Joanne LeBlanc

Comparison of functional outcome following acute care in young, middle-aged and elderly patients with traumatic brain injury

Primary objective: To compare functional physical and cognitive outcome of patients in three age groups with mild, moderate and severe traumatic brain injury (TBI) at discharge from acute care. Research design: Retrospective database review. Methods and procedures: Scores on the Extended Glasgow Outcome Scale (GOSE) and on the FIM™ instrument,discharge destination and length-of-stay (LOS) were gathered and compared for 2327 patients with TBI admitted to a level 1 trauma hospital from 1997–2003 divided into three age groups; 971 patients between 18–39 years, 672 between 40–59 years and 684 aged 60–99 years. Main outcomes and results: Relative to younger adults with similar TBI severity, elderly patients showed worse outcome on the GOSE and FIM™ instrument (physical and cognitive ratings) and longer LOS. No difference was observed between the young and middle-aged groups except for cognitive FIM™ ratings and LOS for severe TBI. A higher percentage of elderly patients went to in-patient rehabilitation, to long-term care facilities or died compared to young and middle-aged patients. A higher number of young and middle-aged patients were discharged home. Conclusions: Further development of services in early rehabilitation as well as post-rehabilitation geared to the specific needs of the elderly patient with TBI is required as the population ages.

Long-term outcome after severe traumatic brain injury: the McGill interdisciplinary prospective study.

ObjectiveTo obtain a comprehensive understanding of long-term outcome after severe traumatic brain injury (sTBI). ParticipantsForty-six patients with sTBI. DesignComparison of interdisciplinary evaluation results at discharge from acute care and at 2 to 5 year follow-up. Main MeasuresExtended Glasgow Outcome Scale, the FIM™ instrument, and the Neurobehavioral Rating Scale-Revised. ResultsSignificant improvement was observed on the FIM™ instrument, the Extended Glasgow Outcome Scale, and on 3 factors of the Neurobehavioral Rating Scale-Revised. These measures at discharge were significant predictors of outcome. ConclusionPatients with sTBI 2 to 5 years postinjury showed relatively good physical and functional outcome but poorer cognitive and emotional outcome.

Prediction of the level of cognitive functional independence in acute care following traumatic brain injury

Primary objective: To determine a predictive model for cognitive functional outcome of patients with traumatic brain injury (TBI) at discharge from acute care. Methods and procedure: Three hundred and thirty-five patients were included in this analysis. Variables considered were age, education, initial score on the Glasgow Coma Scale (GCS), duration of post-traumatic amnesia (PTA), cerebral imaging results and the need for neurosurgical intervention. Experimental interventions: Functional Independence Measure (FIM). Main outcomes and results: Results of this analysis indicated better cognitive FIM at discharge from acute care settings for patients with TBI when PTA was less than 24 hours, when level of education was higher, when no parietal lesion was identified, when no neurosurgical intervention was required, for patients with TBI who were younger and who presented with a higher GCS score upon admission. Conclusions: This model will help to plan resource allocation for treatment and discharge planning within the first weeks following TBI.

Impact of a specialized multidisciplinary tracheostomy team on tracheostomy care in critically ill patients

BACKGROUND A multidisciplinary tracheostomy team was created in 2005 to follow critically ill patients who had undergone a tracheostomy until their discharge from hospital. Composed of a surgeon, surgical resident, respiratory therapist, speech-language pathologist and clinical nurse specialist, this team has been meeting twice a week for rounds involving patients who transitioned from the intensive care unit (ICU) to the medical and surgical wards. Our objective was to assess the impact of this multidisciplinary team on downsizing and decannulation times, on the incidence of speaking valve placement and on the incidence of tracheostomy-related complications on the ward. METHODS This study was conducted at a tertiary care, level-1 trauma centre and teaching hospital and involved all patients who had received a tracheostomy during admission to the ICU from Jan. 1 to Dec. 31, 2004 (preservice group), and from Jan. 1 to Dec. 31, 2006 (postservice group). We compared the outcomes of patients who required tracheostomies in a 12-month period after the team was created with those of patients from a similar time frame before the establishment of the team. RESULTS There were 32 patients in the preservice group and 54 patients in the postservice group. Under the new tracheostomy service, there was a decrease in incidence of tube blockage (5.5% v. 25.0%, p = 0.016) and calls for respiratory distress (16.7% v. 37.5%, p = 0.039) on the wards. A significantly larger proportion of patients also received speaking valves (67.4% v. 19.4%, p < 0.001) after creation of the team. Furthermore, there appeared to be a decreased time to first tube downsizing (26.0 to 9.4 d) and decreased time to decannulation (50.4 to 28.4 d), although this did not reach statistical significance owing to our small sample size. CONCLUSION Standardized care provided by a specialized multidisciplinary tracheostomy team was associated with fewer tracheostomy-related complications and an increase in the use of a speaking valve.

Prediction of outcome at discharge from acute care following traumatic brain injury

ObjectiveTo compute outcome probabilities for persons with traumatic brain injury at discharge from acute care. ParticipantsThree hundred thirty-nine patients with traumatic brain injury (239 mild, 48 moderate, 52 severe). SettingLevel I trauma center. Main MeasuresPredictor variables considered were age, education, Glasgow Coma Scale score, duration of posttraumatic amnesia, cerebral imaging results, and need for neurosurgical intervention. Outcome measures were Extended Glasgow Outcome Scale and discharge destination. ResultsLogistic regressions showed that a shorter posttraumatic amnesia decreased the probability of moderate to severe disability. Moreover, discharge home was less probable for patients with positive cerebral imaging. ConclusionThis model can help predict rehabilitation needs upon discharge from an acute care hospital.

Comprehensive Clinical Picture of Patients with Complicated vs Uncomplicated Mild Traumatic Brain Injury

To compare the acute clinical profile of patients with uncomplicated vs complicated mild TBI (MTBI), socio-demographic and medical history variables were gathered for 176 patients diagnosed with MTBI and with (complicated, N = 45) or without (uncomplicated, N = 131) positive findings on cerebral imaging. Neurological examination, neuropsychological assessment and self-evaluation of post-concussive symptoms were done at 2 weeks post trauma. Patients with complicated MTBI were more likely to show auditory and vestibular system dysfunction. Surprisingly, the uncomplicated group reported more severe post-concussive symptoms than patients with positive CT scans. The groups showed no other difference in neurological, psychological, or cognitive outcome. A complete neurological examination should be done acutely in patients with MTBI to determine more specific follow-up required.

Early outcome in patients with traumatic brain injury, pre-injury alcohol abuse and intoxication at time of injury

Primary objective: To investigate the relationship between pre-injury alcohol abuse and intoxication at time of injury on duration of post-traumatic amnesia (PTA) as well as on early functional and neurobehavioural outcomes in persons with traumatic brain injury (TBI) hospitalized in an acute care setting. Methods and procedure: Sixty persons with mild, moderate and severe TBI admitted to the intensive care unit were part of this retrospective study. Main outcomes: Duration of PTA, length of stay (LOS), Extended Glasgow Outcome Scale (GOS-E) score, the FIM™ score as well as early neuropsychological outcome measured by the Neurobehavioural Rating Scale Revised (NBRS-R). Results: 2-factor ANOVAs and chi-squares tests showed that PTA and LOS were significantly longer in the group of patients with pre-injury alcohol abuse, regardless of whether they were intoxicated or not at the time of injury. Moreover, the FIM™ total and cognitive scores were significantly higher for the group intoxicated on admission compared to the sober group. However, GOS-E scores and results on the NBRS-R were similar. Conclusions: Despite a longer PTA and LOS, global and neurobehavioural outcomes at discharge from acute care were not different for those with pre-injury alcohol abuse.

Early prediction of language impairment following traumatic brain injury

Primary objective: This study investigated which factors collected early in the acute care setting (age, education, cerebral imaging, Glasgow Coma Scale score) would predict initial impairments of language comprehension and expression in patients with traumatic brain injury (TBI) of all severity. Methods and procedures: Results of language tests carried out during the patients’ stay in an acute tertiary trauma centre were obtained. These tests measured performance in the areas of confrontation naming, auditory comprehension, semantic and letter category naming and comprehension of verbal absurdities. Data for the predictive variables were gathered by retrospective chart review. Stepwise multiple linear regressions were carried out on the predictive variables. Main outcomes and results: Education and TBI severity as measured with the GCS score were the most significant factors predicting language deficits in the acute care setting. Conclusions: These findings will serve to guide health care professionals in predicting prognosis for cognitive-communication deficits post-TBI and in planning for appropriate resources in speech-language pathology to meet these patients’ needs.

Overview of traumatic brain injury patients at a tertiary trauma centre

OBJECTIVE The goal of this study was to provide a general descriptive and cognitive portrait of a population with traumatic brain injury (TBI) at the time of their acute care stay. MATERIAL AND METHODS Three hundred and forty-eight TBI patients were assessed. The following data were collected for each patient: age, level of education, duration of post-traumatic amnesia, Galveston Orientation Amnesia Test score, Glasgow Coma Scale score, results of cerebral imaging, Neurobehavioral Rating Scale score, the Functional Independence Measure cognitive score and the Glasgow Outcome Scale score. RESULTS The clinical profile of the population revealed a mean age of 40.2 (+/-18.7) and a mean of 11.5 (+/-3.6) years of education. Most patients presented with frontal (57.6%) and temporal (40%) lesions. Sixty-two percent had post-traumatic amnesia of less than 24 hours. Seventy percent presented with mild TBI, 14% with moderate and 15% with severe TBI. The cognitive deficits most frequently observed on the Neurobehavioral Rating Scale were in the areas of attention, memory and mental flexibility as well as slowness and mental fatigability. Most patients had good cognitive outcome on the Functional Independence Measure and scores of 2 and 3 were frequent on the GOS. Forty-five percent of the patients returned home after discharge, 51.7% were referred to in or out patient rehabilitation and 3.2% were transferred to long-term care facilities. CONCLUSION Because of the specialized mandate of acute care institutions, the information provided here concerning characteristics of our TBI population is essential for more efficient decision-making and planning/programming with regards to care and service delivery.

Effect of an integrated reality orientation programme in acute care on post-traumatic amnesia in patients with traumatic brain injury

Primary objective: To assess the effect of an integrated reality orientation programme (North Star Project) in acute care on the duration of post-traumatic amnesia (PTA) of patients suffering from traumatic brain injury (TBI). It was hypothesized that those patients having participated in this programme would show a shorter PTA than those patients that did not. Method: Duration of PTA for 12 patients with TBI who were part of the North Star Project was compared with that of 26 patients matched for initial GCS and age for whom this approach was not available (control group). Results: Length of PTA was shorter by 5 days for the North Star patients. This result was not statistically significant (p = 0.19) but is clinically relevant. No between-group difference was found for Glasgow Coma Scale. Conclusions: Consequences of shorter PTA would include increased and more appropriate patient interaction and earlier transfer to rehabilitation. The North Star project also allows the family to become more actively involved in the treatment of their loved one. Further study is required to evaluate this intervention strategy to improve orientation for the patient with TBI.