Program for unconscious patients cuts LOS, costs

It’s a response enhancement program

A small percentage of brain injury survivors remain unconscious after their injury, sometimes staying in a coma or other unconscious state for months. Brooks Rehabilitation Hospital in Jacksonville, FL, has developed a response enhancement program that more accurately identifies those patients’ levels of consciousness and provides more efficient and effective care.

"These patients are suspected to have what we call a disorder of consciousness,’" says Cynthia Beaulieu, PhD, ABPP-Cn, senior clinical neuropsychologist for the hospital. "Trying to diagnose a disorder of consciousness is very tedious because there are so few things you can look at as to whether or not a patient is responding to what’s expected. We have to determine a valid diagnosis before deciding whether they should remain at the rehab hospital or go into a long-term care facility."

Correctly diagnosing and treating the patient can save health care resources and time, Beaulieu says. Brooks Rehabilitation Hospital has compared length of stay (LOS) and outcomes data to patient outcomes data for 1997, the year before the program started.

The findings show a significant decrease in LOS once the program began. For example, in 1997, the hospital had five patients with disorders of consciousness; in 1998, there were six. The total rehab LOS, not adjusted for the greater number of patients in 1998, was a month less for the 1997 patients. The 1997 patients spent 100.8 days in rehab in a consciousness disorder state, and the 1998 patients who went through the special program spent 70.7 days while in that state. Some of those patients subsequently were referred to a long-term care facility, and some were referred to the rehab hospital’s brain injury program, depending on whether they had regained consciousness.

The response enhancement program also was successful in improving the amount of time it took for patients to transition into the brain injury program. In 1997, three patients were transferred into the brain injury program, and it took them a total of 54.4 days to make the transition. After the program began, three patients took a total of 27.2 days to transition into the brain injury program.

"By solely structuring the way we assessed and collected the data on these patients, we were able to cut the time in half," Beaulieu says. "The important thing is to identify those patients who will not benefit from rehab yet and get them into a less costly level of care."

The hospital’s program addresses how to correctly identify, treat, and refer. "You need to feel comfortable that you are sending them into the level of care they need rather than having lingering questions regarding their level of consciousness," she says.

Before the program, clinicians were overly cautious in deciding that a patient was not rehab-ready and, therefore, should be sent to a long-term care facility, Beaulieu says. After the program began, the hospital sent patients who were not emerging from their unconscious states to long-term care facilities in about half the time it sent the patients who had not been part of the program.

Program has cost-shifting advantages

Beaulieu says the hospital has not yet analyzed all of the cost data but has found that more health care dollars are saved for patients to use after they emerge from the consciousness disorder state under the program. Before the program, about two-thirds of the patients’ total charges were accounted for when the patient was in the consciousness disorder phase. After the program, less than half of the charges were accrued during that phase. That means patients with dollar caps on their health care insurance will have more money for rehabilitation if they regain consciousness, as some do, and those who do not will have more money for long-term care.

"We became more efficient in how we were using their money and using less of it when they were in the disorder of consciousness phase," she says. "Part of the program was to standardize who did what and when it was done, so it’s the same people from day to day doing the same thing at the same time." Before the program, any therapist could have performed stimulation on a patient, and the record of what they did would not be seen by all disciplines involved with the patient, she adds. "Now everyone is aware of what everyone else is doing and what the results are."

Beaulieu offers this look at how the program works:

Improve assessment process. The hospital formed a committee to determine the central modalities that are most crucial for determining the patient’s ability to respond to the environment. The committee included Beaulieu as well as representatives from nursing, physical medicine rehab, and occupational, physical, recreational, and speech therapy.

The Brooks consciousness disorder team met weekly, discussing and searching for answers to these types of questions: What stimuli are best for determining a patient’s ability to respond to the environment? How frequently do you have to assess the patient’s responses to these stimuli? Once a week or twice a week? How often should the data be collected?

The team found that therapists often were overlapping each other in testing patients. Two therapists would apply the same form of stimulation at different times on different days and report very different results that could not be interpreted clinically. So the team developed stimulation protocols that control for how the stimulation is administered, who administers it, when it’s administered, and how the patient’s responses are scored.

The job of the rehab staff is to assess which state of consciousness best matches a particular patient’s behaviors. The various states include:

— coma state, in which a patient shows no response to outside stimuli other than minimal reflexive action or a response to deep pain;

— vegetative state, in which the patient’s eyes might open spontaneously or other small indications might reveal that the patient is responding to stimuli, such as grasping a finger when placed in the patient’s hand or blinking in response to facial stimulation;

— minimally conscious syndrome, in which a patient shows a pattern of response to stimuli and may respond inconsistently to simple commands such as "shake my hand" or "open your mouth."

Another state that mimics the consciousness disorder states is the "locked-in" syndrome. In this state, patients are conscious but cannot respond to stimuli. They may respond visually and answer questions through eye blinking. This syndrome needs to be ruled out before a diagnosis can be made.

Hold team meetings and talk with the family. Once a patient is referred to the hospital and is a candidate for the response enhancement program, the rehab team meets and conducts a comprehensive evaluation of the patient with all team members present. That way, everyone who will be treating the patient can see which behaviors the patient exhibits, if any. "Also, the team leader will do a family interview to determine a variety of things about the patient, such as the patient’s likes and preferences and dislikes," Beaulieu says. "So when we administer stimuli like music, we can play something the patient favored as opposed to something the patient disliked."

The team leader also finds out what smells are familiar to the patient and what type of textures the patient likes. The family is asked to bring in photos of family members and discuss any nicknames to which the patient might respond.

"We build these into what we do with the patient on a day-to-day basis," Beaulieu says.

Administer protocols. For the first week, the hospital has one therapist administer stimuli protocols in the morning and a different therapist administer them in the afternoon. That gives the team two sets of data per protocol per day, and the team can assess whether therapists are rating the patient consistently and whether there are differences in the morning and afternoon behaviors.

Beaulieu compares those data to what occurs the second week, analyzing whether the patient has made any progress or shown any change in consciousness level. "Depending on these analyses, we determine whether or not our recommendation is for a continued stay, or, if they have gone two to three weeks without any change, then we look at discharge placement. If they change from week to week, we argue with third-party payers to keep them there."

The team keeps the family informed each week of the patient’s prognosis and what it means. "So their hope is maintained, but they’re not given false or unrealistic expectations," she explains.

Teach families to watch for change. The treatment team encourages families to watch therapists test the patient’s response, using stimula tion. The team teaches them how one type of hand twitching or grasping might be just a reflexive action, while another indicates a response to the stimuli. "We tell patients that when a patient responds, it’s more likely to be due to something the family has done rather than what we do, and that’s why we encourage family involvement," Beaulieu says.

Need More Information?

Cynthia Beaulieu, PhD, ABPP-Cn, Senior Clinical Neuropsychologist, Brooks Rehabilitation Hospital, 3599 University Blvd. S., Jacksonville, FL 32216. Phone: (904) 858-7744.