Assessing adaptive behaviour in the post-acute setting following traumatic brain injury: Initial reliability and validity of the Adaptive Behaviour and Community Competency Scale (ABCCS)

The Measure of an Outcome: Comparing Norming and Stacking to Benchmark the Effectiveness of Brain Injury Rehabilitation Services

Practitioners have a clinical, ethical, academic, and economic responsibility to dispassionately consider how effective their services are. Approaches to measure how "good" or "bad" healthcare is include clinical audit, satisfaction surveys, and routine outcome measurement. However, the process of comparing the clinical outcomes of a specific service against the 'best' services in the same specialism, also known as benchmarking, remains challenging, and it is unclear how it affects quality improvement. This paper piloted and compared two different approaches to benchmarking to assess clinical outcomes in neurorehabilitation. Norming involved comparing routine measures of clinical outcome with external validators. Stacking involved pooling and comparing internal data across several years. The analyses of routine clinical outcome data from 167 patients revealed significant differences in the patient characteristics of those admitted to the same service provider over time, but no differences in outcomes achieved when comparing with historical data or with external reference data. These findings illustrate the potential advantages and limitations of using stacking and norming to benchmark clinical outcomes, and how the results from each approach might be used to evaluate service effectiveness and inform quality improvement within the field of brain injury rehabilitation.

The interrelationship of functional skills in individuals living in the community, following moderate to severe traumatic brain injury

OBJECTIVE

The Adaptive Behaviour and Community Competency Scale was used to investigate the interrelationship of 22 basic and instrumental activities of daily living (ADL/IADL) in individuals with moderate to severe traumatic brain injury (TBI). The relationship of self-awareness to task performance was also investigated.

RESEARCH DESIGN

Prospective descriptive study.

METHOD

The profiles of 100 community dwelling individuals were used to compare the degree to which independence in each ADL/IADL was associated with independence in every other ADL/IADL. The interrelationship of these skills was further explored in a factor analysis, and comparisons made between the degree of self-awareness of those who could and could not complete IADL independently.

RESULTS

We found evidence of a hierarchy of skills: individuals who were independent in IADL were more able to perform ADL, than vice versa. Factor analysis supported a two-factor solution distinguishing ADL and IADL. Self-awareness was more strongly associated with IADL than with ADL independence.

CONCLUSIONS

A subset of individuals with moderate to severe TBI are able to perform a range of IADL. This group appears to have higher levels of self-awareness than those who are limited to performing only ADL skills. Implications for the applications of functional retraining interventions are discussed.

The relational neurobehavioral approach: can a non-aversive program manage adults with brain injury-related aggression without seclusion/restraint?

PURPOSE

The Relational Neurobehavioral Approach (RNA) is a set of non-aversive intervention methods to manage individuals with brain injury-related aggression. New data on interventions used in the RNA and on how the RNA interventions can be used with patients with acquired brain injury (ABI) who have differing levels of functional impairment are provided in this paper.

METHOD

The study was conducted over a 6-week period in a secure 65-bed program for individuals with ABI that is housed in two units of a skilled nursing facility (SNF). Implementation of the RNA was compared between two units that housed patients with differing levels of functional impairment (n = 65 adults). Since this was a hierarchical clustered dataset, Generalized Estimating Equations regression was used in the analyses.

RESULTS

RNA interventions used to manage the 495 aggressive incidents included the following: Aggression ignored, Closer observation, Talking to patient, Reassurance, Physical distraction, Isolation without seclusion, Immediate medication by mouth, Holding patient. Different interventions were implemented differentially by staff based on level of functional impairment and without use of seclusion or mechanical restraint.

CONCLUSIONS

The RNA can be used to non-aversively manage aggression in patients with brain injury and with differing levels of functional impairment. Programs adopting the RNA can potentially manage brain injury-related aggression without seclusion or mechanical restraint. Implications for Rehabilitation The Relational Neurobehavioral Approach (RNA) is a set of non-aversive intervention methods to manage individuals with brain injury-related aggression. RNA methods can be used to manage aggression in patients with brain injury who have differing levels of functional impairment. Successful implementation of the RNA may allow for the management of brain injury-related aggression without seclusion or mechanical restraint.

Factors influencing community case management and care hours for clients with traumatic brain injury living in the UK

OBJECTIVE

To investigate the relationship between deficits associated with traumatic brain injury (TBI) and case management (CM) and care/support (CS) in two UK community samples.

RESEARCH DESIGN

Prospective descriptive study.

METHOD

Case managers across the UK and from a single UK CM service contributed client profiles to two data sets (Groups 1 and 2, respectively). Data were entered on demographics, injury severity, functional skills, functional-cognition (including executive functions), behaviour and CM and CS hours. Relationships were explored between areas of disability and service provision.

RESULTS

Clients in Group 2 were more severely injured, longer post-injury and had less family support than clients in Group 1. There were few significant differences between Groups 1 and 2 on measures of Functionalskill, Functional-cognition and Behaviour disorder. Deficits in Functionalskills were associated with CS, but not CM. Deficits in measures of executive functions (impulsivity, predictability, response to direction) were related to CM, but not to CS. Insight was related to both CM and CS. Variables related to behaviour disorder were related to CM, but were less often correlated to CS.

CONCLUSIONS

The need for community support is related not only to Functionalskills (CS), but also to behaviour disorder, self-regulatory skills and impaired insight (CM).