Title : A patient’s journey following severe TBI: I fell once, but I keep falling
Abstract:
Introduction: 10,000 people are hospitalized with traumatic brain injuries (TBI) yearly in Ireland. Many factors determine the care a patient receives including, geographical location, advocacy, and access to specialists. It is important to analyse complex cases and patient journeys through the healthcare system to improve care. The Major Trauma Audit collects data points for the acute phase, however there is limited data available for the post-acute phase.
Case Description: 43-year-old gentleman who was brought in by ambulance following a fall down a flight of stairs, with a severe head injury. He had a GCS of 3/15 on initial presentation. Imaging showed multicompartmental intracranial haemorrhages, oedema, midline shift, and herniation. In addition, there were multiple skull fractures. He required transfer to a tertiary centre for decompressive bifrontal craniectomy. He had significant functional impairments; however, he was discharged to a nursing home able to walk with a RZF and assistance of 1. Unfortunately, he encountered some delays in accessing rehabilitation, which resulted in bilateral upper and lower limb contractures impacting his function. Ultimately, he required surgical correction for his lower limb contractures. He remains awaiting a cranioplasty, 3 years later.
Discussion: Patients under 65, with severe TBI are a vulnerable population and require ongoing advocacy to access care tailored to their needs. Sometimes, delays in accessing post-acute surgical, medical and rehabilitation interventions occur due to circumstances beyond the control of the treating physicians. The resultant outcome can be costly to both patients and the state. Therefore, we hope to highlight the challenges encountered by this patient in his health journey and how quality improvement initiatives within the newly developed trauma system of care can prevent such suboptimal outcomes.
Audience Take Away:
•Discuss the current risk of Nursing Homes as transitional placement
- Inappropriate setting for <65 years old
- Lack of coordinated inter-disciplinary team input and monitoring for complications of TBI
•Discuss the benefits of timely cranioplasty
- May enhance the chances of neurological recovery
- Avoids/treats syndrome of trephined
?Common presenting features include motor weakness (61%), cognitive deficits (44%), language deficits (30%), altered consciousness (28%), and headaches (20%) with an average of 5 months from craniectomy to symptoms
- Improved craniofacial cosmesis
•Discuss the Need for coordinated case management with safety nets throughout TBI journey and how Ireland is working to achieve this
- Vulnerable population with communication challenges
- Current dependence on family members as advocates
- Limited access to interpreters
- Ireland’s Trauma Network strategy
- Advanced Decision Making Act
•Discuss prevention and management of fixed deformities after TBI
- Appropriate positioning and seating
- Maintenance of joint range of motion
- Management of tone (splinting, stretching, toxin, and surgical)
Explain how the audience will be able to use what they learn
We hope that through this presentation that physicians and rehabilitation teams in other networks can identify challenges and strengths within their own trauma networks and how they best serve patient’s with severe traumatic brain injuries.
