Traumatic brain injury (TBI) is a health condition that is expressed through a wide range of symptoms, and it is caused by a sudden impact on the head which causes brain damage (Georges & Booker, 2018). The impact may be caused by a severe fall, vehicle accident, assault and sports injuries. The injury that occurs during the impact moment is known as a primary injury. These type of injuries may affect the entire brain or a particular lobe of the brain. During an impact, the skull may be fractured or not, at the same time, the brain suffers damage by crashing on the inside part of the skull, which may result to bruising, nerve tearing or bleeding. When the damage occurs the person may immediately be unable to recall events, they may be confused, unconscious or even have blurry vision.
The condition may get worse with time as the effects of the damage gradually progress to affect the functionality of the brain. There is delayed trauma immediately after the impact occurs, the brain swells and pushes against the skull. Consequently, the flow of oxygen-rich blood is constrained; this is termed as secondary injury. Its damages are more significant than primary injury. Generally, traumatic brain injuries are categorized into three groups depending on the severity of the damage, it can either be mild, moderate or severe.
A1. Pathophysiology of traumatic brain injury
After the occurrence of a traumatic brain injury, the cerebral injury is first characterized by impaired regulation of cerebral blood flow, damaged tissues and impaired metabolism. Subsequently, an ischemia-like pattern develops and causes lactic acid to accumulate as a result of increased membrane permeability, anaerobic glycolysis and subsequent oedema formation. Because the anaerobic metabolism is not sufficient to sustain cellular energy conditions, the adenosine triphosphate stores exhaust, and this leads to malfunction of energy-dependent membrane ion pumps.
The pathophysiology process then moves to the second stage which is demonstrated by the depolarization of terminal membrane which is also accompanied by an extreme release of neurotransmitters and activation of voltage-dependent Ca2+– and Na+-channels (Dixon, K. J. (2017). Subsequently the upsurge of Na+– and Ca2+– cause the intracellular processes to be self-digesting. Lipid peroxides, phospholipases, and proteases are activated by Ca2+ and consequently leads to an increase in the concentration of free radicals and fatty acids inside the cells. Additionally, the nucleosomal DNA and biological membranes undergo progressive structural changes due to the activation of endonucleases, translocases, and caspases which initiate the change. The collective actions of all these events lead to the degradation of cellular structures and vascular membranes. Ultimately, these results in necrosis or programmed cell death.
A2. Standard of practice TBI
The standard of practice for TBI begins with prevention of secondary brain injury as it is the primary concern for all immediate interventions following the occurrence of TBI. Caring for a patient that has suffered a TBI should begin at the injury location, the focus of care at the site should be to secure the patient’s airway and ensure circulation and sufficient ventilation. Resuscitation should take the primary urgency when traumatic brain injury occurs. The process needs to be performed by emergency physicians and trauma surgeons on the patient. Once the individual gains stability, they should be transported to a healthcare facility that offers care for neuro-traumatized patients. Further clinical examination at the center should follow upon patient admission.
The Glasgow coma scale is widely used to assess the patient’s level of consciousness at the time of presentation and during subsequent clinical assessments. Intracranial pressure ICP is observed in patients with a low Glasgow Coma Scale which is less than nine. It is also indicated in patients who cannot undergo neurologic assessment. Additionally, considerations must be placed when the patient has systolic blood pressure is lower than 90mmHg or is over 40 years (Scholten, Vasterling, & Grimes, 2017).
A2a. Evidence-based pharmacological treatments
The choice of pharmacological treatments used in Florida is based on the outcomes of multidisciplinary collaboration as well as the decision of the patient or their decision maker. The selection of an evidence-based intervention is made through an analysis of the presenting neurological disabilities, the time elapsed since the occurrence of the injury and the nature of the lesion.
Psychostimulants drugs are often used to treat health problems related to executive functioning. For example, methylphenidate is one such drug that treats the disorder which presents with symptoms similar to those of a brain injury. When methylphenidate is used to treat patients in the acute stage after TBI, the results show improved concentration, attention and memory (Huang et. al., 2016). These results are observable within one month but do not persist past three months. Therefore the use of the drug impact TBI management by only offering an intervention that reduces recovery time though it does not alter morbidity.
The use of antidepressants is also often employed in Florida as these type of drugs have demonstrated efficacy in treating post brain injury psychiatric sequelae. Behavioral disorders in TBI patients have been found to be treatable by Selective serotonin reuptake inhibitors (SSRIs) (Yue et al., 2017). These class of drugs are found to improve neuropsychiatric, neurocognitive, and neurobehavioral deficits, particularly depression, recent memory loss, and agitation. The drugs function to improve behavioral disorders and thus facilitate TBI management by improving health outcomes related to emotions and cognitive abilities.
A2b. Clinical guidelines for assessment, diagnosis, and patient education for TBI
The assessment of TBI takes various from the point of injury to treatment and recovery period. The GCS is the primary assessment method that is frequently used, the scale is used to objectively determine the depth of the comma, to improve reporting of the injury and to assist in communication between healthcare providers. The scale is modified to fit the assessment needs of the pediatric population given that the nervous system of this population is not mature.
TBI assessment is also done through computed tomography (CT) findings. An increase in abnormalities in the CT findings correlates with an increase in the severity of TBI. Mild injuries show low abnormality rates in CT scans while those with severe injuries present with an increased abnormality in CT scans.
Hypotension is also used to make assessments as research demonstrates that there is a connection between poor outcomes and systemic hypotension appearing at any time after injury. Morbidity and mortality increase with the occurrence of hypotension at any time between the point of injury and resuscitation. The link between hypotension and poor outcomes persists in relation to age and consideration of the presence of extracranial injuries
The diagnosis of TBI is performed by a healthcare professional who conducts several tests to assess a patient’s level of consciousness, physical injuries, nerve and brain functioning. The already described Glasgow coma scale is one of the primary tests. A speech and language pathologist conducts a language and speech test. The tests evaluate the ability to coordinate muscles that regulate speech, reading and writing as well as the capacity to understand and use vocabularies
Cognition tests are also used to diagnose TBI as severe TBI leads to cognitive disabilities such as reasoning, thinking, memory and information processing. High-level cognitive ability is lost when TBI is severe and hence the need to evaluate these abilities. Patients also undergo neurophysiological tests for TBI diagnosis to assess their basic sensory-motor processes and the level of high cognitive functioning.
Imaging tests are also employed to perform diagnosis; these tests takes patient’s brain images. They include computerised tomography which uses X-rays to collect brain images which provide quick findings on the status of the injured brain. Magnetic resonance imaging which uses magnets is another type of imaging test which is more detailed than a CT scan. Intracranial pressure (ICP) monitoring is a test that measures the pressure inside the skull which may be as a result of brain swelling.
Patient education is essential for improving their skills and capabilities to enable them to lead a self-dependent life with improved self-esteem. Patient education is likely to take place during rehabilitation when a patient receives help to allow them to attain the highest level of function and also improve their quality of life. Patient education includes equipping the person with self-care skills to enable them to manage daily living activities. The skills may include feeding, sexual functioning, grooming, toileting, and bathing. Patients also receive education about managing health condition issues such as pain, adaptive techniques and safety issues.
A2c. Comparison of standard practice for managing TBI within Florida and national practices.
The standard practice for managing TBI in Florida is similar to the standards used nationally as the practice followed evidence-based guidelines which are consistent throughout the country. The standards of practice are similar with regards to the process of assessing, diagnosing and treating the condition. Similar tests and treatment methods are employed nationally and within Florida. The only difference in standards of practice between the nation and Florida State pertains to unique hospital rehabilitation practices.
A3. Characteristics of and resources for a patient who manages the selected disease well
Healthcare access is one of the major factors that impact TBI management and outcome. Quality healthcare is associated with better brain injury management and treatment. Right from the point of injury occurrence to the rehabilitation period, a patient must access quality care for them to have the best outcomes. Those that achieve best disease management have quality healthcare access to ensure that they go through the best assessment and treatment which promotes quality health outcomes.
One of the characteristics that affect the management of TBI is age. Age is a significant determinate of TBI outcomes. Higher mortality is observed in older patients experiencing severe or moderate TBI. Additionally, old age is associated with increased mortality. Therefore proper management of TBI resulting in improved health outcomes is related to young age.
Social factors such as family support are additional characteristics that influence proper disease management. Family support has a significant impact on the psychosocial outcome; patients that manage the disease well have strong family support. Level of family functioning before injury occurrence is high in those that efficiently manage the disease, the interaction between a patient and their family members impact emotional adjustment and consequently treatment outcomes.
A3a. Disparities between management of TBI on a national and international level.
The rate of TBI occurrence is rapidly increasing on a global scale. Nationally, management of the disease may significantly differ with the management strategies employed by other nation’s especially low and middle-income countries. The discrepancies in the level of technology between these types of nations lead to a considerable difference in the levels of disease management.
On a national level, current TBI management depends on injury management before hospitalization and the choice of a trauma healthcare facility. The selection of a facility that uses evidence-based protocols, intensive care units, and neurosurgical intervention has a significant impact on disease management. In comparison to international standards and particularly those of low and middle-income countries, TBI management is poor for these other countries due to inadequate infrastructure and human resource.
A4. Factors that contribute to a patient being able to manage TBI
Access to care is a critical factor in the management of TBI. Medical care ensures that the patient receives evidence-based treatment that targets restoring mental and other body functions. Access to care allows a patient to obtain the best treatment and rehabilitation; additionally, by accessing care, patients can receive the best education in disease management.
The availability of sufficient financial resources has a significant impact on the magnet of TBI. Financially stable patients demonstrate better management outcome than those facing financial constraints. Availability of money enables a patient to seek the best medical care and treatment intervention; consequently, they are likely to have better outcomes.
Having insurance coverage affects TBI management as the condition may require long-term treatment. Insurance coverage enables a patient to manage the condition since the insurance caters for hospital bills which may be very expensive, and the patient cannot pay from their pocket. Thus having insurance relieves the patient of financial worry and enables them to concentrate on recovery and consequently achieve better disease management.
A4a. Explain how a lack of the factors discussed in part A4 leads to an unmanaged disease process.
Lack of access to care leads to poor disease management as the right care is not delivered and the health of the patient is likely to deteriorate. Patients that are not receiving proper care lack the skills and knowledge to manage their condition which contributes to incidents of poor management practices.
Financial resources allow a patient to pay for medical expenses, in case a patient is not able to raise hospital bills then they cannot access quality care which leads to an unmanaged disease. Lack of financial resources also affects the recovery process as the patient is worried about the expense leading them not to focus on disease management.
Lack of insurance cover is detrimental to disease management as the costs involved may be too high for the patient to raise. The inability to cater for medical cots translates to poor health access and the patient gets stressed leading them to experience poor management outcomes.
A4i. Characteristics of a patient with the selected disease that is unmanaged.
Patients with unmanaged TBI experience reduced survival rates as they do not get proper medical care that improves their quality of life and reduces mortality. These patients also suffer from long term disabilities. Unmanaged TBI leads to increased malfunction of the brain causing a patient to experience other physical disabilities. Lack of management allows secondary brain injury to progress and subsequently affecting other abilities.
The patient’s family is significantly affected by TBI as they must learn how to cope with the condition as well as play caring roles to the sick family member. Lack of knowledge on the disease may be one of the most significant burden on family members as they may lack the appropriate skills to help the patient manage the condition. The need to meet the financial, emotional and social needs of the sick family member may be overwhelming and adversely affect family functioning.
Additional costs are involved in managing TBI, and this affects both the population in the community and family members. Financial resources that would otherwise be used in other developmental projects are used in treatment TBI patients and equipping traumatic healthcare facilities. The population in the community may be unable to make social connection with a TBI patient who losses their cognitive ability which may cause social problems in the society.
B1. Financial costs associated with TBI for patients, families, and populations from diagnosis to treatment.
The financial costs associated with TBI is tremendous as the condition incurs enormous costs from the diagnosis to treatment and rehabilitation. Diagnosis equipment costs communities a lot of money, and the patient also has to pay for the services. Families without insurance coverage spend a lot of money paying for treatment as TBI is a long-term condition that does not have a cure as it is only manageable. The need to keep a patient under continued care results to high costs in the long term.
The occurrence of TBI results in indirect costs which are experienced by both the family and population in the community. Where the condition is severe and the patient losses high-level functioning ability, the individual becomes unproductive, and this affects the family level of income. The presence of unproductive people in society who spend a lot on medical bills is detrimental to the development of a community.
To promote the best practices for TBI management in my present healthcare organization, I would advance for an aggressive patient admission and treatment process which sees that TBI victims quickly received care after injury. The time taken to receive medical treatment since the occurrence of injury is found to have a significant impact on the treatment outcomes. As such, there is a need to establish a system that offers fast healthcare services to TBI patients.
Another strategy to promote best practices is advancing clinical research to create enhanced evidence-based guidelines that are specific to different populations. Lack of specific treatment methods for different populations leads to poor health outcomes, the management of TBI requires that interventions be specific to a particular population for the best results.
C1. Strategies you could use to implement best practices for managing the selected disease in your current healthcare organization
One of the strategies for promoting the best practices for managing TBI is setting up a research department and allocating funds to support research mainly focused on TBI management. In so doing, it will be possible to make scientific breakthroughs in developing better guidelines for managing TBI.
Increasing the number of healthcare professionals that specialize in treating traumatic brain injury is essential in promoting management practices. Increased number of professionals ensure that every patient receives maximum care and attention, consequently, the health of the patient improves as any adverse changes are immediately noticed and treated.
TBI management is not complete without the involvement of the patient’s family. Involving the family in management ensures that the patient receives the best care even when at home. One of the strategies to engage the family is to set up a rehabilitation and education centre where both the patient and family receive extensive education and skills in disease management. The approach is likely to improve management outcomes given that having the right skills is critical in delivering holistic disease management.
C2. Discuss an appropriate method to evaluate the implementation of each of the strategies from part C1.
An appropriate method for evaluating the setup of a research department entails forming a committee or board of directors that will oversee the implementation process. The members must be knowledgeable in the healthcare field to ascertain that the intended research activities will directly impact TBI management practices.
To evaluate the process of increasing the number of healthcare professional strategy requires an assessment of the needs of the healthcare facility with regards to TBI patients’ management. The needs of the patients dictate the number of professionals needed and their areas of practice. As such, an assessment of the presenting needs will be the most appropriate evaluation strategy.
Establishing a rehabilitation and educational center will be evaluated by designing an outcome measure guideline that assesses the healthcare progress of patients after going through rehabilitation and receiving the education. The measurements can be compared against outcomes for patients that have not gone through such a program to determine the effectiveness of the rehabilitation and education center.
Georges, A., & Booker, J. G. (2018). Traumatic Brain Injury. In StatPearls [Internet]. StatPearls Publishing.
Dixon, K. J. (2017). Pathophysiology of traumatic brain injury. Physical Medicine and Rehabilitation Clinics, 28(2), 215-225.
Scholten, J., Vasterling, J. J., & Grimes, J. B. (2017). Traumatic brain injury clinical practice guidelines and best practices from the VA state of the art conference. Brain injury, 31(9), 1246-1251.
Huang, C. H., Huang, C. C., Sun, C. K., Lin, G. H., & Hou, W. H. (2016). Methylphenidate on cognitive improvement in patients with traumatic brain injury: a meta-analysis. Current neuropharmacology, 14(3), 272-281.
Yue, J., Burke, J., Upadhyayula, P., Winkler, E., Deng, H., Robinson, C., … & Ngwenya, L. (2017). Selective serotonin reuptake inhibitors for treating neurocognitive and neuropsychiatric disorders following traumatic brain injury: an evaluation of current evidence. Brain sciences, 7(8), 93.