Discharge Management for Traumatic Brain Injury

Original Editor - Wendy Walker

Top Contributors - Wendy Walker, Naomi O'Reilly, Lucinda hampton, Rachael Lowe and Kim Jackson  

General Principles of Good Practice for Discharge

Good discharge planning can make all the difference to the individuals ongoing well being following a traumatic brain injury. Discharge planning should involve, from the outset, the patient and their family/carers, and the rights and wishes of the patient should always be listened to and respected.

If possible, it is considered beneficial that the discharge occur in the morning, providing the afternoon and evening hours for the individual to settle into their new environment before going to sleep. Earlier in the week is also better than a Friday as many services may not be available over the weekend.

For patients returning home, adaptations may need to be provided prior to discharge. The video below gives a brief look at the process.

[1]

Planning for Discharge

A formal discharge meeting should be arranged, involving but not limited to the patient, hospital nursing staff, medical social worker, rehabilitation staff including physiotherapist, occupational therapist, speech and language therapist where relevant, social services staff, close family members, carers (if appropriate). In many hospitals, there is a named professional who has overall responsibility for discharge planning and discharge following traumatic brain injury is often guided by a discharge planning pathway such as this example Mild Traumatic Brain Injury Discharge Pathway from Sunshine Coast Hospital and Health Services in Queensland, Australia or the Regional Acquired Brain Injury Implementation Group Acquired Brain Injury Inpatient Care Pathway: Neurorehabilitation, which incorporates discharge planning following inpatient rehabilitation.

The level of change an individual and their family may have to make will depend on the severity of the brain injury. In many cases following a severe  traumatic brain injury, the family may be taking on a full time caring role and need a wide range of supports. With a mild brain injury, a nearly complete recovery may be expected but the family may need to assist the person with ongoing rehabilitation at home for behavioural issues and cognitive changes such as memory problems. In many cases the individual may be able to go on a trial visit home for a day and/or overnight before actually being discharged home.

Information Provided on Discharge

The hospital should provide information on:

  • Symptoms of complications that could require urgent treatment
  • Activities to avoid, and for how long eg. driving
  • Prescriptions and Medications
  • Cognitive changes, which may be expected, and suggestions on their management
  • Ongoing rehabilitation requirements
  • Any special dietary requirements if the patient has problems with swallowing eg. soft diet, or thickened fluids
  • Contact details for key professionals and all health providers involved when discharged
  • If appropriate, details on how to manage incontinence/urinary catheter

Note it is very important to check with the individual and their carers/family, where relevant, that they understand the process and feel comfortable with the arrangements. This leaflet, from Beaumont Hospital Ireland, is an example of a Post Head Injury Patient Discharge Information.

Return to Work

Workshop for the people with a disability in Vietnam.
People who have suffered mild to moderate traumatic brain injury may be able to return to the work they were involved in before their brain injury. Return to work is an important measure of integration into the community. One author reports that individuals with brain injury who fail to return to work have a lowered subjective wellbeing when compared to those who succeed in returning to work.[2]

Studies show that only 30% of people with moderate traumatic brain injury and 80% of people with mild traumatic brain injury successfully return to work.[3]

Barriers to Returning to Work

  • Cognitive Impairment
  • Loss of Motivation
  • Fatigue
  • Lack of Support provided in the work environment
  • Inadequate Communication between medical professionals and the employer/manager with the result that the employer does not know how to support the person with traumatic brain injury [4]

Common Sequelae Post Discharge

Below a few of the sequelae commonly seen post traumatic brain injury.

  • Heterotopic Ossification, which is a build up of new bone at the joint has been found to occur in between 10% and 20% of patients with moderate to severe traumatic brain injury.[5] The most common sites is the hip, followed by the elbow. [6]
  • Pituitary Dysfunction, leading to neuroendocrine dysfunction, is a recognised but potentially under-diagnosed complication of traumatic brain injury. [7][8] It is often labelled Post-traumatic Hypopituitrism. This can result in "neuro-behavioural sequelae" including concentration difficulties, fatigue, anxiety and depression.[9] One  study specifically looked at the time of onset of pituitary dysfunction, and concluded "the risk of developing endocrine dysfunction after traumatic brain injury increased during the entire 5-year follow-up period."[10]
  • Post Traumatic Seizures, which in turn cause further damage to the brain
  • Bladder Bowel Dysfunction and Genitourinary Complications
  • Nutritional Deficits
  • Degenerative Brain Diseases and Dementia
  • Mental Health Problems

NOTE: for more information see Medical Complications in Traumatic Brain Injury page.

Resources

Brain injury can upend an individual and their family. It can often be a difficult, life-long road and not always obvious to others. There are a wide range of organisations the provide support services for individuals following discharge from hospital.

Headway, UK's Brain Injury Association, act as a lifeline for people living with Acquired Brain Injury providing services to help individuals with their own goals for recovery in order to assist them to make the most of their potential, improve quality of life and level of independence. Headway also provide a wide range of fact sheets for individuals, family members and professionals including;

Synapse, Australia's Brain Injury Association, provides a range of support services for people who have been impacted by brain injury and disability. They promote quality of life, self-determination and choice through information, specialist support and targeted research activities and provide a wide range of fact sheets individuals, family members and professionals including;

Brain Injury Association of America, are the primary authority on medical diagnosis and treatment, disease management, research and life challenges associated with brain injury in the United States of America. It was founded by individuals who wanted to improve the quality of life for their family members and patients who had sustained brain injuries. They advance awareness, research, treatment, and education and to improve the quality of life for all people affected by brain injury and and provide a wide range of fact sheets individuals, family members and professionals including;

References

  1. Summer Foundation Hospital Discharge Part E – NDIS Planning Available from: https://www.youtube.com/watch?v=4iVH4gu3J2c (last accessed 19.10.2019)
  2. Cicerone, K.D. Cognitive Rehabilitation for traumatic brain injury and stroke: Updated review of the literature from 1998 through 2002 with recommendations for clinical practice. America: Archives of Physical medicine and rehabilitation, 2000;92,(4),1596-1615.
  3. Vuadens,P. & Arnold,P & Bellmann,A. Return to work after a traumatic brain injury- Vocational Rehabilitation. Pari: Springer Paris; 2006.
  4. Law, M., Baum, C.M. & Dunn, W. Occupational performance assessment. In C.H Christiansen, C.M Baum & J. Bass- Haugen (Eds.). Occupational therapy: performance, participation & well being (3rd edition). Thorofare New Jersey: Slack Incorporated; 2005.
  5. Hsu JE, Keenan MA. Current review of heterotopic ossification. UPOJ 2010; 20: 126-130
  6. Mavrogenis AF, Soucacos PN, Papagelopoulos PJ. Heterotopic Ossification Revisited. Orthopedics. 2011Jan;34(3):177
  7. Chin Lik Tan, Seyed Alireza Alavi, Stephanie E Baldeweg et al. 2017 The screening and management of pituitary dysfunction following traumatic brain injury in adults: British Neurotrauma Group guidance. Journal of Neurology, Neurosurgery & Psychiatry, vol 88, Issue 11. Nov 2017.
  8. Agha A, Sherlock M, Phillips J, Tormey W, Thompson CJ Eur J Endocrinol. 2005 Mar; 152(3):371-7
  9. Amir M. Molaie, and Jamie Maguire. Neuroendocrine Abnormalities following Traumatic Brain Injury: An important contributor to Neuropsychiatric Sequelae. Frontiers in Endocrinology 2018;9;176.
  10. Wei-Hsun Yang, Pau-Chung Chen,a, Ting-Chung Wang. Endocrine dysfunction following traumatic brain injury: a 5 year follow-up nationwide-based study. Scientific Reports. 2016;6;32987