Predictors of mortality and rehabilitation location in adults with prolonged coma following traumatic brain injury

INTRODUCTION

Traumatic brain injury (TBI) is a leading cause of death and disability, often resulting in prolonged coma and disordered consciousness. There are currently gaps in understanding the factors affecting rehabilitation location and outcome after TBI.

OBJECTIVE

To identify the impact of demographics, comorbidities, and complications on discharge disposition in adults with prolonged coma following TBI.

DESIGN

Retrospective cohort study.

SETTING

Tertiary care hospitals and trauma centers in the United States.

PARTICIPANTS

Patients 18 years of age or older with TBI and prolonged coma during the years 2008 to 2015.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Demographics, clinical injury data, comorbidities, and complications were collected, and odds ratios (ORs) and descriptive analysis were calculated for mortality, long-term rehabilitation, and home discharge without services.

RESULTS

A total of 6929 patients with TBI and prolonged coma were included in the final analysis; 3318 (47.9%) were discharged to rehabilitation facilities, 1859 (26.8%) died, and 1752 (25.3%) were discharged home. Older patients and those with higher injury severity scores had significantly higher ORs for mortality and rehab discharge. A total of 58.3% of patients presented with at least one comorbidity. Non-White ethnicities and self-pay/uninsured patients were significantly less likely to be discharged to a rehab facility. Furthermore, comorbidities including congestive heart failure (CHF) and diabetes were associated with a significantly increased OR for mortality and rehab discharge compared to home discharge without services.

CONCLUSIONS

Comorbidities, age, and injury severity were the most significant risk factors for increased mortality and acute rehab discharge. Maximizing the treatment of comorbidities including CHF and diabetes has the potential to decrease mortality and adverse outcomes following TBI with prolonged coma.

The Australian Traumatic Brain Injury Initiative: Systematic Review and Consensus Process to Determine the Predictive Value of Demographic, Injury Event, and Social Characteristics on Outcomes for People With Moderate-Severe Traumatic Brain Injury

The objective of the Australian Traumatic Brain Injury (AUS-TBI) Initiative is to develop a data dictionary to inform data collection and facilitate prediction of outcomes of people who experience moderate-severe TBI in Australia. The aim of this systematic review was to summarize the evidence of the association between demographic, injury event, and social characteristics with outcomes, in people with moderate-severe TBI, to identify potentially predictive indicators. Standardized searches were implemented across bibliographic databases to March 31, 2022. English-language reports, excluding case series, which evaluated the association between demographic, injury event, and social characteristics, and any clinical outcome in at least 10 patients with moderate-severe TBI were included. Abstracts and full text records were independently screened by at least two reviewers in Covidence. A pre-defined algorithm was used to assign a judgement of predictive value to each observed association. The review findings were discussed with an expert panel to determine the feasibility of incorporation of routine measurement into standard care. The search strategy retrieved 16,685 records; 867 full-length records were screened, and 111 studies included. Twenty-two predictors of 32 different outcomes were identified; 7 were classified as high-level (age, sex, ethnicity, employment, insurance, education, and living situation at the time of injury). After discussion with an expert consensus group, 15 were recommended for inclusion in the data dictionary. This review identified numerous predictors capable of enabling early identification of those at risk for poor outcomes and improved personalization of care through inclusion in routine data collection.

Community Emergency Care Use by Veterans in an Era of Expanding Choice

Importance

Recently passed legislation aimed at improving access to care has considerably expanded options for veterans to receive emergency care in community, or non-Veterans Affairs (VA) settings. However, national trends in community emergency department (ED) use by veterans are unknown.

Objective

To examine national, temporal trends in the frequencies and types of ED visits provided in community settings and explore the association between facilities' purchase of community care with facility and regional characteristics.

Design, Setting, and Participants

Retrospective, observational cross-sectional study of ED visits over fiscal years (FY) 2016 to 2022. VA and community ED encounter data were obtained from the VA Corporate Data Warehouse and the Office of Integrated Veteran Care. Participants were veterans receiving ED care at VA facilities or paid for by the VA in the community. Data were analyzed from June to September 2023.

Main Outcomes and Measures

The primary outcome measures included community ED visit volume, disposition, and payments over time. Also, the most common and costly ED visits were assessed. Negative binomial regression analysis examined associations between facility and regional characteristics and the rate of ED visits purchased in community settings relative to all ED visits.

Results

There were 19 787 056 ED visits, predominantly at VA facilities (14 532 261 visits [73.4%]), made by 3 972 503 unique veterans from FY 2016 to 2022. The majority of ED users were male (3 576 120 individuals [90.0%]), and the median (IQR) age was 63 (48-73) years. The proportion of community ED visits increased in absolute terms from 18% in FY 2016 to 37% in FY 2022. Total community ED payments, adjusted to 2021 dollars, were $1.18 billion in FY 2016 and over $6.14 billion in FY 2022. The most common reasons for ED visits in the community were for nonspecific chest pain (305 082 visits [6%]), abdominal pain (174 836 visits [3%]), and septicemia (149 968 visits [3%]). The average proportion of ED visits purchased by a VA facility increased from 14% in FY 2016 to 32% by FY 2022. In multivariable analyses, facilities with greater ED volume and low-complexity facilities had higher expected rates of community emergency care than lower volume and high-complexity facilities, respectively.

Conclusions and Relevance

As veterans increasingly use community EDs for acute, unscheduled needs, attention to factors associated with veterans' use of acute care services in different settings are important to identify access barriers and to ensure veterans' health care needs are met.

Access to Rehabilitation After Hospitalization for Traumatic Brain Injury: A National Longitudinal Cohort Study in Sweden

BACKGROUND

Rehabilitation is suggested to improve outcomes following traumatic brain injury (TBI), however, the extent of access to rehabilitation among TBI patients remains unclear.

OBJECTIVE

To examine the level of access to rehabilitation after TBI, and its association with health and sociodemographic factors.

METHOD

We conducted a longitudinal cohort study using Swedish nationwide healthcare and sociodemographic registers. We identified 15 880 TBI patients ≥18 years hospitalized ≥3 days from 2008 to 2012 who were stratified into 3 severity groups; grade I (n = 1366; most severe), grade II (n = 5228), and grade III (n = 9268; least severe). We examined registered contacts with specialized rehabilitation or geriatric care (for patients ≥65 years) during the hospital stay, and/or within 1 year post-discharge. We performed a generalized linear model analysis to estimate the risk ratio (RR) for receiving specialized rehabilitation or geriatric care after a TBI based on sociodemographic and health factors.

RESULTS

Among TBI patients, 46/35% (grade I), 14/40% (grade II), and 5/18% (grade III) received specialized rehabilitation or geriatric care, respectively. Being currently employed or studying was positively associated (RR 1.7, 2.3), while living outside of a city area was negatively associated (RR 0.36, 0.79) with receiving specialized rehabilitation or geriatric care. Older age and a prior substance use disorder were negatively associated with receiving specialized rehabilitation (RR 0.51 and 0.81).

CONCLUSION

Our results suggest insufficient and unequal access to rehabilitation for TBI patients, highlighting the importance of organizing and standardizing post-TBI rehabilitation to meet the needs of patients, regardless of their age, socioeconomic status, or living area.

A retrospective review of patients who sustained traumatic brain injury in Ireland 2014-2019

INTRODUCTION

Traumatic brain injury (TBI) is the most significant cause of death and disability resulting from major trauma. The aim of this study is to describe the demographics of TBI patients, the current pathways of care and outcomes in the Republic of Ireland from 2014 to 2019.

METHODS

We performed a retrospective review of all TBI patients meeting inclusion criteria in Ireland's Major Trauma Audit (MTA) from 2014 to 2019. Severe TBI was defined as an abbreviated injury scale (AIS) ≥3 and GCS ≤8.

RESULTS

During the study period, 30,891 patients sustained major trauma meeting inclusion criteria for MTA, of which 7,393 (23.9%) patients met the inclusion criteria for TBI; 1,025 (13.9%) were classified as severe. The median age was 60.6 years (IQR 36.9-78.0), 54.3 years (32.8-73.4) for males and 71.7 years (50.0-83.0) for females (p<0.001). Of patients with severe TBI, 185 (18.0%) were brought direct to a neurosurgical centre, 389 (37.9%) were transferred to a neurosurgical centre and 321 (31.3%) had a neurosurgical intervention performed. In patients sustaining severe TBI, older patients (Adjusted OR, 0.96,95% CI 0.95-0.97) and patients requiring another surgery (OR 0.31, 95%CI 0.18-0.53) were less likely to be secondarily transferred to a neurosurgical centre. There were 47 (4.6%) patients with severe TBI discharged to rehabilitation. The 30-day mortality in Ireland was 11.6% in all TBI patients and 45.5% in severe TBI patients. Older patients and patients with higher ISS had a higher chance of death. Male patients, patients treated in neurosurgical centre, patients who had neurosurgery or non-neurosurgical surgery had a higher chance of survival.

CONCLUSION

This population-based study bench marks the 'as is' for patients with TBI in Ireland. We found that presently in Ireland, the mortality rate from severe TBI appears to be higher than that reported in international literature, and only a minority of severe TBI patients are brought directly from the incident to a neurosurgical centre. The new major trauma system should focus on providing effective and efficient access to neurosurgical, neuro-critical and neuro-rehabilitative care for patients who sustain TBI.

Factors influencing clinicians' referral or admission decisions for post-acute stroke or traumatic brain injury rehabilitation: A scoping review

Demand for post-acute stroke and traumatic brain injury (TBI) rehabilitation outweighs resource availability. Every day, clinicians face the challenging task of deciding which patient will benefit or not from rehabilitation. The objectives of this scoping review were to map and compare factors reported by clinicians as influencing referral or admission decisions to post-acute rehabilitation for stroke and TBI patients, to identify most frequently reported factors and those perceived as most influential. We searched four major databases for articles published between 1946 and January 2021. Articles were included if they reported clinicians' perceptions, investigated referral or admission decisions to post-acute rehabilitation, and focused on patients with stroke or TBI. Twenty articles met inclusion criteria. The International Classification of Functioning, Disability and Health framework was used to guide data extraction and summarizing. Patient-related factors most frequently reported by clinicians were age, mental status prior to stroke or TBI, and family support. The two latter were ranked among the most influential by clinicians working with stroke patients, whereas age was ranked of low importance. Organizational factors were reported to influence decisions (particularly the availability of post-acute care services) as well as clinicians' characteristics (eg, knowledge). Moreover, clinicians' prediction of patient outcome ranked among the most important driver of referral or admission decisions by clinicians working with stroke patients. Findings highlight the complex nature of decision-making regarding patient selection for rehabilitation and provide insight on important factors that frontline clinicians need to consider when having to make rapid decisions in high-pressured acute care environments.

Traumatic brain injury epidemiology and rehabilitation in Ireland: a protocol paper

Background: Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. In Ireland, a dearth of research means that we neither know the number of people affected by TBI, nor have the required data to improve neuro-rehabilitation services. This is a study protocol to examine the epidemiology and pathways through rehabilitation for a cohort of TBI survivors in the Republic of Ireland. Aims:  1. To document the epidemiological data of TBIs in Ireland. 2. To explore the pathway of TBI survivors through rehabilitation/health services. 3. To document the experiences of those providing care for TBI survivors in Ireland Methods: This is a quantitative cohort study. Existing routine datasets will be used to report epidemiological data. Participants with moderate or severe TBI will be recruited through two brain injury service providers, two acute hospitals that provide neurosurgical services, and the National Rehabilitation Hospital. Participants with TBI will be surveyed on two separate occasions, to explore their use of health and rehabilitation services. Those providing care or support to TBI survivors will be surveyed, on one occasion. Additionally, data from the medical records of TBI survivors will be extracted to capture key information about their TBI, such as mechanism of injury, severity, hospitalisation and follow-up. TBI survivors' use of health care will be followed prospectively for six months. Expected outcomes: The epidemiological data of TBI in Ireland will be documented. Data on survivors' experiences of how rehabilitation services are accessed, and any barriers encountered with rehabilitation/health services will be reported. The experiences of those providing care or support for TBI survivors will be captured. It is expected that the outcomes of the study will support advocacy efforts toward the redevelopment of neuro-rehabilitation services in the Republic of Ireland.

Cognitive-motor dissociation and time to functional recovery in patients with acute brain injury in the USA: a prospective observational cohort study

BACKGROUND

Recovery trajectories of clinically unresponsive patients with acute brain injury are largely uncertain. Brain activation in the absence of a behavioural response to spoken motor commands can be detected by EEG, also known as cognitive-motor dissociation. We aimed to explore the role of cognitive-motor dissociation in predicting time to recovery in patients with acute brain injury.

METHODS

In this observational cohort study, we prospectively studied two independent cohorts of clinically unresponsive patients (aged ≥18 years) with acute brain injury. Machine learning was applied to EEG recordings to diagnose cognitive-motor dissociation by detecting brain activation in response to verbal commands. Survival statistics and shift analyses were applied to the data to identify an association between cognitive-motor dissociation and time to and magnitude of recovery. The prediction accuracy of the model that was built using the derivation cohort was assessed using the validation cohort. Functional outcomes of all patients were assessed with the Glasgow Outcome Scale-Extended (GOS-E) at hospital discharge and at 3, 6, and 12 months after injury. Patients who underwent withdrawal of life-sustaining therapies were censored, and death was treated as a competing risk.

FINDINGS

Between July 1, 2014, and Sept 30, 2021, we screened 598 patients with acute brain injury and included 193 (32%) patients, of whom 100 were in the derivation cohort and 93 were in the validation cohort. At 12 months, 28 (15%) of 193 unresponsive patients had a GOS-E score of 4 or above. Cognitive-motor dissociation was seen in 27 (14%) patients and was an independent predictor of shorter time to good recovery (hazard ratio 5·6 [95% CI 2·5-12·5]), as was underlying traumatic brain injury or subdural haematoma (4·4 [1·4-14·0]), a Glasgow Coma Scale score on admission of greater than or equal to 8 (2·2 [1·0-4·7]), and younger age (1·0 [1·0-1·1]). Among patients discharged home or to a rehabilitation setting, those diagnosed with cognitive-motor dissociation consistently had higher scores on GOS-E indicating better functional recovery compared with those without cognitive-motor dissociation, which was seen as early as 3 months after the injury (odds ratio 4·5 [95% CI 2·0-33·6]).

INTERPRETATION

Recovery trajectories of clinically unresponsive patients diagnosed with cognitive-motor dissociation early after brain injury are distinctly different from those without cognitive-motor dissociation. A diagnosis of cognitive-motor dissociation could inform the counselling of families of clinically unresponsive patients, and it could help clinicians to identify patients who will benefit from rehabilitation.

FUNDING

US National Institutes of Health.

In the Aftermath of Acute Hospitalization for Traumatic Brain Injury: Factors Associated with the Direct Pathway into Specialized Rehabilitation

Previous research has demonstrated that early initiation of rehabilitation and direct care pathways improve outcomes for patients with severe traumatic brain injury (TBI). Despite this knowledge, there is a concern that a number of patients are still not included in the direct care pathway. The study aim was to provide an updated overview of discharge to rehabilitation following acute care and identify factors associated with the direct pathway. We analyzed data from the Oslo TBI Registry—Neurosurgery over a five-year period (2015–2019) and included 1724 adults with intracranial injuries. We described the patient population and applied multivariable logistic regression to investigate factors associated with the probability of entering the direct pathway. In total, 289 patients followed the direct pathway. For patients with moderate–severe TBI, the proportion increased from 22% to 35% during the study period. Significant predictors were younger age, low preinjury comorbidities, moderate–severe TBI and disability due to TBI at the time of discharge. In patients aged 18–29 years, 53% followed the direct pathway, in contrast to 10% of patients aged 65–79 years (moderate–severe TBI). This study highlights the need for further emphasis on entering the direct pathway to rehabilitation, particularly for patients aged >64 years.

The neuroethics of disorders of consciousness: a brief history of evolving ideas

Neuroethical questions raised by recent advances in the diagnosis and treatment of disorders of consciousness are rapidly expanding, increasingly relevant, and yet underexplored. The aim of this thematic review is to provide a clinically applicable framework for understanding the current taxonomy of disorders of consciousness and to propose an approach to identifying and critically evaluating actionable neuroethical issues that are frequently encountered in research and clinical care for this vulnerable population. Increased awareness of these issues and clarity about opportunities for optimizing ethically-responsible care in this domain are especially timely given recent surges in critically ill patients with unusually prolonged disorders of consciousness associated with coronavirus disease 2019 (COVID-19) around the world. We begin with an overview of the field of neuroethics: what it is, its history and evolution in the context of biomedical ethics at large. We then explore nomenclature used in disorders of consciousness, covering categories proposed by the American Academy of Neurology, the American Congress of Rehabilitation Medicine, and the National Institute on Disability, Independent Living, and Rehabilitation Research, including definitions of terms such as coma, the vegetative state, unresponsive wakefulness syndrome, minimally conscious state, covert consciousness, and the confusional state. We discuss why these definitions matter, and why there has been such evolution in this nosology over the years, from Jennett and Plum in 1972 to the Multi-Society Task Force in 1994, the Aspen Working Group in 2002 and up until the 2018 American and 2020 European Disorders of Consciousness guidelines. We then move to a discussion of clinical aspects of disorders of consciousness, the natural history of recovery, and ethical issues that arise within the context of caring for persons with disorders of consciousness. We conclude with a discussion of key challenges associated with assessing residual consciousness in disorders of consciousness, potential solutions and future directions, including integration of crucial disability rights perspectives.

Traumatic brain injury epidemiology and rehabilitation in Ireland: a protocol paper

Background: Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. In Ireland, a dearth of research on TBI means that we neither know the number of people affected by this injury, nor have the information required to improve neuro-rehabilitation services. Aims: This is the protocol for a study that will examine pathways through rehabilitation for survivors of TBI in the Republic of Ireland. The experiences of family members providing care or support to a person with TBI will also be explored. Additionally, the study will estimate the incidence and prevalence of TBI in Ireland. Epidemiological data and information on how people with TBI access rehabilitation and health services will support advocacy efforts towards the redevelopment of neuro-rehabilitation services. Methods: The research is a mixed method, observational cohort study design. Participants with moderate to severe TBI will be recruited through two brain injury service providers, two acute hospitals that provide neurosurgical services, and the National Rehabilitation Hospital. Questionnaires will be administered to participants with TBI on two separate occasions, six months apart, and to family members providing care or support to an individual with TBI, on one occasion. Data from the medical records of participants will be abstracted to capture key information about their brain injury. TBI survivor participants’ use of health care will be followed prospectively for six months.  Expected outcomes: The study will outline participants’ pathways through rehabilitation in Ireland, to understand how rehabilitation services are accessed, and the barriers to accessing these services. The incidence and prevalence of TBI in Ireland will be estimated. Experiences of family members providing care or support to an individual with TBI will be   detailed. The outcomes of the study will support ongoing efforts to improve care for TBI survivors in Ireland and to redevelop neuro-rehabilitation services.

Right people, right time? a qualitative study of service access experiences of adults with acquired brain injury following discharge from inpatient rehabilitation

Purpose:

The intention of this paper is to develop the personal concept of appropriate access. We report on the service access experiences and opportunities of adults with an acquired brain injury after leaving inpatient rehabilitation. The benefits of appropriate access underpin standards in early and long-term recovery, though users’ access needs are highly personal.

Methods:

The study used a qualitative design involving 16 semi-structured interviews with Australian adults with an acquired brain injury after discharge from inpatient brain rehabilitation. Data were thematically analysed.

Results:

Three main themes were derived from the analysis. Theme 1 shows that participants valued being steered to services that providers thought appropriate for them early after discharge from inpatient rehabilitation. Theme 2 highlights the tensions between timing and personal recovery and perceived needs. Theme 3 captures participants’ insights into the challenges of gaining access vis-a-vis what the system offers and the enablers of actualising appropriate access.

Conclusion:

The positive experiences of being directed to specialist services early after discharge suggest that continuity of care constitutes appropriateness of access for participants in this study. However, it is also clear that continuity should not displace flexibility in the timing of services, to accord with individuals’ perceived needs. This, in addition to enablement of access opportunities, through funding and transport, are important in maintaining a personalised approach.

Predictors of Access to Rehabilitation in the Year Following Traumatic Brain Injury: A European Prospective and Multicenter Study

BACKGROUND

Although rehabilitation is beneficial for individuals with traumatic brain injury (TBI), a significant proportion of them do not receive adequate rehabilitation after acute care.

OBJECTIVE

Therefore, the goal of this prospective and multicenter study was to investigate predictors of access to rehabilitation in the year following injury in patients with TBI.

METHODS

Data from a large European study (CENTER-TBI), including TBIs of all severities between December 2014 and December 2017 were used (N = 4498 patients). Participants were dichotomized into those who had and those who did not have access to rehabilitation in the year following TBI. Potential predictors included sociodemographic factors, psychoactive substance use, preinjury medical history, injury-related factors, and factors related to medical care, complications, and discharge.

RESULTS

In the year following traumatic injury, 31.4% of patients received rehabilitation services. Access to rehabilitation was positively and significantly predicted by female sex (odds ratio [OR] = 1.50), increased number of years of education completed (OR = 1.05), living in Northern (OR = 1.62; reference: Western Europe) or Southern Europe (OR = 1.74), lower prehospital Glasgow Coma Scale score (OR = 1.03), higher Injury Severity Score (OR = 1.01), intracranial (OR = 1.33) and extracranial (OR = 1.99) surgery, and extracranial complication (OR = 1.75). On contrast, significant negative predictors were lack of preinjury employment (OR = 0.80), living in Central and Eastern Europe (OR = 0.42), and admission to hospital ward (OR = 0.47; reference: admission to intensive care unit) or direct discharge from emergency room (OR = 0.24).

CONCLUSIONS

Based on these findings, there is an urgent need to implement national and international guidelines and strategies for access to rehabilitation after TBI.

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.

Lawsuit and Traumatic Brain Injury: The Relationship Between Long-Lasting Sequelae and Financial Compensation in Litigants. Results From the PariS-TBI Study

Purpose: People with traumatic brain injury are frequently involved in a litigation because another person was at fault for causing the accident. A compensation amount will often be settled to compensate the victim for the past, present, future damages and losses suffered. We report descriptive data about the full and final personal compensation amount and investigated its association with patient's outcomes.

Methods: We used a longitudinal prospective study of severe TBI patients injured in 2005–2007 (PariS-TBI). Questions regarding involvement in a litigation were asked concurrently with 4 and 8-year outcomes.

Results: Among 160 participants assessed 4 and/or 8 years post-injury, a total of 67 persons declared being involved in a litigation, among which 38 people reported a compensation amount of a mean €292,653 (standard deviation = 436,334; interquartile 25–50–75 = 37,000–100,000–500,000; minimum = 1,500-maximum = 2,000,000). A higher compensation amount was associated with more severe disability and cognitive impairment in patients, and with more informal care time provided by caregivers. However, no significant association related to patient's gender, age, years of education, motor/balance impairment, return to work status, mood and related to caregiver's subjective burden was found.

Conclusion: Financial compensation was related to victims' long-term severity of impairment, although some extreme cases with severe disability were granted very poor compensation.

Change in Function Over Inpatient Rehabilitation After Hypoxic Ischemic Brain Injury: A Population-Wide Cohort Study

OBJECTIVE

To estimate change in motor, cognitive, and overall functional performance during inpatient rehabilitation (IR) and to identify potential determinants of these outcomes among patients with hypoxic-ischemic brain injury (HIBI).

DESIGN

Population-based retrospective cohort study using Ontario's health administrative data.

SETTING

Inpatient rehabilitation.

PARTICIPANTS

Survivors of HIBI 20 years and older discharged from acute care between fiscal years 2002-2003 and 2010-2011 and admitted to IR within 1 year of acute care discharge (N=159).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Functional status as measured by FIM, total, and scores on motor and cognitive subscales.

RESULTS

A higher proportion (77%) of HIBI patients in the study were male and 28% were older than 65 years. We observed material improvements in FIM total, motor, and cognitive scores from across the IR episode. Potential determinants of total FIM gain were living in rural location (β, 10.4; 95% CI, 0.21-21), having shorter preceding acute care length of stay (15-30 vs >60 days β, 10.4; 95% CI, 1.4-19.5), and failing to proceed directly to IR following acute care discharge (β, 8.7; 95% CI, 1.8-15.5). Motor FIM gain had similar identified potential determinants. Identified potential determinants of cognitive FIM gain were shorter (ie, 31-60 vs >60 days) preceding acute care, longer IR and length of stay, and proceeding directly to IR. There were no sex differences in functional gain.

CONCLUSIONS

Inpatient rehabilitation is beneficial to HIBI survivors. Timely access to these services may be crucial in achieving optimal outcomes for these patients.

Evidence-based position paper on Physical and Rehabilitation Medicine professional practice for Adults with Acquired Brain Injury. The European PRM position (UEMS PRM Section)

BACKGROUND

Acquired brain injury (ABI) is damage to the brain that occurs after birth caused either by a traumatic or by a nontraumatic injury. The rehabilitation process following ABI should be performed by a multi-professional team, working in an interdisciplinary way, with the aim of organizing a comprehensive and holistic approach to persons with every severity of ABI. This Evidence Based Position Paper represents the official position of the European Union through the UEMS Physical and Rehabilitation Medicine (PRM) Section and designates the professional role of PRM physicians for people with ABI. The aim was to formulate recommendations on the PRM physician's professional practice for persons with ABI in order to promote their functioning and enhance quality of life.

METHODS

This paper has been developed according to the methodology defined by the Professional Practice Committee of the UEMS-PRM Section: a systematic literature search has been performed in PubMed and Core Clinical Journals. On the basis of the selected papers, recommendations have been made as a result of five Delphi rounds.

RESULTS

The literature review as well as thirty-one recommendations are presented.

CONCLUSIONS

The expert consensus is that structured, comprehensive and holistic rehabilitation program delivered by the multi-professional team, working in an interdisciplinary way, with the leadership and coordination of the PRM physician, is likely to be effective, especially for those with severe disability after brain injury.

Late Functional Changes Post-Severe Traumatic Brain Injury Are Related to Community Reentry Support: Results From the PariS-TBI Cohort

OBJECTIVES

To explore late functional changes after a traumatic brain injury and their relation to patients' characteristics and reentry support.

DESIGN

Prospective follow-up of an inception cohort of adults with severe traumatic brain injury recruited in 2005-2007 in the Parisian area, France. One and 4-year assessments were performed by trained neuropsychologists. One-to-4-year change in the Glasgow Outcome Scale-Extended defined 3 groups: "improvement," "stability," and "worsening." Relationships between these groups and patients' characteristics were analyzed.

RESULTS

Among 504 recruited patients and 245 four-year survivors, 93 participated in both evaluations. Overall Glasgow Outcome Scale-Extended improved by 0.4. Forty percent of the sample improved, 44% were stable, and 16% worsened. Being in a more unfavorable group was related to preinjury alcohol abuse and to higher anxiety and depression at 4 years. Attendance to a specialized community reentry unit was related to higher chances of being in the "improvement" group in univariate analyses and after adjustment for age, time to follow command, preinjury alcohol and occupation, and mood disorders (adjusted odds ratio [OR] = 4.6 [1.1-20]).

CONCLUSION

Late functional changes were related to psychosocial variables and to reentry support. The effect of reentry support on late recovery needs to be confirmed by further investigations.

Objective and Subjective Burden of Informal Caregivers 4 Years After a Severe Traumatic Brain Injury: Results From the PariS-TBI Study

OBJECTIVE

Prospective assessment of informal caregiver (IC) burden 4 years after the traumatic brain injury of a relative.

SETTING

Longitudinal cohort study (metropolitan Paris, France).

PARTICIPANTS

Home dwelling adults (N = 98) with initially severe traumatic brain injury and their primary ICs.

MAIN OUTCOME MEASURES

Informal caregiver objective burden (Resource Utilization in Dementia measuring Informal Care Time [ICT]), subjective burden (Zarit Burden Inventory), monetary self-valuation of ICT (Willingness-to-pay, Willingness-to-accept).

RESULTS

Informal caregivers were women (81%) assisting men (80%) of mean age of 37 years. Fifty-five ICs reported no objective burden (ICT = 0) and no/low subjective burden (average Zarit Burden Inventory = 12.1). Forty-three ICs reported a major objective burden (average ICT = 5.6 h/d) and a moderate/severe subjective burden (average Zarit Burden Inventory = 30.3). In multivariate analyses, higher objective burden was associated with poorer Glasgow Outcome Scale-Extended scores, with more severe cognitive disorders (Neurobehavioral Rating Scale-revised) and with no coresidency status; higher subjective burden was associated with poorer Glasgow Outcome Scale-Extended scores, more Neurobehavioral Rating Scale-revised disorders, drug-alcohol abuse, and involvement in litigation. Economic valuation showed that on average, ICs did not value their ICT as free and preferred to pay a mean Willingness-to-pay = &OV0556;17 per hour to be replaced instead of being paid for providing care themselves (Willingness-to-accept = &OV0556;12).

CONCLUSION

Four years after a severe traumatic brain injury, 44% of ICs experienced a heavy multidimensional burden.

Loss to Follow-Up and Social Background in an Inception Cohort of Patients With Severe Traumatic Brain Injury: Results From the PariS-TBI Study

OBJECTIVES

To assess determinants of loss to follow-up (FU) at 2 time points of an inception traumatic brain injury (TBI) cohort.

DESIGN AND PARTICIPANTS

The PariS-TBI study consecutively included 504 adults with severe TBI on the accident scene (76% male, mean age 42 years, mean Glasgow Coma Scale 5). No exclusion criteria were used.

MAIN MEASURE

Loss to FU at 1 and 4 years was defined among survivors as having no outcome data other than survival status.

RESULTS

Among 257 1-year survivors, 118 (47%) were lost to FU at 1 year and 98 (40%) at 4 years. Main reasons for loss to FU were impossibility to achieve contact (109 at 1 year, 52 at 4 years) and refusal to participate (respectively 5 and 24). At 1 year, individuals not working preinjury or with nonaccidental traumas were more often lost to FU in univariate and multivariable analyses. At 4 years, loss to FU was significantly associated with preinjury alcohol abuse and unemployment. Relationship with injury severity was not significant.

CONCLUSIONS

Socially disadvantaged persons are underrepresented in TBI outcome research. It could result in overestimation of outcome and biased estimates of sociodemographic characteristics' effects. These persons, particularly unemployed individuals, require special attention in clinical practice.

Clinicians' perceptions of decision making regarding discharge from public hospitals to in-patient rehabilitation following trauma

Objective The aim of the present study was to investigate the perceptions of consultant surgeons, allied health clinicians and rehabilitation consultants regarding discharge destination decision making from the acute hospital following trauma. Methods A qualitative study was performed using individual in-depth interviews of clinicians in Victoria (Australia) between April 2013 and September 2014. Thematic analysis was used to derive important themes. Case studies provided quantitative information to enhance the information gained via interviews. Results Thirteen rehabilitation consultants, eight consultant surgeons and 13 allied health clinicians were interviewed. Key themes that emerged included the importance of financial considerations as drivers of decision making and the perceived lack of involvement of medical staff in decisions regarding discharge destination following trauma. Other themes included the lack of consistency of factors thought to be important drivers of discharge and the difficulty in acting on trauma patients' requests in terms of discharge destination. Importantly, as the complexity of the patient increases in terms of acquired brain injury, the options for rehabilitation become scarcer. Conclusions The information gained in the present study highlights the large variation in discharge practises between and within clinical groups. Further consultation with stakeholders involved in the care of trauma patients, as well as government bodies involved in hospital funding, is needed to derive a more consistent approach to discharge destination decision making. What is known about the topic? Little is known about the drivers for referral to, or acceptance at, in-patient rehabilitation following acute hospital care for traumatic injury in Victoria, Australia, including who makes these decisions of behalf of patients and how these decisions are made. What does this paper add? This paper provides information regarding the perceptions of acute hospital consultant surgeons and allied health, as well as rehabilitation clinicians, in terms of discharge destination decision making from the acute hospital following trauma. The use of case studies further highlights differences between, and within, these specialities with regard to this decision making. This research also highlights the importance of financial considerations as drivers of decision making, and the lack of consistency of the factors thought to be important drivers of discharge between these different clinical groupings. What are the implications for practitioners? This research shows that financial factors are significant drivers of discharge destination decision making for trauma patients. The present study highlights opportunities to engage with stakeholders (acute care, rehabilitation, administration, government and patients) to develop more consistent discharge processes that optimise the use of rehabilitation resources for those patients who could benefit from in-patient rehabilitation.

Integrated Health Care Management of Moderate to Severe TBI in Older Patients-A Narrative Review

PURPOSE OF REVIEW

Traumatic brain injuries are common, especially within the elderly population, which is typically defined as age 65 and older. This narrative review aims at summarizing and critically evaluating important aspects of their health care management in covering the entire pathway from prehospital care to rehabilitation and beyond.

RECENT FINDINGS

The number of older patients with traumatic brain injury (TBI) is increasing, and there seem to be differences in all aspects of care along their pathway when compared to younger patients. Despite a higher mortality and a generally less favorable outcome, the current literature shows that older TBI patients have the potential to make significant improvements over time. More research is needed to evaluate the most efficient and integrated clinical pathway from prehospital interventions to rehabilitation as well as the optimal treatment of older TBI patients. Most importantly, they should not be denied access to specific treatments and therapies only based on age.

Self-awareness four years after severe traumatic brain injury: discordance between the patient’s and relative’s complaints. Results from the PariS-TBI study

Objective:

To evaluate the patient’s awareness of his or her difficulties in the chronic phase of severe traumatic brain injury (TBI) and to determine the factors related to poor awareness.

Design/Setting/Subjects:

This study was part of a larger prospective inception cohort study of patients with severe TBI in the Parisian region (PariS-TBI study).

Intervention/Main measures:

Evaluation was carried out at four years and included the Brain Injury Complaint Questionnaire (BICoQ) completed by the patient and his or her relative as well as the evaluation of impairments, disability and quality of life.

Results:

A total of 90 patient-relative pairs were included. Lack of awareness was measured using the unawareness index that corresponded to the number of discordant results between the patient and relative in the direction of under evaluation of difficulties by the patient. The only significant relationship found with lack of awareness was the subjective burden perceived by the relative (Zarit Burden Inventory) ( r = 0.5; P < 0.00001). There was no significant relationship between lack of awareness and injury severity, pre-injury socio-demographic data, cognitive impairments, mood disorders, functional independence (Barthel index), global disability (Glasgow Outcome Scale), return to work at four years or quality of life (Quality Of Life after Brain Injury scale (QOLIBRI)).

Conclusion:

Lack of awareness four years post severe TBI was not related to the severity of the initial trauma, sociodemographic data, the severity of impairments, limitations of activity and participation, or the patient’s quality of life. However, poor awareness did significantly influence the weight of the burden perceived by the relative.

Dynamics of clinical recovery during the early phase of rehabilitation in patients with severe traumatic and non-traumatic brain injury

PURPOSE

Our aim was to describe the changes in the functional outcome at the early phase of rehabilitation following severe brain injury and to identify the factors associated with faster recovery.

METHODS

This retrospective analysis included 182 patients who were transferred from the intensive care unit (ICU) to a post-ICU neurorehabilitation unit following traumatic brain injury (TBI) (n = 82) or cerebrovascular accident (CVA) (n = 100). Admission, discharge and changes in scores were calculated for the Functional Independent Measurement (FIM) and the Wessex Head Injury Matrix (WHIM). Patients with high dynamics of clinical recovery were defined by delta FIM scores ≥22.

RESULTS

Upon admission to the neurorehabilitation unit, 97% of patients had a FIM score <50 and 41% a WHIM score <32. Patients showed significantly improved FIM (+17 points; 7-37) and WHIM (+11 points; 3-19) scores with an over 22-day stay (14-38). Those with faster recovery (45%) were more likely those with high FIM and WHIM scores at admission. The nature and severity of the brain insult were not associated with the dynamics of recovery.

CONCLUSIONS

Within a 2-6 week stay in a post-ICU neurorehabilitation unit, patients with severe disability could achieve partial functional independence and showed cognitive improvements.

Employment outcome four years after a severe traumatic brain injury: results of the Paris severe traumatic brain injury study

OBJECTIVE

To describe employment outcome four years after a severe traumatic brain injury by the assessment of individual patients' preinjury sociodemographic data, injury-related and postinjury factors.

DESIGN

A prospective, multicenter inception cohort of 133 adult patients in the Paris area (France) who had received a severe traumatic brain injury were followed up postinjury at one and four years. Sociodemographic data, factors related to injury severity and one-year functional and cognitive outcomes were prospectively collected.

METHODS

The main outcome measure was employment status. Potential predictors of employment status were assessed by univariate and multivariate analysis.

RESULTS

At the four-year follow-up, 38% of patients were in paid employment. The following factors were independent predictors of unemployment: being unemployed or studying before traumatic brain injury, traumatic brain injury severity (i.e., a lower Glasgow Coma Scale score upon admission and a longer stay in intensive care) and a lower one-year Glasgow Outcome Scale-Extended score.

CONCLUSION

This study confirmed the low rate of long-term employment amongst patients after a severe traumatic brain injury. The results illustrated the multiple determinants of employment outcome and suggested that students who had received a traumatic brain injury were particularly likely to be unemployed, thus we propose that they may require specific support to help them find work. Implications for rehabilitation Traumatic brain injury is a leading cause of persistent disablity and can associate cognitive, emotional, physical and sensory impairments, which often result in quality-of-life reduction and job loss. Predictors of post-traumatic brain injury unemployment and job loss remains unclear in the particular population of severe traumatic brain injury patients. The present study highlights the post-traumatic brain injury student population require a close follow-up and vocational rehabilitation. The study suggests that return to work post-severe traumatic brain injury is frequently unstable and workers often experience difficulties that caregivers have to consider.

Negative impact of litigation procedures on patient outcomes four years after severe traumatic brain injury: results from the PariS-traumatic brain injury study

PURPOSE

To analyze the effect of litigation procedures on long-term outcomes in severe traumatic brain injury.

MATERIALS AND METHODS

Prospective observational follow-up of an inception cohort including 504 adults with severe traumatic brain injury recruited in 2005-2007 in the Parisian area, France, with initial, one- and four-year outcomes measures.

RESULTS

Four years after the traumatic brain injury, 147 patients, out of 257 who survived the acute phase, were assessed. Among these patients, 53 patients declared being litigants and 78 nonlitigants (litigation status was unknown in 16 cases). Sociodemographic characteristics, type of injury and initial severity did not differ significantly between litigants and nonlitigants, except for Injury Severity Score (worse in litigants) and the proportion of road traffic accidents (higher in litigants). One- and four-year outcomes were significantly worse in litigants for autonomy, participation, psychiatric and cognitive function but not quality of life (measured with the Glasgow Outcome Scale-Extended, the working activity status, the Brain Injury Community Rehabilitation Outcome, the Hospital Anxiety and Depression scale, the Neurobehavioral Rating Scale-revised and the Quality of Life after Brain Injury, respectively). Multivariate analyses highlighted litigation procedure as an independent significant predictor of lower autonomy, participation and psychiatric function and tended to predict lower cognitive function, but not lower quality of life, after adjustment for pretrauma characteristics, Injury Severity Score, road traffic accidents and work-related accident status.

CONCLUSIONS

Patients with severe traumatic brain injury have a worse prognosis when involved in a litigation procedure and require special attention in clinical practice. Implications for rehabilitation The influence of litigation procedure on health and social outcomes in severe traumatic brain injury is a major issue that entail numerous levels of complexities. A wide range of interactions and factors related to the prolonged process of litigation against a third party may influence recovery. Results from the PariS-Traumatic Brain Injury study suggest that patients with a severe Traumatic Brain Injury who are involved in a litigation procedure within French jurisdiction compensation scheme have a worse prognosis than patients who do not. Health professionals should be aware of the potential adverse effects of litigation procedures on recovery, and provide appropriate interventions and information to patients and families in such cases.

Traumatic brain injury among female offenders in a prison population: results of the FleuryTBI study

AIM

The study was designed to estimate the prevalence of traumatic brain injury (TBI) in a French prison population of female offenders, study the variables known to be associated with TBI, and compare our results with those obtained among male offenders as described in a previous paper.

PARTICIPANTS

All female offenders (adults and juveniles) consecutively admitted to Fleury-Mérogis prison over a 3-month period were included in the study.

METHOD

During the admission procedure, female offenders were interviewed by healthcare staff using a self-reported questionnaire.

RESULTS

In all, 100 female offenders were included. The rate of self-reported TBI was high, with a prevalence of 21%. The first cause of TBI was violence related (35%) and a majority of female offenders with a history of TBI reported having sustained more than one TBI. When compared with those who did not report a TBI, epilepsy and use of alcohol were higher among female offenders with a history of TBI. Perceived health was significantly worse for women who reported a TBI.

CONCLUSIONS

This study findings provide additional evidence that TBI among offender populations is serious and that specific actions need to be developed and implemented in correctional settings such as screening for TBI upon arrival.

Recurrence of heterotopic ossification after removal in patients with traumatic brain injury: A systematic review

OBJECTIVE

A systematic review of the literature to determine whether in patients with neurological heterotopic ossification (NHO) after traumatic brain injury, the extent of the neurological sequelae, the timing of surgery and the extent of the initial NHO affect the risk of NHO recurrence.

DATA SOURCES

We searched MEDLINE via PubMed and Cochrane library for articles published up to June 2015. Results were compared with epidemiological studies using data from the BANKHO database of 357 patients with central nervous system (CNS) lesions who underwent 539 interventions for troublesome HO.

RESULTS

A large number of studies were published in the 1980s and 1990s, most showing poor quality despite being performed by experienced surgical teams. Accordingly, results were contradictory and practices heterogeneous. Results with the BANKHO data showed troublesome NHO recurrence not associated with aetiology, sex, age at time of CNS lesion, multisite HO, or "early" surgery (before 6months). Equally, recurrence was not associated with neurological sequelae or disease extent around the joint.

CONCLUSIONS

The recurrence of NHO is not affected by delayed surgery, neurological sequelae or disease extent around the joint. Surgical excision of NHO should be performed as soon as comorbid factors are under control and the NHO is sufficiently constituted for excision.

Prevalence of traumatic brain injury and epilepsy among prisoners in France: Results of the Fleury TBI study

OBJECTIVE

The first aim of this study was to estimate the prevalence of TBI and epilepsy in a French prison population and to study variables known to be associated with TBI. The second aim was to compare prisoners with and without a history of TBI.

PARTICIPANTS

All offenders (females, males and juveniles) admitted consecutively to Fleury-Mérogis prison over a period of 3 months were included in the study.

DESIGN

During the admission procedure, offenders were interviewed by healthcare staff using a self-reported questionnaire.

RESULTS

In all, 1221 prisoners were included. The rates of TBI and epilepsy were high, with a prevalence of 30.6% and 5.9%, respectively. Psychiatric care, anxiolytic and antidepressant treatment, use of alcohol and cannabis were all significantly higher among offenders with a history of TBI. Moreover, the number of times in custody and the total time spent in jail over the preceding 5 years were significantly higher among offenders with a history of TBI.

CONCLUSIONS

These results provide further evidence that specific measures need to be developed such as, first of all, screening for TBI upon arrival in prison.

Associations between care pathways and outcome 1 year after severe traumatic brain injury

OBJECTIVE

To assess associations between real-world care pathways for working-age patients in the first year after severe traumatic brain injury and outcomes at 1 year.

SETTING AND DESIGN

Prospective, observational study with recruitment from 6 neurosurgical centers in Sweden and Iceland. Follow-up to 1 year, independently of care pathways, by rehabilitation physicians and paramedical professionals.

PARTICIPANTS

Patients with severe traumatic brain injury, lowest (nonsedated) Glasgow Coma Scale score 3 to 8 during the first 24 hours and requiring neurosurgical intensive care, age 18 to 65 years, and alive 3 weeks after injury.

MAIN MEASURES

Length of stay in intensive care, time between intensive care discharge and rehabilitation admission, outcome at 1 year (Glasgow Outcome Scale Extended score), acute markers of injury severity, preexisting medical conditions, and post-acute complications. Logistic regression analyses were performed.

RESULTS

A multivariate model found variables significantly associated with outcome (odds ratio for good outcome [confidence interval], P value) to be as follows: length of stay in intensive care (0.92 [0.87-0.98], 0.014), time between intensive care discharge and admission to inpatient rehabilitation (0.97 [0.94-0.99], 0.017), and post-acute complications (0.058 [0.006-0.60], 0.017).

CONCLUSIONS

Delays in rehabilitation admission were negatively associated with outcome. Measures to ensure timely rehabilitation admission may improve outcome. Further research is needed to evaluate possible causation.

Determinants of Admission to Inpatient Rehabilitation Among Acute Care Survivors of Hypoxic-Ischemic Brain Injury: A Prospective Population-Wide Cohort Study

OBJECTIVE

To investigate demographic and acute care clinical determinants of admission to inpatient rehabilitation (IR) among patients with hypoxic-ischemic brain injury (HIBI) who survive the initial acute care episode.

DESIGN

Population-wide prospective cohort study using Canadian Institutes for Health Information administrative health data from Ontario, Canada. All patients who survived their HIBI acute care episode during the study period remained eligible for the outcome, admission to IR, for 1 year postacute care discharge.

SETTING

Inpatient rehabilitation.

PARTICIPANTS

We included all patients with HIBI using International Classification of Diseases, Tenth Revision, Canadian Enhancement codes recorded at acute care admission who were ≥20 years old (N=599) and discharged from acute care between the 2002 and 2010 fiscal years, inclusive. Six patients were excluded from analyses because of missing data.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Admission to IR.

RESULTS

Of HIBI survivors admitted to IR within 1 year of acute care discharge (n=169), most (56.2%) had an IR admitting diagnosis indicating anoxic brain damage. Younger age, being a man, lower comorbidity burden, longer length of stay of preceding acute care episode, and shorter duration in special care were most predictive of admission to IR in multivariable regression models. Women had an almost 2-fold lower incidence of admission to IR (risk ratio, .62; 95% confidence interval, .46-.84).

CONCLUSIONS

Older age, higher comorbidity burden, and shorter lengths of stay and delayed discharge from acute care are associated with lower incidence of IR admission for patients with HIBI. That women are almost 2-fold less likely to receive rehabilitation requires further investigation.

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.

A pilot project of early integrated traumatic brain injury rehabilitation in singapore

Objective. Document acute neurosurgical and rehabilitation parameters of patients of all traumatic brain injury (TBI) severities and determine whether early screening along with very early integrated TBI rehabilitation changes functional outcomes. Methods. Prospective study involving all patients with TBI admitted to a neurosurgical department of a tertiary hospital. They were assessed within 72 hours of admission by the rehabilitation team and received twice weekly rehabilitation reviews. Patients with further rehabilitation needs were then transferred to the attached acute inpatient TBI rehabilitation unit (TREATS) and their functional outcomes were compared against a historical group of patients. Demographic variables, acute neurosurgical characteristics, medical complications, and rehabilitation outcomes were recorded. Results. There were 298 patients screened with an average age of 61.8 ± 19.1 years. The most common etiology was falls (77.5%). Most patients were discharged home directly (67.4%) and 22.8% of patients were in TREATS. The TREATS group functionally improved (P < 0.001). Regression analysis showed by the intervention of TREATS, that there was a statistically significant FIM functional gain of 18.445 points (95% CI −30.388 to −0.6502, P = 0.03). Conclusion. Our study demonstrated important epidemiological data on an unselected cohort of patients with TBI in Singapore and functional improvement in patients who further received inpatient rehabilitation.