Invited Commentary
January 24, 2024
Guideline Implementation Is Improving Trauma Care in the Wild, Wild West
Jeffrey K. Jopling, Lisa M. Kodadek, Elliott R. Haut
JAMA Surg. 2024;159(4):372-373. doi:10.1001/jamasurg.2023.7154
Acore tenet in the care of patients with brain injury is prevention of secondary brain injury. In the immediate postinjury period, the patient’s physiology must be carefully managed to adequately perfuse and oxygenate the brain. Maintaining optimal oxygenation, ventilation, blood pressure, and temperature is critical to maximize patient outcomes.1 Even a single instance of deviation from the optimal ranges can lead to additional irreversible brain injury and increase the risk of death. We know the data, but historically have had difficulty changing practice to achieve these targets. How can trauma systems manage patients with brain injury in a way that ensures these physiologic evidence-based goals are met?
The trauma care continuum takes place in a series of task- and decision-dense environments. Decisions should be driven by data and we should use a learning health-care system designed to provide evidence-based care.2 The National Academies of Medicine reminds us that well-implemented practice-management guidelines are key to delivery of evidence-based care at a system level.2 Practice-management guidelines speed implementation of research into practice, improve quality and safety of care, reduce disparities, lower health care costs, and reduce practice variation.3
Within this context, the Excellence in Prehospital Injury Care (EPIC) study team implemented an emergency medical services (EMS) guideline across the state of Arizona. Their initial findings demonstrated that guideline implementation was associated with improvement in survival to hospital discharge for patients with severe traumatic brain injury (TBI).4 Gaither and et al5 conducted a preplanned secondary analysis of EPIC, bringing into focus the positive effect that guideline implementation had on outcomes for patients with severe TBI receiving positive pressure ventilation in the prehospital setting. They found that regardless of the airway intervention used, patients in the postguideline implementation phase were more likely to receive guideline-concordant care and had improved survival to hospital discharge relative to their counterparts treated in the preimplementation phase.
Interestingly, aggressive prevention of hypoxia and hyperventilation only seemed to account for a modest proportion of the improvements in survival to hospital discharge. Another aspect of their bundled care, prevention and management of hypotension, was likely a key driver of outcomes. We suspect that patients in their study who had multisystem blunt or penetrating trauma also benefited from additional guidelines implemented over time, such as prehospital administration of blood products or use of aggressive early hemorrhage control techniques (ie, wound packing, tourniquet).6
Possibly the most impressive accomplishment by the EPIC study group is their successful implementation of a practical EMS guideline at the state level. A survey of 32 statewide protocols found that their achievement is relatively unique.7 It should not be. This study offers critical insight into a successful strategy for large-scale translation of knowledge in the prehospital setting. We suggest other prehospital leaders use the tenets of implementation science to optimize care delivery systems.7 Their findings reinforce the fact that evidence-based guidelines improve outcomes and provide further support for the critical role of guideline implementation in trauma care systems.8,9
