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Block H, Bellon M, Hunter SC, George S. Barriers and enablers to managing challenging behaviours after traumatic brain injury in the acute hospital setting: a qualitative study. BMC Health Serv Res 2023; 23:1266. [PMID: 37974214 PMCID: PMC10655469 DOI: 10.1186/s12913-023-10279-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 11/06/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Challenging behaviours after traumatic brain injury (TBI) in the acute setting are associated with risk of harm to the patient and staff, delays in commencing rehabilitation and increased length of hospital stay. Few guidelines exist to inform practice in acute settings, and specialist services providing multi-disciplinary expertise for TBI behaviour management are predominantly based in subacute inpatient services. This study aims to investigate acute and subacute staff perspectives of barriers and enablers to effectively managing challenging behaviours after TBI in acute hospital settings. METHODS Qualitative focus groups were conducted with 28 staff (17 from acute setting, 11 from subacute setting) across two sites who had experience working with patients with TBI. Data were analysed using inductive-deductive reflexive thematic analysis. Data were applied to the constructs of the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to generate themes representing barriers and enablers to managing challenging behaviours after TBI in the acute hospital setting. RESULTS Four barriers and three enablers were identified. Barriers include (1) Difficulties with clinical decision making; (2) Concerns for risks to staff and patients; (3) Hospital environment; (4) Intensive resources are required. Enablers were (1) Experienced staff with practical skills; (2) Incorporating person-centred care; and (3) Supportive teams. CONCLUSION These findings can inform pre-implementation planning for future improvements to TBI behaviour management in acute hospital settings. Difficulties with clinical decision making, concerns for risks of injury, the hospital environment and lack of resources are major challenges. Implementation strategies developed to address barriers will need to be trialled, with multi-disciplinary team approaches, and tailored to the acute setting.
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Affiliation(s)
- Heather Block
- Caring Futures Institute, College of Nursing and Health Science, Flinders University, Adelaide, Australia.
- Division of Allied Health, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, Australia.
| | - Michelle Bellon
- Caring Futures Institute, College of Nursing and Health Science, Flinders University, Adelaide, Australia
| | - Sarah C Hunter
- Caring Futures Institute, College of Nursing and Health Science, Flinders University, Adelaide, Australia
| | - Stacey George
- Caring Futures Institute, College of Nursing and Health Science, Flinders University, Adelaide, Australia
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Leppla I, Tobolowsky W, Patel S, Mahdanian A, Lobner K, Caufield-Noll C, Ponor IL, Roy D. Scoping Review on Educational Programs for Medical Professionals on the Management of Acute Agitation. J Acad Consult Liaison Psychiatry 2023; 64:457-467. [PMID: 37211211 DOI: 10.1016/j.jaclp.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 05/09/2023] [Accepted: 05/14/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Agitation is a common reason for psychiatric consultation in the general hospital. The consultation-liaison (CL) psychiatrist is often tasked with teaching the medical team how to manage agitation. OBJECTIVE The purpose of this scoping review is to explore what resources the CL psychiatrist has for educational tools on teaching about agitation management. Given the frequency with which CL psychiatrists help with on-the-ground management of agitation, we hypothesized that there would be a scarcity of educational resources to teach front-line providers how to manage agitation. METHODS Following current Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a scoping review was conducted. The literature search focused on the electronic databases MEDLINE (PubMed), Embase (Embase.com), The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Methodology Register), PsycInfo (EbscoHost), Cumulated Index to Nursing and Allied Health Literature (CINAHL) (EbscoHost), and Web of Science. Using Covidence software, after screening for titles and abstracts, full texts were screened independently and in duplicate according to our inclusion criteria. For data extraction, we created a predefined set of criteria according to which each article was analyzed. We then grouped the articles in the full-text review according to which patient population a curriculum was designed for. RESULTS The search yielded a total of 3250 articles. After removing duplicates and reviewing procedures, we included 51 articles. Data extraction captured article type and details; educational program information (staff training, web modules, instructor led seminar); learner population; patient population; and setting. The curricula were further divided based on their target patient population, specifically the acute psychiatric patient (n = 10), the general medical patient (n = 9), and the patient with a major neurocognitive disorder such as dementia or traumatic brain injury (n = 32). Learner outcomes included staff comfort, confidence, skills, and knowledge. Patient outcomes included measurements of agitation or violence using validated scales, PRN medication use, and restraint use. CONCLUSIONS Despite there being numerous agitation curricula in existence, we found that a large majority of these educational programs were done for patients with major neurocognitive disorders in the long-term care setting. This review highlights the gap in education related to agitation management for both patients and providers in the general medical setting, as less than 20% of total studies are focused on this population. The CL psychiatrist plays a critical role in assisting in agitation management in this setting, which often requires collaboration between technicians, nurses, and nonpsychiatric providers. It calls into question whether the lack of educational programs makes the implementation of management interventions more difficult and less effective, even with the assistance of the CL psychiatrist.
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Affiliation(s)
- Idris Leppla
- Johns Hopkins School of Medicine, Baltimore, MD; Johns Hopkins Psychiatry & Behavioral Sciences, Baltimore, MD.
| | - William Tobolowsky
- Johns Hopkins School of Medicine, Baltimore, MD; Johns Hopkins Psychiatry & Behavioral Sciences, Baltimore, MD
| | | | - Artin Mahdanian
- Johns Hopkins School of Medicine, Baltimore, MD; Johns Hopkins Psychiatry & Behavioral Sciences, Baltimore, MD
| | | | | | - I Lucia Ponor
- Johns Hopkins School of Medicine, Baltimore, MD; Johns Hopkins Department of Medicine, Baltimore, MD
| | - Durga Roy
- Johns Hopkins School of Medicine, Baltimore, MD; Johns Hopkins Psychiatry & Behavioral Sciences, Baltimore, MD
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Downe S, Nowland R, Clegg A, Akooji N, Harris C, Farrier A, Gondo LT, Finlayson K, Thomson G, Kingdon C, Mehrtash H, McCrimmon R, Tunçalp Ö. Theories for interventions to reduce physical and verbal abuse: A mixed methods review of the health and social care literature to inform future maternity care. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001594. [PMID: 37093790 PMCID: PMC10124898 DOI: 10.1371/journal.pgph.0001594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
Despite global attention, physical and verbal abuse remains prevalent in maternity and newborn healthcare. We aimed to establish theoretical principles for interventions to reduce such abuse. We undertook a mixed methods systematic review of health and social care literature (MEDLINE, SocINDEX, Global Index Medicus, CINAHL, Cochrane Library, Sept 29th 2020 and March 22nd 2022: no date or language restrictions). Papers that included theory were analysed narratively. Those with suitable outcome measures were meta-analysed. We used convergence results synthesis to integrate findings. In September 2020, 193 papers were retained (17,628 hits). 154 provided theoretical explanations; 38 were controlled studies. The update generated 39 studies (2695 hits), plus five from reference lists (12 controlled studies). A wide range of explicit and implicit theories were proposed. Eleven non-maternity controlled studies could be meta-analysed, but only for physical restraint, showing little intervention effect. Most interventions were multi-component. Synthesis suggests that a combination of systems level and behavioural change models might be effective. The maternity intervention studies could all be mapped to this approach. Two particular adverse contexts emerged; social normalisation of violence across the socio-ecological system, especially for 'othered' groups; and the belief that mistreatment is necessary to minimise clinical harm. The ethos and therefore the expression of mistreatment at each level of the system is moderated by the individuals who enact the system, through what they feel they can control, what is socially normal, and what benefits them in that context. Interventions to reduce verbal and physical abuse in maternity care should be locally tailored, and informed by theories encompassing all socio-ecological levels, and the psychological and emotional responses of individuals working within them. Attention should be paid to social normalisation of violence against 'othered' groups, and to the belief that intrapartum maternal mistreatment can optimise safe outcomes.
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Affiliation(s)
- Soo Downe
- Research in Childbirth and Health Group, THRIVE Centre, University of Central Lancashire, Preston, United Kingdom
| | - Rebecca Nowland
- Maternal and Infant Nurture and Nutrition Group, THRIVE Centre, University of Central Lancashire, Preston, United Kingdom
| | - Andrew Clegg
- Synthesis, Economic Evaluations and Decision Science (SEEDS) Group, University of Central Lancashire, Preston, United Kingdom
| | - Naseerah Akooji
- Lancashire Clinical Trials Unit, University of Central Lancashire, Preston, United Kingdom
| | - Cath Harris
- Synthesis, Economic Evaluations and Decision Science (SEEDS) Group, University of Central Lancashire, Preston, United Kingdom
| | - Alan Farrier
- Healthy and Sustainable Settings Unit, University of Central Lancashire, Preston, United Kingdom
| | | | - Kenny Finlayson
- Research in Childbirth and Health Group, THRIVE Centre, University of Central Lancashire, Preston, United Kingdom
| | - Gill Thomson
- Maternal and Infant Nurture and Nutrition Group, THRIVE Centre, University of Central Lancashire, Preston, United Kingdom
| | - Carol Kingdon
- Research in Childbirth and Health Group, THRIVE Centre, University of Central Lancashire, Preston, United Kingdom
| | - Hedieh Mehrtash
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Rebekah McCrimmon
- School of Community Health and Midwifery, University of Central Lancashire, Preston, United Kingdom
| | - Özge Tunçalp
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Block H, Hunter SC, Bellon M, George S. Implementing a behavior management approach in the hospital setting for individuals with challenging behaviors during acute traumatic brain injury. Brain Inj 2022; 36:1176-1186. [PMID: 35996950 DOI: 10.1080/02699052.2022.2110941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
PRIMARY OBJECTIVE This study aimed to determine if implementing a clinically pragmatic behavior management approach for challenging behaviors during acute TBI reduces use of restraints, security incidences, acute length of stay admission and cost, thereby improving progress to rehabilitation. RESEARCH DESIGN This pilot study involved a behavior management group (n = 27), compared with a historical control group (n = 74). METHOD AND PROCEDURES The behavior management group received care following the implementation of a behavior management approach for challenging behaviors during acute TBI at two hospitals in South Australia. MAIN OUTCOMES AND RESULTS Fidelity results demonstrated high level of adherence to the implemented behavior management approach. The behavior management group had significant lower use of mechanical restraints (p = 0.03), and significantly lower acute admission costs (p = 0.034). Trends in lower pharmacological restraint usage, lower acute hospital length of stay and time from admission to rehabilitation acceptance were recorded. CONCLUSIONS These pilot results contribute to improving quality of health care but methodological limitations make outcomes difficult to interpret as a direct result of the intervention. Future studies are required to investigate evidence-based behavior management interventions for acute TBI patients using more rigorous knowledge translation implementation designs.
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Affiliation(s)
- Heather Block
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia.,Division of Allied Health, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, Australia
| | - Sarah C Hunter
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Michelle Bellon
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Stacey George
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
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The Use of Atypical Antipsychotics for Managing Agitation After Traumatic Brain Injury. J Head Trauma Rehabil 2021; 36:149-155. [PMID: 32898031 DOI: 10.1097/htr.0000000000000614] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE This study examined the use of antipsychotics for managing agitation during posttraumatic amnesia (PTA) after traumatic brain injury (TBI) and its relationship with agitated behavior. DESIGN Observational prospective study with correlational design. SETTING Inpatient rehabilitation hospital for TBI. PARTICIPANTS A total of 125 consecutive admissions who were in PTA and had moderate-severe TBI. MEASURES Antipsychotic use was compared with agitation levels as measured by the total scores on the Agitated Behavior Scale (ABS). RESULTS Atypical antipsychotics were used in one-third of participants to manage agitation. Antipsychotic use was more common in participants with high levels of global agitation; however, there were many on antipsychotics who had mild or even no agitation according to the ABS. Uncontrolled observational data found no reduction in agitation after antipsychotic commencement or dose increase. CONCLUSIONS Antipsychotics are commonly used to manage agitation after TBI despite limited evidence of efficacy. Agitation should be formally monitored in PTA to ensure antipsychotics are used to manage more severe agitation and for evaluating treatment response. Research is needed to understand why prescribers are using antipsychotics when agitation is mild or below clinical thresholds.
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Dasgupta M, Beker L, Schlegel K, Hillier LM, Joworski L, Crunican K, Coulter C. A Non-Pharmacologic Approach to Manage Behaviours in Confused Medically Ill Older Adults in Acute Care. Can Geriatr J 2021; 24:125-137. [PMID: 34079606 PMCID: PMC8137457 DOI: 10.5770/cgj.24.469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Non-pharmacological interventions are recommended to manage challenging behaviours among cognitively impaired older adults, however few studies have enrolled patients in acute care. This study aimed to determine the feasibility of implementing non-pharmacological interventions to manage behaviours in hospitalized older adults. Method A self-identity approach was used to identify potentially engaging activities for 13 older medically ill adults admitted to acute hospital; these activities were trialed for a two-week period. Data were collected on frequency of intervention administration and assistance required, as well as frequency of behaviours and neuroleptic use in the seven days prior to and following the trial of activities. Results Per participant, 5–11 interventions were prescribed. Most frequently interventions were tried two or more times (46%); 9% were not tried at all. Staff or family assistance was not required for 27% of activities. The mean number of documented behaviours across participants was 4.8 ± 2.3 in the pre-intervention period and 2.1 ± 1.9 in the post-intervention period. Overall the interventions were feasible and did not result in increasing neuroleptic use Conclusion Non-pharmacologic interventions may be feasible to implement in acute care. More research in this area is justified.
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Affiliation(s)
- Monidipa Dasgupta
- Division of Geriatric Medicine, Shulich School of Medicine, Western University, London, ON.,Lawson Health Research Institute, London, ON
| | | | - Kim Schlegel
- London Health Sciences Centre, London, ON.,Fanshawe College, London, ON
| | - Loretta M Hillier
- GERAS Centre for Aging Research, Hamilton Health Sciences, Hamilton, ON
| | | | | | - Corrine Coulter
- Department of Family Medicine, Shulich School of Medicine, Western University, London, ON
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Abraham J, Hirt J, Kamm F, Möhler R. Interventions to reduce physical restraints in general hospital settings: A scoping review of components and characteristics. J Clin Nurs 2020; 29:3183-3200. [PMID: 32558091 DOI: 10.1111/jocn.15381] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 03/26/2020] [Accepted: 06/05/2020] [Indexed: 12/01/2022]
Abstract
AIMS AND OBJECTIVES To describe the characteristics of interventions for reducing physical restraints in general hospital settings. BACKGROUND Physical restraints, such as bedrails and belts in beds and chairs, are commonly used in general hospital settings. However, there is no clear evidence on their effectiveness but some evidence on potential risks for harm. DESIGN Scoping review. METHODS We conducted a systematic database search (MEDLINE via PubMed, CINAHL, Cochrane Library; March 2020) and snowballing techniques. We included both interventional studies and quality improvement projects conducted in general hospital settings and published in English or German language. Two reviewers independently performed the study selection and data extraction. The Scoping Reviews (PRISMA-ScR) Checklist was used. RESULTS We included 31 articles (published between 1989 and 2018), 15 quality improvement projects and 16 intervention studies. Only five studies used a controlled design. Most studies and quality improvement projects investigated multicomponent interventions including education (predominantly for nursing staff) and additional components (e.g. case conferences). Three studies examined simple educational programmes without additional components. CONCLUSIONS A large number of multicomponent interventions for preventing and reducing physical restraints in general hospital settings have been developed. The interventions differed widely regarding the components, contents and settings. Well-designed evaluation studies investigating the effects of such interventions are lacking. RELEVANCE TO CLINICAL PRACTICE Multicomponent educational interventions might be one approach to change clinical practice, but only insufficient information is available about potential effects of these approaches.
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Affiliation(s)
- Jens Abraham
- Institute for Health and Nursing Science, Medical Faculty, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Julian Hirt
- Institute for Health and Nursing Science, Medical Faculty, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany.,Department of Health, Center for Dementia Care, Institute of Applied Nursing Sciences, FHS St. Gallen, St. Gallen, Switzerland
| | - Friederike Kamm
- Institute for Health and Nursing Science, Medical Faculty, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Ralph Möhler
- Institute for Health and Nursing Science, Medical Faculty, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany.,School of Public Health, Bielefeld University, Bielefeld, Germany
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Draganich C, Gerber D, Monden KR, Newman J, Weintraub A, Biggs J, Philippus A, Makley M. Disrupted sleep predicts next day agitation following moderate to severe brain injury. Brain Inj 2019; 33:1194-1199. [DOI: 10.1080/02699052.2019.1631484] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Christina Draganich
- Craig Hospital, Englewood, CO, USA
- University of Colorado Department of PM&R, Aurora, CO, USA
| | - Don Gerber
- Craig Hospital, Englewood, CO, USA
- University of Colorado Department of PM&R, Aurora, CO, USA
| | - Kimberley R. Monden
- Craig Hospital, Englewood, CO, USA
- University of Colorado Department of PM&R, Aurora, CO, USA
| | | | - Alan Weintraub
- Craig Hospital, Englewood, CO, USA
- University of Colorado Department of PM&R, Aurora, CO, USA
| | | | | | - Michael Makley
- Craig Hospital, Englewood, CO, USA
- University of Colorado Department of PM&R, Aurora, CO, USA
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9
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Safety Profile of Children in an Enclosure Bed. CLIN NURSE SPEC 2016; 31:36-44. [PMID: 27906732 DOI: 10.1097/nur.0000000000000261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Pediatric nurses care for many children in the hospital setting whose behavioral challenges can impact safety. One intervention utilized to prevent injury and improve safety when caring for this population of children has been the enclosure bed. Scant information was found in the literature that discusses the use of the enclosure bed in the pediatric setting. The purpose of this article is to examine the use of the enclosure bed in the pediatric setting. A secondary aim is to identify the population of children where an enclosure bed was implemented and the safety factors associated with use of the enclosure bed. METHODS An exploratory retrospective chart review was conducted of 208 pediatric enclosure bed encounters in an acute care setting over a 2-year period. Variables included demographics, length of stay and bed use, behavioral medications, restraint and sitter usage, skin breakdown, fall risk, and falls. RESULTS Three categories of children based on cognitive function, no cognitive impairment, new cognitive impairment, and congenital cognitive impairment, were extracted from the chart review. Significant differences were found between groups of children and between safety variables observed with enclosure bed use. Children with new-onset cognitive impairment were more likely to incur falls, skin breakdown, and injury during use of the enclosure bed. CONCLUSION Use of the enclosure bed is a reasonable intervention in certain children to ensure their safety in the hospital setting. This information will enhance nursing knowledge related to providing safe and optimal care of this challenging population of children.
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Moessner A, Malec JF, Beveridge S, Reddy CC, Huffman T, Marton J, Schmerzler AJ. Preliminary evaluation of a measure for reliable assessment of need for constant visual observation in adults with traumatic brain injury. Brain Inj 2016; 30:1343-1349. [PMID: 27715319 DOI: 10.1080/02699052.2016.1193629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PRIMARY OBJECTIVE To develop and provide initial validation of a measure for accurately determining the need for Constant Visual Observation (CVO) in patients with traumatic brain injury (TBI) admitted to inpatient rehabilitation. RESEARCH DESIGN Rating scale development and evaluation through Rasch analysis and assessment of concurrent validity. METHODS AND PROCEDURES One hundred and thirty-four individuals with moderate-severe TBI were studied in seven inpatient brain rehabilitation units associated with the National Institute for Disability, Independent Living and Rehabilitation Research (NIDILRR) TBI Model System. Participants were rated on the preliminary version of the CVO Needs Assessment scale (CVONA) and, by independent raters, on the Levels of Risk (LoR) and Supervision Rating Scale (SRS) at four time points during inpatient rehabilitation: admission, Days 2-3, Days 5-6 and Days 8-9. OUTCOMES AND RESULTS After pruning misfitting items, the CVONA showed satisfactory internal consistency (Person Reliability = 0.85-0.88) across time points. With reference to the LoR and SRS, low false negative rates (sensitivity > 90%) were associated with moderate-to-high false positive rates (29-56%). CONCLUSIONS The CVONA may be a useful objective metric to complement clinical judgement regarding the need for CVO; however, further prospective study is desirable to further assess its utility in identifying at-risk patients, reducing adverse events and decreasing CVO costs.
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Affiliation(s)
- Anne Moessner
- a Mayo Clinic Department of Physical Medicine & Rehabilitation , Rochester , MN , USA
| | - James F Malec
- b Physical Medicine and Rehabilitation , Indiana University School of Medicine and Rehabilitation Hospital of Indiana , Indianapolis , IN , USA
| | - Scott Beveridge
- c UPMC Mercy Hospital Rehabilitation Institute , Pittsburgh , PA , USA
| | | | - Tracy Huffman
- d The Ohio State University Wexner Medical Center , Columbus , OH , USA
| | - Julia Marton
- e Department of Rehabilitation , Baylor Institute for Rehabilitation-Dallas Campus , Dallas , TX , USA
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Care management of the agitation or aggressiveness crisis in patients with TBI. Systematic review of the literature and practice recommendations. Ann Phys Rehabil Med 2015; 59:58-67. [PMID: 26700025 DOI: 10.1016/j.rehab.2015.11.001] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 11/16/2015] [Accepted: 11/16/2015] [Indexed: 11/21/2022]
Abstract
UNLABELLED The agitation crisis in the awakening phase after traumatic brain injury (TBI) is one of the most difficult behavioral disorders to alleviate. Current treatment options are heterogeneous and may involve excessive sedation. Practice guidelines are required by professionals in charge of TBI patients. Few reviews were published but those are old and based on expert opinions. The purpose of this work is to propose evidence-based guidelines to treat the agitation crisis. METHODS The elaboration of these guidelines followed the procedure validated by the French health authority for good practice recommendations, close to the Prisma statement. Guidelines were elaborated on the basis of a systematic and critical review of the literature. RESULTS Twenty-eight articles concerning 376 patients were analyzed. Recommendations are: when faced with an agitation crisis, the management strategy implies to search for an underlying factor that should be treated such as pain, acute sepsis, and drug adverse effect (expert opinion). Physical restraints should be discarded when possible (expert opinion). Neuroleptic agent with a marketing authorization can be used in order to obtain a quick sedation so as to protect the patient from himself, closed ones or the healthcare team but the duration should be as short as possible (expert opinion). The efficacy of beta-blockers and antiepileptics with mood regulation effects like carbamazepine and valproate yield the most compelling evidence and should be preferably used when a background regimen is envisioned (grade B for beta-blocker and C for antiepileptics). Neuroleptics, antidepressants, benzodiazepines, buspirone may be prescribed but are considered second-line treatments (expert opinion). CONCLUSION This study provides a strategy for treating the agitation crisis based on scientific data and expert opinion. The level of evidence remains low and published data are often old. New studies are essential to validate results from previous studies and test new drugs and non-pharmaceutical therapies.
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Aadal L, Mortensen J, Nielsen JF. Monitoring Agitated Behavior After acquired Brain Injury: Onset, Duration, Intensity, and Nursing Shift Variation. Rehabil Nurs 2015; 41:289-97. [PMID: 26542895 DOI: 10.1002/rnj.251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2015] [Indexed: 11/11/2022]
Abstract
PURPOSE To describe the onset, duration, intensity, and nursing shift variation of agitated behavior in patients with acquired brain injury (ABI) at a rehabilitation hospital. DESIGN Prospective descriptive study. METHODS A total of 11 patients with agitated behavior were included. Agitated behavior was registered with the Agitated Behavior Scale (ABS). The nurse or therapist allocated the individual patient assessed ABS during each shift. Intensity of agitated behavior was tested using exact test. A within-subject shift effect was analyzed with repeated-measure ANOVA. FINDINGS The onset of agitated behavior was at a median of 14 (1-28) days from admission. Seven patients remained agitated beyond 3 weeks from onset. Severe intensity of agitation was observed in 86 of 453 nursing shifts. Differences in agitated behavior between day, evening, and night shifts were found, F(2.20) = 7.90, p = .008, with tendencies of increased agitated behavior in day and evening shifts compared to night shifts. CONCLUSION Agitated behavior had a late onset, was severe, and long-lasting in the present sample of patients. CLINICAL RELEVANCE The study increases awareness on the potential challenge of agitated behavior in patients with ABI.
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Affiliation(s)
- Lena Aadal
- Hammel Neurorehabilitation and Research Centre, Hammel, Denmark.
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Bogner J, Barrett RS, Hammond FM, Horn SD, Corrigan JD, Rosenthal J, Beaulieu CL, Waszkiewicz M, Shea T, Reddin CJ, Cullen N, Giuffrida CG, Young J, Garmoe W. Predictors of Agitated Behavior During Inpatient Rehabilitation for Traumatic Brain Injury. Arch Phys Med Rehabil 2015. [DOI: 10.1016/j.apmr.2015.04.020] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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14
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Duraski SA. Clinical consultation: nonpharmacologic management of agitated behaviors after traumatic brain injury. Rehabil Nurs 2011; 36:135, 145. [PMID: 21721392 DOI: 10.1002/j.2048-7940.2011.tb00079.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Sylvia A Duraski
- Brain Injury Medicine and Rehabilitation Program, Rehabilitation Institute of Chicago, IL, USA.
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Nott MT, Chapparo C, Heard R, Baguley IJ. Patterns of agitated behaviour during acute brain injury rehabilitation. Brain Inj 2011; 24:1214-21. [PMID: 20715891 DOI: 10.3109/02699052.2010.506858] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To monitor daily shift-by-shift changes in agitated behaviour during adult brain injury rehabilitation. DESIGN A prospective, descriptive study. METHODS Eight participants were monitored daily for up to 28 days. The Agitated Behaviour Scale (ABS) evaluated behaviour during three nursing shifts (morning, afternoon, night). Severity of agitation, peak intensity and concomitant behaviours were calculated. Shift differences and patterns of behavioural changes were analysed. RESULTS Four hundred and seven recordings were taken with the ABS. All participants demonstrated multiple agitated behaviours (between 3-13 concomitant behaviours per person); the most common behaviours were representative of the ABS Disinhibition sub-scale. Weekly peak intensity ranged from 14-55 on the ABS. Mean ABS scores were highest during the afternoon shift and lowest at night. Improved cognition was associated with resolving agitated behaviour; while persistent agitated behaviour was associated with low levels of cognition. Minimal agitated behaviour was observed in participants who emerged from post-traumatic amnesia. CONCLUSIONS Agitated behaviour during acute brain injury rehabilitation has a complex clinical presentation. High levels of agitation observed during the afternoon shift may be associated with low levels of structured activities available at that time, higher levels of environmental stimuli during visiting times and increased cognitive fatigue. Lower cognitive ability was related to consistently higher levels of agitated behaviour and vice-versa.
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Affiliation(s)
- Melissa T Nott
- Brain Injury Rehabilitation Service, Westmead Hospital, Wentworthville, NSW, Australia.
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