One of the primary principles of caring for people with neurobehavioral issues is maintaining a calm and controlled environment. TIRR Memorial Hermann’s new Neurobehavioral Program houses these patients in a dedicated area of an established brain injury unit, where they are cared for by a highly trained group of clinicians.
“The volume and acuity of traumatic brain injury patients admitted to TIRR Memorial Hermann makes this an important and necessary part of the care we offer our patients,” says Christopher Falco, MD, an attending physician in the Brain Injury Rehabilitation Program at the rehabilitation hospital. “By housing them in one area and maintaining a controlled environment with limited foot traffic, we’re able to limit overstimulation and provide the calm environment they require.”
Neurobehavioral programs in the United States are clustered at academic medical centers with established rehabilitation hospitals. “We’ve always cared for patients with neurobehavioral issues,” Dr. Falco says. “To provide better, more consistent care we established a lead physician and created a team approach. Our goal was to improve outcomes by involving a small, highly trained staff in their frontline care. The work therapists and neuropsychologists do is important, but they see patients for an hour a day at the most. The nursing staff and our patient care assistants have more interaction and face time with patients because they are with them the remainder of the day. The approach our nursing staff uses with patients with neurobehavioral issues is crucial to the success of the program.”
The neuropsychologist is the first person to be called when neurobehavioral issues arise. Neuropsychologist Lindsey Harik, PhD, who recently joined the TIRR Memorial Hermann staff, is part of Dr. Falco’s team.
He credits clinical neuropsychologist Margaret Struchen, PhD, manager of the Psychology/Neuropsychology Department at TIRR Memorial Hermann and an assistant professor in the department of Physical Medicine and Rehabilitation at Baylor College of Medicine, with providing leadership that has led to the success of the program.
“Therapists who have a particular interest in working with this patient population have volunteered to participate, so we’re assured that the therapist assignment will be appropriate,” Dr. Falco says. “We’ve also made efforts to educate the entire hospital staff. The frontline staff, nursing staff and PCAs are well prepared and established. Because the remainder of the hospital staff – respiratory therapists, dietitians, environmental services and cafeteria – will interact with them as well, we provide orientation classes every quarter with presentations on the program and our goals, along with basic training on how to best interact with patients who have neurobehavioral issues. The orientation program has been a big success, and we’ve enjoyed doing it.”
Five teams of residents at TIRR Memorial Hermann are engaged in quality improvement projects that will benefit patients by streamlining processes for greater efficiency and improving the quality of care. All five projects focus on patient care in the inpatient rehabilitation setting.
With the guidance of faculty members from the departments of Physical Medicine and Rehabilitation at Baylor College of Medicine and McGovern Medical School at UTHealth, 32 residents at the two medical schools are implementing change, tracking results and learning to work together in teams. “Our goal is to teach residents how to perform a quality assessment project within the scope of their practice in ways that improve patient care,” says Joel Frontera, MD, assistant professor, residency program director and vice chair for education in the department of Physical Medicine and Rehabilitation at UTHealth. “Each group selected a process they felt needed to be added or improved upon in the hospital setting. One of the great things about the project is giving residents the opportunity to work closely with hospital staff they do not normally interact with on a consistent basis. The staff members provided feedback and direction to refine the residents’ interventions and improve outcomes. Working on these assignments also expands the residents’ point of view by giving them a better understanding of how a hospital operates.”
Projects for 2017-18 are focused on shortening door-to-admission order time by 15 percent on new hospital admissions by having the front desk page the resident on call; implementing aggressive respiratory secretions management techniques for tetraplegic patients developed in the rehabilitation setting in the trauma ICU, including interventions such as mechanical insufflators-exsufflators and metanebs; improving sleep quality for patients with brain injury by decreasing nighttime noise levels; evaluating the Neurological Examination (NEURE) skills of junior residents and their self-confidence with these skills; and increasing the percentage of antibiotics ordered with a specific duration, instead of the default 30-day duration, by 10 percent by implementing an antibiotics section on the pre-admission screening that denotes antibiotic start date, duration and indication.
The residents make an annual oral presentation of their methodology and results each March. “One of the requirements for maintenance of board certification for physiatrists is a practice improvement project,” says Dr. Frontera, an attending physician at TIRR Memorial Hermann. “The projects they design and complete at TIRR Memorial Hermann teach them how to become good clinicians and also show them how quality of care and delivery of service are tied to outcomes. Patient care is very important to us at TIRR. Projects like these help residents understand the value of little things and how they add up to contribute to quality care and good outcomes.”