https://orcid.org/0000-0002-3794-4158
Figures
Abstract
Early incorporation of rehabilitation services for severe traumatic brain injury (TBI) patients is expected to improve outcomes and quality of life. This study aimed to compare the outcomes regarding the discharge destination and length of hospital stay of selected TBI patients before and after launching an acute intensive trauma rehabilitation (AITR) program at King Saud Medical City. It was a retrospective observational before-and-after study of TBI patients who were selected and received AITR between December 2018 and December 2019. Participants’ demographics, mechanisms of injury, baseline characteristics, and outcomes were compared with TBI patients who were selected for rehabilitation care in the pre-AITR period between August 2017 and November 2018. A total of 108 and 111 patients were managed before and after the introduction of the AITR program, respectively. In the pre-AITR period, 63 (58.3%) patients were discharged home, compared to 87 (78.4%) patients after AITR (p = 0.001, chi-squared 10.2). The pre-AITR group’s time to discharge from hospital was 52.4 (SD 30.4) days, which improved to 38.7 (SD 23.2) days in the AITR (p < 0.001; 95% CI 6.6–20.9) group. The early integration of AITR significantly reduced the percentage of patients referred to another rehabilitation or long-term facility. We also emphasize the importance of physical medicine and rehabilitation (PM&R) specialists as the coordinators of structured, comprehensive, and holistic rehabilitation programs delivered by the multi-professional team working in an interdisciplinary way. The leadership and coordination of the PM&R physicians are likely to be effective, especially for those with severe disabilities after brain injury.
Citation: Chowdhury S, Leenen LPH (2021) Does access to acute intensive trauma rehabilitation (AITR) programs affect the disposition of brain injury patients? PLoS ONE 16(8): e0256314. https://doi.org/10.1371/journal.pone.0256314
Editor: Angela M. Boutté, Walter Reed Army Institute of Research, UNITED STATES
Received: April 25, 2021; Accepted: August 3, 2021; Published: August 16, 2021
Copyright: © 2021 Chowdhury, Leenen. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its S1 File.
Funding: No funding.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Trauma is a significant public health burden in Saudi Arabia due to the high road traffic crash rate [1]. It has severe, devastating, and often life-threatening consequences. Care for the injured after a crash is exceptionally time sensitive; delays in any stage can make a difference in outcomes. Survivors of significant trauma may experience severe functional impairment and reduced quality of life [2]. Severe injuries are often associated with motor, sensory, and autonomic impairments, including loss of bladder control and bowel evacuation. These contribute to significant morbidity and impact an individual’s ability to move about their home and community and bathe and dress independently [3–5].
Advanced rehabilitation services have become critical for enhancing a patient’s functional health status following significant trauma. Early intensive rehabilitation significantly reduces dependency, lessening the need for ongoing community care [6]. The World Health Organization recommends that rehabilitation be available and accessible to anyone who experiences a severe traumatic injury [7]. Acute intensive trauma rehabilitation (AITR) programs following traumatic injuries have also improved functional recovery. However, access is often limited and not available at all hospitals [8]. For example, only 1.5% of patients in Beijing, China, receive this service compared with 50% to 58% in Ontario, Canada [9, 10].
In Saudi Arabia, King Fahad Medical City (KFMC) rehabilitation hospital is the only hospital under the Ministry of Health providing holistic rehabilitation services in the region since 2004 [11]. Due to the limited number of inpatient beds and a huge burden of rehabilitation candidates, the waiting time for patients’ acceptance is 6–12 months. Another private rehabilitation center is also available that has limited access due to eligibility and insurance coverage. On the other hand, King Saud Medical City (KSMC) in Riyadh is a major trauma center in the region. It receives the most severely injured polytrauma patients from all over the country. A dedicated trauma unit has managed all polytrauma patients since 2016.
KSMC lacked consultant physiatrists, and the physical medicine and rehabilitation (PM&R) department was severely understaffed for such a major hospital in the region until 2017. With only one PM&R registrar, the focus of services was on outpatient care. There were the physiotherapy, occupational therapy, speech-language pathology, and prosthesis and orthosis departments, which were all inadequately involved with patient care because there was no integration between services. Since the trauma unit’s inception in 2016, we have been trying to improve trauma care, especially chronic care, for severely injured brain trauma patients. Since then, we have undertaken different administrative measures, including recruiting PM&R professionals, increasing logistics, and collaborating with the KFMC rehabilitation center. As a part of that collaboration, one visiting consultant physiatrist from KFMC used to visit the KSMC trauma unit once a week to assess the chronic trauma patients and select rehabilitation candidates. He also provided expert opinion for interim hospital care before those patients were transferred to his rehabilitation center. The waiting time for the transfer was long. These chronic patients were receiving essential non-intensive hospital care—such as physiotherapy, occupational therapy, tracheostomy care, and speech-language therapy—in the trauma unit. It was causing bed occupation, increased length of hospital stay, and increased cost. Around this time, two more consultant physiatrists joined KSMC. Subsequently, an integrated multidisciplinary AITR program was implemented at KSMC in December 2018.
This study aimed to compare the outcomes regarding discharge destination and length of hospital stay of selected traumatic brain injury (TBI) patients before and after the launch of the multidisciplinary AITR program.
Materials and methods
Setting
KSMC is one of the largest hospitals in Saudi Arabia, with 1,400 inpatient beds. KSMC’s emergency department (ED) is the busiest in the kingdom [12]. Three physiatrists oversee the KSMC PM&R department. The department started the AITR program in coordination with physiotherapy, occupational therapy, speech-language pathology, prosthesis and orthosis, and the social work department in December 2018.
AITR
AITR is an acute in-hospital intensive rehabilitation program for a selected group of severely injured trauma patients who receive at least two to three sessions of different therapies—including physiotherapy, speech-language therapy, occupational therapy, and Botox therapy—for three to four hours each day with breaks in between, five days a week, as decided by the physiatrist [13].
The AITR program was created with specific clinical goals. The multidisciplinary team’s training was designed to help people regain function, acquire activities of daily living (ADL) independence, and reintegrate into their homes and communities. The program included physical and sensory-motor training from physiotherapy, functional re-training such as self-care and instrumental ADL from occupational therapy, and psycho-social re-training including social skills from speech therapy [13].
Assessment and selection of TBI patients for AITR
The PM&R department engages with trauma patients’ management at an early stage of their in-hospital courses. A consultant physiatrist does weekly rounds on trauma patients to assess needs and select candidates for AITR. When a patient has fully recovered from an acute head injury, has regained consciousness, and is able to participate in rehabilitation, the physiatrist sets up short-term integrated goals for the patients in collaboration with the treating trauma surgeon and other relevant departments (e.g., physiotherapy, occupational therapy, speech-language pathology, prosthesis and orthosis, and social work) in a multidisciplinary team meeting. Assessment is based on a favorable outcome regarding achievement of independence in daily activities after providing the service. The plans are then revised with patient progress. The persistent vegetative and worse-prognosis patients are recommended for nursing care only. After AITR, if a patient is improved with the achievement of independence in daily activities, they are discharged home with outpatient follow-up at our PM&R department as needed. If the patient needs further rehabilitation to achieve the goals, they are transferred to a long-term rehabilitation facility. The selection criteria or preconditions for AITR are described in Table 1.
Design
This was a retrospective observational before-and-after study of TBI patients who were referred to PM&R and received AITR between December 01, 2018, and December 31, 2019. The TBI patients who died in the hospital, transferred to another hospital during acute care, or were discharged from the hospital after rapid and good recovery that did not require rehabilitation and remained persistent vegetative were excluded. The data were compared with the pre-integration of inpatient rehabilitation for TBI patients who were assessed and selected for rehabilitation care between August 01, 2017, and November 30, 2018.
Before discharge home, a patient had to be able to: (1) execute self-care activities such as feeding, grooming, dressing, and toileting; (2) move from bed to chair/wheelchair/shower chair independently; (3) securely handle household appliances; and (4) walk with or without support inside the ward [13]. These criteria remained the same in pre-AITR and AITR era.
Data collection
The data of selected TBI patients who were referred for possible rehabilitation care were collected from the PM&R department and trauma unit records. Then for these selected patients, the data of patient demographics, mechanism of injuries, baseline admission characteristics (on presentation to ED), length of stay, and discharge destination in terms of home or rehabilitation center were extracted from the KSMC trauma registry. Discharge destination and time to discharge from hospital were the primary outcome variables.
Statistical analysis
The data were analyzed using SPSS 25.0 (IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp.) and R (RStudio Team 2020). The data were subgrouped into the two periods before and after the implementation of AITR. Demographic, mechanism of injury, and baseline injury characteristics (on presentation to ED) were compared to assess equivalence between the two subgroups. The continuous and normally distributed data (e.g., age, respiratory rate, heart rate, systolic blood pressure, international normalized ratio, base excess, PH, abbreviated injury scale [AIS] head, and length of stay) were summarized using mean (standard deviation [SD]) and compared using Student’s t-test. Skewed and ordinal data (e.g., Glasgow Coma Scale) were summarized using the median (inter-quartile range [IQR]) and compared using the nonparametric Mann-Whitney U-test. Count data (e.g., male sex, mechanism, trauma team activation, blood transfusion in ED, injury-severity score, and discharge destination) were summarized using proportions and compared using the nonparametric chi-square test. A p-value of < 0.05 was considered significant.
Results
A total of 5,933 trauma patients were included in the KSMC registry between August 2017 and December 2019. Of these, 3,419 (57.6%) patients were admitted pre-AITR era and 2,514 (42.4%) patients were admitted after the introduction of AITR. During the pre-AITR period, 2,021 (59.1%) patients sustained TBI, of which 118 (5.8%) died, 1,737 (86%) were discharged after rapid and good recovery that did not require rehabilitation, and 166 (8.2%) became chronic TBI patients (who required rehabilitation care or were persistent vegetative patients). Among the chronic TBI patients, 108 (65%) were selected for the rehabilitation care, and the remaining persistent vegetative patients were selected for nursing care. On the other hand, during the AITR era, 1,578 (62.8%) patients sustained TBI, of which 105 (6.7%) died, 1,315 (83.3%) were discharged after rapid and good recovery that did not require rehabilitation, and 158 (10%) became chronic TBI patients. Among the chronic TBI patients, 111 (70.3%) were selected for AITR, and the remaining persistent vegetative patients were selected for nursing care (Fig 1).
In the combined group of chronic TBI patients selected for rehabilitation care (n = 219), the demographics were mainly young males (195, 89%) with a mean age of 28.2 (SD 14.2) years. The age distribution is presented in the violin plot (Fig 2).
The commonest mechanism of injury was motor vehicle crashes (192, 87.7%) followed by falls (22, 10%) and assaults (5, 2.3%). Eighty-four (38.4%) patients had trauma team activation (TTA) by the ED, and 27 (12.3%) patients received a blood transfusion in the ED. Ninety-three (42.5%) patients had an injury severity score (ISS) between 16 and 25, followed by 81 (37%) patients less than 16 and 45 (20.5%) patients above 26. The average length of ICU and hospital stay were 18 (SD 10.2) and 45.5 (SD 27.8) days, respectively.
The comparison of selected TBI patients’ demographics, mechanisms of injury, baseline (on presentation to ED) characteristics, and outcomes between pre-AITR and AITR are described below (Table 2). There was no significant difference in the AIS for the head between the groups (p = 0.437).
In the pre-intervention period, there were 63 (58.3%) patients discharged to home, compared to 87 (78.4%) after the intervention (p = 0.001; chi-squared 10.2). Time to discharge from hospital pre-intervention was 52.4 (SD 30.4) days, which improved to 38.7 (SD 23.1) days after the introduction of the new AITR program (p < 0.001; 95% CI 6.6–20.9) (Table 2).
The comparison of length of hospital stay between pre-AITR and AITR is presented in the violin plot (Fig 3).
Discussion
We compared two similar groups (head injury) and an almost equal number of patients with two different rehabilitation strategies—AITR vs. non-intensive or minimal in-hospital rehabilitation (pre-AITR)—in two different periods (pre-AITR: Aug 2017–Nov 2018; AITR: Dec 2018–Dec 2019). This study demonstrated that integrating an intensive rehabilitation program with acute trauma care was associated with a significantly higher proportion of patients being discharged home and after a shorter length of stay in the hospital. As a result, the waiting list of rehabilitation candidates and the load on the only rehabilitation center in Riyadh, KFMC, are decreased.
In our cohort, the heart rate (108.7 bpm vs. 96.9 bpm; p = 0.001) at presentation to ED was significantly higher in the pre-AITR than AITR group. As the systolic blood pressure did not change in both groups (125.9 mm Hg vs. 125.5 mm Hg; p = 0.906), the difference in shock status was not significant. Moreover, the weak difference of blood transfusion requirement (16.7% vs. 8.1%; p = 0.054) in ED supports against significant difference in shock status between the two groups. The international normalized ratio (1.2 vs. 1.1; p = 0.004) was significantly higher in the pre-AITR group. Higher blood transfusion requirements in this group should have corrected the coagulopathy. Moreover, trauma system development in Saudi Arabia is recent, and defects in pre-hospital patient transfer could contribute to the difference in both groups. However, as these parameters are corrected with resuscitation measures immediately in our ED, these should not directly affect the selection of patients or outcomes in both groups.
The TTA rate in the pre-AITR cohort was significantly higher (47.2% vs. 29.7%; p = 0.007). However, ISS was comparatively lower (p = 0.002) in the pre-AITR group, which seems inconsistent as more severe injuries should get more activation. Although TTA is based on specific criteria, it is subjective (at emergency physician discretion) and may have information bias due to over- or under-triage and should not affect outcomes directly.
In our study, ISS in the AITR group was significantly higher (p = 0.002). However, the AIS-head did not show a statistically significant difference (p = 0.437) between the groups, which means we dealt with similar groups of head-injury patients in both rehab strategies. With comparable AIS, the higher ISS in the AITR group indicates more polytrauma [14–16]. On the other hand, with more polytrauma, the AITR group had a significantly lower length of hospital stay (38.7 days vs. 52.4 days; p < 0.001), which favored the success of the AITR program.
Rehabilitation service is an essential pillar of the trauma system and plays a vital role in trauma patients’ outcomes. In our situation, it is a challenge to transfer a trauma patient to a rehabilitation center due to a long waiting list. Delay in transfer causes increases in the length of hospital stay and cost. Long waits for rehabilitation have a negative impact on the functional and cognitive recovery of severely injured patients [17].
Identifying factors that contribute to the prediction of discharge disposition is crucial for efficient resource utilization and reducing cost. Several factors may influence discharge location after hospitalization [18]. Functional status due to early and advanced professional rehabilitation can affect the discharge destination. Nursing home management for all ages has demonstrated a significantly lower quality of life across multiple domains as compared with those living elsewhere [19, 20]. Return to living at home is an important patient-reported outcome following a traumatic injury. Receiving specialized acute rehabilitation is a significant and robust predictor of return to home. Specialized acute intensive rehabilitation helps patients with severe trauma maximize function and independence and return to home. Improving access to specialized acute intensive rehabilitation could potentially reduce discharges to nursing homes or other non-home destinations [21].
The introduction of a multidisciplinary AITR program was a challenge at KSMC. Bringing various allied health-care services under one umbrella was a difficult administrative decision. The PM&R department is understaffed; a dedicated ward with all relevant resources such as a gymnasium is not available to date.
This study is limited to being a retrospective cohort and only a moderate sample of patients. However, it includes consecutive patients during 29 months from the most active trauma center in the country. With only 111 cases of AITR, we attempted to develop a model to improve the trauma patient’s outcomes. The study did not analyze in depth the cognitive and functional recovery, bladder and bowel control, etc. An analysis of the Functional Independence Measure (FIM) and the Neurobehavioral Cognitive Status Examination (NCSE) in both groups would have given more strength to the study. A national trauma registry with a systematic collection of data on patient outcomes would be invaluable to assess such a program.
Conclusions
The implementation and early integration of AITR significantly reduced the percentage of patients referred to another rehabilitation or long-term facility. It also reduced the length of stay in the hospital. Continuation and expansion of the program to other trauma services with ongoing surveillance are indicated. We also emphasize the importance of PM&R specialists as the coordinators of structured, comprehensive, and holistic rehabilitation programs delivered by the multi-professional team, working in an interdisciplinary way [22]. The leadership and coordination of a PM&R physician are likely to be effective, especially for those with severe disabilities after brain injury.
References
- 1. Al-Naami MY, Arafah MA, Al-Ibrahim FS. Trauma care systems in Saudi Arabia: an agenda for action. Ann Saudi Med. 2010 Jan-Feb;30(1):50–8. pmid:20103958.
- 2. Stocchetti N, Zanier ER. Chronic impact of traumatic brain injury on outcome and quality of life: a narrative review. Crit Care. 2016 Jun 21;20(1):148. pmid:27323708.
- 3. Saunders LL, Clarke A, Tate DG, Forchheimer M, Krause JS. Lifetime prevalence of chronic health conditions among persons with spinal cord injury. Arch Phys Med Rehabil. 2015 Apr;96(4):673–9. Epub 2014 Dec 9. pmid:25497516.
- 4. Craven C, Hitzig SL, Mittmann N. Impact of impairment and secondary health conditions on health preference among Canadians with chronic spinal cord injury. J Spinal Cord Med. 2012 Sep;35(5):361–70. pmid:23031173.
- 5. New PW, Simmonds F, Stevermuer T. Comparison of patients managed in specialised spinal rehabilitation units with those managed in non-specialised rehabilitation units. Spinal Cord. 2011 Aug;49(8):909–16. Epub 2011 Apr 5. pmid:21468042.
- 6. Wahab R, Yip NH, Chandra S, Nguyen M, Pavlovich KH, Benson T, et al. The implementation of an early rehabilitation program is associated with reduced length of stay: a multi-ICU study. J Intensive Care Soc. 2016 Feb;17(1):2–11. Epub 2015 Sep 21. pmid:28979452.
- 7.
Bickenbach J, Officer A, Shakespeare T, von Groote P. International perspectives on spinal cord injury. World Health Organization. 2013 [cited 2021 March 17]. https://apps.who.int/iris/handle/10665/94190
- 8. Shah AA, Zuberi M, Cornwell E, Williams M, Manicone P, Kane T, et al. Gaps in access to comprehensive rehabilitation following traumatic injuries in children: a nationwide examination. J Pediatr Surg. 2019 Nov;54(11):2369–2374. Epub 2019 Jun pmid:31255326.
- 9. Li J, Liu G, Zheng Y, Hao C, Zhang Y, Wei B, et al. The epidemiological survey of acute traumatic spinal cord injury (ATSCI) of 2002 in Beijing municipality. Spinal Cord. 2011 Jul;49(7):777–82. Epub 2011 Mar 8. pmid:21383758.
- 10. Couris CM, Guilcher SJ, Munce SE, Fung K, Craven BC, Verrier M, et al. Characteristics of adults with incident traumatic spinal cord injury in Ontario, Canada. Spinal Cord. 2010 Jan;48(1):39–44. Epub 2009 Jun 23. pmid:19546873.
- 11.
King Fahad Medical City [Internet]. [cited 2020 August 29]. https://www.kfmc.med.sa/EN/RehabilitationHospital/Pages/default.aspx
- 12. Chowdhury S, Bahatheq S, Alkaraawi A, Falatah MM, Almutairi RF, Alfadhel S, et al. Surgical site infections after trauma laparotomy: an observational study from a major trauma center in Saudi Arabia. Saudi Med J. 2019 Mar;40(3):266–70. pmid:30834422.
- 13. Zhu XL, Poon WS, Chan CC, Chan SS. Does intensive rehabilitation improve the functional outcome of patients with traumatic brain injury (TBI)? A randomized controlled trial. Brain Inj. 2007 Jun;21(7):681–90. pmid:17653942.
- 14. Javali RH, Krishnamoorthy , Patil A, Srinivasarangan M, Suraj , Sriharsha . Comparison of injury severity score, new injury severity score, revised trauma score and trauma and injury severity score for mortality prediction in elderly trauma patients. Indian J Crit Care Med. 2019 Feb;23(2):73–77. pmid:31086450.
- 15. Moore EE, Cogbill TH, Malangoni MA, Jurkovich GJ, Shackford SR, Champion HR, et al. Organ injury scaling. Surg Clin North Am. 1995 Apr;75(2):293–303. pmid:7899999.
- 16. Carroll CP, Cochran JA, Price JP, Guse CE, Wang MC. The AIS-2005 revision in severe traumatic brain injury: mission accomplished or problems for future research? Ann Adv Automot Med. 2010;54:233–8. pmid:21050606.
- 17. Sirois MJ, Lavoie A, Dionne CE. Impact of transfer delays to rehabilitation in patients with severe trauma. Arch Phys Med Rehabil. 2004 Feb;85(2):184–91. pmid:14966701.
- 18. James MK, Robitsek RJ, Saghir SM, Gentile PA, Ramos M, Perez F. Clinical and non-clinical factors that predict discharge disposition after a fall. Injury. 2018 May;49(5):975–82. Epub 2018 Feb 14. pmid:29463382.
- 19. Putzke JD, Richards JS. Nursing home residence: quality of life among individuals with spinal cord injury. Am J Phys Med Rehabil. 2001 Jun;80(6):404–9. pmid:11400708.
- 20. Silver J, Ljungberg I, Libin A, Groah S. Barriers for individuals with spinal cord injury returning to the community: a preliminary classification. Disabil Health J. 2012 Jul;5(3):190–6. Epub 2012 May pmid:22726860.
- 21. Cheng CL, Plashkes T, Shen T, Fallah N, Humphreys S, O’Connell C, et al. Does specialized inpatient rehabilitation affect whether or not people with traumatic spinal cord injury return home? J Neurotrauma. 2017 Oct 15;34(20):2867–76. Epub 2017 May 24. pmid:28447870.
- 22. Grabljevec K, Singh R, Denes Z, Angerova Y, Nunes R, Boldrini P, et al. Evidence-based position paper on physical and rehabilitation medicine professional practice for adults with acquired brain injury: the European PRM position (UEMS PRM Section). Eur J Phys Rehabil Med. 2018 Dec;54(6):971–9. Epub 2018 Aug 29. pmid:30160441.