Incidence and outcomes of unplanned escalation-of-care complications for patients with traumatic brain injury.

INTRODUCTION Traumatic brain injury (TBI) is a leading cause of morbidity and mortality, and unplanned escalation-of-care complications such as intubations, intensive care unit (ICU) transfers, and operating room (OR) visits may reflect both injury severity and gaps in triage. Although linked to adverse outcomes in general trauma populations, they remain poorly characterized in TBI. The objective of this study was to define the frequency, co-occurrence, and consequences of these unplanned complications.

METHODS We conducted a retrospective cohort study of adults with blunt TBI in the ACS TQIP database (2017-2022). Exposures were unplanned ICU admission, intubation, and OR visit, examined individually and cumulatively. Outcomes included hospital length of stay (LOS), discharge disposition, and inpatient mortality. Descriptive analyses characterized complication frequency and overlap, spline models assessed risk across presenting Glasgow Coma Scale (GCS), and regression models evaluated associations with complication burden and mortality among surgically-managed patients.

RESULTS Among 132,984 patients (median age, 63 years), 3.5 % experienced at least one unplanned complication. Rates were higher among surgically-managed patients, and intubation with ICU transfer was the most common combination. The probability of unplanned complications followed a non-linear relationship with GCS, peaking in the moderate range (10-12) and consistently higher among surgical patients. Increasing complication burden was associated with longer LOS and lower rates of favorable discharge. In adjusted models, unplanned intubations strongly predicted mortality (OR 1.80; 95 % CI, 1.43-2.27), unplanned ICU transfers were associated with lower mortality (OR 0.57; 95 % CI, 0.42-0.76), and unplanned OR visits showed no significant association.

CONCLUSIONS Unplanned escalation-of-care complications are uncommon but clinically meaningful in TBI, disproportionately affecting surgically-managed patients. These complications carry distinct prognostic significance, with intubation signaling high mortality risk, ICU transfer associated with lower risk, and higher complication burden linked to longer stays and poorer discharge outcomes. These unplanned complications represent reproducible indicators of acute instability and potential targets for improved triage and quality improvement.