Even though up to 2 million people sustain traumatic brain injury (TBI) each year, their long-term physical, behavioral and/or cognitive impairments may remain under-diagnosed and untreated (NIH, 1999). The resulting disorders frequently result in functional limitations (Cicerone et al., 2005; Coelho, DeRuyter, & Stein, 1996).
As a level-one trauma center, Duke University Hospital routinely admits patients with TBI to the Adult Trauma Service. The Division of Speech Pathology and Audiology provides speech-language, cognitive, and swallowing services to all patients at Duke, including those with TBI. In the past, referral to speech pathology for cognitive-communicative TBI assessment was limited to those patients whose physicians specifically asked for the assessment. However, the attending physician's focus in treating these multi-injured trauma patients was frequently on resuscitation, stabilization, and treatment to maintain life.
Confounding factors—such as baseline substance abuse/withdrawal, psychiatric issues, and hospital sedation—coupled with brief, generic, and informal physician- or nurse-administered cognitive examinations resulted in under-identification of mild and even moderate TBI. As a consequence, referral for speech pathology evaluation and treatment of the resulting cognitive-communicative disorders was inconsistent and underutilized.
In an attempt to improve service provision, the speech pathology and trauma service coordinators joined forces to conduct a performance improvement project. Their goal was to identify the scope, need, and utilization of services to determine if the identification of and intervention with patients with TBI could be improved. This project, conducted in five phases, led to an alternative model of service delivery that improved and enhanced services to this population.
Phase One: Identification of Need
The first step was to identify the use of existing services through a retrospective review of all speech pathology consults for inpatients with TBI admitted to the adult trauma service during a 60-day time period. Results showed that physicians ordered speech pathology consults for cognitive-communicative evaluation for less than 10% of patients that met TBI criteria. These criteria included Glasgow Coma Scale (GCS) < 15; positive brain CT; loss of consciousness; report of amnesia; altered mental status; and/or a traumatic mechanism of injury such as ejection from a motor vehicle (Kay et al., 1993).
Based on this retrospective review, the speech pathology and trauma coordinators developed a two-pronged approach to improve service provision to TBI patients that includes:
- Educating care providers, patients, and patients' families about TBI.
- Improving service delivery to patients with TBI.
Phase Two: Improved Clinical Education and Service Delivery
The clinical education focus for the Division of Speech Pathology and Audiology was to enhance knowledge and skills in TBI management, implement new practice patterns, and improve service delivery. An intensive TBI education program was developed and provided to all clinicians.
In addition, a speech-language pathologist was identified to coordinate all services to inpatients in the Adult Trauma Service. This SLP addressed all consults, attended all trauma rounds to advocate for necessary cognitive-communicative services, participated in discharge planning, and served as a consistent physical reminder of the services provided by speech pathology. The multidisciplinary team embraced all of these changes.
Another SLP also began to attend the weekly Outpatient Trauma Clinic that provides medical follow-up to all trauma patients after discharge. This SLP re-evaluated the cognitive-communicative status of all patients identified as having TBI during their inpatient stay, determined if recommended services were being received, and provided education to patients and their families.
Simultaneously, the Adult Trauma Service spearheaded a similar initiative. The speech pathology and trauma coordinators formed a "TBI Advocacy Team" comprising medical professionals from different disciplines (e.g., physical therapy, occupational therapy, social work, patient resources). Meeting regularly, the team identified enhancements related to TBI services specific to their respective disciplines, identified individual and multidisciplinary goals, developed data collection strategies, and accumulated and analyzed data.
The team also focused on increasing TBI awareness and education for staff and patients. Additional TBI education (lectures, in-services, etc.) was provided to nurses, physicians, and medical students. Speech pathology staff—with multidisciplinary input—developed a comprehensive patient and family TBI education book that is provided to all inpatients with TBI and their families.
Phase Three: Pilot Project
The follow-up data collected by the TBI Advocacy Team during Phase Two revealed that the newly implemented educational and service-delivery measures had increased the provision of cognitive-communicative services to 50% of inpatients who met the TBI criteria. Although this statistic represented an improvement, it also indicated that not all patients were receiving necessary services under the existing physician-requested consultation model.
After reviewing the data, the Trauma Service medical director initiated a three-month pilot project that revised the existing physician-ordered consultation model to a "standing order" model of screening and evaluation driven by the Division of Speech Pathology and Audiology.
During the pilot study, all TBI patients admitted with blunt force injuries above the neck automatically received a TBI screening (using the criteria previously defined) by Speech Pathology within 24 hours of admission. Both "pass" and "fail" results were documented in the medical record. If any of the TBI criteria was met ("fail"), a cognitive-communicative evaluation was automatically conducted.
Pilot-study results showed that 100% of adult trauma service admissions meeting TBI criteria received a TBI screening and, when warranted, subsequent cognitive-communicative evaluation. Our unpublished data reveal that approximately one-third of the patients passed the screening and did not require a full cognitive-communicative evaluation. The remaining two-thirds required a full assessment; of those, approximately half needed immediate cognitive-communicative treatment and half were determined to have signs or symptoms of mild TBI that necessitated follow-up services to reevaluate their cognitive-communicative abilities after discharge.
Because of the success of the pilot and demonstration of improved services to patients with TBI, the "standing order" model was permanently implemented. Although data on patient outcomes are not available for this pilot project, care of patients with TBI improved as we shifted from providing few or no services to being actively involved with their evaluation and treatment.
Phase Four: Improved Re-evaluation
As more individuals with TBI were being identified and more cognitive-communicative deficits were being diagnosed, a coordinated discharge follow-up plan was needed. Before the study, most patients with moderate or severe TBI would receive post-discharge TBI follow-up, including cognitive-communicative treatment, either at inpatient rehabilitation facilities or through outpatient services. However, those with mild TBI often did not receive TBI follow-up services, especially high-functioning patients with mild TBI who may have been assessed as "within normal limits" but still had mild impairments.
To address this issue, a follow-up plan has been implemented to ensure that all inpatients identified with mild TBI receive adequate post-discharge treatment. This plan attempted to address functional issues likely to surface when the patient with mild TBI is discharged and attempts to resume daily life at home or work—just as more subtle, but equally serious, signs and symptoms of TBI are likely to emerge. Under the new plan, all inpatients who fail the TBI screening receive a re-evaluation four weeks after discharge—even if they functioned at a high level during their hospital stay.
By building on the existing Outpatient Trauma Clinic (described in Phase Two), the speech and trauma coordinators implemented a re-evaluation program for discharged inpatients with TBI. Program patients with TBI who receive a medical follow-up are also re-evaluated for recovery of physical, behavioral, and cognitive aspects of TBI. Based on re-evaluation findings, referrals are then made for more comprehensive TBI services (e.g., speech-language treatment, neurology, neuropsychology).
Phase Five: Continual Improvements
The desire to improve TBI services grew from a small performance improvement project into a full-scale, multidisciplinary service-delivery model change that continues to evolve almost two years later. The TBI Advocacy Team continues to address process improvements and identify new challenges.
These new challenges include creating a Multidisciplinary Outpatient TBI Clinic with the appropriate disciplines in one location to further enhance comprehensive follow-up services for TBI patients. The clinic facilitates patient safety, customer satisfaction, and resource utilization efficacy, and has encouraged the expansion of the inpatient screening process and outpatient follow-up to other hospital services (e.g., neurology, neurosurgery, and orthopedics) and to the pediatric population.
Expectations remain high for this evolving project, which may serve as a best practice model for hospitals and medical centers across the nation.