3.1 Acute Management

The most severe consequences of an acquired brain injury are often not due to the initial trauma itself. Secondary brain injury can result in edema, ischemia, elevated intracranial pressure and inadequate cerebral perfusion pressure as well as a cellular cascade resulting in calcium imbalances, excitatory amino acid release and free radical production; all of which can lead to cell death 24. For this reason, the speed and intensity with which patients are cared for is of the utmost importance. Assessments of how to acutely treat ABI patients generally fall into one of four categories; pre-hospital care, hospital facility type, adherence to acute care guidelines, and discharge destination. Each of these areas presents a unique challenge. 

Pre-hospital care can be the difference between life and death. Concerns regarding the time to intervention are perhaps the most obvious component of pre-hospital care but debate has also arisen regarding the types of treatments that are suitable prior to hospital arrival. In 2000, the Brain Trauma Foundation released guidelines for pre-hospital management of brain injured patients. An Emergency Medical Service task force developed a consensus based algorithm 25. Nevertheless, Bulger et al. 26writes “the variability in the out of hospital treatment of patients after traumatic injury in the United States is unknown.” Similarly, this is the case in other countries that have begun to examine protocols for out-of-hospital care 27;28. Research has been conducted regarding the efficiency of transfer and access to trauma centers in general 26but little to no research has been performed relative to Brain Injury and related sequelae specifically.

Facility type is also of prime interest relative to the specific needs of the patient. Trauma care facilities have proven to be superior to general care facilities for emergency medical care. MacKenzie et al. 29noted patients with an abbreviated injury score (AIS) ≥ 3 to the head showed a 90% survival rate at 12 month follow up in trauma centers compared to only 64.3% in non-trauma centers. However, the availability of trauma centers tends to be dictated by local needs and resources. In the absence of such a facility, local centers must be able to handle ABI effectively and transport them when necessary to a properly equipped center.

Guidelines have been established by organizations such as the Brain Trauma Foundation (BTF) and the EBIC to try to develop standardization of treatment and to aid in the dissemination of information. Audits of guideline implementation can help to ensure that a proper level of care is provided in all types of medical centers. In the US alone, it is estimated that a modest improvement to 50% adherence of BTF guidelines from 33% would result in 989 lives saved annually 30.

The final stage of acute care involves the transition to post-acute care. Once patients are medically stable they are transferred to one of three places: home, long term care or a rehabilitation unit. Rehabilitation units for ABI patients can consist of hospital-based inpatient rehabilitation centers or specialized rehabilitation units that often focus on behavioral issues. How and by whom this decision is made may greatly affect the type of care that is received by patients. Several factors, such as availability of rehabilitation spaces, the patient’s support needs and the patient’s financial situation may play a role in this decision. In the US, Medicaid patients were 68% and HMO patients were 23% more likely to be discharged to a skilled nursing facility than those on a fee-for-service plan 31. In Canada, patients injured in a motor vehicle accident were 1.6 times more likely to be discharged home with support services than those who were injured in a fall 32, likely due to the greater availability of resources accompanying the former injury. 

What is the evidence supporting the guidelines for care received while patients remain in acute care?

  1. There is Level 2 evidence that patients cared for in a Level I trauma center achieve better outcomes than patients cared for in a Level II center.
  2. There is Level 2 evidence that staff with more dedicated commitment to trauma care leads to better patient outcomes.
  3. There is Level 2 evidence suggesting that a reduction in the time spent in acute care and in a rehabilitation facility does not have a negative impact on overall patient outcomes. 
  4. There is Level 4 evidence indicating the overall cost of care is higher for those who sustain a severe TBI versus those who sustain a moderate TBI.
  5. There is Level 4 evidence that adherence to BTF guidelines for acute care results in improved outcomes and decreased mortality.

Nine studies were identified that empirically compared outcomes related to different acute care strategies. Three papers assessed the implementation of BTF guidelines in acute care practice 33-35, one assessed implementation of SIGN guidelines 36, two assessed facility structure 37;38, one compared outcomes between centers in developed and developing countries 39, one looked at the outcomes of 2 groups patients each treated in an acute care facility then transferred to rehabilitation but for different lengths of time40, and one looked at the treatment received and cost of care for TBI patients over a 2 year period 41.

Fakhry et al. 34undertook a pre-post design to evaluate the benefits of BTF guideline implementation. Patients treated under guideline conditions showed improvements in Glasgow Outcome Scale score, length of stay, cost per patient and mortality rates. The use of a non-TBI control group adds credibility to these results. Similarly,  Palmer et al. 35also performed a pre-post analysis of BTF guideline implementation. Patients in this study showed a 9.13 times greater odds ratio in favor of “good outcome” in 6 month GOS scores. The authors noted that there was a $97,000 increase in acute care costs associated with guideline care, which they claim was justifiable in light of the improved outcomes.

Bulger et al. 33identified ICP management as an indicator of the aggressiveness of acute care management. Centers adhering to an “aggressive” protocol were significantly more likely to administer ICP monitoring, provide neurosurgical consultation, use osmotic agents and perform head CT scans. While these centers reported decreased mortality rates, the division was arbitrary and further study into potential confounding factors is necessary.  In a similar study conducted in the UK, patient outcomes were compared after implementation of the SIGN guidelines for head injury management in 2000.Jones et al. 36reported that after 2000, fewer patients made full recoveries (GOS 5) and more incidences of CCP insult were recorded. They also noted significantly more children being referred from tertiary care centers and fewer from Emergency Departments. 

McGarry et al.41looked that the outcomes and costs associated with care for those who had sustained a moderate or severe TBI. As one might expect higher costs for care were associated with severity of injury, with costs being much higher for those who had sustained a severe TBI ($8,187 to $50,438). Of those included in the study, 80% had had a MRI or CT scan; nearly one third were on ventilators; and another two-thirds were treated in an intensive care unit. Mortality rates were also higher for those who had sustained a severe TBI.

In two studies evaluating facility structure, DuBose et al.38evaluated hospital designation and Mains et al. 37assessed trauma team composition.  DuBose et al. 38reported that patients cared for in a Level I trauma centre showed decreased mortality rates, fewer complications, and were less likely to experience progression of neurological insult relative to patients care in a Level II trauma centre. These results were maintained even after adjusting for patient severity. Mains et al. 37evaluated patient outcomes during three timeframes corresponding to systemic changes in a Level I traumacenter. During time 1, the ward was staffed by in-house general surgery residents and attendings. During time two, a core trauma panel was established so that the ward was staffed by in-house trauma surgeons, which remained during time three except for the addition of physician’s assistants. Patients managed during time two showed decreased mortality and median ICU LOS. Patients care for during time three saw further reductions in overall mortality and mean and median hospital LOS. The authors suggest that staff commitment to trauma care may play a role in improving patient outcomes.

Hawkins et al. 40looked at outcomes of two groups of patients. The first group (Group 1) underwent hospital care for a total of 82 days (36 days in acute care and 46 days undergoing rehabilitation), while the second group (Group2) remained in hospital for a total of 51 days (26 days in acute care followed by 25 days in rehab). At time of discharge from acute care, FIM scores between the two groups were found to be different (51-Group 1 and 57-Group 2) but not significantly so. Patients in Group 1 did require more physical assistance and had significantly lower scores on the communication and social cognition subscales of the FIM then those in Group 2. When looking at FIM scores of those with GCS </=8 (n=39-Group1 and n=32-group2), those in Group 1 were found to be more independent in mobility and locomotion then Group 2 at time of discharge from rehabilitation. At the one year follow-up FIM scores between the two groups showed no significant differences overall nor were there differences on the scores of the subcomponents of the scale. Shorter lengths of stay in hospital did not adversely affect functional outcomes of patients. Age rather than GCS seemed to play a strong role in predicting who returned to work, with those in the youngest category (<30 years) returning to work faster. Overall 25% of patients were able to return to work. The reduced length of stay in hospital placed greater demands outpatient rehabilitation services and family members or primary care givers.

Finally, Harris et al. 39compared outcomes of patients treated in a Level I trauma center in the United States to those of patients cared for in two Jamaican hospitals.  Interventions provided to patients were significantly different between countries. Patients cared for in the USA received more CT scans, were more likely to be admitted to an ICU and were more likely to undergo ICP monitoring. Although overall mortality was the same between countries, patients who were severely injured were more likely to survive in the USA. Interestingly, patients cared for in Jamaica showed greater improvements in both GOS and selected FIM outcomes. The authors suggest that the clinical significance of these findings are unknown and that further research is necessary.  

The remainder of the studies identified provided descriptive observations of acute care management in diverse settings. Their observations can be summarized within the four groups identified earlier; pre-hospital care, hospital facility type, guideline adherence and discharge destination.

Three of the studies identified made reference to pre-hospital care of ABI patients 8;27;42. Baethmann et al. 27was the only study to specifically focus on pre-hospital and early hospital care. They used medical students as observers during primarily helicopter rescues of suspected brain injured patients. In 75% of cases, the rescue team arrived at the accident scene in less than 11 minutes after dispatch center alarm; intubation was made within 37 min; admission to the hospital was within 74 min; and the CT scan was completed within 120 min. The use of helicopter rescue with an on-board emergency physician made transfers more efficient as well as referrals to neurotrauma centers more accurate. Citerio et al. 8found patients admitted directly from the accident site to a neurotrauma center in Italy took 79±149 min to reach the first emergency room. Those patients not admitted directly to a neurotrauma center only took 59±137 min to reach the first emergency room but averaged 300±254 min before reaching the neurotrauma center.  Myburgh et al.,42showed variation in vital sign documentation in Australia. The mean time to admission at the first hospital was 63±58.4 min and 56.4% of these patients were admitted directly to a tertiary trauma center. The time of arrival to a trauma center versus a non-trauma center was comparable. No papers compared differences between groups, so no comparison of pre-hospital strategy can be made.

None of the papers further evaluated outcomes of patients admitted to trauma centers compared to non-trauma centers but many made comments regarding facility type. Patients were cared for in trauma centers or neurosurgical units in 66% 9and 62% of cases 43in the UK and Japan respectively. Some key differences between neurotruama units relative to general wards were coordination by a neurosurgeon or neurologist, presence of a specialized ICU unit for TBI patients and higher guideline adherence rates. Future study into the efficacy of neurotrauma centers relative to ABI patient outcomes is warranted.

Guideline adherence was the most highly analyzed component of acute ABI care. Most of the papers identified guideline adherence as an acute care goal. In addition to the Fakhry et al. 34and Bulger et al. 33papers, some interesting comparisons were seen. In the survey by Rusnak et al. 44only adherence to the recommendations regarding BP, oxygenation resuscitation, and cerebral perfusion pressure maintenance were seen to be significantly related to ICU survival in Austria 44. In the USA, Level I centers were significantly more likely to adhere to most AANS guideline recommendations 45.  One encouraging outcome of this adherence was the decreased use of contraindicated treatments such as corticosteroids. Goodacre 46reported that after implementation of the NICE guidelines in the UK, admission rates increased while LOS remained the same resulting in increased costs of care.  In Norway, Heskestad 47reported that despite guideline development, over triage of CT scans and admissions were often seen in patients with minimal and mild injuries however, 100% compliance was seen in patients with moderate injuries.  In a similar study, Palchak et al. 48retrospectively compared a decision rule for CT scans and admissions to physician suspicion of TBI.  They noted that the decision rule was more sensitive and could have resulted in 289 fewer CT scans being performed.  However, the physician’s suspicion was more specific. The decision rule would have missed one TBI in a child that was discharged home from the Emergency Department.  More definitive studies linking guideline adherence to beneficial outcomes need to be performed to further compare their effectiveness.

The final stage of acute ABI is the discharge of medically stable patients. Discharge destination varies significantly based on regional differences. Factors such as the health care system, regional funding, rehabilitation facility availability, and the patient’s specific needs can all play a role in the final decision. We identified four articles with descriptions of discharge disposition. Chan et al. 31showed these US patients with Medicaid health insurance were significantly more likely to go to a skilled nursing facility than those who were covered by HMOs or fee-for-service plans.  Esselman et al. 49analyzed discrepancies between US patients injured violently versus those who were non-violently injured. They saw no difference in referral rates to rehabilitation or skilled nursing facilities for violently injured patients relative to non-violently injured patients even though they were more likely to be funded by Medicaid. In Canada, universal health care is designed to allow for equal access to healthcare resources but there is variability based on different provincial health care plans and the availability of additional third-party insurance funding. Kim et al. 50found that relative to rehabilitation, this is not always the case.  Patients injured in a motor vehicle accident were 1.6 times more likely to be discharged home without support services than those injured in falls with similar injuries. This suggests that insurance supplementation can influence resource access. Finally, Foster et al. 51found Australian patients who were younger and treated in a designated brain injury rehabilitation unit were more likely to be referred for inpatient rehabilitation.

 

The rehabilitation of acquired brain injury (ABI) patients involves a comprehensive effort by several members of an interdisciplinary team including physicians, nurses, and occupational therapists. Considering the incidence and consequences of ABI, it is important to understand the effectiveness of rehabilitation. Efficacy, as measured by functional outcome, will be assessed in this chapter across the continuum, from inpatient rehabilitation to community interventions.  The question, ‘does rehab work?’ will be addressed.