Care coordination and procedural outcomes of percutaneous endoscopic gastrostomy and tracheostomy placement in severe traumatic brain injury

Background Clinicians face complex decisions regarding the timing of long-term ventilatory and nutritional support in patients with traumatic brain injury (TBI). Although early percutaneous endoscopic gastrostomy (PEG) and tracheostomy have been associated with improved outcomes, the optimal timing of these procedures remains uncertain. Methods We conducted a retrospective review of 263 adult TBI patients who underwent PEG and/or tracheostomy between January 2016 and December 2023 at a single Level I trauma center. Patients were stratified by timing of intervention: early (≤7 days), standard (8–14 days), and late (≥15 days). Outcomes included hospital length of stay (LOS), intensive care unit (ICU) LOS, and number of complications. Negative binomial regression was used to model count-based outcomes, with results reported as adjusted rate ratios (aRR) and adjusted for age, sex, BMI, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), Charlson Comorbidity Index (CCI), provider specialty, and simultaneous PEG and tracheostomy placement. Results Early PEG was independently associated with reduced hospital LOS (aRR = 0.61, 95% CI 0.42–0.87, p = .007), shorter ICU LOS (aRR = 0.61, 95% CI 0.42–0.89, p = .009), and fewer complications (aRR = 0.59, 95% CI 0.35–1.00, p = .048). Early tracheostomy was independently associated with shorter ICU LOS (aRR = 0.56, 95% CI 0.36–0.86, p = .008). The association between early tracheostomy and fewer complications did not reach statistical significance in the primary analysis (aRR = 0.58, 95% CI 0.33–1.04, p = .067) but was significant after adjustment for institutional calendar period in sensitivity analyses (aRR = 0.51, 95% CI 0.32–0.81, p = .005). Increasing age was independently associated with shorter hospital LOS among PEG patients (aRR = 0.99, 95% CI 0.97–0.99, p = .018). Provider specialty, BMI, ISS, CCI, and GCS were not independently associated with hospital LOS, ICU LOS, or complication burden in either the PEG or tracheostomy cohorts. Conclusion Early PEG and tracheostomy were independently associated with shorter ICU stays, while early PEG was also associated with fewer complications. The association between early tracheostomy and reduced complications reached significance only in sensitivity analyses. These findings highlight the importance of timely procedural decision-making and underscore the need for prospective studies to establish evidence-based guidelines for optimal PEG and tracheostomy timing in TBI care.