7 days from admission. Univariate and multivariate regression were used to compare hospital and ICU length of stay (LOS), as well as rates of respiratory complications including acute respiratory distress syndrome (ARDS), ventilator-associated pneumonia (VAP), and unplanned intubation.

Results: Of 21,367 patients, 7,787 were treated by ETC and 13,580 by LTC. Median age was 42 in ETC and 44 in LTC. Injury mechanism, Glasgow Coma Score (GCS), head AIS, injury severity score (ISS), and extracranial injuries were comparable between groups. Unadjusted mortality was 7.0% at ETC versus 6.4% at LTC. In multivariate analysis controlling for age, sex, ISS, and smoking, ETC had average ICU LOS 4.2 days less than LTC (95% CI: 3.8 to 4.5, p< 0.01) and hospital LOS 4.3 days less than LTC (95% CI: 3.6 to 5.0, p< 0.01). ETC demonstrated a significantly lower incidence of ARDS (aOR: 0.78, 95% CI 0.68 to 0.90, p< 0.01) and unplanned intubation (aOR: 0.88, 95% CI 0.80 to 0.97, p< 0.01) compared to LTC. No difference was identified in VAP rates.

Conclusion : There remains wide facility-level variability in early tracheostomy utilization in TBI. ETC suffered lower respiratory complication rates, but there was no benefit in VAP reduction. Lower intubation rates observed in ETC suggests a clinical importance to early tracheostomy. ETC significantly decreased resource utilization in terms of ICU and hospital LOS. Center-level approach to early tracheostomy should be examined as a possible quality improvement target in adult TBI.