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Currrent Issue: Volume 5, Number 1, 2017

Article

Development and Implementation of a Pharmacological Toolkit to Help Providers Manage Level of Consciousness Following Traumatic Brain Injury: A Quality Improvement Project

1University of Massachusetts Boston, Capstone Defense


American Journal of Medicine Studies. 2017, 5(1), 1-17
doi: 10.12691/ajms-5-1-1
Copyright © 2017 Science and Education Publishing

Cite this paper:
Peter Iremar Santana. Development and Implementation of a Pharmacological Toolkit to Help Providers Manage Level of Consciousness Following Traumatic Brain Injury: A Quality Improvement Project. American Journal of Medicine Studies. 2017; 5(1):1-17. doi: 10.12691/ajms-5-1-1.

Correspondence to: Peter  Iremar Santana, University of Massachusetts Boston, Capstone Defense. Email: psire.usa@gmail.com

Abstract

Introduction: Traumatic brain injury (TBI) is a serious public health concern in the USA. Each year, TBIs contribute to a total of 52,000 deaths, accounting for 30% of all injury-related deaths and cases of permanent disability. Approximately 5 million survivors of TBI in the USA live with some form of disability [1]. Due to the severity of the brain injuries, some patients will experience a reduced level of consciousness. Early use of pharmacological treatment is fundamental to improve patient outcomes. Background: Providers presently seek guidelines to help them choose the right medication quickly and accurately. A pharmacological toolkit was designed to help providers in the neurology unit to enhance patients’ level of consciousness and improve quality of care following a traumatic brain injury. The theoretical model for this project is the Havelock Theory of Change, which was used to guide the team during the stages of change. The Logic Model was used during the development and implementation of the toolkit. Methods: This project was developed and implemented in the medical neurological unit at the long term acute care and rehabilitation hospital. An educational program was initiated for providers to help them use the evidence based pharmacological toolkit to prescribe neuro-stimulates for patients with TBIs who demonstrated poor levels of consciousness. The Coma Recovery Scale -Revised (CRS-R) scale [2] was used to reassure if effectiveness of the neuropharmacology was feasible to treat poor alertness. The percentage of improvement on CRS-R score of 27.68%, with improvement of 3 points on CRS-R score, is a significant improvement to this QI project. The data was collected over six months and captured the variability reflecting improvement. A post implementation survey was answered by providers to track the benefit and practicability of the tool. Results: The level of satisfaction was high based on the survey response. Conclusion: Use of a neuropharmacological toolkit promises to help providers to treat severe traumatic brain injury in patients experiencing poor level of alertness. In conclusion, following the national brain injury organization recommendations, every institution needs to develop their own guideline to treat TBIs.

Keywords

References

[1]  Paul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury. www.cdc.gov/TraumaticBrainInjury. Updated 2010. Accessed 10/16, 2015.
 
[2]  Giacino J, Kalmar K. Coma recovery scale-revised. The center for outcome measurement in brain injury. COMBI The Center for Outcome Measurement In Brain Injury Web site. http://www.tbims.org/combi/crs. Published May 14, 2016. Updated 2016. Accessed 5/14, 2016.
 
[3]  Pistoia F, Mura E, Govoni S, Fini M, Sarà M. Awakenings and awareness recovery in disorders of consciousness: Is there a role for drugs? CNS Drugs. 2010; 24(8): 625-638.
 
[4]  Seel RT, Douglas J, Dennison AC, Heaner S, Farris K, Rogers C. Specialized early treatment for persons with disorders of consciousness: Program components and outcomes. Arch Phys Med Rehabil. 2013; 94(10):1908-1923.
 
[5]  Giacino J, Whyte J, Bagiella E, Kalmar K, Childs N, Khademi A. Placebo-controlled trial of amantadine for severe traumatic brain injury. New England Journal of Medicine. 2012; 366(9) (3/2012): 819-26.
 
Show More References
[6]  Whyte J. Disorders of consciousness: The changing landscape of treatment. Neurology. 2014; 82(13): 1106-1107.
 
[7]  Ugoya SO, Akinyemi RO. The place of L-dopa/carbidopa in persistent vegetative state. Clin Neuropharmacol. 2010; 33(6): 279-284.
 
[8]  Whyte J, Giacino J. Disorders of consciousness. In: Arciniegas DB, Zasler ND, Vanderploeg RD, Jaffee MS., ed. Management of adults with traumatic brain injury. 1st ed. Washington,DC: American Psychiatric Publishing; 2013:103-124.
 
[9]  Dougall D, Poole N, Agrawal N. Pharmacotherapy for chronic cognitive impairment in traumatic brain injury. Cochrane Database of Systematic Reviews. 2015; 12.
 
[10]  Talsky A, Pacione LR, Shaw T, et al. Pharmacological interventions for traumatic brain injury. BC Med J. 2010; 53: 26-31.
 
[11]  Guidelines for the management of severe traumatic brain injury. Brain Trauma Foundation Web site. http://www.braintrauma.org/upload/06/06Guidelines_Management_2007. Updated 06, 2007. Accessed 10/09, 2015.
 
[12]  Traumatic brain injury rates of TBI-related emergency department visits, hospitalizations, and deaths - united states, 2001-2010. Centers for Disease Control and Prevention Web site. https://www.cdc.gov/traumaticbraininjury/data/rates.html. Updated 2010. Accessed 10/16, 2015.
 
[13]  Chew E, Zafonte R. Pharmacological management of neurobehavioral disorders following traumatic brain injury. Journal of Rehabilitation Research & Development. 2009; 46(04/30/2009): 851-78.
 
[14]  Hughes S, Colantonio A, Santaguida PL, Paton T. Amantadine to enhance readiness for rehabilitation following severe traumatic brain injury. Brain Inj. 2009; 19 (14)(12/2005): 19197-206.
 
[15]  Meythaler JM, Brunner RC, Johnson A, Novack TA. Amantadine to improve neurorecovery in traumatic brain injury-associated diffuse axonal injury: A pilot double-blind randomized trial. J Head Trauma Rehabil. 2002; 17(4):300-313.
 
[16]  Leone H, Polsonetti BW. Amantadine for traumatic brain injury: Does it improve cognition and reduce agitation? J Clin Pharm Ther. 2005; 30(2): 101-104.
 
[17]  Krimchansky BZ, Keren O, Sazbon L, Groswasser Z. Differential time and related appearance of signs, indicating improvement in the state of consciousness in vegetative state traumatic brain injury (VS-TBI) patients after initiation of dopamine treatment. Brain Inj. 2004; 18(11): 1099-1105.
 
[18]  Fridman E, Krimchansky B, Bonetto M, Galperin T, Gamzu E, Leiguarda R. Continuous subcutaneous apomorphine for severe disorders of consciousness after traumatic brain injury. Allied Health; Biomedical; Europe UK & Ireland. 2010; 24(4)(04/2010): 636-41.
 
[19]  Du B, Shan A, Zhang Y, Chen D, Cai K. Zolpidem arouses patients in vegetative state after brain injury: Quantitative evaluation and indications. PubMed-index for MEDLINE. 2014; 347(3)(03/2014): 178-82.
 
[20]  Whyte J, Rajan R, Rosenbaum A, Katz D, Kalmar K, Sell R. Zolpidem and restoration of consciousness. American Journal Physician Medical Rehabilitation. 2014; 93(2)(02/2014): 101-13.
 
[21]  Kim Y, Ko M, Na S, Park S, Kim K. Effects of single-dose methylphenidate on cognitive performance in patients with traumatic brain injury: A double-blind placebo-controlled study. University School of Medicine, Seoul, republic of Korea. 2006; 24(1/2012): 24-30.
 
[22]  Kim J, Whyte J, Patel S, et al. Methylphenidate modulates sustained attention and cortical activation in survivors of traumatic brain injury: A perfusion fMRI study. Psychopharmacology (Berl). 2012; 222(1): 47-57.
 
[23]  Krimchansky BZ, Keren O, Sazbon L, Groswasser Z. Differential time and related appearance of signs, indicating improvement in the state of consciousness in vegetative state traumatic brain injury (VS-TBI) patients after initiation of dopamine treatment. Brain Inj. 2004; 18(11): 1099-1105.
 
[24]  Moein P, Ford SA, Asnaashari A, et al. The effect of boswellia serrata on neurorecovery following diffuse axonal injury. Brain Inj. 2013; 27(12): 1454-1460: 1454-1460.
 
[25]  McAllister TW, Flashman LA, McDonald BC, et al. Dopaminergic challenge with bromocriptine one month after mild traumatic brain injury: Altered working memory and BOLD response. J Neuropsychiatry Clin Neurosci. 2011; 23(3): 277-286.
 
[26]  Tyson B. Havelock's theory of change. Bright Hub Project Management Web site. http://www.brighthubpm.com/change-management/86803-havelocks-theory-of-change/. Updated 2010. Accessed 10/06, 2015.
 
Show Less References