Specialized early treatment for persons with disorders of consciousness: program components and outcomes

OBJECTIVES

To describe a specialized early treatment program for persons with disorders of consciousness (DOC) that includes family education; to identify rates of secondary conditions, imaging used, and selected interventions; and to evaluate outcomes.

DESIGN

A single-center, retrospective, pre-post design using electronic medical record data.

SETTING

A Commission on Accreditation of Rehabilitation Facilities-accredited, long-term acute care hospital that provides acute medical and inpatient rehabilitation levels of care for people with catastrophic injuries.

PARTICIPANTS

Persons (N=210) aged 14 to 69 years with DOC of primarily traumatic etiology admitted at a mean ± SD of 41.0 ± 27.2 days postinjury; 2% were in coma, 41% were in the vegetative state, and 57% were in the minimally conscious state.

INTERVENTIONS

An acute medical level of care with ≥90 minutes of daily interdisciplinary rehabilitation and didactic and hands-on caretaking education for families.

MAIN OUTCOME MEASURES

Coma Recovery Scale-Revised, Modified Ashworth Scale, and discharge disposition.

RESULTS

Program admission medical acuity included dysautonomia (15%), airway modifications (79%), infections (eg, pneumonia, 16%; urinary tract infection, 14%; blood, 11%), deep vein thrombosis (17%), pressure ulcers (14%), and marked hypertonia (30% in each limb). There were 168 program interruptions (ie, 139 surgeries, 29 nonsurgical intensive care unit transfers). Mean length of stay ± SD was 39.1 ± 29.4 days (range, 6-204d). Patients showed improved consciousness and respiratory function and reduced presence or severity of pressure ulcers and upper extremity hypertonia. At discharge, 54% showed sufficient emergence from a minimally conscious state to transition to mainstream inpatient rehabilitation, and 29% did not emerge but were discharged home to family with ongoing programmatic support; only 13% did not emerge and were institutionalized.

CONCLUSIONS

Persons with DOC resulting primarily from a traumatic etiology who receive specialized early treatment that includes acute medical care and ≥90 minutes of daily rehabilitation are likely to show improved consciousness and body function; more than half may transition to mainstream inpatient rehabilitation. Families who receive comprehensive education and hands-on training with ongoing follow-up support may be twice as likely to provide care for medically stable persons with DOC in their homes versus nursing facility placement.

Simulation and anaesthesia

Training in anaesthesia relies on the duration and quality of clinical experience. It involves exposure to a range of interventions. This works well in routine cases, but when an uncommon and life-threatening event occurs, the anaesthetist needs to carry out multiple tasks simultaneously. Aviation has remarkable similarities with the practice of anaesthesia. Over the years, the aviation industry has used simulation to train and assess individuals very effectively. Anaesthetists face rapidly evolving clinical situations. This needs appropriate decision-making and communication with others in the theatre team. Simulation, using current technology, offers innovative and reproducible training experience. It enables standardised scenario building and reflective learning. Various non-technical aspects of an anaesthetist's day-to-day work could also be addressed to during such training. The technology could be used very effectively for the assessment of competence too. Simulation has been used for technology development and appraisal over the years.

Leadership Training: A New Application of Crisis Resource Management and Distance Education in a Large Group Format at a Medical Simulation Facility

INTRODUCTION

Leadership and teamwork skills must be practiced to gain full value from a leadership course. The leadership role is one of the main points highlighted during a Crisis Resource Management (CRM) session. While a typical CRM session offered in a medical simulation laboratory uses a medical crisis to elicit behaviors for videotaping and debriefing, the CRM principles are generic and applicable to leadership training outside medical practice.

METHODS

The Simulation Development and Cognitive Science Laboratory of the Pennsylvania State University College of Medicine offered a CRM course to high school students using a pediatric full human simulator (M.E.T.I.) The students rotated through two sessions: as hands-on participants in the Simulation Laboratory, and in a remote education mode. During the remote session, they viewed their peers via a video link, discussed the crisis and were able to assist their peers.

RESULTS

The 17 students valued the overall session at a high level (4.9 ± 0.2 on a five-point scale; mean ± SD). The majority of students (n=10) indicated that they felt involved in both the hands-on and remote sessions (≥7 on a ten-point scale).

CONCLUSION

Based on the results, all participants believed the session was of great value and that they could use CRM principles in everyday situations. We believe that the participants found significant value in the CRM session as a leadership skills resource. Most students also felt involved in the remote sessions, thereby enabling a larger group of trainees to learn about and experience CRM principles.