Prediction of Outcome at Discharge From Acute Care Following Traumatic Brain Injury

Relationships between predisposing, precipitating, and perpetuating factors and executive functioning following mild traumatic brain injury

INTRODUCTION

The aim of this study was to determine the sociodemographic and MTBI-related variables associated with executive functioning (EF).

METHODS

Based on the theoretical model of Hou and colleagues, data on predisposing (age, education, premorbid IQ), precipitating (post-traumatic amnesia, loss of consciousness, presence of frontal lesions, post-accident time to evaluation) and perpetuating (anxious and depressive affects and post-concussive symptoms) factors were retrospectively collected from the medical records of 172 patients with MTBI. EF data based on the 3 processes included in Miyake's prediction model (2000) (updating, cognitive flexibility and inhibition) were collected using respectively the Digit span task of the Weschler - 4^th edition, the Trails A and B as well as the initiation time on the Tower of London- Drexel University.

RESULTS

Updating was significantly associated with education, premorbid IQ, age, anxiety, and depressive affect. Inhibition was associated with education and age. No variable was associated with cognitive flexibility.

CONCLUSIONS

Following a MTBI, clinicians should consider that level of education and pre-morbid IQ may "predispose" patients to higher EF performances. They should also measure level of anxiety and depressive affect knowing that these may "perpetuate" some EF impairments (specifically the updating process).

Selection of discharge destination for patients with moderate-to-severe traumatic brain injury

OBJECTIVES

To investigate criteria acute care interdisciplinary providers use to select discharge destination for patients with traumatic brain injury (TBI).

DESIGN

Cross-sectional, exploratory survey study.

METHODS

Data were collected from interdisciplinary providers at a U.S. Level I trauma centre via electronic survey. We invited 199 providers to participate and 27 responded (13.5% response rate). Responses were received from physicians and physical, occupational, and speech therapists.

RESULTS

Findings showed variability in standard criteria and clinical judgment criteria providers used to select discharge destination for patients with TBI receiving acute care. There was limited agreement on standard criteria used to select discharge destination. Findings showed some agreement between providers on clinical judgment criteria used to select home as discharge destination and to prevent discharge to home. Most common clinical judgment criteria included therapists' recommendations on discharge location, patient's level of independence in activities of daily living, planned family support and ventilator dependence. Agreement on clinical judgment criteria became more limited when stratifying by discipline, frequency of patient care and experience.

CONCLUSIONS

Findings on clinical judgment criteria providers use to select acute care discharge destination for patients with TBI are inconclusive.

Prediction of functional outcome and discharge destination in patients with traumatic brain injury after post-acute rehabilitation

As the survival rate of traumatic brain injury increases, the burden of care for patients with traumatic brain injury is emerging as a socioeconomic issue and the discharge destination is one of the important outcome measures in the post-acute rehabilitation unit. To investigate the predictors of functional outcome and discharge destination in patients with traumatic brain injury after post-acute rehabilitation. A retrospective review was performed on 86 patients who were admitted to the rehabilitation unit between January 2010 and June 2017. Multiple regression analysis was used as a statistical method to identify the factors affecting Modified Barthel Index and discharge destination. The number of days from traumatic brain injury onset to rehabilitation unit admission (odds ratio = 0.959, P = 0.049), brain surgery for traumatic brain injury management (odds ratio = 0.160, P = 0.021), initial Glasgow Coma Scale score (odds ratio = 1.269, P = 0.022) and Mini-Mental State Examination score at admission (odds ratio = 1.245, P < 0.001) were the predictive factors for higher Modified Barthel Index after rehabilitation. Underlying vascular risk factors (odds ratio = 0.138, P = 0.015), Modified Barthel Index score after rehabilitation (odds ratio = 1.085, P < 0.001) and deductible-free insurance (odds ratio = 0.211, P = 0.032) were the predictive factors of home discharge. The functional outcome of patients with traumatic brain injury after rehabilitation was related to the severity of initial injury, cognitive function at admission and rehabilitation timing. The discharge destination after rehabilitation was related to functional outcome, insurance issues and underlying vascular risk factors.

Acute prediction of outcome and cognitive-communication impairments following traumatic brain injury: The influence of age, education and site of lesion

BACKGROUND

Communication impairment following a traumatic brain injury (TBI) has been well documented, yet information regarding communication skills in the acute period following the injury is limited in the literature. Also, little is known about the influence of TBI severity (mild, moderate or severe) on cognitive-communication impairments and how these impairments are related to short-term functional outcome. The goal of this study was to assess the performance of adults with mild, moderate and severe TBI on different language tests and to determine how this performance is related to functional capacity. We also aimed to explore which variables among age, sex, education, TBI severity and site of cerebral damage would predict initial language impairments.

METHODS

Several language tests were administered to a sample of 145 adult patients with TBI of a range of severities admitted to an acute care service and to 113 healthy participants from the community.

RESULTS

TBI patients of a range of severities performed poorly on all language tests in comparison to the healthy controls. In addition, patients with mild TBI performed better than the moderate and severe groups, except on the reading test and on the semantic naming test. In addition, their performance on verbal fluency, conversational discourse and procedural discourse tasks predicted acute functional outcome. Finally, age, education and TBI severity and site of lesion predicted some language performance. A left temporal lesion was associated with poorer performance in conversational discourse and auditory comprehension tasks, a left frontal lesion with a decrease in the verbal fluency results and a right parietal lesion with decreased auditory comprehension and reasoning skills.

CONCLUSION

Health care professionals working in the acute care setting should be aware of the possible presence of cognitive-communication impairments in patients with TBI, even for those with mild TBI. These deficits can lead to functional communication problems and assistance may be required for tasks frequently encountered in acute care requiring intact comprehension and expression.

Electronic Health Data Predict Outcomes After Aneurysmal Subarachnoid Hemorrhage

BACKGROUD

Using electronic health data, we sought to identify clinical and physiological parameters that in combination predict neurologic outcomes after aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

We conducted a single-center retrospective cohort study of patients admitted with aSAH between 2011 and 2016. A set of 473 predictor variables was evaluated. Our outcome measure was discharge Glasgow Outcome Scale (GOS). For laboratory and physiological data, we computed the minimum, maximum, median, and variance for the first three admission days. We created a penalized logistic regression model to determine predictors of outcome and a multivariate multilevel prediction model to predict poor (GOS 1-2), intermediate (GOS 3), or good (GOS 4-5) outcomes.

RESULTS

One hundred and fifty-three patients met inclusion criteria; most were discharged with a GOS of 3. Multivariate analysis predictors of mortality (AUC 0.9198) included APACHE II score, Glasgow Come Scale (GCS), white blood cell (WBC) count, mean arterial pressure, variance of serum glucose, intracranial pressure (ICP), and serum sodium. Predictors of death/dependence versus independence (GOS 4-5)(AUC 0.9456) were levetiracetam, mechanical ventilation, WBC count, heart rate, ICP variance, GCS, APACHE II, and epileptiform discharges. The multiclass prediction model selected GCS, admission APACHE II, periodic discharges, lacosamide, and rebleeding as significant predictors; model performance exceeded 80% accuracy in predicting poor or good outcome and exceeded 70% accuracy for predicting intermediate outcome.

CONCLUSIONS

Variance in early physiologic data can impact patient outcomes and may serve as targets for early goal-directed therapy. Electronically retrievable features such as ICP, glucose levels, and electroencephalography patterns should be considered in disease severity and risk stratification scores.

Prediction of occupational disability from psychological and neuropsychological evidence in forensic context

Within the fields of psychiatry, psychology, and neuropsychology, medical examiners are often tasked with providing an opinion about an injured individual's health prognosis and likelihood of returning to work. Traditionally, examiners have conducted such assessments by employing clinical intuition, expert knowledge, and judgment. More recently, however, an accumulation of research on factors predictive of disability has allowed examiners to provide prognostications using specific empirically supported evidence. This paper integrates current evidence for four common clinical issues encountered in forensic assessments-musculoskeletal pain, depression, Posttraumatic Stress Disorder, and traumatic brain injury. It discusses an evidence-informed, cross-diagnostic and multifactorial model of predicting disability that is emerging from the literature synthesis, along with recommendations for best forensic assessment practice.

Does activity limitation predict discharge destination for postacute care patients?

OBJECTIVE

This study aimed to examine the ability of different domains of activity limitation to predict discharge destination (home vs. nonhome settings) 1 mo after hospital discharge for postacute rehabilitation patients.

DESIGN

A secondary analysis was conducted using a data set of 518 adults with neurologic, lower extremity orthopedic, and complex medical conditions followed after discharge from a hospital into postacute care. Variables collected at baseline include activity limitations (basic mobility, daily activity, and applied cognitive function, measured by the Activity Measure for Post-Acute Care), demographics, diagnosis, and cognitive status. The discharge destination was recorded at 1 mo after being discharged from the hospital.

RESULTS

Correlational analyses revealed that the 1-mo discharge destination was correlated with two domains of activity (basic mobility and daily activity) and cognitive status. However, multiple logistic regression and receiver operating characteristic curve analyses showed that basic mobility functioning performed the best in discriminating home vs. nonhome living.

CONCLUSIONS

This study supported the evidence that basic mobility functioning is a critical determinant of discharge home for postacute rehabilitation patients. The Activity Measure for Post-Acute Care-basic mobility showed good usability in discriminating home vs. nonhome living. The findings shed light on the importance of basic mobility functioning in the discharge planning process.

Pathways of care the first year after moderate and severe traumatic brain injury-discharge destinations and outpatient follow-up

PRIMARY OBJECTIVE

To determine the pathways of care within the first year after traumatic brain injury (TBI) and to explore whether provided care is related to residual impairments.

RESEARCH DESIGN

Retrospective study of 343 patients with moderate and severe TBI admitted to a Level-1 trauma centre.

METHODS AND PROCEDURES

Discharge destinations from hospital to home and frequency of outpatient visits were determined. Outcome was defined 1 year after injury by the Extended Glasgow Outcome Scale and Return to Work.

RESULTS

Most (94%) patients had returned home 1-year after injury despite cognitive (76%), behavioural (67%) and physical (55%) impairments. One in four patients was severely disabled and 32% had resumed work on a previous level. Two-thirds of all patients went home as secondary discharge destination and 50% needed inpatient rehabilitation. Almost half of patients needed outpatient care, mostly for behavioural and cognitive impairments. One in 10 patients consulted a psychiatrist, with 55% unfavourable outcome. Of those patients initially discharged to home without follow-up, eventually 10% needed outpatient rehabilitation.

CONCLUSIONS

One-year after injury most patients had returned home with residual impairments and frequent medical consultations. This finding warrants further investigation to define appropriate aftercare by various medical specialists aimed at long-term community integration.

Description of the moderate brain injured patient and predictors of discharge to rehabilitation

OBJECTIVE

To describe patients with moderate traumatic brain injury (TBI) treated and discharged at levels I and II trauma centers in the United States; and to describe the predictors of discharge to rehabilitation after acute care.

DESIGN

Retrospective, cross-sectional, descriptive study.

SETTING

Trauma centers.

PARTICIPANTS

Patients with moderate TBI (N=2087; age range, 18-64 y) as reported in the 2010 National Sample Project.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

Discharge destination (rehabilitation vs home with no services).

RESULTS

Multivariate logistic regression models revealed that demographic, clinical, and financial characteristics influenced the likelihood of being discharged to rehabilitation. Increased age, increased severity, Medicare use, longer length of stay, and trauma center locations in the Midwest and Northeast all increased the likelihood of discharge to rehabilitation.

CONCLUSIONS

The decision to discharge a person with moderate TBI from acute care to rehabilitation appears to be based on factors other than just clinical need. These findings should be considered in creating more equitable access to postacute rehabilitation services for patients with moderate TBI because they risk long-term physical and cognitive problems and have the potential for productive lives with treatment.

Dual-task training for balance and mobility in a person with severe traumatic brain injury: a case study

BACKGROUND AND PURPOSE

Attentional impairments following severe traumatic brain injury (TBI) are common and can lead to decreased functional mobility and balance, as well as deficits in previously automatic movements such as walking and stair climbing. The purpose of this case study was to determine the feasibility and potential value of incorporating a cognitive-motor dual-task training program into physical therapy for a patient with a severe TBI.

CASE DESCRIPTION

The patient was a 26-year-old woman who sustained a severe TBI during a motor vehicle accident 46 days prior to physical therapy evaluation. On the 8-level Rancho Los Amigos Cognitive Function Scale, her functioning was classified as level IV. She had impairments in attention, functional mobility, and balance, all of which limited her ability to participate in activities of daily living.

INTERVENTION

: Physical therapy was provided over 26 days within the inpatient rehabilitation setting. Interventions included mobility tasks such as walking, balancing, and stair climbing. Mobility training was paired with specific secondary cognitive and motor tasks.

OUTCOMES

Dual-task training may have contributed to improvements on outcome measures designed to test divided attention including the Walking While Talking Test and Trail Making Test and a greater rate of improvement in walking speed and time to descend stairs when compared to the baseline phase.

DISCUSSION

Addition of cognitive-motor dual-task training to standard physical therapy in the inpatient rehabilitation setting appears to be feasible and may have value for improving function in individuals with severe TBI.

VIDEO ABSTRACT AVAILABLE

(see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A41) for more insights from the authors.

Addressing neuropsychiatric disturbances during rehabilitation after traumatic brain injury: current and future methods

Cognitive, emotional, behavioral, and sensorimotor disturbances are the principal clinical manifestations of traumatic brain injury (TBI) throughout the early postinjury period. These post-traumatic neuropsychiatric disturbances present substantial challenges to patients, their families, and clinicians providing their rehabilitative care, the optimal approaches to which remain incompletely developed. In this article, a neuropsychiairically informed, neurobiologically anchored approach to understanding and meeting challenges is described. The foundation for thai approach is laid, with a review of clinical case definitions of TBI and clarification of their intended referents. The differential diagnosis of event-related neuropsychiatric disturbances is considered next, after which the clinical and neurobiological heterogeneity within the diagnostic category of TBI are discussed. The clinical manifestations of biomechanical force-induced brain dysfunction are described as a state of post-traumatic encephalopathy (PTE) comprising several phenomenologically distinct stages, PTE is then used as a framework for understanding and clinically evaluating the neuropsychiatric sequelae of TBI encountered commonly during the early post-injury rehabilitation period, and for considering the types and timings of neurorehabilitative interventions. Finally, directions for future research that may address productively the challenges to TBI rehabilitation presented by neuropsychiatric disturbances are considered.

A critical review of the literature on early rehabilitation of patients with post-traumatic amnesia in acute care

AIMS AND OBJECTIVES

To identify the effect of early rehabilitation of patients with post-traumatic amnesia in patients with traumatic brain injury, to review and critically assess evidence related to the timing of intervention and to identify the effect on outcome of a specific neurological rehabilitation in acute care.

BACKGROUND

Up to 70% of patients with traumatic brain injury will experience post-traumatic amnesia. Although duration of post-traumatic amnesia is correlated negatively with outcome for patients with traumatic brain injury, there is limited evidence relating to what influence timing and effect may have on enhancing early rehabilitation patient outcomes.

DESIGN

A critical literature review.

METHODS

Searches for systematic reviews were undertaken in Medline, CINAHL, Cochrane, PSYC INFO and Neurotraume databases. The efficacy of intervention and timing was classified based on a hierarchy of study designs for questions about health care interventions based on soundness of design.

RESULTS

Six reviews and 11 original studies were included and comprised the review. Many studies used weak designs and small sample size, thus limiting their ability to control confusing variables and outcomes. Few studies included papers with the information about timing and effect of early post-traumatic amnesia intervention. Only one study showed an effect of a reality orientation programme in acute care. Although there was no significant detail reported on the possibility of reducing the post-traumatic amnesia period, the study showed clinical relevance.

CONCLUSION

This review highlights the limited evidence of the effect of early rehabilitation of patients with post-traumatic amnesia. Future research should be conducted to identify the effectiveness of early intervention.

RELEVANCE TO CLINICAL PRACTICE

Although nurses are treating patients with post-traumatic amnesia without systematic assessment, the limited evidence available does little to direct nurses as to the best approach to start early rehabilitation of post-traumatic amnesia to promote good outcomes.

Evaluation of moderate traumatic brain injury

INTRODUCTION

Traumatic brain injury (TBI) affects nearly 1.4 million Americans annually with an estimated 5.3 million US citizens living with disability. There is no standardized course of treatment for individuals with moderate TBI. This study aims to evaluate the patient demographics and acute care course for those with moderate TBI.

METHODS

This is a descriptive study of 40 persons diagnosed with moderate TBI to examine demographic, clinical, and discharge variables associated with this injury.

RESULTS

Falls, the most frequent mechanism of injury, were seen in more than 50% of individuals 65 years and older. The 21-to 64-year age group was more likely to be injured from motor vehicle crashes. Fifty percent of the patients were discharged; however, only 1 in 9 patients older than 65 years was discharged. Glasgow Coma Scale was not correlated with discharge destination. Cognitive status was screened in the hospital setting on 9 patients, and orders for outpatient screening/evaluation were done on an additional 17 patients.

CONCLUSION

Moderate TBI is a unique subset of brain injury. Having a better understanding of its course of recovery will help develop appropriate management guidelines for this group.