Management of traumatic brain injury (TBI): a clinical neuroscience-led pathway for the NHS, 2021, Li et al

Management of traumatic brain injury (TBI): a clinical neuroscience-led pathway for the NHS

Lucia M Li, NIHR clinical lecturer,A Michael D Dilley, consultant neuropsychiatrist,B Alan Carson, consultant neuropsychiatrist and honorary professor,C Jaq Twelftree, AHP consultant in neuro-rehabilitation,D Peter J Hutchinson, professor of neurosurgery,E Antonio Belli, professor of trauma neurosurgery,F Shai Betteridge, consultant clinical neuropsychologist,G Paul N Cooper, consultant neurologist,H Colette M Griffin, consultant neurologist,I Peter O Jenkins, consultant neurologist,J Clarence Liu, consultant neurologist,K David J Sharp, NIHR professor and consultant neurologist,L Richard Sylvester, consultant neurologist,M Mark H Wilson, professor of brain injury,N Martha S Turner, principal clinical psychologist and neuropsychologist,O and Richard Greenwood, neurology consultantP


ABSTRACT
Following hyperacute management after traumatic brain injury (TBI), most patients receive treatment which is inadequate or inappropriate, and delayed. This results in suboptimal rehabilitation outcome and avoidable detrimental chronic effects on patients’ recovery. This worsens long-term disability, and magnifies costs to the individual and society. We believe that accurate diagnosis (at the level of pathology, impairment and function) of the causes of disability is a prerequisite for appropriate care and for accessing effective rehabilitation. An expert-led, integrated care pathway is needed to deliver accurate and timely diagnosis and optimal treatment at all stages during a TBI patient’s care.

We propose the introduction of a specialist interdisciplinary traumatic brain injury team, led by a neurosciences-trained brain injury consultant. This team would engage acutely and for a longer term after TBI to provide accurate diagnoses, which guides subsequent management and rehabilitation. This approach would also encourage more efficient collaboration between research and the clinic. We propose that the current major trauma network is leveraged to introduce and evaluate this proposal. Improvements to patient outcomes through this approach would lead to reduced personal, societal and economic impact of TBI.



Open access: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8002793/

 

A very interesting paper discussing current and proposed NHS Nuero-led Trauma care pathways.

The following text is taken from the paper:


Current service provision and patient flow

After trauma, the priority in the UK has been to reduce mortality after moderate/severe TBI, with the focus being on improvement of pre-hospital, acute neurosurgical and critical care, and acute or early inpatient rehabilitation.1,15 Since the introduction of the major trauma centre (MTC) system (which seeks to enable early rapid resuscitation and targeted interventions that maximise survival), patient flow and mortality have improved, particularly for those most severely injured.16,17

However, it is not enough to save lives; we must also seek to restore them. Hyperacute critical care and surgical treatment must be accompanied and followed by specialist care and rehabilitation to achieve good functional outcomes. Although the major trauma network has led to clear pathways for acute early specialist inpatient rehabilitation (‘level 1’; see Box Box1),1), the rehabilitation prescription is poorly implemented post-discharge and there is often no TBI-specific outpatient follow-up, despite evidence that it is helpful.7,18,19

Furthermore, the lack of a formal TBI care pathway means that the majority of acute TBI patients not requiring critical or neurosurgical care are initially seen by clinicians who are not trained in the diagnosis and management of consequences at the level of pathology and neurological impairment. These patients, who present less dramatically, find themselves scattered throughout a hospital under various specialties (eg orthopaedics, general surgery, internal medicine or care of the elderly), and are subsequently discharged without specialist input or follow-up. This includes the rising numbers of elderly patients sustaining TBI through falls, whose injury severity may not even be initially recognised due to their altered physiology and the low energy mechanism of injury; TBI patients discharged directly from ED or presenting directly to community teams; and patients under acute medical and surgical specialties with polytrauma / other acute problems accompanied by unidentified TBI.

TBI is often referred to as a ‘hidden handicap’ because disability after TBI results largely from cognitive, emotional and behavioural problems, rather than physical impairments. There is also the issue of the ‘frontal lobe paradox’ when patients perform well on routine screening but major problems emerge once in the community as a result of the ‘saying-not-doing’ / ‘knowing–doing dissociation’. This is when patients know and say what they want and need to do, and yet fail to engage with therapy or perform necessary tasks, rapidly leading to, for example, loss of employment and relationship breakdown.

All this frequently leads to inaccurate and delayed diagnoses, and poor understanding and recognition of the causes of disability after TBI, which often relate not only to the TBI but also to its interaction with underlying medical or psychological issues. Inevitably, subsequent rehabilitation and care is haphazard, management breaks down over time, the appearance of serious sequelae is not recognised nor investigated, and inappropriate or no treatment is initiated. This leads to preventable complications, slower recovery, lost opportunities for return to independence and productivity, and devastating personal and societal consequences.