Interdisciplinary Team Approach to the Aucte Trauma
Patient
Gemma Wavish
Outline
Interdisciplinary Team Approach to the Acute Trauma Patient
Trauma Conference
August 2005
Gemma Wavish (PT)
Anna Miles (SLT)
Ever Saley (OT)
Why have an interdisciplinary approach to Trauma Patients in the Acute Setting?
Sheil et al (2001) in a prospective controlled trial of TBI patients found…
Rehab included orientation tasks, range of movement exercises, general conversation, supervision during meals, gait re-education, education to family, home visits…
Rehab was interdisciplinary with joint goals & health assistant input to increase rehab intensity.
Increased intensity of early rehab led to more rapid progress & earlier discharges home.
Background History of Patient’s admission
61 year old man.
Work place accident- a large steel tube shot out of a 250 ton ram at high pressure & hit him in the face.
GCS 12/15 at the scene. Breathing difficulties due to excessive bleeding. Intubated & ventilitated. Pharynx/ mouth packed.
CT head: left Frontal & Temporal Contusions.
Small Sub Arachnoid Haemorrhage.
Multiple Facial lacerations & #s including trauma to orbit, maxillary sinuses, nose, maxilla, hard palate & mandible.
Early Intervention (Week 1) included…
Max-Fax surgery.
ITU admission.
Oro-gastric feeding.
PEG inserted early secondary to facial injuries.
Weaned from ventilation. Tracheostomy still insitu.
Drowsy but following commands.
Transferred to Neurosurgery High Dependency Unit (Day 6)…
Patient/Family introduced to roles.
IDT assessments commenced.
Initial goals set.
Early education provided (verbal & written).
Patient remained drowsy but able to participate in 5-10 minutes of therapy input.
Awaiting further Max-Fax Surgery.
Interdisciplinary Goals for Week 2…
Maximise communication ability through variety of augmentative communication devices.
To improve awareness and orientation.
To manage secretions and prevent chest complications.
To maintain passive & active joint range of movement.
To aim to sit out of bed for >30 mins per day.
Russell (1999) Journal of Advanced Nursing, Vol 29 (4) found the following in an exploratory study of people who’d been in ICU…
The psychological problems experienced after discharge may be prevented by improved communication between staff & patients in ICU.
Good communication led to optimised outcomes.
Poor communication caused anxiety & contributed to less than optimal recoveries after discharge.
Cognitive- Communication Strategies used…
Limit number of visitors & visitor duration
Ask short, simple questions especially yes/no questions
Re-orientate regularly
Use nod/shake head for yes/no
Use white board while sitting in chair
Use picture chart to communicate basic needs with nurses
Modified Westmead PTA Assessment
This standardised assessment was developed by Shores et al (1996) at Westmead Hospital, NSW, Australia.
The scale is suitable for assessment of Post Traumatic Amnesia (PTA) in clients with closed head injury.
The scale is divided into two major sections: 1.) Seven questions on orientation 2.) Five questions of recent memories.
The client is considered as being out of PTA when he has achieved a perfect score of 12/12 over three consecutive days.
Interdisciplinary Goals for Week 3 -following Max-Fax surgery
Family Meeting.
Tracheostomy weaning.
To continue improving awareness through use of modified Westmead and orientation therapy.
To improve balance to >40/56 on Berg Balance score.
To progress walking to a distance of >50 metres with assistance of 1.
Mr.E’s progress Week 3
Initially unable to wean trache due to further max fax surgery.
Joint SLT/ PT sessions; cleared for cuff deflation.
Trache extubated.
Inconsistently orientated to place, disorientated to time with short term memory issues. Westmead Score 7/12.
Exercise tolerance increased to walking 100 metres with assistance of 1.
Interdisciplinary Goals- Week 4
To be able to eat and drink for enjoyment.
To maximise orientation.
To be able to shower and dress with supervision only.
To be safe and independent mobilising on ward.
To do 12 stairs with supervision.
Dysphagia & TBI data (Murdock & Theodoros, 2001) …
Literature reports incidence of dysphagia in TBI 25%-82%
Duration of ventilation=dysphagia severity
- more than 15 days- 90%
- 8-14 days- 75%
- 7 days- 42.9%
Winstein 1983 94% of patients with dysphagia on admission achieved functional oral intake within 5 months
When oral intake will return?
Mackay et al 1999 cited in Murdock & Theodoros (2001)
RLA Level 4 in order to commence oral intake
RLA Level 6 in order to manage full oral intake
Mr.E’s progress Week 4
Speech 100% intelligible.
Tolerating fluids through a straw but unable to trial solids due to bands on teeth.
Orientated to place although not fully orientated to time.
Starting to look around his environment.
Trying to initiate conversation.
Can walk to toilet with supervision.
Needs minimal assistance with personal cares.
Able to mobilise 400m to gym with supervision.
Able to complete 24 stairs with supervision.
Mr.E’s presentation on discharge to Rehab Week 5…
Good family support.
RLA Level 6. Short term memory issues persisted.
Cognitive & cognitive-communication deficits relating to persisting PTA (9/12 on Westmead).
Drinking well through a straw, all other intake through PEG due to tightness of rubber bands on teeth.
Safe and Independent mobilising on ward.
Berg Balance = 56/56.
After rehab (2 months post onset)
PEG removed & total oral intake, needing swallowing monitoring.
Independent with personal cares.
Reduced short term memory.
Fatigue issues.
Reduced community mobility.
Mr. E was discharged home to his supportive wife with ongoing follow up and support from neuropsychologist, OT, SLT, PT.
References:
Sheil, Burn, Clark, Burnett, McLellan, Wilson(2001) The effects of increased rehabilitation therapy after brain injury: results of a prospective controlled trial. Clinical Rehabilitation. Vol 15: 501-514
Russell, S (1999) An Exploratory study of patients’ perceptions, memories & experiences of an intensive care unit. Journal of Advanced Nursing. Vol 29(4):783-791
Mackay (1999)
Murdock & Theodoros (2001) Traumatic Brain Injury. Singular Press.
Marosszeky,Ryan,Batchelor, Marosszeky(1998) Westmead PTA protocol.
Berg, Wood- Dauphine, Williams and Gayton(1989) Measuring balance in the elderly; preliminary development of an instrument, Physiotherapy Canada, 41(6):304-311
Presenters contacts if any further questions….
Gemma Wavish-PT: gemmaw@adhb.govt.nz
Anna Miles- SLT: annamiles@adhb.govt.nz
Ever Saley-OT: esaley@adhb.govt.nz
|
Ministry of Health
