Looking forward: Lessons from the pandemic in promoting and improving TBI care
Andrew Reisner, M.D., Laura Lippa, M.D., Andres M Rubiano, M.D.
Neurotrauma Committee, World Federation of Neurological Societies (WFNS)
“The farther back you can look, the farther forward you are likely to see.”
In reflecting on what has been accomplished over the last few decades in the field of neurotrauma, the achievements are in large part thanks to the efforts of many, including prior WFNS Neurotrauma Committee members. The development of evidence-based guidelines, committee consensus statements, and multinational research efforts have solidified the knowledge we have and as importantly, highlighted important data that remains lacking. Perhaps most strikingly, we now have ample data to support the enormity of traumatic brain injury (TBI) worldwide.
Despite underreporting in some regions of the world there are an estimated from 27.1 million to 69 million new cases of TBI annually worldwide.1,2 Even in this variation in estimates, there is agreement that TBI is a major health challenge in all countries. It is also indisputable that disparities exist in incidence, care, and research efforts between high-income countries (HICs) and low- and middle-income countries (LMICs), with the latter experiencing almost triple the proportion of TBI cases.2 Both pre- and post-pandemic, neurotrauma represents a significant portion of the neurosurgical workload globally, and workload burdens on neurosurgeons have been exacerbated by COVID-19. In many ways, the pandemic has “forced” us to re-examine our practices. For example, there is a greater awareness of the need for both task shifting and task sharing during the Covid-19 pandemic.3 Task shifting is employing trained, but less qualified individuals; task sharing is a similar transference of responsibility within a tiered system with clear communication within the team.3 In low-resource settings, it has been shown that task sharing allows better communication and improved outcomes than task shifting.4
We stress that task sharing is not task offloading. Indeed, neurosurgeons need to take the lead in whatever changes are implemented so that quality of patient care and patient outcome are not negatively affected – but ideally enhanced. There are many ongoing educational programs in which neurosurgeons participate in training trauma surgeons and emergency responders worldwide. These laudable efforts will continue to be supported by the WFNS' Neurotrauma Committee. For obvious reasons, neurosurgical attention has traditionally focused on the more severe end of the TBI spectrum. Until recently, patients who sustained “milder” TBIs, including concussions, did not receive the full and comprehensive attention that we now know is warranted. Greater attention to mild cases is the result of greater appreciation that mild TBI is not always a benign injury. Yet, with this awareness among the public and community-practicing physicians, the sheer number of mild TBI cases can overload even well-resourced neurosurgical systems. One potential solution to meet this increased demand is for neurosurgeons to take the lead in arming allied (surgical and nonsurgical) medical colleagues and nurse providers to appropriately manage patients with TBI over the entire spectrum of the disease.
A good example of organized activities for improving TBI care in low resources settings was the Mulago National Hospital in Uganda, where a training program for nurses to avoid secondary injuries in emergency and critical care settings was implemented.5 In Latin America, an International Neurotrauma Fellowship program based on neurosurgeon North-South collaborations promotes the shared training between neurosurgeons and emergency physicians in non-invasive devices at the emergency room for early detection of intracranial hypertension and intracranial hemorrhage during the pandemic’s worse peak.6,7 Another example from an HIC in the organization of care for TBI during the pandemic was the Concussion Program at Children’s Healthcare of Atlanta (USA).8 This program was established to meet a massive and sudden need for community-based concussion care. A central feature of the program was to provide concussion-specific decision support tools for pediatric care providers in the community who had been largely unaccustomed to routinely treating concussion patients. This education included how to take care of concussed youth and when to refer —and more importantly, when not to refer — to the neurosurgeon, emergency department, or for CT scans. Some video series on concussion prevention, diagnosis, treatment and scenarios and a toolkit were placed on-line and included assessment tools, criteria for emergency department and CT scan referral, “red flags” that the child may have a more severe TBI, and advice about cognitive rest. Other elements include tailored materials and fact sheets for coaches, patients, and parents that were available in both English and Spanish. To ensure continued support, a dedicated concussion nurse coordinator was trained and employed in an integrated, task-sharing manner to act as a resource for both parents and health care professionals on a “concussion hotline.”
This are just some of many examples where neurotrauma surgeons can serve as community educators and leaders in promoting head injury prevention and appropriate TBI management. Pre-pandemic efforts at task shifting have now become more important because the pandemic heightened workforce burden and reduced the overall capacity of neurotrauma surgeons. The pandemic has heighted the value of enhanced communication and greater connectivity. It has also forced us to think of new strategies to streamline neurotrauma care. The 2021-2023 WFNS Neurotrauma Committee will not only continue to support ongoing educational, preventative, and treatment programs, but it will endeavor to institute innovative programs (such as task sharing), the need for which has been underscored during the pandemic.
We conclude by emphasizing that we look forward to engaging with you, and take this opportunity to wish you, your families, and patients a happy new year and a better tomorrow for all.
1 James SL, Theadom, A, Ellenbogen RG, Bannick MS, Montjoy-Venning W, Lucchesi LR, et al. Global, regional, and national burden of traumatic brain injury and spinal cord injury, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet Neurology, 2019;18(1):56-87.
2 Dewan MC, Rattani A, Gupta S, Baticulon RE, Hung YC, Punchak M, et al. Estimating the global incidence of traumatic brain injury. Journal of Neurosurgery, 2019;130:1080-1097.
3 Robertson FC, Lippa L, and Broekman MLD. Task shifting and task sharing for neurosurgeons amidst the COVID-19 pandemic. Journal of Neurosurgery, 2020;133:5–7.
4 Meara JG, Leather AJM, Hagander L, Alkire BC, Alonso N, Ameh EA et al. Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. The Lancet, 2015;386(9993):569-624.
5 Gamble M, Luggya TS, Mabweijano J, Nabulime J, Mowafi H. Impact of nursing education and a monitoring tool on outcomes in traumatic brain injury. Afr J Emerg Med. 2020 Dec;10(4):181-187
6 Rubiano AM, Griswold DP, Adelson PD, Echeverri RA, Khan AA, Morales S, Sánchez DM, Amorim R, Soto AR, Paiva W, Paranhos J, Carreño JN, Monteiro R, Kolias A, Hutchinson PJ. International Neurotrauma Training Based on North-South Collaborations: Results of an Inter-institutional Program in the Era of Global Neurosurgery. Front Surg. 2021 Jul 29;8:633774. doi: 10.3389/fsurg.2021.633774
7 Correa MA, Cardona S, Fernández LL, Griswold DP, Olaya SL, Sánchez DM, Rubiano AM. Implementation of the infrascanner in the detection of post-traumatic intracranial bleeding: A narrative review. Brain Disorders, 2022; 5; 100026.
8 Reisner A, Popoli DM, Burns TG, Marshall DL, Jain S, Hall LB, et al. The central role of community-practicing pediatricians in contemporary concussion care: A case study of Children’s Healthcare of Atlanta’s Concussion Program. Clinical Pediatrics, 2015;54(11):1031–1037.