This Article

Citations


Creative Commons License
Except where otherwise noted, this work is licensed under Creative Commons Attribution-NonCommercial 4.0 International License.

Early Rehabilitation in Head Injury; Can We Improve the Outcomes?


1 Osborn Neurorehabilitation Unit, Northern General Hospital, UK
*Corresponding author: Rajiv Singh, Osborn Neurorehabilitation Unit, Northern General Hospital, UK. Tel.: +44-114215651, Fax: +44-1142715649, E-mail: rajiv.singh@sth.nhs.uk.
Archives of Trauma Research. 2013 December; 2(3): 103-107. , DOI: 10.5812/atr.13665
Article Type: Research Article; Received: Jul 17, 2013; Accepted: Oct 13, 2013; epub: Dec 1, 2013; ppub: Dec 1, 2013

Abstract


Background: The quality of care after head injury is still very variable with a little coordination\n between different specialties. Acute care dominates, often with little regard to\n rehabilitation needs.

Objectives: To improve the outcomes of all head injury admissions to hospital, including mild and\n moderate, by creating a head injury team to supervise a rehabilitation clinical\n pathway.

Patients and Methods: A head injury team was established to manage the care of all non-neurosurgical\n admissions with head injury to a large teaching hospital. Apart from inpatient care, the\n team coordinates various services involved in the care of head injuries, arranged\n suitable follow-ups, supported relatives and trained healthcare staff on general wards\n in the treatment of head injured patients. Follow-up clinics at 6 weeks and 6 months\n were arranged.

Results: In the first three years, the team managed the care of 812 admissions. Mean age was\n 44.3 years (SD = 24.8) and mean length of hospital stay was 6.1 days (SD = 10.9). Of\n these individuals, 674 attended for 6 month follow-up with 52.2% having a good outcome\n on Extended Glasgow outcome score. Patients and their relatives' feedbacks were\n excellent with an average score of 4.7/5 on overall satisfaction rating. Following\n presentations at national meetings and elsewhere, other centers in the United Kingdom\n are now setting up similar pathways.

Conclusions: A dedicated clinical pathway and head injury team can improve the quality of care for\n all admissions with head injury and enhance the role for rehabilitation medicine input\n at an early stage.

Keywords: Craniocerebral Trauma; Critical Pathways; Healthcare Quality; Physical and Rehabilitation Medicine

1. Background


The management of head injury demands a wide variety of specialist skills and presents
complex problems. Many individuals never seek medical advice or are discharged from accident
and emergency departments with no follow-up and there is a high level of unmet need (1). Those with a severe injury are usually admitted
to the neurosurgical or orthopaedic wards. But they are lucky if they receive neurological
rehabilitation afterwards or ongoing referral for rehabilitation in the community.
Furthermore, the management of those with mild or moderate injury is even more variable and
patients can receive a wide range of care. Those who are admitted may end up under a number
of different specialties; brain injury specialists in rehabilitation medicine are rarely
involved at an early stage. There is no coordination of overall care needs and the lack of
responsibility leaves patients and families with an unsatisfactory service and hospitals
with a clinical governance risk. This situation is common all over the United Kingdom. In
order to address this unhappy situation, we introduced an acute brain injury care pathway in
Sheffield. The aim was to improve the caring quality for all brain injury admissions, not
just those with a severe brain injury. Prior to the introduction of the pathway, head
injuries in this region were admitted to different departments depending on their immediate
need on admission without any thought to an overall coordination of care. Such specialties
included general surgery, orthopaedics, neurosurgery, ENT, care of elderly, A&E beds or
could be discharged the same day.


After admission there was no specialist input from a team specialized in brain injury.
Patients were often being discharged with little support or regard for social circumstances.
Their families were often put under great strain and the lack of coordinated follow up and
inconsistencies in quality of care put the hospital at significant clinical governance
risk.


The introduction of national policies and standards including the national services
framework for long-term neurological conditions (NSF) and National Institute for Clinical
Excellence (NICE) head injury guidelines in 2005 (2, 3) created a
drive to develop head injury services. It was clear that many of the guideline requirements
could be met by an appropriate head injury pathway, coordinated to meet the needs of
patients. Since then, there have been further initiatives to improve the quality of major
trauma services nationally. This has added to the impetus to improve head injury care
(4, 5).


In recent years, many different areas of medical practice have developed clinical pathways
using a multidisciplinary team approach to set standards, assess quality of care, measure
performance and avoid inconsistencies of care (6-8). Such pathways are
attractive because they improve the quality of care and safety for patients and hopefully
improve the outcomes (9, 10). However, a literature search using
MEDLINE and EMBASE revealed little in the published literature as regards use of such
pathways in head injury management. In severe brain injury, a pathway has been shown to
improve some patient outcomes and reduce costs (11). A significant study by Fakhry et al. found that the outcomes could be
improved but only included severe brain injuries (12). Other studies have shown that a pathway reduced the
length of stay but other outcomes were unchanged (13, 14).
However the aim in Sheffield was to improve the care of all admitted injuries not just the
most severe injuries. There is a growing awareness of the significant risks to even those
with moderate and mild brain injury (15) and the development of head injury guidelines has resulted in many such
patients being admitted for overnight observation and management (16, 17). The aims of the pathway was to reduce the variations in quality of care
for all admissions with TBI, to bring all admissions under a specialist in brain injury and
to aid compliance with meeting national recommendations for head injury care. Clinical
governance and patient safety are of vital importance and it was hoped that eventually it
would be possible to show an improvement in long-term patient outcomes.

2. Objectives


To improve the outcomes of all head injury admissions to hospital, including mild and
moderate, by creating a head injury team to supervise a rehabilitation clinical pathway.

3. Materials and Methods


A taskforce was set up by a group of key brain injury stakeholders. This included local
government, community health providers and voluntary sector organisations as well as
hospital departments which routinely admit head injury patients. It was important that all
TBI patients were included in the pathway. Six beds were set up as the head injury
observations unit (HIOU). An acute brain injury team (ABIT) was created based in the
rehabilitation medicine department to have the responsibility for the care of patients
admitted to these beds. The team consists of a brain injury specialist doctor, a clinical
nurse specialist and a brain injury social worker.


All patients with head injury or suspected injuries are admitted to the observation unit.
Criteria for admission are based on the NICE guidelines for head injury (3). These are extensive but include abnormal
CT scans not admitted to neurosurgery, diminished Glasgow coma score or any unresolved
clinical concerns that preclude discharge (e.g. alcohol intoxication). The unit can also
take step-down patients from ITU while a management plan is made for ongoing care or
management.


The pathway does not specify the exact treatment required in each the parent specialties
involved in head injury care. For instance it has not produced protocols for ITU, ENT or
neurosurgical management; these protocols remain the responsibility of the relevant
departments. The pathway is about coordinating overall care and being responsible for
patients who do not fall clearly into specialties such as neurosurgery. Those patients
initially admitted to neurosurgery or ITU are again taken up by the brain injury team on
discharge from those units.


Each day, the team joined the emergency ward rounds and take over the care of any patients
admitted the previous day. Referrals from other units such as care of elderly can be seen
and patients either taken over or advice given. The ABIT is therefore a key link between the
varying elements of services that are involved in brain injury, including neurosciences,
surgery, ENT, general medicine and care of elderly as well as community services. The team
provides smooth transitions between services as required and facilitates appropriate follow
ups or reviews by relevant specialists and ascribes to the use of a rehabilitation model at
an early stage to improve patient service and outcome.


Patients received therapy input from neurorehabilitation staff who have the appropriate
skill set and training for the head injury group. The team manages patients’ care
needs on the observation unit and if longer term in-patient care is required for brain
injury rehabilitation then patients can be transferred to the main neurorehabilitation ward
itself. This is useful for those with more severe injury who require a longer stay or for
assessing detailed cognitive problems and safety issues for discharge.


Relatives are often forgotten the acute settings (18) have to deal with ill patients on discharge. Caregiver
stress is recognized as a significant problem (19-21). Considerable evidence
is emerging that interventions directed at family support can be effective (19, 22). The team was active in supporting families to fulfill their role. The
social worker has a key role to play the interface with relatives and can point to the
resources such as local head injury groups, benefit agencies and several leaflets developed
by the group. On discharge, patients are given contact numbers for continuing support and a
referral to community brain injury services is made if needed.

4. Results


To facilitate the new pathway, a number of operational policies, referral and transfer
criteria, discharge checklist and documentation pro forma had to be devised for head injury
observation. A head injury follow-up clinic has been set up for all patients including those
discharged from emergency department within 24 hours. At the clinic, any on-going problem is
identified and appropriate assessments undertaken. It is known that 5% of even mild head
injuries have significant disabling symptoms at the first year and the appropriate
management of mild TBI can reduce the incidence of these symptoms (23, 24). The aim of the clinic is to reassure patients and treat any persisting
symptoms or complications.


A key benefit of the pathway was to educate other health staff as to the significance of
head injury and its treatment. Intuitively, the training of staff and increased confidence
in dealing with head injury should improve outcomes. However, this is difficult to show the
use of appropriate objective outcome measures. A rolling program to train nursing staff,
junior doctors and therapists is in place and the profile of head injury management has been
raised across the region. Indeed the pathway has been highlighted nationally through the
British society of rehabilitation medicine and other professional bodies as a model of
excellence. Presentations on one year data at national and international meetings have
highlighted the strengths of such a service and other regional units are looking at the
pathway in order to try and recreate similar systems elsewhere. The pathway has featured in
the local press and the team lectured on various aspects of brain injury extensively. The
team acted as advocates for the importance of brain injury services and hopefully will
influence future service development.


In the last year, the United Kingdom has followed models of trauma care in other countries,
most notably the United States and has set up regional major trauma centers (4, 5). An important part in caring such individuals is the rehabilitation that
they receive (25). The resulting
development of trauma rehabilitation in the United Kingdom has acted as a fresh impetus to
the role of rehabilitation medicine specialists in the acute stages of traumatic injury and
the brain injury team has been pivotal in the development of national as well as the local
trauma rehabilitation systems.


For those of us who are interested in rehabilitation medicine (RM) as a specialty, the
development of head injury and trauma rehabilitation pathways has presented an opportunity
for RM to show its value within acute healthcare systems. Traditionally RM is involved at a
later stage after injury if indeed at all. We now have an opportunity to make a difference
to patients by introducing good rehabilitation principles at the outset of care rather than
waiting for referrals from other colleagues at a later stage. We believe strongly that all
head injury patients who are discharged from A&E or after overnight stay, should be
followed up by a specialist to reduce the incidence of future problems.


For the hospital trust, the problem of overall patient responsibility has been solved.
Patients are now under a specialist in brain injury who will coordinate appropriate
referrals and care. Decisions are taken and clinical governance is much improved.


The ultimate measure of success would be to show a change in objective outcomes after head
injury. Unfortunately there was no previous record of head injury outcome measurement in our
hospital until the team was set up and started to collect such data. It is therefore
impossible to show a definitive improvement in any such outcome measurments. Furthermore, it
is known that head injury data is notoriously poorly coded (26) and there is considerable variation in the measures that
different units use (27). The
most common measure that is used is the extended Glasgow outcome score (E-GOS) (28). Compared to most other measures, it is
relatively quick to administer and has less room for subjective reporting. This is the key
outcome that we decided to report. We have reported previously on one year data but numbers
were understandably insufficient and many people took time to become aware of the new
service (29).


In Table 1 we present data from the first three
years of admissions under the pathway. These are patients who returned to the head injury
clinic at 6 months follow-up. In this period, there were 812 admissions to the pathway. Of
these, 674 attended both the initial clinic and then follow-up at 6 months for evaluation of
outcome using the extended Glasgow outcome score (E-GOS).


Table 1.
Clinical and Demographic Features of Head Injury Admissions (based on 674 patients out of 812 who reattended at 6 months)

From Table 1, it is clear that the majority of
individuals had a mild or moderate injury while only 21% having a severe TBI. We also found
that a considerable number of patients live alone and that depression was common with 32%
showing significant depressive symptoms. It is already well known that mood disorders are
common after brain injury ( 30 , 31 ). Emotional difficulties magnified in
individuals with cognitive and physical impairments and our results highlighted the need to
address this issue. The role of the social worker in facilitating further input, discussion
and referral to appropriate support groups has been invaluable. The early use of education,
medication and neuropsychological input has all been beneficial.


The majority of individuals had a good outcome using E-GOS (52%). This compares favorably
to landmark studies which range from 44 - 49% (17, 32, 33).

Acknowledgments

There are no acknowledgements.

Footnotes

Implication for health policy/practice/research/medical education: We can improve the outcomes of head injury care by using a clinical pathway under the control of a dedicated head injury team.
Authors’ Contribution: Rajiv Singh is the guarantor and lead writer. Julie Batterley and Sarah Bruce helped with redrafts and wrote the protocols. Prasad helped with data collection and analysis.
Financial Disclosure: No conflict of interest exists for any author.
Funding/Support: None declared.

References


  • 1. Beecham J, Perkins M, Snell T, Knapp M. Treatment paths and costs for young adults with acquired brain injury in the United Kingdom. Brain Inj. 2009;23(1):30-8. [DOI] [PubMed]
  • 2. Department of Health . The national service framework for long-term conditions 2005.
  • 3. Department of Health . Head injury: triage, assessment, investigation and early management of head injury in infants, children and adults 2007.
  • 4. National Audit Office . Major Trauma care in England 2010.
  • 5. NHS . . Emergency and urgent care services: Major Trauma services. 2010; Available from: http://www.nhs.uk/nhsengland/a...
  • 6. Kitchiner Denise, Bundred Peter. Integrated care pathways. Arch Dis Child. 1998;75(2):166-8. [DOI]
  • 7. Davies Richard, Gray Colin. Care pathways and designing the health-care built environment: an explanatory framework. Intl J Care Pathw. 2009;13(1):7-16. [DOI]
  • 8. Kwan Joseph, Sandercock Peter. In-Hospital Care Pathways for Stroke: A Cochrane Systematic Review. Stroke. 2003;34(2):587-8. [DOI]
  • 9. Kitchiner Denise, Bundred Peter. Integrated care pathways increase use of guidelines. BMJ. 1998;317(7151):147. [DOI]
  • 10. Garnick DW, Hendricks AM, Brennan TA. Can practice guidelines reduce the number and costs of malpractice claims? JAMA. 1991;266(20):2856-60. [PubMed]
  • 11. Vitaz TW, McIlvoy L, Raque GH, Spain D, Shields CB. Development and implementation of a clinical pathway for severe traumatic brain injury. J Trauma. 2001;51(2):369-75. [PubMed]
  • 12. Fakhry SM, Trask AL, Waller MA, Watts DD. Management of brain-injured patients by an evidence-based medicine protocol improves outcomes and decreases hospital charges. J Trauma. 2004;56(3):492-9. [PubMed]
  • 13. Espinosa-Aguilar A, Reyes-Morales H, Huerta-Posada CE, de Leon IL, Lopez-Lopez F, Mejia-Hernandez M, et al. Design and validation of a critical pathway for hospital management of patients with severe traumatic brain injury. J Trauma. 2008;64(5):1327-41. [DOI] [PubMed]
  • 14. McIlvoy L, Spain DA, Raque G, Vitaz T, Boaz P, Meyer K. Successful incorporation of the Severe Head Injury Guidelines into a phased-outcome clinical pathway. J Neurosci Nurs. 2001;33(2):72-8. [PubMed]
  • 15. Mooney G, Speed J, Sheppard S. Factors related to recovery after mild traumatic brain injury. Brain Inj. 2005;19(12):975-87. [DOI] [PubMed]
  • 16. Yates PJ, Williams WH, Harris A, Round A, Jenkins R. An epidemiological study of head injuries in a UK population attending an emergency department. J Neurol Neurosurg Psychiatry. 2006;77(5):699-701. [DOI] [PubMed]
  • 17. Thornhill S, Teasdale GM, Murray GD, McEwen J, Roy CW, Penny KI. Disability in young people and adults one year after head injury: prospective cohort study. BMJ. 2000;320(7250):1631-5. [PubMed]
  • 18. Wallace CA, Bogner J, Corrigan JD, Clinchot D, Mysiw WJ, Fugate LP. Primary caregivers of persons with brain injury: life change 1 year after injury. Brain Inj. 1998;12(6):483-93. [PubMed]
  • 19. Nabors N, Seacat J, Rosenthal M. Predictors of caregiver burden following traumatic brain injury. Brain Inj. 2002;16(12):1039-50. [DOI] [PubMed]
  • 20. Ergh TC, Rapport LJ, Coleman RD, Hanks RA. Predictors of caregiver and family functioning following traumatic brain injury: social support moderates caregiver distress. J Head Trauma Rehabil. 2002;17(2):155-74. [PubMed]
  • 21. Marwit SJ, Kaye PN. Measuring grief in caregivers of persons with acquired brain injury. Brain Injury. 2006;20(13-14):1419-29. [DOI]
  • 22. Kreutzer JS, Stejskal TM, Ketchum JM, Marwitz JH, Taylor LA, Menzel JC. A preliminary investigation of the brain injury family intervention: impact on family members. Brain Inj. 2009;23(6):535-47. [DOI] [PubMed]
  • 23. Ponsford J, Willmott C, Rothwell A, Cameron P, Kelly AM, Nelms R, et al. Impact of early intervention on outcome following mild head injury in adults. J Neurol Neurosurg Psychiatry. 2002;73(3):330-2. [PubMed]
  • 24. Paniak C, Toller-Lobe G, Durand A, Nagy J. A randomized trial of two treatments for mild traumatic brain injury. Brain Inj. 1998;12(12):1011-23. [PubMed]
  • 25. NHS Clinical Advisory Groups Report . . Regional Trauma Networks for Major Trauma 2010;
  • 26. Maas AI. Standardisation of data collection in traumatic brain injury: key to the future? Crit Care. 2009;13(6):1016. [DOI] [PubMed]
  • 27. Rivara FP, Ennis SK, Mangione-Smith R, MacKenzie EJ, Jaffe KM. Variation in adherence to new quality-of-care indicators for the acute rehabilitation of children with traumatic brain injury. Arch Phys Med Rehabil. 2012;93(8):1371-6. [DOI] [PubMed]
  • 28. Wilson JT, Pettigrew LE, Teasdale GM. Structured interviews for the Glasgow Outcome Scale and the extended Glasgow Outcome Scale: guidelines for their use. J Neurotrauma. 1998;15(8):573-85. [PubMed]
  • 29. Singh R, Venkateshwara G, Kirkland J, Batterley J, Bruce S. Clinical pathways in head injury: improving the quality of care with early rehabilitation. Disabil Rehabil. 2012;34(5):439-42. [DOI] [PubMed]
  • 30. Bombardier CH, Fann JR, Temkin NR, Esselman PC, Barber J, Dikmen SS. Rates of major depressive disorder and clinical outcomes following traumatic brain injury. JAMA. 2010;303(19):1938-45. [DOI] [PubMed]
  • 31. Fann JR, Hart T, Schomer KG. Treatment for depression after traumatic brain injury: a systematic review. J Neurotrauma. 2009;26(12):2383-402. [DOI] [PubMed]
  • 32. Elf K, Nilsson P, Enblad P. Outcome after traumatic brain injury improved by an organized secondary insult program and standardized neurointensive care. Crit Care Med. 2002;30(9):2129-34. [DOI] [PubMed]
  • 33. MRC CRASH Trial Collaborators . . Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients. BMJ. 2008;336(7641):425-9. [DOI]
  • 34. Marshall S, Haywood K, Fitzpatrick R. Impact of patient-reported outcome measures on routine practice: a structured review. J Eval Clin Pract. 2006;12(5):559-68. [DOI] [PubMed]

Table 1.

Clinical and Demographic Features of Head Injury Admissions (based on 674 patients out of 812 who reattended at 6 months)

Characteristic No. (%) Mean (SD)
Gender
Male 460 (68.3)
Female 214 (31.7)
Severity of injury
Mild 239 (35.5)
Moderate 293 (43.5)
Severe 142 (21.0)
Etiology
Assault 114 (16.9)
Fall 336 (49.9)
Road Traffic Accident 170 (25.2)
Work accident 45 (6.7)
Fits 9 (1.3)
Ethnicity
White 635 (94.2)
Other 39 (5.8)
Home support
Alone 354 (52.5)
Supported 320 (47.5)
Alcohol excess
Yes 182 (27.0)
No 492 (73.0)
Warfarin
Yes 51 (7.6)
No 623 (92.4)
CT scan findings
Nil 246 (36.4)
Contusions 191 (28.4)
Intracranial bleed 164 (24.3)
DAI 73 (10.9)
Depressive symptoms
Yes 219 (32.4)
No 455 (67.6)
Glasgow outcome score
1 - 4 36 (5.4)
5. Moderate Lower 120 (17.8)
6. Moderate Upper 166 (24.6)
7. Good Lower 203 (30.1)
8. Good Upper 149 (22.1)
Age , mean (SD), y 44.3 (24.8)
Length of stay, mean (SD), d 6.1 (10.9)