Research Reports - Specialized early treatment for persons with disorders of consciousness: Program components and outcomes

Arch Phys Med Rehabil. 2013 May 31

Seel RT, Douglas J, Dennison AC, Heaner S, Farris K, Rogers C

OBJECTIVE: To describe a specialized early treatment program for persons with
disorders of consciousness (DOC) that includes family education; to identify
rates of secondary conditions, imaging used and selected interventions; and to
evaluate outcomes. DESIGN: A single center, retrospective, pre-post design using
electronic medical record data. SETTING: A CARF-accredited, long-term acute care
hospital that provides acute medical and inpatient rehabilitation levels of care
for people with catastrophic injuries. PARTICIPANTS: 210 persons aged 14 to 69
with DOC of primarily traumatic etiology admitted at a mean of 41.0 (SD=27.2)
days post-injury; 2% were in coma, 41% were in the vegetative state and 57% were
in the minimally conscious state. INTERVENTIONS: An acute medical level of care
with 90+ minutes of daily interdisciplinary rehabilitation and didactic and
hands-on caretaking education for families. MAIN OUTCOME MEASURES: Coma Recovery
Scale-Revised, Modified Ashworth Scale, and discharge disposition. RESULTS:
Program admission medical acuity included dysautonomia - 15%, airway
modifications - 79%, infections (e.g., pneumonia - 16%, urinary tract infection -
14%, and blood - 11%), deep vein thrombosis - 17%, pressure ulcers - 14%, and
marked hypertonia - 30% in each limb. There were 168 program interruptions (i.e.,
139 surgeries, 29 non-surgical intensive care unit transfers). Mean length of
stay was 39.1±29.4 (range 6-204 days). Patients showed improved consciousness and
respiratory function and reduced pressure ulcers and upper extremity hypertonia.
At discharge, 54% showed sufficient emergence to transition to mainstream
inpatient rehabilitation and 29% did not emerge but were discharged home to
family with on-going programmatic support; only 13% did not emerge and were
institutionalized. CONCLUSIONS: Persons with DOC due primarily to traumatic
etiology who receive specialized early treatment that includes acute medical care
and 90+ minutes of daily rehabilitation are likely to show improved consciousness
and body function; more than half may transition to mainstream inpatient
rehabilitation. Families who receive comprehensive education and hands on
training with on-going follow-up support may be twice as likely to provide care
for medically stable persons with DOC in their homes v. nursing facility
placement.

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