Clinical Inertia: The Care Gap between Clinical Guidelines and Clinical Practice in Neurotrauma

Abstract

Traumatic brain injury is an important cause of disability, especially in the young population. According to Center for Disease Control and prevention data, there has been an increase in cases in the last 2 decades, despite the notable development of preventive technologies and the development of management guides. Clinical inertia is a concept where late initiation or lack of intensification of treatment in a patient and the failure to achieve the goals established from the beginning. This can be defined in the management term as therapeutic inertia. This concept is well known in pathologies such as hypertension and diabetes, in which we do not reach the therapeutic goal, and this carries the risk of deterioration of the patient. It is known that therapeutic inertia occurs in half of the cases due to failures by the clinicians, in 30% associated with the patient himself, and 20% due to the characteristics of the health care system. The burden of brain trauma injury leads to multiple Swiss cheese breakthroughs with clinical inertia is one of the unknown factors. To better understand the element of clinical inertia and traumatic brain injury management, a brief visit to the process of traumatic brain injury will be helpful. Traumatic brain injury management starts in the field, followed by a transit time to the trauma bay. In trauma bay, most of the level trauma centers already have a trauma team present to receive traumatic brain injury. Here things can get complicated. The patient needs to have 2 levels of trauma reviews including imaging studies, a neurosurgical consult, and further management. Some patients go to the operating room but mostly end up in the trauma intensive care for at least 72 hours before a major neurosurgical procedure is performed. After 72 hours, the neurocritical care management has different phases: acute phase, stabilization phase/non-survival phase, and discharge planning. All these phases lead to multiple areas of clinical inertia. This clinical inertia is related to progression of care, change of shifts, the arrival of new admits, and major disasters like the present Covid-19 pandemic. Looking at the progression of care in traumatic brain injury patients, multiple steps can be reviewed, and a stage is set to reduce the risk of clinical inertia (Fig. 1).