Factors Associated With Time to Decannulation in Patients With Tracheostomy Following Severe Traumatic Brain Injury

BACKGROUND

Prolonged tracheal tube placement following severe traumatic brain injury (TBI) can cause serious complications. Safe removal requires sufficient ability for independent breathing and airway protection. Thus, identifying important factors for time to removal of the tracheal tube (decannulation) is essential for safe and efficient weaning. This study aimed to identify significant factors for time to decannulation in a Danish population of subjects with tracheostomy after TBI.

METHODS

This was a retrospective register-based cohort study. Subjects with moderate and severe TBI and a tracheal tube were selected from the Danish Head Trauma Database between 2011-2021. Time to decannulation was calculated as time from injury to decannulation. Associations between selected explanatory variables representing demographic and clinical characteristics and time to decannulation were analyzed using linear regression models.

RESULTS

A total 324 subjects were included with a median of 44 d to decannulation. Primary analysis found that an improvement in swallowing ability during the initial 4 weeks of rehabilitation was associated with an 8.2 d reduction in time to decannulation (95% CI -12.3 to -4.2, P < .001). Change in overall sensorimotor ability reduced time to decannulation by 0.94 (95% CI -0.78 to -0.10, P = .03) d. Change in cognitive abilities from rehab admission to 4-week follow-up did not significantly affect the number of days to decannulation (P = .66). Secondary analysis showed pneumonia was associated with the largest estimated increase of 24.4 (95% CI 15.9-32.9, P < .001) d and that increased cognitive functioning at rehabilitation admission was associated with a significant reduction in time to decannulation.

CONCLUSIONS

This study found that a change in swallowing ability is a potentially significant factor for reducing time to decannulation. Identifying factors that could explain differences in time to decannulation is essential for patient outcomes, especially if these factors are modifiable and could be targeted in rehabilitation and treatment.

Robotic technology (ROBERT®) to enhance muscle strength in the hip flexor muscles following spinal cord injury: a feasibility study

STUDY DESIGN

Feasibility study.

OBJECTIVE

To determine the feasibility of conducting a large trial designed to determine whether the ROBERT® can be used to increase the strength of the hip flexor muscles after spinal cord injury (SCI). The ROBERT® is a robotic device that provides assisted active movement while supporting the weight of the leg. Focus was on recruitment capability, suitability, and acceptability of the intervention and outcome measure.

SETTING

Specialised SCI centre in Denmark.

METHODS

All first-time admitted patients were screened to assess participant recruitment capability. Four people with SCI < 3 months tested a protocol consisting of 60 repetitions of hip flexion in supine conducted with the assistance of the ROBERT® three times a week for 4 weeks. Feasibility was assessed based on adherence to the protocol and completion rate and from the participants' perspectives. Maximal voluntary contraction (MVC) was accessed at baseline and four weeks.

RESULTS

The recruitment rate was 8% (7 months). The four participants completed 44 out of 48 sessions (92%). No adverse events occurred. One physiotherapist was required to set-up and supervise each session. The active exercise time varied from 7.5 to 17 min. The participants found the ROBERT® a good supplement to their usual rehabilitation. We were able to measure MVC in even very weak hip flexor muscles with a dynamometer MicroFET2 fixed to a frame.

CONCLUSION

The ROBERT® was feasible and acceptable. The participants perceived it as a supplement, not a replacement to usual physiotherapy. However, recruitment to the study was slow.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05558254. Registered 28th September 2022.

Diet-induced ketosis in adult patients with subacute acquired brain injury: a feasibility study

Background

Research in animal models on cerebral metabolism after brain injury highlights the potential benefits of ketosis in reducing secondary brain injury, but studies in humans are lacking.

Aim

This study aimed to examine if a 6-week ketogenic diet intervention with added medium-chain triglycerides (MCT) was feasible in adult patients with acquired brain injury in the subacute phase, whether ketosis could be achieved and maintained, and to what extent serious adverse reactions, adverse reactions, serious adverse events, and adverse events occured.

Methods

Patients ≥18 years of age diagnosed with subacute acquired brain injury and an expectation of hospitalisation ≥6 weeks were included in the intervention group. Patients not included in the intervention group were included in a standard care reference group. The intervention consisted of a ketogenic diet supplemented with MCT to obtain a plasma concentration of β-hydroxybutyrate (BHB) ≥0.5 mmol/L. Patients who were enterally fed were given KetoCal® 2.5:1 LQ MCT Multi Fiber (Nutricia A/S, Allerød, Denmark), supplemented with Liquigen® (Nutricia A/S, Allerød, Denmark). Patients consuming oral nutrition were given KetoCal® 2.5:1 LQ MCT Multi Fiber supplemented with Liquigen®, in addition to ketogenic meals.

Results

During a 13-week inclusion period, 12 of 13 eligible patients (92% [95% CI: 67% to 99%]) were included in the intervention group, and 17 of 18 excluded patients (94% [95% CI: 74% to 99%]) were included in the reference group. Eight patients (67%) completed the 6-week intervention. It took a median of 1 day to achieve ketosis from starting a 100% MCT ketogenic diet, and it was maintained for 97% of the intervention period after ketosis was obtained. There were no serious adverse reactions to the MCT ketogenic diet, and patients experienced adverse reactions not considered serious in 9.5% of days with the intervention. The MCT ketogenic diet was accepted by patients on all intervention days, and in the two patients transitioning from enteral feeding to oral intake, there were no complications related to transitioning.

Conclusion

Intervention with MCT ketogenic diet is feasible and tolerated for 6 weeks in hospitalised adult patients with subacute acquired brain injury. Randomised controlled trials are needed to assess the benefits and harms of the MCT ketogenic diet and the effect on patients' recovery.Clinical trial registration: ClinicalTrials.gov, identifier [NCT04308577].

Wants and needs for involvement reported by relatives of patients with a malignant brain tumor: a scoping review

OBJECTIVE

The objective of this scoping review was to identify and map the breadth of available evidence on relatives' wants and needs for involvement throughout the course of the disease in patients with a malignant brain tumor.

INTRODUCTION

Patients diagnosed with a malignant brain tumor often have a poor prognosis, including a rapid progression of the disease, with changing physical, cognitive, and psychosocial symptoms. The caregiver burden is described as multifaceted, and relatives often neglect their own physical, emotional, and social needs.

INCLUSION CRITERIA

This review included studies that defined or assessed the wants and needs for involvement of relatives of patients with a malignant brain tumor throughout the disease and treatment trajectory. The populations were relatives of patients with a malignant brain tumor in various settings.

METHODS

The JBI methodology for scoping reviews was followed in accordance with a previously published a priori protocol. An extensive search was conducted in the MEDLINE (PubMed), CINAHL (EBSCOhost), and Embase (Ovid). Gray literature was searched using Grey Matters and BASE. The initial search was conducted in February 2020 and updated in March 2022. This review was limited to studies published since January 2010 in English, German, or Scandinavian languages. The data were extracted using a data extraction tool (authors, year of publication, country of origin, setting, study methods, and findings related to wants and needs for involvement) created by the authors. Textual data mapping of wants and needs for involvement were synthesized narratively using a basic qualitative content analysis. The review findings are reported as a descriptive summary, with tables and figures to support the data.

RESULTS

The search identified 3830 studies, of which 10 were included. The studies were conducted in 6 countries and were published between 2010 and 2018. In total, 4 studies applied a qualitative study design that used semi-structured interviews, 2 studies applied a mixed methods design that used questionnaires and semi-structured interviews, 1 study applied a multi-method design, and 3 studies used a quantitative survey. Research was conducted in a variety of settings, including community palliative care, inpatient centers, outpatient, home, and post-bereavement. The findings showed that most of the relatives' needs were related to the caregiver role. The relatives were actively involved in the patients' disease and treatment trajectories. However, relatives were often required to adopt the caregiver role and a large amount of responsibility at short notice. Thus, they expressed a need for a stronger connection with health care professionals because their needs changed as rapidly as the disease progressed. Relatives also had a need related to maintaining hope, which was essential for their involvement. Relatives' wants for involvement in the patients' disease and treatment trajectories depended on a significant and timely amount of information.

CONCLUSIONS

The findings reveal that relatives are actively involved in the patients' disease and treatment trajectories. The relatives want and need support for their involvement, which is related directly to the accessibility and availability of health care professionals, as the demands placed on them change rapidly throughout the progression of the disease. One way to address relatives' wants and needs may be to further strengthen the relationship between the relatives and health care professionals.

SUPPLEMENTAL DIGITAL CONTENT

A Danish-language version of the abstract of this review is available as Supplemental Digital Content [ http://links.lww.com/SRX/A26 ]. A German-language version of the abstract of this review is available at Supplemental Digital Content [ http://links.lww.com/SRX/A35 ].

How well do nurses know their patients? Agreement between patients' degree-of-worry and nurses' estimation of patients' degree-of-worry-An observational study

AIM

To assess the agreement between patients' self-reported degree-of-worry (DOW) and nurses' evaluation of patients' DOW.

DESIGN

An observational cohort study with patients and their primary nurses.

METHODS

Between 22 February and 27 March 2021, data collection among patients and their nurses in an emergency department was carried out. Patients ≥18 years, cognitively intact and Danish or English speaking were eligible to participate. Nurses regardless of seniority and gender were eligible for participation. The single-item degree-of-worry measure, 'how worried are you about the condition you are here today on a scale from 1 to 10, where 1 is minimally worried and 10 is maximum worried' as well as information on gender, age, co-morbidity, triage level and medical reason for encounter was collected from patients. The corresponding nurses were asked; 'how worried do you think your patient is about the condition he/she is there today on a scale from 1 to 10, where 1 is minimally worried and 10 is maximum worried?' Nurses also supplied data on gender, age, seniority as a Registered Nurse and in the ED. Agreement between patients' self-reported degree-of-worry and nurses' evaluation of patients' degree-of-worry was assessed with weighted Cohen's Kappa.

RESULTS

A total of 194 patient-nurse pairs were included for analysis. The agreement between patients' DOW and nurses' evaluation of patients' DOW categorised as DOWlow , DOWmiddle and DOWhigh was in total agreement in n = 85 pairs (43.8%) of the ratings, which corresponds to a weighted Cohen's Kappa of 0.19 (0.08-0.30; p < 0.001).

CONCLUSION

Nurses estimate of their patients' DOW was in very poor agreement. This indicates that nurses are not able to assess the patient's DOW to a satisfactory level. This result is troubling as it may have serious consequences for patient care as it indicates that the nurses do not know their patients' perspectives.

Facilitators and inhibitors of traumatic brain injury transfers: A fieldwork investigation

AIM

Intensified healthcare specialization has increased the need for patient transfers. We aimed to describe in-hospital and interhospital patient transfer decisions during the traumatic brain injury (TBI) trajectory from a nursing perspective.

DESIGN

Ethnographic fieldwork.

METHODS

We used participant observation and interviews at three sites representing the acute, subacute and stable stages of the TBI trajectory. Deductive analysis was applied supported by transition theory.

RESULTS

During the acute stage (neurointensive care), transfer decisions were facilitated by physicians assisted by critical care nurses, in the subacute stage (highly specialized rehabilitation), transfer decisions were collaborative among in-house healthcare professionals, community staff and family, and during the stable stage (municipal rehabilitation), transfer decisions were made by non-clinical staff. Most of the resources allocated during the trajectory went towards highly specialized rehabilitation, whereas more resources are needed during the end of the trajectory.

NO PATIENT OR PUBLIC CONTRIBUTION

Patients and the public were not involved in this study .

Rehabilitative intervention for successful decannulation in adult patients with acquired brain injury and tracheostomy: a systematic review

PURPOSE

Tracheostomy and dysphagia are independently associated with increased complications and poorer functional outcome after acquired brain injury (ABI). The aim of this study was to identify and evaluate rehabilitation to restore functional swallowing ability and respiratory capacity during tracheal tube weaning.

MATERIALS AND METHODS

The review was conducted according to PRISMA guidelines. Any study design with adult patients with ABI and tracheostomy was eligible. The primary outcome was decannulation.

RESULTS

A total of 2647 records were identified and eight papers included. Four studies investigated pharyngeal electrical stimulation (PES), two explored Facial Oral Tract Therapy (F.O.T.T.), one respiratory physiotherapy (RPT), and one study investigated external subglottic air flow (ESAF). Two RCTs found a significant difference between intervention and control on successful decannulation and readiness for decannulation in favour of PES. Time from rehabilitation admission and tracheostomy to decannulation was significantly reduced after implementing an F.O.T.T.-based protocol.

CONCLUSION

Four interventions were identified, PES, F.O.T.T., RPT, and ESAF, all aimed at increasing oropharyngeal sensory input through stimulation. Due to heterogeneity of interventions, designs and outcome measures, effect could not be estimated. This review highlights the limited research on rehabilitative interventions and thus the limited evidence to guide clinical rehabilitation.

Interventions facilitating the involvement of relatives of patients with acquired brain injury or malignant brain tumour through the course of disease: a scoping review protocol

INTRODUCTION

Research identifying the needs of relatives of patients with an acquired brain injury or malignant brain tumours is emerging, and the importance of relative involvement is widely acknowledged. However, the intention of involvement does not seem to be present in current practice and healthcare professionals' routines. The complexity of involvement of relatives is comprehensive, and there is a lack of overview of interventions facilitating and enhancing involvement of relatives. This scoping review aims to identify and map the available evidence on interventions facilitating involvement of relatives of patients with acquired brain injury or malignant brain tumour throughout the disease trajectory.

METHODS AND ANALYSIS

The proposed scoping review will be performed following the Joanna Briggs Institute's methodology for scoping reviews. Published and unpublished literature in English, Scandinavian and German from January 2010 to August 2022 will be considered. The searches will be conducted using electronic bibliographic databases. This scoping review will consider studies describing interventions provided by multidisciplinary healthcare professionals. The key aspects of the interventions could, for example, be educational, informational, emotional, social or physical support aiming towards involvement of the relatives. This scoping review will consider all study designs, except for literature reviews of all types and designs. The data will be extracted using a data extraction tool developed to record specific data, including details of authors, year of publication, country, setting, study population, study design and key aspects of the intervention (mode, duration, intensity, provider) and type of primary and secondary outcomes applied to measure the interventions. The results will be presented in tabular form, accompanied by a descriptive summary related to the objective of the present scoping review.

ETHICS AND DISSEMINATION

This scoping review is conducted as part of a larger postdoc project, which has been approved by the Danish Data Protection Agency (ID P-2020-547). The results will be disseminated through a peer-reviewed journal and presented at local, national and international conferences on brain injuries and brain cancer.

Automated Oxygen Administration Alleviates Dyspnea in Patients Admitted with Acute Exacerbation of COPD: A Randomized Controlled Trial

Objective

Devices for Automated Oxygen Administration (AOA) have been developed to optimize the therapeutic benefit of oxygen supplementation. We aimed to investigate the effect of AOA on multidimensional aspects of dyspnea and as-needed consumption of opioids and benzodiazepines, as opposed to conventional oxygen therapy, in hospitalized patients with Acute Exacerbation of COPD (AECOPD).

Method and Patients

A multicenter randomized controlled trial across five respiratory wards in the Capital Region of Denmark. Patients admitted with AECOPD (n=157) were allocated 1:1 to either AOA (O2matic Ltd), a closed loop device automatically delivering oxygen according to the patient's peripheral oxygen saturation (SpO₂), or conventional nurse-administered oxygen therapy. Oxygen flows and SpO₂ levels were measured by the O2matic device in both groups, while dyspnea, anxiety, depression, and COPD symptoms were accessed by Patient Reported Outcomes.

Results

Of the 157 randomized patients, 127 had complete data for the intervention. The AOA reduced patients' perception of overall unpleasantness significantly on the Multidimensional Dyspnea Profile (MDP) with a difference in medians of -3 (p=0.003) between the intervention group (n=64) and the control group (n=63). The AOA also provided a significant between group difference in all single items within the sensory domain of the MDP (all p-values≤0.05) as well as in the Visual Analogue Scale - Dyspnea (VAS-D) within the past three days (p=0.013). All between group differences exceeded the Minimal Clinical Important Difference of the MDP and VAS-D, respectively. AOA did not seem to have an impact on the emotional response domain of the MDP, the COPD Assessment Test, the Hospital Anxiety and Depression Scale, or use of as-needed opioids and/or benzodiazepines (all p-values>0.05).

Conclusion

AOA reduces both breathing discomfort and physical perception of dyspnea in patients admitted with AECOPD but did not seem to impact the emotional status or other COPD symptoms.

Lack of systematicity in research prioritisation processes - a scoping review of evidence syntheses

BACKGROUND

A systematically and transparently prepared research priority-setting process within a specific scientific area is essential in order to develop a comprehensive and progressive evidence-based approach that will have a substantial societal impact on the site of interest. On the basis of two consensus workshops, the authors suggest the following methods for all such processes: use of experts, stakeholder involvement, literature review, and ranking.

OBJECTIVES

The identification, categorisation, and discussion of methods for preparing a research prioritisation process.

METHODS

Eligibility criteria: Evidence synthesis includes original studies presenting a research prioritisation process and which listed the methods used to create a research prioritisation process. Only evidence syntheses related to health research were included.

DATA SOURCES

We searched the following electronic databases, without limiting by date or language: MEDLINE Ovid, Embase Ovid, Epistemonikos, and CINAHL EBSCO.

CHARTING METHODS

The methods used were mapped and broken down into different elements, and the use of the elements was determined. To support the mapping, (A) all of the elements were collapsed into unique categories, and (B) four essential categories were selected as crucial to a successful research prioritisation process.

RESULTS

Twelve evidence syntheses were identified, including 416 original studies. The identification and categorisation of methods used resulted in 13 unique categories of methods used to prepare a research agenda.

CONCLUSION

None of the identified categories was used in all of the original studies. Surprisingly, all four of the essential categories were used in only one of the 416 original studies identified. There is seemingly no international consensus on which methods to use when preparing a research prioritisation process.

PROTOCOL REGISTRATION

The protocol was registered in Open Science Framework ( https://osf.io/dygz8/ ).

Wants and needs for involvement experienced by relatives of patients with an acquired brain injury: a scoping review

OBJECTIVE

This scoping review identifies and maps the breadth of available evidence on relatives' wants and needs for involvement in the care of patients with an acquired brain injury.

INTRODUCTION

Acquired brain injuries often occur suddenly and unexpectedly. Suffering from an acquired brain injury has major consequences, not only for the patients, due to the devastating impact on their physical, cognitive, social, and psychological well-being, but also for the relatives who may need to take on a lifelong role as carers. Research has cited some benefits of involving relatives in the care of patients, including positive effects on the patients' health outcomes; however, there are few studies showing how relatives can be involved.

INCLUSION CRITERIA

Studies that defined or assessed relatives' wants and needs for involvement with the care of patients with an acquired brain injury in all settings were included. Studies were included if they described any kind of wants and needs for involvement experienced from the perspective of relatives. The review considered all study designs, except for literature reviews.

METHODS

The JBI methodology for conducting a scoping review was employed in accordance with an a priori published protocol. An extensive search was conducted in MEDLINE (PubMed), CINAHL (EBSCO), and Embase (Ovid). Gray literature was searched using Grey Matters and BASE. The initial search was conducted in February 2020 and updated in September 2021. This review was limited to studies published in English, German, or Scandinavian languages since January 2010. The data were extracted using a data extraction tool (authors, year of publication, country of origin, setting, study methods, and findings related to wants and needs for involvement) created by the authors. The review findings are reported as a descriptive summary, with tables and figures supporting the data.

RESULTS

The search identified 3854 studies, 31 of which were included. The studies were published between 2010 and 2021 and were conducted across 9 countries. In total, 16 studies applied a qualitative study design, 4 studies used a descriptive approach, 4 studies used a quantitative research design, 4 studies reported using a mixed methods design, and 3 studies employed a multi-methods design. The studies were conducted across a variety of settings, ranging from acute care to home. The international literature on the involvement of relatives with patients with acquired brain injuries comprises multiple published studies on different aspects of the topic and within various care contexts. The findings identified few studies describing wants and needs experienced by relatives in relation to involvement in the patient's disease trajectory.

CONCLUSIONS

The findings show that relatives' wants and needs are primarily related to information and communication, but are also related to collaboration with health care professionals. The findings illustrate that the complexity of involvement is comprehensive, with multiple aspects to consider.

Dialogue is a prerequisite for the nurse-patient relationship in nutritional care: A secondary analysis using the fundamentals of care framework

BACKGROUND

Providing good nutritional care is complex as it goes beyond assessing and ensuring the patients' dietary needs. So far, nutritional research has mainly focused on establishing evidence for the nutritional treatment, while less attention has been on the complexity of providing nutritional care. The Fundamentals of Care (FoC) describes five elements (focus, knowledge, anticipate, evaluate and trust) essential for establishing a nurse-patient relationship as a foundation for quality care. By studying how these elements shape nutritional care and dialogue, we can explore and describe the complexity of nutritional care.

AIM

By using the FoC framework as an analytic framework, this study explores how the nurse-patient relationship shapes the nutritional care of orthopaedic patients.

METHOD

This study is a secondary analysis using deductive content analysis of interviews with patients undergoing major orthopaedic surgery, nursing staff and observations of interactions between nursing staff and patients. The core dimension of the FoC framework, 'Establishment of relationship,' was used as an analytic framework.

RESULT

The nurses perceived serving meals and providing nutritional supplements as an essential part of the nutritional care. Still, the nutritional care was organised as a routine task to be less time-consuming. Appropriate care was initiated when the nursing staff explored patients´ food preferences. When the nursing staff failed to familiarise themselves with the patient's preferences, the patients interpreted nutritional care as unrelated to their needs, resulting in a lack of trust.

CONCLUSION

The need for efficiency within nutritional care must not compromise the patients' need for dialogue with the nurse. Establishing a trusting relationship between nurses and patients prevents nutritional care from becoming a routine task unrelated to the patients' needs.

The value of social networks to individuals with a severe traumatic brain injury: a mixed methods approach

PURPOSE

In this study, we investigate the nature and strength of the social relations of working-age individuals who have survived a severe traumatic brain injury.

MATERIALS AND METHODS

Fifty-three survivors diagnosed with severe traumatic brain injury completed the social network analysis questionnaire, enabling us to map their social networks using the software program EgoNet.QF. This was combined with interviews with four survivors and their significant members of their network and constructed narrative cases of the resources gained from their network.

RESULTS

Half the survivors lost friends because of the brain injury. The most common social network post injury comprised parents followed by spouses. Close relatives experienced a dramatic change in the nature of their relationships with the survivor. They also struggled greatly with the rehabilitation health system, which in many cases affected their own careers.

CONCLUSION

Persons with severe traumatic brain injury and their close relatives predominantly learn to manage the new situation, with functionality driving social interaction. However, as social networks often are limited to the close family, these individuals are placed in a vulnerable position.IMPLICATIONS FOR REHABILITATIONExisting networks (whether few or many) are of major importance for individuals with traumatic brain injury in the rehabilitation process.Close social relations possess knowledge about the survivor with traumatic brain injury that is important for the rehabilitation process.To support individuals and their families who lack strong resources and social networks, health care professionals should systematically identify these persons from admission to hospital and primary care.When these persons have been identified, individual plans for how to strengthen their network can be developed in collaboration with the individuals and their existing social network.

Life goals as a driving force in traumatic brain injury rehabilitation: a longitudinal dyadic perspective

BACKGROUND

Traumatic brain injury significantly impacts survivors and their families. Rehabilitation following traumatic brain injury is often complex due to the physical, psychological, and socio-economic problems survivors face. Life goals are considered a motivational factor in rehabilitation.

OBJECTIVE

The aim was to explore expectations, problems, and strategies for goal setting in survivors of traumatic brain injury and their family caregivers for one-year during rehabilitation.

METHODS

A longitudinal qualitative study using dyadic interviews with survivors and family caregivers was carried out at three time points during the first year following traumatic brain injury. Data was analyzed according to Braun and Clarke's thematic analysis.

RESULTS

Eight survivors of traumatic brain injury and their family caregivers completed 24 interviews. Three themes and one sub-theme were identified: 1) life goals as a driving force (subtheme: dyadic discrepancies and conflicts); 2) conflicts between specific, measurable, achievable, realistic, and timed (SMART) goals and life goals; and 3) changing perceptions of the impact of impairments.

CONCLUSIONS

Life goals are important motivation in the rehabilitation process. Health care professionals must integrate life goals and rehabilitation goals (i.e. SMART goals) to decrease barriers and survivor ambivalence about rehabilitation. Involving both survivors and family caregivers in goal setting increases rehabilitation success.

Facilitators and barriers of relatives’ involvement in nursing care decisions and self-care of patients with acquired brain injury or malignant brain tumour: A scoping review protocol

Introduction

Involving relatives can contribute to better quality of care and treatment, and lead to higher satisfaction with hospitalisation in the patients, relatives and healthcare professionals. Nurses play an important role in developing a trusting relationship and facilitating relatives’ involvement, since they are around the patient and relatives all day. Thus, involvement is central to the nursing practice. However, involving relatives seems complex and multifaceted with many possible facilitators and barriers to nurses.’

Objective

The objective of this scoping review is to identify and map the available evidence concerning possible facilitators and barriers to nurses involving relatives in the course of treating disease in individuals who have sustained an acquired brain injury or malignant brain tumour in all settings.

Methods and analysis

The proposed scoping review will be performed following the Joanna Briggs Institute’s (JBI) methodology for scoping reviews. Indexed and grey literature in English, Scandinavian or German languages from 2010 to the present will be considered. The searches will be conducted using bibliographic databases: Medline (via PubMed), CINAHL (via EBSCO) and EMBASE (via OVID). Two reviewers will independently screen the studies and determine if their title, abstract and full text meet the study’s inclusion criteria. In case of disagreement, a third and fourth reviewer will be consulted. A customised data extraction form will be used to extract data from the included studies. The results will be presented in tabular form, accompanied by a narrative summary related to the objective of the present scoping review. This scoping review will consider studies that involve nurses caring for individuals with an acquired brain injury or malignant brain tumour in all settings (community, primary care, health care centres, hospital and long-term care institutions). Studies will be included if they describe any kind of facilitators or barriers to involving relatives, and the review will consider all study designs.

Feeling all alone in the world - experiences of patients with a neurological disease during a COVID-19 visitor ban: An interview study

AIM

The aim of this study was to explore how patients with neurological disease experienced a COVID-19 visitor ban and to identify ways of improving the quality of care.

BACKGROUND

In March 2020, a temporary visitor ban was introduced in Danish hospitals to reduce the spread of COVID-19. This led to changes in clinical practice, leaving patients without their loved ones beside them. Since neurological patients are already considered vulnerable due to physical, and sometimes cognitive impairment, we urgently wished to investigate these circumstances to facilitate appropriate support.

DESIGN

This study was conducted using a qualitative explorative design.

METHODS

Fourteen patients with neurological disease were interviewed using a semi-structured interview guide. Data were analysed through inductive thematic analysis.

RESULTS

For most patients, being hospitalized during the COVID-19 visitor ban was a painful experience with the potential to negatively influence both their mental and physical health.

Neurorehabilitation for people with disorders of consciousness: an international survey of health-care structures and access to treatment, (Part 1)

AIMS

The provision of rehabilitation services for people with disorders of consciousness (DoC) may vary due to geographical, financial, and political factors. The extent of this variability and the implementation of treatment standards across countries is unknown. This study explored international neurorehabilitation systems for people with DoC.

METHODS

An online survey (SurveyMonkey®) was disseminated to all members of the International Brain Injury Association (IBIA) DoC Special Interest Group (SIG) examining existing rehabilitation systems and access to them.

RESULTS

Respondents (n = 35) were from 14 countries. Specialized neurorehabilitation was available with varying degrees of access and duration. Commencement of specialized neurorehabilitation averaged 3-4 weeks for traumatic brain injury (TBI) and 5-8 weeks for non-traumatic brain injury (nTBI) etiologies. Length of stay in inpatient rehabilitation was 1-3 months for TBI and 4-6 months for nTBI. There were major differences in access to services and funding across countries. The majority of respondents felt there were not enough resources in place to provide appropriate neurorehabilitation.

CONCLUSIONS

There exists inter-country differences for DoC neurorehabilitation after severe acquired brain injury. Further work is needed to implement DoC treatment standards at an international level.

Patients' Perspective on Automated Oxygen Administration during Hospitalization for Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Qualitative Study Nested in a Randomized Controlled Trial

Recently, health technology systems offering monitoring of the peripheral oxygen saturation level and automated oxygen administration (AOA) have emerged. AOA has been shown to reduce duration of hypoxemia and the length of hospital stay, but the patients' perspective on AOA has not been investigated. This qualitative study, based on the interpretive description methodology, aimed to explore how patients hospitalized with exacerbation of chronic obstructive pulmonary disease (COPD) experience being treated with AOA. Eighteen patients treated with AOA were included in the study. Data was collected during admission or in the patients' homes using semi-structured interviews focusing on patients' experiences of AOA using the word "robot" as used by patients. The findings revealed two themes "adaptation of behavior to the robot" and "robots can make patients feel safe but not cared for" and six subthemes. Our findings illustrate how patients were willing to compromise their own therapy and thereby safety by avoiding behavior triggering AOA alarms and disturbing their fellow patients and the health care professionals. Adherence, defined as patients' consistency in taking their medications as prescribed, becomes an important point of attention for health professionals when applying individualized robotic therapies such as AOA to patients with COPD. To support patients in the process of managing adherence to therapeutic technology, we propose a person-centered care approach that, through education and communication with the patients, generates an understanding of how they can self-manage AOA and its alarms without activating avoiding behavior that threatens their treatment and recovery.

Treatment of Dysphagia with Biofeedback and Functional Electrical Stimulation in a Patient with Wallenberg Syndrome: A Prospective Case Report

Biofeedback games and automated functional electrical stimulation (FES) can be used in the treatment of dysphagia. This case study aims to evaluate the effect of the treatment on a 77-year-old man with chronic Wallenberg syndrome and his and the therapist’s experiences when using this therapy form. The participant received intensive treatment for nine days with Facial Oral Tract Therapy, biofeedback games and FES. The Penetration Aspiration Scale was scored using Functional Endoscopic Evaluation of Swallowing at baseline and the end of the intervention period. Swallowing-specific parameters were measured daily, and interviews were conducted with the patient and therapist during the intervention period. The patient and therapist both expressed a positive attitude to the ease of use and usefulness of this technology, despite there being no measurable change in the participant’s swallowing and eating function and only small improvements in swallowing parameters. The experience from this study was that biofeedback games and FES gave only small improvements in swallowing for this participant but were motivating and easy to use. Further research is needed to investigate the effect of this therapy on other participants with a more robust research design.

Scoping review to identify and map non-pharmacological, non-surgical treatments for dysphagia following moderate-to-severe acquired brain injury

INTRODUCTION

Dysphagia is a common and critical consequence of acquired brain injury (ABI) and can cause severe complications. Dysphagia rehabilitation is transforming from mainly compensatory strategies to the retraining of swallowing function using principles from neuroscience. However, there are no studies that map interventions available to retrain swallowing function in patients with moderate-to-severe ABI.

OBJECTIVE

To systematically map the accessible research literature to answer the research question: Which non-surgical, non-pharmacological interventions are used in the treatment of dysphagia in patients with moderate and severe ABI in the acute and subacute phase? DESIGN: Scoping review based on the methodology of Arksey and O'Malley and methodological advancement by Levac et al. DATA SOURCES: MEDLINE, Embase, Cochrane Library, CINAHL, PsycINFO, Web of Science, OTseeker, speechBITE and PEDro were searched up until 14 March 2021.

ELIGIBILITY CRITERIA

All studies reporting rehabilitative interventions within 6 months of injury for patients with moderate-to-severe ABI and dysphagia were included.

DATA EXTRACTION AND SYNTHESIS

Data was extracted by two independent reviewers and studies were categorised based on treatment modality.

RESULTS

A total of 21 396 records were retrieved, and a final of 26 studies were included. Interventions were categorised into cortical or non-cortical stimulation of the swallowing network. Cortical stimulation interventions were repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation. Non-cortical were complex swallowing interventions, neuromuscular electrical stimulation, pharyngeal electrical stimulation (PES), sensory stimulation, strengthening exercises and respiratory muscle training.

CONCLUSION

This scoping review provides an overview of rehabilitative dysphagia interventions for patients with moderate and severe ABI, predominantly due to stroke, in the acute and subacute phase. Positive tendencies towards beneficial effects were found for rTMS, complex swallowing interventions, PES and cervical strengthening. Future studies could benefit from clear reporting of patient diagnosis and disease severity, the use of more standardised treatment protocols or algorithms and fewer but standardised outcome measures to enable comparison of effects across studies and interventions.

Family involvement in the treatment of patients with an acquired brain injury or malignant brain tumor: a scoping review protocol

OBJECTIVE

The objective of this review is to scope the evidence on the wants and needs of families with regards to their level of involvement in treatment for patients with an acquired brain injury or malignant brain tumor.

INTRODUCTION

Severe acquired brain injury and malignant brain tumor are diseases occurring unexpectedly and suddenly. Sustaining a severe acquired brain injury or malignant brain tumor has major consequences for patients and their relatives because of its devastating impact on physical, cognitive, social, and psychological well-being. The neurocognitive deficits have been shown to put strain on families in particular.

INCLUSION CRITERIA

This scoping review will consider studies involving relatives (≥18 years) of patients (≥18 years) with severe acquired brain injury or malignant brain tumor (WHO grade 3 and 4) from different settings (municipalities, primary care, health care centers, hospital, and long-term care institutions). Studies will be included if they describe any kind of involvement by relatives, and the review will consider all study designs, regardless of their rigor.

METHODS

Indexed and gray literature in English, Scandinavian, or German from January 2010 to the present will be considered. The searches will be conducted using bibliographic databases. Studies will be independently screened according to the inclusion criteria by two reviewers based on title, abstract, and full text. In case of disagreement, a third and fourth reviewer will be consulted. A customized data extraction form will be used to extract data from the included studies. The results will be presented in tabular form, accompanied by a narrative summary related to the objective of the present scoping review.

Inclusion, delivery, assessment, and outcomes in longitudinal research on sleep disturbance and agitation in TBI-rehabilitation: lessons learned and future considerations

PURPOSE

This article presents some issues for consideration before scaling from a pilot study to a larger investigation in longitudinal observational studies of traumatic brain injury (TBI) rehabilitation.

MATERIALS AND METHODS

We present a case to discuss protocol improvements in longitudinal TBI-rehabilitation studies. The case was a pilot study conducted at two university hospitals in Denmark investigating 1-year outcomes related to sleep disturbance and agitation during neurointensive care. We included patients with moderate and severe TBI determined by the Glasgow Coma Scale, sleep disturbance was assessed using actigraphy, and agitation was assessed using the Agitated Behavior Scale.

RESULTS

Patients (n = 29) were more severely ill and had poorer six-month outcomes in Eastern vs. Western Denmark. Recovery was similar at one-year follow-up. Protocol improvements were needed in relation to inclusion criteria, intervention delivery, patient assessment, and follow-up outcomes.

CONCLUSION

In TBI-rehabilitation studies, we suggest adding the severity of disease score to the initial GCS score and a delirium detection score to the ABS score. Actigraphy should not be used during deep sedation. Established procedures should be in place along all stages of the study protocol, including preparation and periodic assessment of study nurses to optimize data quality.

Two Coarse Spatial Patterns of Altered Brain Microstructure Predict Post-traumatic Amnesia in the Subacute Stage of Severe Traumatic Brain Injury

Introduction: Diffuse traumatic axonal injury (TAI) is one of the key mechanisms leading to impaired consciousness after severe traumatic brain injury (TBI). In addition, preferential regional expression of TAI in the brain may also influence clinical outcome. Aim: We addressed the question whether the regional expression of microstructural changes as revealed by whole-brain diffusion tensor imaging (DTI) in the subacute stage after severe TBI may predict the duration of post-traumatic amnesia (PTA). Method: Fourteen patients underwent whole-brain DTI in the subacute stage after severe TBI. Mean fractional anisotropy (FA) and mean diffusivity (MD) were calculated for five bilateral brain regions: fronto-temporal, parieto-occipital, and midsagittal hemispheric white matter, as well as brainstem and basal ganglia. Region-specific calculation of mean FA and MD only considered voxels that showed no tissue damage, using an exclusive mask with all voxels that belonged to local brain lesions or microbleeds. Mean FA or MD of the five brain regions were entered in separate partial least squares (PLS) regression analyses to identify patterns of regional microstructural changes that account for inter-individual variations in PTA. Results: For FA, PLS analysis revealed two spatial patterns that significantly correlated with individual PTA. The lower the mean FA values in all five brain regions, the longer that PTA lasted. A pattern characterized by lower FA values in the deeper brain regions relative to the FA values in the hemispheric regions also correlated with longer PTA. Similar trends were found for MD, but opposite in sign. The spatial FA changes as revealed by PLS components predicted the duration of PTA. Individual PTA duration, as predicted by a leave-one-out cross-validation analysis, correlated with true PTA values (Spearman r = 0.68, p permutation = 0.008). Conclusion: Two coarse spatial patterns of microstructural damage, indexed as reduction in FA, were relevant to recovery of consciousness after TBI. One pattern expressed was consistent with diffuse microstructural damage across the entire brain. A second pattern was indicative of a preferential damage of deep midline brain structures.

Transcutaneous Vagus Nerve Stimulation in Patients With Severe Traumatic Brain Injury: A Feasibility Trial

OBJECTIVES

Preclinical studies have shown that surgically implanted vagus nerve stimulation (VNS) promotes recovery of consciousness and cognitive function following experimental traumatic brain injury (TBI). The aim of this study is to report the feasibility and safety of a noninvasive transcutaneous vagus nerve stimulation (tVNS) in patients with persistent impairment of consciousness following severe TBI.

MATERIALS AND METHODS

The feasibility of tVNS was evaluated in five patients presenting with diffuse axonal injury and reduced dominant EEG activity one month following severe TBI. tVNS was applied to the left cymba conchae of the external ear using a skin electrode four hours daily for eight weeks. Possible effects of tVNS on physiological parameters and general side effects were recorded. In addition, we report the rate of recovery using coma recovery scale revised (CRS-R).

RESULTS

The tVNS regime of four hours daily for eight weeks was feasible and well tolerated with little side effects and no clinically relevant effects on physiological parameters. Three patients showed improvements (>3 points) in the CRS-R following eight weeks tVNS.

CONCLUSION

We demonstrated that tVNS is a feasible and safe VNS strategy for patients following severe TBI. Controlled studies are needed to clarify whether tVNS has a potential to promote recovery of consciousness following severe TBI.

The effect of intensified nonverbal facilitation of swallowing on dysphagia after severe acquired brain injury: A randomised controlled pilot study

BACKGROUND

There is little high-level evidence for the effect of the nonverbal facilitation of swallowing on swallowing ability in the subacute stage of rehabilitation following severe acquired brain injury (ABI).

OBJECTIVE

To pilot test a randomised controlled trial to determine the effect of an intensification of the nonverbal facilitation of swallowing on dysphagia.

METHODS

Ten patients with severe ABI and dysphagia were randomised into two groups at a highly specialised neurorehabilitation clinic.The intervention group received an intensification of the nonverbal facilitation of swallowing and the control group received basic care of the face and mouth in addition to treatment as usual for two sessions of 20 minutes per day for three weeks.Outcomes were Functional Oral Intake Scale (FOIS), Penetration Aspiration Scale (PAS), and electrophysiological swallowing specific parameters (EMBI).

RESULTS

The intensified intervention was feasible. PAS and FOIS scores improved in both groups, with no differences between groups. The swallowing specific parameters reflected clinically observed changes in swallowing.

CONCLUSIONS

PAS and FOIS are feasible instruments to measure dysphagia. It is possible and valid to measure swallowing frequency and kinematics using electromyography and bioimpedance. The definitive study should have widened inclusion criteria and optimise intervention timing to maintain patient arousal.

Limited Colocalization of Microbleeds and Microstructural Changes after Severe Traumatic Brain Injury

Severe traumatic brain injury (TBI) produces shearing forces on long-range axons and brain vessels, causing axonal and vascular injury. To examine whether microbleeds and axonal injury colocalize after TBI, we performed whole-brain susceptibility-weighted imaging (SWI) and diffusion tensor imaging (DTI) in 14 patients during the subacute phase after severe TBI. SWI was used to determine the number and volumes of microbleeds in five brain regions: the frontotemporal lobe; parieto-occipital lobe; midsagittal region (cingular cortex, parasagittal white matter, and corpus callosum); deep nuclei (basal ganglia and thalamus); and brainstem. Averaged fractional anisotropy (FA) and mean diffusivity (MD) were measured to assess microstructural changes in the normal appearing white matter attributed to axonal injury in the same five regions. Regional expressions of microbleeds and microstructure were used in a partial least-squares model to predict the impairment of consciousness in the subacute stage after TBI as measured with the Coma Recovery Scale-Revised (CRS-R). Only in the midsagittal region, the expression of microbleeds was correlated with regional changes in microstructure as revealed by DTI. Microbleeds and microstructural DTI-based metrics of deep, but not superficial, brain regions were able to predict individual CRS-R. Our results suggest that microbleeds are not strictly related to axonal pathology in other than the midsagittal region. While each measure alone was predictive, the combination of both metrics scaled best with individual CRS-R. Structural alterations in deep brain structures are relevant in terms of determining the severity of impaired consciousness in the acute stage after TBI.

Nurses' contribution to relatives' involvement in neurorehabilitation: Facilitators and barriers

AIM

The aim of the present study was to identify possible facilitators and barriers that differently positioned relatives are facing when being actively involved in the rehabilitation process of patients with traumatic brain injury.

DESIGN

A qualitative secondary analysis of data from a qualitative study.

METHODS

Data comprised participant observations and semi-structured interviews with relatives of patients with traumatic brain injury. Data were analysed using a qualitative content analysis.

RESULTS

Three exemplary cases illustrate how relatives' differential and unequal resources function as facilitators and barriers. Facilitators for involvement are as follows: participating in nursing care situations, the possibility for being present during hospitalization, the relationship with the providers, experience with illness, dedication and proactivity. Contrary, being reactive, non-participating in nursing care situations, unable to express own wants and needs, and minimal flexibility from workplace are barriers to involvement.

Development of muscle contractures and spasticity during subacute rehabilitation after severe acquired brain injury: a prospective cohort study

Objective: This study investigated the development of contractures, passive stiffness, and spasticity in the ankle joint in patients with severe acquired brain injury (ABI) from admission to rehabilitation unit until 1-year post-injury compared to healthy controls. Design: An observational longitudinal cohort study Methods and procedures: Nineteen patients (26 affected ankle joints) with severe ABI >17 years old and with paresis of a lower limb admitted to sub-acute neurorehabilitation were compared to 14 healthy controls (28 ankle joints). Passive and reflex-mediated ankle joint stiffness was obtained measuring torque, range of motion, velocity and acceleration of the ankle movements. Data was collected at inclusion, after 4-5 weeks, after 8-9 weeks and at 1-year follow-up. Outcomes and results: At admittance to rehabilitation range of motion and stiffness was significantly lower compared to controls. Range of motion decreased by one degree in three weeks and passive ankle joint stiffness increased significantly by 1% per week. More patients than controls had no stretch reflex. Conclusion: Patients with severe ABI show reduced mobility and increased passive stiffness despite less spasticity in the ankle joint compared to healthy controls. Research and clinical practice should therefore focus intensively on the prevention of contractures in the ankle joint. ISRCTN17910097.

Protocol for a scoping review study to identify and map treatments for dysphagia following moderate to severe acquired brain injury

INTRODUCTION

Dysphagia is highly prevalent in patients with acquired brain injury (ABI) and is associated with high morbidity and mortality. However, dysphagia management varies greatly between units and internationally, and there is currently no consensus, standard intervention or treatment. A review mapping the existing literature on dysphagia treatment is needed. In this paper, the protocol for a scoping review to identify and map dysphagia treatment following ABI is outlined.

OBJECTIVE

The objective of the scoping review is to systematically map the existing research literature to answer the research question: Which non-surgical, non-pharmacological interventions are used in the treatment of dysphagia in patients with moderate and severe acquired brain injury in the acute and subacute phase? METHODS AND ANALYSIS: The methodological framework for the study is based on methodology by Arksey and O'Malley and methodological advancement by Levac et al. We will search electronic databases in June 2019: MEDLINE (Ovid); Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library); EMBASE (Ovid); CINAHL (EBSCO); PsycINFO; Science Citation Index Expanded on Web of Science; OTseeker; Speechbite and PEDro. The search terms will be limited to patients with moderate to severe ABI and dysphagia. Four review authors will independently conduct an initial screening of title and abstract and subsequent full-text review of included studies. Data will be extracted and summarised in diagrammatic or tabular form (numerical summary), and a descriptive format (narrative summary). The strategy for data synthesis entails qualitative methods to categorise the interventions based on the treatment modality and subgroup diagnosis.

ETHICS AND DISSEMINATION

Scoping the existing literature will provide a foundation for further evaluating and developing our dysphagia treatment and inform future studies assessing the effectiveness of treatments. The review is part of an ongoing expansive research into dysphagia. The results will be disseminated through a peer-reviewed publication and conference presentations.

Nociception Coma Scale-Revised: Nurses' Experience in Clinical Practice

BACKGROUND

The Nociception Coma Scale-Revised (NCS-R) is a rating scale developed and validated for measurement of nociception and pain among patients with brain injuries in unresponsive wakefulness syndrome or minimally conscious state. However, little is known about its use in daily clinical practice.

AIMS

The aim of this study was to explore clinical experience with the NCS-R by means of focus group interviews with nurses and nurse assistants in a subacute rehabilitation ward for patients with severe brain injuries.

DESIGN

Qualitative focus group interview study.

SETTINGS

Department for highly specialized neurorehabilitation for patients with severe brain injuries.

PARTICIPANTS/SUBJECTS

Nurses and nurse assistants.

METHODS

In total, 12 experienced registered nurses and nurse assistants participated in two recorded focus group interviews. The participants were selected from the subacute neurorehabilitation ward on the following criteria: Employed at the ward for at least 11 months and being introduced to and having experience with using the NCS-R in own patients for a minimum period of 6 months. An inductive qualitative analysis was conducted by reading the interview text through several times, and meaning units were defined first separately and later jointly between the authors. Then meaning units were coded and categorized into subthemes and themes.

RESULTS

We found three themes, general relevance of the NCS-R, NCS-R versus level of consciousness, and overall assessment of pain in patients with disorders of consciousness, with a total of eight subthemes.

CONCLUSIONS

The content and subscales of the NCS-R are relevant for pain assessment in patients with severe brain injury in subacute rehabilitation. However, with the present cutoff value at 4 points, challenges are associated with using NCS-R, especially in patients with unresponsive wakefulness syndrome because they are at risk of not being assessed with respect to pain.

Hospital meals are existential asylums to hospitalized people with a neurological disease: A phenomenological-hermeneutical explorative study of the meaningfulness of mealtimes

AIM

Hospital meals are challenging for neurological patients. Patients struggle with both physical eating disabilities and social issues during mealtimes. The aim of this study was to examine the meaningfulness of the phenomenon of hospital meals for hospitalized patients with a neurological disease.

DESIGN

Interviews (N = 23) with neurological patients were analysed and interpreted to gain in-depth comprehensive knowledge of the phenomenon of hospital mealtimes.

METHOD

Data were analysed and interpreted in a three-phased process using a phenomenological-hermeneutic approach inspired by Paul Ricouer.

RESULTS

Four themes were identified: (a) A lonely ride together with others; (b) Letting the chaotic setting fade into the background; (c) Mechanical activity with great personal significance; and (d) Humanizing the setting when eating in the hospital. Mealtimes were supporting existential moments to patients. Offering a calm mealtime setting was experienced by the patients as an asylum where uplifting and comforting feelings were raised.

Bedside vital parameters that indicate early deterioration

Purpose

The purpose of this paper is to determine associations between initially recorded deviations in individual bedside vital parameters that contribute to total Modified Early Warning Score (MEWS) levels 2 or 3 and further clinical deterioration (MEWS level=4).

Design/methodology/approach

This was a prospective study in which 27,504 vital parameter values, corresponding to a total MEWS level⩾2, belonging to 1,315 adult medical and surgical inpatient patients admitted to a 90-bed study setting at a university hospital, were subjected to binary logistic and COX regression analyses to determine associations between vital parameter values initially corresponding to total MEWS levels 2 or 3 and later deterioration to total MEWS level ⩾4, and to evaluate corresponding time intervals.

Findings

Respiratory rate, heart rate and patient age were significantly (p=0.012, p<0.001 and p=0.028, respectively) associated with further deterioration from a total MEWS level 2, and the heart rate also (p=0.009) from a total MEWS level 3. Within 24 h from the initially recorded total MEWS levels 2 or 3, 8 and 17 percent of patients, respectively, deteriorated to a total MEWS level=4. Patients initially scoring MEWS 2 had a 27 percent 30-day mortality rate if they later scored MEWS level=4, and 8.7 percent if they did not.

Practical implications

It is important to observe all patients closely, but especially elderly patients, if total MEWS levels 2 or 3 are tachypnoea and/or tachycardia related.

Originality/value

Findings might contribute to patient safety by facilitating appropriate clinical and organizational decisions on adequate time spans for early warning scoring in general ward patients.

Measuring Neurobehavioral Disabilities Among Severe Brain Injury Survivors: Reports of Survivors and Proxies in the Chronic Phase

Background: Neurobehavioral disability (NBD) has a major influence on long-term psychosocial outcome following acquired brain injury, as it affects not only the survivor of the brain injury, but the whole family.

Objectives: To investigate (1) the frequency of NBD among survivors of severe brain injury measured by the Danish version of the St Andrew's-Swansea Neurobehavioural Outcome Scale (SASNOS) rated by patients and proxies, (2) factors associated with NBD, and (3) concordance between reports of NBD completed by patients and proxies.

Methods: SASNOS was administered at an outpatient unit as a part of a follow-up assessment after discharge from intensive neurorehabilitation. SASNOS consists of five factors describing the following domains: Interpersonal Behavior, Cognition, Aggression, Inhibition and Communication, and both the patient and a proxy were asked to complete the questionnaire. Data collection was conducted over a period of 2 years, and 32 patients and 31 proxies completed the questionnaire. Mean time since injury was 19.4 months (10.0 SD). Most patients were male (68.8%), and most proxies were female (58.1%). Most of the patients had suffered a traumatic brain injury (68.8%).

Results: A fourth of this patient group reported themselves below the normal range on the major domains of Interpersonal Behavior and Cognition. Significant associations between proxies' reports and time since injury, cohabitant status, and the patient's score on the Extended Glasgow Outcome Scale were found. Furthermore, significant differences were found between patient and proxy ratings. Proxies rated patients as having fewer problems on the Interpersonal Behavior domain, and more problems in relation to Cognition. Cognition was the only domain, where patients rated themselves higher indicating fewer problems, compared with their proxies. On both the Aggression and Communication domains, proxies rated patients higher indicating fewer problems than the patients themselves.

Conclusion: Danish brain injury survivors experienced NBD as measured by SASNOS. Differences were found between patient and proxy ratings in relation to Cognition and Interpersonal Behavior. The NBDs identified can affect the survivor's ability to reintegrate and participate in activities of daily living, emphasizing how a systematic assessment is required.

Strengthening nursing role and functions in stroke rehabilitation 24/7: A mixed-methods study assessing the feasibility and acceptability of an educational intervention programme

AIM

To assess the feasibility of a nursing educational intervention for inpatient stroke rehabilitation and its acceptability from the nursing staff's perspective.

BACKGROUND

There is currently a lack of interventions that integrate the diversity of nurses' role and functions in stroke rehabilitation and explore their effect on patient outcomes.

DESIGN

We used a convergent, parallel, mixed-method design with data interviews and questionnaires.

METHODS

Data collection was undertaken between February - July 2016. Data from questionnaires (N = 31) were analysed using descriptive statistics. The interviews (N = 10) were analysed using deductive content analysis.

RESULTS

There was a high level of satisfaction with the educational programme in terms of its acceptability and feasibility. The qualitative findings disclosed the nursing staff's experiences with the educational programme. Mixed-methods analysis showed confirmatory results that were convergent and expanded. Only minor adjustments are required before an effect study can be conducted.

Relatives' strategies in subacute brain injury rehabilitation: The warrior, the observer and the hesitant

BACKGROUND

Relative involvement is crucial in rehabilitation when patients are incapable of being involved due to cognitive and functional dysfunction. However, studies have shown that this is complex because of differing understandings of the meaning of involvement as well as diverse needs to be involved.

AIMS AND OBJECTIVES

To explore the experience of the rehabilitation process from the perspectives of relatives of patients with a traumatic brain injury. The aim of the study was, through a theoretical-empirical analysis, to identify relatives' strategies and practices in the rehabilitation process as evidenced in meetings with providers.

DESIGN

A longitudinal study with a qualitative approach, drawing on the theory of Pierre Bourdieu.

METHODS

Data were generated using participant observation and semi-structured interviews. Participants were eleven relatives of patients with a severe traumatic brain injury, followed through in-patient rehabilitation varying from 9-12 weeks. Analysis was undertaken using both an inductive and deductive approach.

FINDINGS

Drawing on Bourdieu's concept of strategy, three relative positions were identified, the warrior, the observer and the hesitant. These positions illustrate how different relative positions and their related dispositions influence the strategies used by relatives of patients with a severe traumatic brain injury evidenced in how they act, participate and relate to both the patient and the providers during the course of rehabilitation.

CONCLUSIONS

Acknowledging the relatives' positions during the rehabilitation process enables better understanding and support of the relatives in the rehabilitation process to meet their (and thus the patients') diverse needs.

RELEVANCE TO CLINICAL PRACTICE

The findings have practical implications in informing how clinicians meet, interact, communicate and involve relatives of adult patients' with traumatic brain injury in decision-making during rehabilitation.

Strengthening the role and functions of nursing staff in inpatient stroke rehabilitation: developing a complex intervention using the Behaviour Change Wheel

Purpose: Over the past two decades, attempts have been made to describe the nurse’s role and functions in the inpatient stroke rehabilitation; however, the nursing contribution is neither clear nor well-defined. Previous studies have highlighted the need for research aimed at developing interventions in the neuro-nursing area. The objective of this paper was to describe the development of a nursing intervention aimed at optimising the inpatient rehabilitation of stroke patients by strengthening the role and functions of nursing staff.

Method: A systematic approach was used, consistent with the framework for developing and evaluating complex interventions by the UK’s Medical Research Council (MRC). Based on qualitative methods and using the Behaviour Change Wheel’s (BCW) stepwise approach, we sought behaviours related to nursing staffs’ roles and functions.

Results: We conducted a behavioural analysis to explain why nursing staff were or were not engaged in these behaviours. The nursing staff’s Capability, Opportunity and Motivation were analysed with regard to working systematically with a rehabilitative approach and working deliberately and systematically with the patient’s goals.

Conclusion: We developed the educational intervention Rehabilitation 24/7. Following the MRC and the BCW frameworks is resource-consuming, but offers a way of developing a practical, well-structured intervention that is theory- and evidence based.

Nursing staffs self-perceived outcome from a rehabilitation 24/7 educational programme - a mixed-methods study in stroke care

Background

During the past two decades, attempts have been made to describe nurses’ contributions to the rehabilitation of inpatients following stroke. There is currently a lack of interventions that integrate the diversity of nurses’ role and functions in stroke rehabilitation and explore their effect on patient outcomes. Using a systematic evidence- and theory-based design, we developed an educational programme, Rehabilitation 24/7, for nursing staff working in stroke rehabilitation aiming at two target behaviours; working systematically with a rehabilitative approach in all aspects of patient care and working deliberately and systematically with patients’ goals. The aim of this study was to assess nursing staff members’ self-perceived outcome related to their capability, opportunity and motivation to work with a rehabilitative approach after participating in the stroke Rehabilitation 24/7 educational programme.

Methods

A convergent mixed-method design was applied consisting of a survey and semi-structured interviews. Data collection was undertaken between February and June 2016. Data from the questionnaires (N = 33) distributed before and after the intervention were analysed using descriptive statistics and Wilcoxon sign rank test. The interviews (N = 10) were analysed using deductive content analysis. After analysing questionnaires and interviews separately, the results were merged in a side by side comparison presented in the discussion.

Results

The results from both the quantitative and qualitative analyses indicate that the educational programme shaped the target behaviours that we aimed to change by addressing the nursing staff’s capability, opportunity and motivation and hence could strengthen the nursing staff’s contribution to inpatient stroke rehabilitation. A number of behaviours changed significantly, and the qualitative results indicated that the staff experienced increased focus on their role and functions in rehabilitation practice.

Conclusion

Our study provides an understanding of the outcome of the Rehabilitation 24/7 educational programme on nursing staff’s behaviours. A mixed-methods approach provided extended knowledge of the changes in the nursing staff members’ self-percived behaviours after the intervention. These changes suggest that educating the nursing staff on rehabilitation using the Rehabilitation 24/7 programme strengthened their knowledge and beliefs about rehabilitation, goal-setting as well as their role and functions.

Prevention of pressure ulcers in patients undergoing subacute rehabilitation after severe brain injury: An observational study

AIMS AND OBJECTIVES

To uncover efforts made by healthcare professionals to prevent pressure ulcers in patients with severe brain injury undergoing treatment at a subacute rehabilitation department.

BACKGROUND

Pressure ulcers are a major burden for patients and also generate considerable healthcare costs. Pressure ulcers are, nevertheless, prevalent in both secondary care and primary care.

DESIGN

In this qualitative study, we performed 24-hour observation on four patients undergoing rehabilitation for severe brain injury. An observation guide was developed inspired by the Braden Scale and Spradley's theory and methods. Observations were analysed using content analysis. Patricia Benner's aspects of clinical grasp were employed in the interpretation of the observations.

FINDINGS

One overarching theme was identified: "Professionalism expressed by preventing intervention, involving the patient, employing clinical grasp and professional pride." Seven subcategories were summed up into the following three categories: organisation of clinical practice, professional assessment and interactions with the patient.

CONCLUSION

The healthcare professionals' actions to prevent pressure ulcers consisted of attaining the necessary knowledge about pressure ulcer care and performing the activities. However, our observations revealed one important additional aspect: a very distinct impression that the healthcare professionals were committed to learning about the patients' former life and actively used this knowledge in their planning and provision of daily patient care. We believe this commitment has a very positive effect on prevention of pressure ulcers.

RELEVANCE TO CLINICAL PRACTICE

Professional knowledge about prevention of pressure ulcer is a necessary requisite, but is not sufficient to ensure effective treatment. To transfer knowledge into practice, we recommend that patients' rehabilitation days be planned in such a manner that activities, mobilisation and training are conducted throughout the day and evening. We also recommend that professional staff are encouraged to seek information about the former life of patients with severe brain injury.

Validation of the Early Functional Abilities scale: An assessment of four dimensions in early recovery after traumatic brain injury

OBJECTIVE

The Early Functional Abilities scale assesses the restoration of brain function after brain injury, based on 4 dimensions. The primary objective of this study was to evaluate the validity, objectivity, reliability and measurement precision of the Early Functional Abilities scale by Rasch model item analysis. A secondary objective was to examine the relationship between the Early Functional Abilities scale and the Functional Independence Measurement™, in order to establish the criterion validity of the Early Functional Abilities scale and to compare the sensitivity of measurements using the 2 instruments.

METHODS

The Rasch analysis was based on the assessment of 408 adult patients at admission to sub-acute rehabilitation in Copenhagen, Denmark after traumatic brain injury.

RESULTS

The Early Functional Abilities scale provides valid and objective measurement of vegetative (autonomic), facio-oral, sensorimotor and communicative/cognitive functions. Removal of one item from the sensorimotor scale confirmed unidimensionality for each of the 4 subscales, but not for the entire scale. The Early Functional Abilities subscales are sensitive to differences between patients in ranges in which the Functional Independence Measurement™ has a floor effect.

CONCLUSION

The Early Functional Abilities scale assesses the early recovery of important aspects of brain function after traumatic brain injury, but is not unidimensional. We recommend removal of the "standing" item and calculation of summary subscales for the separate dimensions.

Return to work predictors after traumatic brain injury in a welfare state

OBJECTIVE

To identify predictors of return to work (RTW) and stable labour market attachment (LMA) after severe traumatic brain injury (TBI) in Denmark.

MATERIALS & METHODS

Patients aged 18-64 years, admitted to highly specialized neurorehabilitation after severe TBI 2004-2012 were included and followed up for ≤6 years. Weekly LMA data were retrieved from a national register of public assistance benefits. Weeks without or with supplemental public assistance benefits were defined as LMA weeks. Time of RTW was defined as first week with LMA. Stable LMA was defined as weeks with LMA ≥75% first year after RTW. Multivariable regressions were used to identify predictors of RTW and stable LMA among preinjury characteristics, injury severity, functional ability and rehabilitation trajectories.

RESULTS

For the analyses of RTW and stable LMA, 651 and 336 patients were included, respectively. RTW was significantly associated with age (adjusted subhazard ratio 0.98, 95% CI 0.97-0.99), education (1.83, 95% CI 1.16-2.89), supplemental benefits (3.97, 95% CI 2.04-7.71), no benefits (4.86, 95% CI 2.90-8.17), length of stay in acute care (0.77, 95% CI 0.60-0.99) and time period of injury (1.56, 95% CI 1.15-2.10). The only significant predictor of stable LMA was age (adjusted odds ratio 0.97, 95% CI 0.95-0.99).

CONCLUSION

RTW after severe TBI was associated with several socio-economic factors, whereas maintaining LMA depended on age only. We suggest that RTW rates could be improved by extensive rehabilitation targeting people that are older and low-educated, as these were less likely to RTW.

Perceptions and experiences of nutritional care following the overwhelming experience of lower extremity amputation: A qualitative study

INTRODUCTION

Good nutritional care of people following major lower extremity amputation is essential as poor nutritional status can lead to delayed wound healing. Working with patients to identify their perspectives on food, views on nutritional care and the need for dietary counselling enables the development of optimised nutritional care.

AIMS AND OBJECTIVES

To explore hospital patients' perspectives on food, dietary counselling and their experiences of nutritional care following lower extremity amputation.

DESIGN

A qualitative, explorative study design was employed.

METHOD

An inductive content analysis of semi-structured interviews with a purposive sample of 17 people over 50 years of age, who had recently undergone major lower extremity amputation, was undertaken. The study was reported according to the consolidated criteria for reporting qualitative research guideline.

FINDINGS

Three themes emerged: responsible for own dietary intake, diet based on preferences and experiences with dietary counselling and feeling overwhelmed. The participants expressed motivation to ensure their nutritional needs were met but described feeling emotionally overwhelmed by the experience of amputation. They appeared not to expect nursing staff to focus on nutritional issues as they expressed belief that they themselves were solely responsible for their dietary intake. They described being motivated to receive nutritional counselling but indicated advice should be compatible with their lifestyle and eating habits.

CONCLUSION

Lower extremity amputation can be an overwhelming experience which affects nutritional intake. People appear to consider themselves responsible for their nutritional care and describe not experiencing or expecting nursing staff to engage in this aspect of care. Dietary counselling by nurses who respect and incorporate patient preferences and experiences following amputation has the potential to enhance nutritional care.

RELEVANCE TO CLINICAL PRACTICE

This study illustrates that nurses caring for people who undergo lower extremity amputation need to recognise that nutritional care is an essential component of nursing and should focus on working in partnership with the patient.