Transcript view slides - AMSUS Continuing Education

Rehabilitation of the Severely Injured
VA Polytrauma/TBI System of Care
DECEMBER 2, 2015
Disclaimers
• We have no financial relationships to disclose.
• We will not discuss off label use and/or investigational
drug use in this presentation.
• PESG and AMSUS staff have no interest to disclose.
• This continuing education activity is managed and
accredited by Professional Education Services Group in
cooperation with AMSUS. PESG, AMSUS, and all
accrediting organization do not support or endorse any
VETERANS
HEALTH ADMINISTRATION
product
or service mentioned in this activity.
Objectives
• Better understand the VA Polytrauma System of Care
services and resources
• Recognize the complex role of caregivers in the
rehabilitation process
• Review lessons learned from the first 10 years of
polytrauma rehabilitation care
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VETERANS HEALTH ADMINISTRATION
Rehabilitation of the Severely Injured
• The purpose of this forum presentation is to discuss and
further develop ongoing collaborative opportunities to meet
the current and future needs of Veterans and Service
Members with severe life-altering injuries
• Family members are also an integral part of the rehabilitation
process and caregiver needs will be discussed
• We are honored to introduce include a Service Member and
his wife as part of our panel today
VETERANS HEALTH ADMINISTRATION
VA Polytrauma System of Care
• 2005 Department of Veterans Affairs (VA) developed
integrated nationwide Polytrauma System of Care (PSC)
• Provides world-class rehabilitation services for Traumatic Brain
Injury (TBI) and Polytrauma (multiple severe injuries)
• Veterans and Service members utilizing these services
transition seamlessly between Department of Defense (DoD)
and Veterans Health Administration (VHA) medical facilities
and back to their home communities
VETERANS HEALTH ADMINISTRATION
VA Polytrauma System of Care
• Services include assessment and treatment by interdisciplinary
teams of rehabilitation specialists, case management, patient
and family education and training, psychosocial support, and
advanced rehabilitation and prosthetic technologies
• Lifelong case management is provided to severely injured
Service Members and Veterans
VETERANS HEALTH ADMINISTRATION
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VA Polytrauma System of Care
Polytrauma System of Care (PSC) Locations: 110 specialized
rehabilitation sites across VA
• 5 Polytrauma Rehabilitation Centers PRC (comprehensive
inpatient rehabilitation, regional referral centers)
• 23 Polytrauma Network Sites PNS (inpatient and
comprehensive outpatient rehabilitation, within network
referrals, includes the 5 PRCs)
• 87 Polytrauma Support Clinic Teams PSCT (comprehensive
outpatient rehabilitation, local referral centers)
VETERANS HEALTH ADMINISTRATION
VA Regional SCI Centers
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VETERANS HEALTH ADMINISTRATION
Amputation System of Care (ASoC)
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VETERANS HEALTH ADMINISTRATION
VA Polytrauma System of Care
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Polytrauma/TBI (PRC)
▪ EC (emerging consciousness)
▪ SCI
▪ Amputee
▪ Pain
▪ Stroke
▪ Vision
▪ Assistive Technology
▪ PTRP (transitional rehabilitation)
▪ Telehealth
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VETERANS HEALTH ADMINISTRATION
VA Polytrauma System of Care
DISCIPLINES AND PARTNERS
DISCIPLINES AND PARTNERS
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Rehabilitation Nursing
Social Work Case Management
Nurse Case Managers
Assistive Technology/Rehab Engineering
Recreation Therapy
Speech Language Pathology
Occupational Therapy
Physical Therapy
Kinesiotherapy
Driving Rehabilitation
Respiratory Therapy
Vocational Rehabilitation
Wound Care Nursing
Physiatry
Pharmacy
Dietitian and Nutrition Services
Rehabilitation Psychology
Neuropsychology
Driving Rehabilitation
Family Counseling
Ophthalmology & Neuro-ophthalmology
Optometry
Blind Rehabilitation
Audiology
Prosthetics and Orthotics
Caregiver Support
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VETERANS HEALTH ADMINISTRATION
VA Polytrauma System of Care
DISCIPLINES AND PARTNERS
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SCI Specialists
Pain Specialists
VA Liaisons
VA Central Office
Federal Recovery Coordinators
Recovery Care Coordinators
OEF/OIF Clinics
Military LiaisonSO
Tricare Case Managers and Medical
Directors/DHA
Chaplain Service
Wellness Program and Integrative Care
VA Pain Management
VBA
Vet Centers
DISCIPLINES AND PARTNERS
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TBI Psychiatry and Mental Health
Dental Service and OMFS
Gen Surgery and Trauma Surgery
Neurosurgery
Orthopedic Surgery
ENT
Endocrinology
Neurology and EEG
GI
Radiology and IR
ID
Plastic Surgery
Urology
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VETERANS HEALTH ADMINISTRATION
Case Introduction and Background
VETERANS HEALTH ADMINISTRATION
Background information
• 31 year old active duty Army service member, helmeted driver of
motorcycle that went off the road at approximately 50 mph, accident
10/4/14
• SM unresponsive at the scene with a GCS of 5; SM intubated and
transported via air ambulance
• GCS 3T at the hospital
• Injuries included facial trauma w/ blood in bilateral auditory canals,
right eye hyphema, multiple facial lacerations/contusions
• Right epidural hematoma, intraparencyhmal hemorrhage, diffuse
axonal injury
• Right linear temporal bone fracture, right sphenoid greater wing and
zygomatic fractures, right maxilla fracture
VETERANS HEALTH ADMINISTRATION
Background information
• Right 3rd rib fracture, bilateral pulmonary contusions, right
scapular fracture, right renal laceration
• Right pupil nonreactive
• PROCEDURES:
• 10/4/14: Right temporal craniectomy, (epidural hematoma
evacuation), right temporal subdural ICP monitor placement
• 10/10/14: Tracheostomy
• 10/10/14: PEG
VETERANS HEALTH ADMINISTRATION
Background information
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Trach w/ trach collar
NPO w/ tube feedings
CT chest 10/8/14 demonstrated PE; LE U/S negative for DVT
Completed 9 day course of antibiotics for pneumonia and 7
day course of antibiotics for UTI
• NWB right UE, sling
• Remained total assist for mobility and ADLs, communication,
eating, bowel/bladder, cognition
• Amantadine 100mg bid initiated
VETERANS HEALTH ADMINISTRATION
Imaging
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CT Head 10/4/14: right temporal epidural hematoma, intraparenchymal
hemorrhage w/ concern for DAI, probable IVH extension of hemorrhage in the
right occipital horn, effacement bilateral lateral ventricles compatible w/ diffuse
brain edema, fractures right body of sphenoid w/ extension into the greater wing,
right zygomatic process, right lateral maxillary wall, left orbital surface zygomatic
bone, extends into greater wing left sphenoid
CT Cervical/Thoracic/Lumbar Spine 10/4/14: no evidence of traumatic injury
CT Chest/Abdomen/Pelvis 10/4/14: right 3rd rib fracture, bilateral pulmonary
contusions, worse on the right, comminuted right scapular fracture w/o extension
into glenoid, right grade 1 renal laceration
CT Head 10/5/14: interval right frontotemporal craniotomy and evacuation of right
temporal lobe epidural hematoma, slightly increased size left thalamic
intraparenchymal hemorrhage; bicerebral foci of hemorrhage appear similar;
concerning for hemorrhagic diffuse axonal injury; slightly decreased effacement
bilateral lateral ventricles
VETERANS HEALTH ADMINISTRATION
Personal History
• SM was stationed at Fort Leonard Wood at the time of the
accident; had served 7 years several different duty stations
• SM has a history of PTSD but had not sought treatment
• SM loves dogs and provides foster care for them at home; he
enjoyed the outdoors and he was very sociable
• SM has a strong support system including his wife, family,
military friends and community
• SM is married to his wife Sheryl
VETERANS HEALTH ADMINISTRATION
PRC: Inpatient Polytrauma/TBI Rehab
• SM was admitted to VA Polytrauma Emerging Consciousness
program November 19, 2015 for planned 12 weeks acute
rehabilitation (actually 21 weeks total(
• Patient minimally responsive on admission
• Mental Status/LOC: eyes open upon initial examination,
drowsy during the majority of the exam; CN: left pupil 5mm
and right 4mm at baseline, face appeared symmetric,
horizontal nystagmus bilaterally, gag reflex intact, unable to
track with eyes, inability to track objects. No palmar or rooting
reflexes elicited. Does respond to visual threat; does not
withdraw/localize pain, unable to follow motor commands
VETERANS HEALTH ADMINISTRATION
PRC: Inpatient Polytrauma/TBI Rehab
• Abnormal EEG indicating possible recurrent seizures; Keppra
added w/ improvement of tremor and twitching
• Spasticity initially severe, treated w/ oral medications and
Botox; Bioness for UE, serial casting Les; eventually intrathecal
baclofen pump
• Initially NPO, eventually upgraded to oral Dysphagia Advanced
Diet with nectar thick liquids at time of discharge
• Dysautonomia treated w/ multiple medications (clonidine,
propranolol, gabapentin)
• Stimulants daytime (methylphenidate, amantadine)
• Talking again at time of discharge
VETERANS HEALTH ADMINISTRATION
Emerging Consciousness EC Program
• 90 day rehabilitation admission and treatment program
• Optimize long term functional outcome
– Regulate and systematically monitor responses of sensory and
environmental stimulation
– Manage medical comorbidities to prevent secondary complications
• Interdisciplinary care includes
– Intensive family support/education
– Social work case management
• Inclusion Criteria
– Admission within first 2 years of injury
– Medically stable to transfer to facility
– Functioning in a coma, vegetative, or minimally conscious state
VETERANS HEALTH ADMINISTRATION
Medical Considerations
• Sleep/Wake Cycle
– Limit barriers to consciousness
– Utilize stimulating medications daytime
– Avoid sedating medications daytime
– Facilitate good sleep
• Seizures
– Baseline EEG
– Medications
• Hydrocephalus: baseline head imaging
• Dysautonomia or autonomic storming
• Endocrine abnormalities
• Tachycardia
• PE or DVT
VETERANS HEALTH ADMINISTRATION
Medical Considerations
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Respiratory care (Pneumonia/respiratory tract infection, trach, etc)
Sepsis or other infection
Urinary tract infection or kidney stones
Bowel and bladder care
GI (emesis, diarrhea, GI bleed, etc)
Nutritional status
Hypermetabolic state
Neuropathy or myopathy
Rash/MRSA skin involvement
Motor restlessness/hyperkinesia/tremor
Hypertonia/spasticity
Osteomyelitis; heterotopic ossification
Pain
VETERANS HEALTH ADMINISTRATION
Animal Assisted Therapy
• Motivation - offer treats with L hand
and to hold the leash while walking
with the dog
• Navigation follow dog while
managing power chair and offer
treats
• Problem solving - basic math
problems related to the dog - “if the
dog is 6 years old and became
certified as a therapy dog at 4, how
many years has he been a therapist?”
Pt. then would hold up correct
number of fingers
VETERANS HEALTH ADMINISTRATION
Assistive Technology
VETERANS HEALTH ADMINISTRATION
Recreational Therapy and Wellness
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Healing Touch
Essential oils or aromatherapy diffusers in patient room
Animal assisted therapy
Fisher House family night
Harley Davidson Store tour
Adapted bowling
Target Center with Sheryl via Light Rail to comedy show
Light rail to Mall of America
Music and computer games
Humor (dirty joke book)
VETERANS HEALTH ADMINISTRATION
Families Make the Difference
Families are involved from the beginning
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VA Liaisons
VA Social Work, Nurse Case Managers and
Admission Coordinators
Family Psychology and Counseling
Family Education and Training
Caregiver Services http://www.caregiver.va.gov
Respite Care
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VETERANS HEALTH ADMINISTRATION
His wife remained at his bedside throughout
his hospital stay
VETERANS HEALTH ADMINISTRATION
Other Rehabilitation Services:
Polytrauma Transitional Rehab Program
• Time limited, goal oriented, residential rehabilitation program that
partners with Veteran and Service Member participants to improve their
physical, cognitive, communicative, behavioral, psychological, and social
functioning after significant injury or illness
• The overarching goal of PTRP is to help participants return to the most
appropriate, least restrictive community setting, by targeting skills
necessary for return to home, school, work, or military service, as feasible
• Interactive therapy programs designed to address the individual needs and
goals of each participant
• Challenge participants through a wide range of individual and group
therapeutic activities and living skills practices
• Focus heavily on community reintegration activities
VETERANS HEALTH ADMINISTRATION
Other Rehabilitation Services: PTRP
Polytrauma Transitional Rehabilitation Program
Who should apply?
• Veteran or Active Duty Service Member who needs
interdisciplinary, post-acute, residential rehabilitation
programming to address participation restrictions in
independent living
• Veteran or Service Member who has a desire to enhance,
preserve and/or restore participant quality of life by
optimizing levels of activity, participation skills and
independence
VETERANS HEALTH ADMINISTRATION
PTRP Admission Criteria
• Be medically and psychiatrically stable
• Have goals for care that are best met in a transitional living
setting and/or have restrictions to community independence
• Be able to be independent in basic ADL’s and mobility
• Have demonstrated sobriety
• Have capacity or designee to make health care, financial,
and/or legal decision
• Have potential to benefit from interdisciplinary service
• Potential to successfully participate in groups
VETERANS HEALTH ADMINISTRATION
Other Rehabilitation Services:
PNS and Outpatient Polytrauma/TBI
• 23 Polytrauma Network Sites (inpatient and comprehensive
outpatient rehabilitation, within network referrals, includes 5
Polytrauma Rehabilitation Centers PRCs)
• 87 Polytrauma Support Clinic Teams (comprehensive
outpatient rehabilitation, local referral centers)
• 39 Polytrauma Points of Contact (2-3 per region) provide:
– Outpatient rehabilitation
– A knowledgeable case manager to facilitate referrals
VETERANS HEALTH ADMINISTRATION
VA Polytrauma System of Care
VETERANS HEALTH ADMINISTRATION
PNS and Outpatient Polytrauma/TBI
TBI Screening and Evaluation
• VA screens all Veterans of combat operations in Iraq and
Afghanistan for mild TBI upon initial entry into VA health care.
• Veterans with positive TBI screen referred for comprehensive
evaluation with specialty providers for definitive diagnosis
• Development of an Individualized Plan of Care for those that
need ongoing rehabilitation services.
Veterans Screened and Treated April 2007 to January 31, 2015:
• 918,737 have been screened for possible mild TBI
• 128,973 screened positive and completed comprehensive
follow-up evaluation
VETERANS HEALTH ADMINISTRATION
PNS and Outpatient Polytrauma/TBI
• Individualized Plan of Care developed by the team of
specialists in collaboration with the Veteran to meet their
needs and recovery goals.
• Case Managers are assigned to every patient to coordinate
resources and services within and across episodes of care
• Telehealth has been added to provide further accommodation
for Veterans
VETERANS HEALTH ADMINISTRATION
Our Service Member
Moving Forward in the System of Care
• Total length of stay in Minneapolis: 21 weeks -185 days
• Intensive caregiver training by nursing with the SM’s wife
• Passes to the Fisher House and outings in preparation for
discharge home
• Wheelchair van purchased prior to discharge
• VBA home adaptation grant delayed discharge to home
• Discharge to St. Louis PNS for ongoing rehab, much closer to
home and Ft Leonard Wood
• Intensive SW case management to assist with VBA benefits,
military benefits, family support/education and discharge
planning
VETERANS HEALTH ADMINISTRATION
Lessons Learned
New programs have been added during the past 10 years
including:
• Assistive Technology Labs
• Emerging Consciousness program
• Transitional Rehabilitation
• Telehealth
• Adaptive driving
• Assisted Living TBI Pilot Program
• Whole Health (Wellness, Integrative Therapy)
• Concussion Coach Mobile App developed
VETERANS HEALTH ADMINISTRATION
Lessons Learned
• Transitioning Active Duty status to Veteran status has
obviously required modification and updating over the years
• Ongoing education and outreach is necessary to reach
Veterans who are not aware of services available to them
• Formal Pain Programs have been developed in response to
significant need for interdisciplinary pain treatment
• Veterans with dementia and TBI will require additional
resources in the future
• CAREGIVERS, CAREGIVERS, CAREGIVERS
Caregiver Program developed: http://www.caregiver.va.gov
VETERANS HEALTH ADMINISTRATION
Other Resources
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Defense and Veterans Brain Injury Center
TBI Model Systems
Polytrauma and Blast-related Injuries Quality Enhancement Research initiative
MVAHCS Medical Foster Home Program
VA Caregiver Support
OEF/OIF Case Management
Veterans Crisis Line Web Chat site
Readjustment Counseling System (Vet Centers)
National Center for Post-Traumatic Stress Disorder
VA Mental Health Program
VETERANS HEALTH ADMINISTRATION
My Lessons Learned
• Work really long hours and you will never experience negative
news stories about the VA or DoD
• Always stop by to say hello to the 100 year old volunteer
• Get your breakfast from Eric who always smiles and tells you
to have a good day
• Get a standing desk so you don’t have to sit so much
• Work in a team room to improve communication; take a break
from the team room once in a while; take a walk over lunch
• Always remember how good it feels to help someone—the
media can’t take that away
VETERANS HEALTH ADMINISTRATION
Questions?
VETERANS HEALTH ADMINISTRATION
VA Polytrauma System of Care
• VHA Polytrauma Website :
http://www.polytrauma.va.gov/
VETERANS HEALTH ADMINISTRATION
CE/CME Credit
If you would like to receive continuing education credit for this activity, please visit:
http://AMSUS.cds.pesgce.com
VETERANS HEALTH ADMINISTRATION
Rehabilitation of the Severely Injured
VA Polytrauma System of Care
Thank You!
DECEMBER 2, 2015