Objective: To assess the impact of introducing a devastating brain injury (DBI) pathway on patient outcome, intensive care unit (ICU) resources, and organ donation practice in the first 3 years of implementation in a regional neurosciences ICU in the South West of England.
Methods: Patients with DBI admitted to our ICU between 2015 and 2018 were identified from our ICU database and their outcomes compared to those of non-DBI patients. Data were also obtained from the national potential donor audit to compare organ donation metrics before and after the introduction of the DBI pathway. Organ donation metrics in DBI patients and non-DBI patients were compared once the pathway had been implemented.
Results: We admitted 85 DBI patients (1.3% of all admissions), with a significantly shorter median length of ICU stay than in non-DBI patients, 1.14 versus 2.93 days (p < 0.001). Decisions for withdraw life-sustaining treatments (WLST) were made significantly earlier in DBI patients, median 26.2 versus 84.8 h (p < 0.001). Over 8% of DBI patients survived, while 31% progressed to brain death compared to 7.1% in the general population (p < 0.001), and 25% become solid organ donors compared to 1.3% of the general population (p < 0.001). There was an increase in the proportion of donors after brain death (DBD) to donors after circulatory death (DCD) in the 3 years following the introduction of the DBI pathway (p = 0.024). There was also an increased proportion of DBD donors to DCD donors of 76% versus 24% in the DBI group compared to 62% versus 38% (p = 0,002) in the non-DBI population. Prognostic scoring systems do not provide accurate estimates of survival rate in this population.
Conclusions: Admitting patients with perceived DBI to ICU and avoiding the early WLST allows identification of unexpected survivors and gives families more time in decision making at the end of life. The DBI pathway increases the potential for organ donation and increases the proportion of DBD donors. These benefits outweigh the small impact of a DBI pathway on ICU resources.
Keywords: Brain death; Clinical decision making; Critical care management; Devastating brain injury; End-of-life care; Neurocritical care; Organ donation; Practice guidelines; Prognosis.