Introduction: Practitioners caring for victims of traumatic brain injury (TBI) routinely face decisions about the aggressiveness of care. The IMPACT prognostic calculator (1) allows a more quantitative consideration of outcome and physician aggressiveness than was previously possible however application of this calculator and its predictions have been subject to little study as yet.

Methods: We conducted an international and multidisciplinary survey of practitioners who provide care to TBI patients using REDCap. We examined physician familiarity with the IMPACT calculator and how the calculations it provides influence patient care. We also aimed to quantitate physician aggressiveness and factors which influence aggressiveness.

Results: 155 physicians completed our survey. 68.4% of neurosurgeons were aware of the IMPACT calculator compared with 43.5% of practitioners from other disciplines. Those familiar with its use indicated that IMPACT calculations mildly influence their clinical decisions and have greatest utility in enhancing communication with victims’ families. Respondents indicated that patient age strongly influenced their decision to provide aggressive care; there was consensus that withholding aggressive care may be appropriate when patient age is 75 years or greater. Similarly there was consensus that withholding aggressive care may be appropriate if an 85% chance of death or poor outcome was accurately predicted. Physician aggressiveness was not significantly influenced by experience, the trauma level of the repondent’s institution or the volume of TBI patients cared for.

Conclusions: The IMPACT prognostic calculator may be employed as a safeguard against nihilism and as a means of reducing variability in physician aggressiveness. Many are unaware of its availability, however. In light of apparent strong consensus it may be appropriate to scrutinize withdrawal of care decisions in patients less than 75 years of age or with less than an 85% chance of death or poor outcome.

Patient Care: We hope this project will increase use of the IMPACT prognostic calculator in the management of TBI victims. We describe an approach which may help prevent nihilism and variability in aggressiveness by practitioners caring for these patients.

Learning Objectives: 1. Increase familiarity with the utility and limitations of the IMPACT prognostic calculator. 2. Conceptualize practitioner aggressiveness quantitatively and learn about consensus views on when aggressive care should be provided.

References: (1) Murray GD, Butcher I, McHugh GS, Lu J, Mushkudiani NA, Maas AI, Marmarou A, Steyerberg EW. Multivariable prognostic analysis in traumatic brain injury: results from the IMPACT study. J Neurotrauma. 2007 Feb;24(2):329-37.