Elsevier

World Neurosurgery

Volume 97, January 2017, Pages 156-168
World Neurosurgery

Original Article
Improving Traumatic Brain Injury Outcomes: The Development of an Evaluation and Referral Tool at Groote Schuur Hospital

https://doi.org/10.1016/j.wneu.2016.09.081Get rights and content

Background

The Western Cape Province of South Africa has a great shortage of diagnostic expertise, rehabilitative infrastructure, and support services for patients with traumatic brain injury (TBI). The neurosurgical outpatient setting is busy and often chaotic, and patients are frequently lost to follow-up. This study sought to continue with the design and development of a comprehensive, yet brief tool to aid patient referrals and ensure that no consequence of TBI is left unidentified and unaddressed.

Methods

There were 47 patients with TBI (mean age, 35 years; range, 18–75 years) assessed. The study was designed in 3 distinct phases, each representing a different stage in the tool's development.

Results

The Groote Schuur Traumatic Brain Injury Evaluation was shortened and simplified. Overall, 81% of the participants indicated cognitive dysfunction. There was a high prevalence of psychological/psychiatric sequelae, with 85% of participants reporting at least 1 such problem.

Conclusions

The findings further highlight the prevalence of the cognitive, behavioral, and psychological consequences of TBI and shed additional light on the particular types of problems that patients with TBI face. Following the identified changes, the questionnaire and algorithm combination are now ready to be validated in the neurosurgical clinical setting.

Introduction

The occurrence of traumatic brain injury (TBI) varies around the world, with incidence rates per population of 100,000 between 150 and 300 per annum.1 Approximately 10 million people sustain a TBI annually.2 In Johannesburg, South Africa, the annual incidence was found to be 316 per 100,000.3 This rate has been reported in other studies, which estimate it to be 1.5–3.5 times higher than the global average.4

There is currently no TBI database in South Africa, and incidence rates can only be estimated. However, the extent of TBI in the Western Cape Province is highlighted by 2013 admissions data from the 2 largest tertiary hospitals—Groote Schuur Hospital (GSH) and Tygerberg Hospital (TGH); 2851 patients with TBI were admitted—1855 at TGH and 996 at GSH (Clinicom data obtained through W. Bryant, written communication, August 2014). Furthermore, an internal audit conducted in 2009 at GSH revealed the high prevalence of head injuries among trauma admissions (N = 10,046); 24% were TBIs, of which 27% (n = 654) were classified as moderate to severe and resulted in inpatient admission (T. King and J. Webster, unpublished data, 2010). Most TBIs are due to interpersonal violence and motor vehicle accidents, including accidents involving pedestrians.5, 6

It is important to classify the severity of TBI, as it corresponds with prognosis. Severe TBI has increased morbidity and mortality rates compared with milder injuries.7, 8 The most recognized method for determining TBI severity is the Glasgow Coma Scale (GCS). A GCS score is derived within 48 hours of a brain injury and can be used to categorize the severity of injury as follows: GCS score 13–15 = mild, GCS score 9–12 = moderate, and GCS score 3–8 = severe. Patients are evaluated according to eye, motor, and verbal responses.9 Severity can also be estimated based on the duration of loss of consciousness (LOC): mild injury is suggested when LOC lasts <30 minutes; moderate injury, when LOC lasts 30 minutes to 6 hours; and severe injury, when LOC lasts >6 hours.10 The duration of the period of amnesia and confusion that accompanies LOC—known as post-traumatic amnesia (PTA)—is also directly related to TBI severity and prognosis.

A large proportion of patients with TBI have long-term disability, including physical (neurological) disability, cognitive problems, and behavioral problems.11, 12 Possible impairments include impulsivity and loss of inhibition, aggression, impaired problem-solving ability, poor insight and judgment, memory problems, personality changes, and aphasia.13, 14, 15, 16 Many patients also experience psychological and psychiatric problems after TBI, with anxiety and depression typically being the most prevalent.2, 17, 18, 19, 20, 21, 22 Such issues are often underdiagnosed, especially in countries such as South Africa.

Cognitive, neurobehavioral, and psychological problems are associated with a major economic burden, as patients who were employed before their injury struggle to return to work. Studies show that only one third of patients return to work after 3 months, and one third never return to employment or to their premorbid level of functioning.23 Patients become dependent on their families for support, which can lead to severe disturbance and dysfunction within family groups, to poor social skills, and ultimately to criminality.24 Families frequently struggle to maintain cohesion and resilience.

A general lack of awareness about TBI exists among the population of South Africa. This reality is emphasized by a study that examined misconceptions about TBI among South African students.25 The research highlights how even well-educated individuals lack fundamental knowledge regarding TBI and its consequences, such as LOC and amnesia.25 Many patients with TBI in South Africa have little formal education.

At the present time, very few resources are available in the Western Cape Province and in South Africa in general for survivors of TBI; data shows that the average length of stay in hospital is typically just 10.2 days for patients at GSH and 15 days for patients at TGH (Clinicom data obtained through W. Bryant, written communication, August 2014). Access to the Western Cape Rehabilitation Centre is also severely limited, and there is no alternative neurorehabilitation center. In 2009, only 16 of 654 patients with TBI at GSH were admitted to a public rehabilitation center (T. King and J. Webster, unpublished data, 2010). Of the 2851 patients with TBI admitted to TGH and GSH in 2013, only 2.9% (n = 82) were admitted to the Western Cape Rehabilitation Centre (Clinicom data obtained through W. Bryant, written communication, August 2014). For the 5-year period 2008–2012, the total number of patients with TBI admitted to the Western Cape Rehabilitation Centre was <9% of all patients with TBI.26

The short time patients spend in the acute care setting limits rehabilitation possibilities, and the lack of specialist rehabilitation facilities negatively affects outcomes. Consequently, patients are discharged to unprepared families without receiving essential knowledge and support. In addition, the Neurosurgery Outpatients Department (NSOPD) at GSH is overwhelmed by numerous difficulties, including a severely restricted amount of time because of the tight schedule that patients have to access various professionals (including neurosurgeons and occupational therapists) and the lack of an adequate referral infrastructure—hence, many patients are lost to follow-up. There is also a lack of neuropsychological expertise, and patients' cognitive and psychological problems frequently go unrecognized and undocumented. Another challenge is that the time frames in which patients are required to return to the NSOPD are primarily dictated, quite rightly, by neurosurgical requirements and not neuropsychological ones. Therefore, the present study was urgently needed to begin to address these issues.

At GSH and in the Western Cape Province in general, there is a lack of adequate and effective culturally appropriate resources for multifaceted screening and cognitive assessment of patients with TBI. These resources are required to identify the presence of cognitive, psychological, and psychiatric problems after TBI. This lack of resources often leads to patients not being referred to the required specialists (e.g., neuropsychologists and psychiatrists). It also leads to patients being discharged to unprepared families who are not provided with any information about a patient's cognitive, psychological, and psychiatric states or what the families should expect as a result. Such problems also exist outside of South Africa. For example, a literature review by the Effective Health Care Program highlighted the concerning lack of evidence for targeted psychiatric screening of patients with TBI given the high burden of this population.27

The cognitive impairments associated with TBI are best assessed by qualified neuropsychologists.28 However, neuropsychologists are a scarce resource in many parts of the world. Many screening batteries are available internationally, but these are primarily for identifying the presence of cognitive dysfunction, and many are culturally inappropriate for use in South Africa, where few norms exist for the population.29 There is consequently a great need to improve the identification of cognitive, psychological, and psychiatric problems in under-resourced settings so that patients with TBI can be more effectively referred and managed with appropriate follow-up.

The initial creation and development of the Groote Schuur Traumatic Brain Injury Evaluation (GSH TBI-E) began in 2011 with a pilot study.30 This pilot study involved designing a TBI screening questionnaire incorporating cognitive and psychiatric questions and background medical information to identify severity of TBI and potential problems. The content of the questionnaire was informed by clinical experience (neurosurgical and neuropsychological) and by knowledge of the consequences of TBI and of the availability of local patient services. The initial conceptualization of the questionnaire led to the creation of an algorithm to be used alongside it. Data were collected from 13 outpatients with TBI at GSH over a 2-month period. A case-by-case analysis revealed key scenarios affecting patient referral. As a result of the analysis, 4 referral categories were initially defined: reassess (by a neurosurgeon) 6 months after trauma, refer to Neuropsychology immediately, refer to Psychiatry immediately, and no further action required from Neuropsychology/Psychiatry.30 The 6-month time frame is based on the clinical belief that the fastest spontaneous recovery from TBI usually occurs in approximately the first 6 months.31 Therefore, it was deemed better to wait until occurrence of some stability in the cognitive and behavioral presentation before formal assessments are performed. The initial pilot study also revealed discrepancies between these recommendations and the referrals/follow-up appointments made in the NSOPD. Therefore, the algorithm was designed to aid referral of patients with TBI into these categories.

The present study built on the results of the pilot study to further develop and refine the questionnaire for effective use in conjunction with the evolving algorithm as a straightforward and dependable tool (the GSH TBI-E). The overall aim was to refine the questionnaire items that best serve the algorithm. Another aim was to collect data from a larger sample to provide further support for the decisions behind the design and content of the questionnaire and algorithm. This is a key step toward improving the identification of cognitive and psychological/psychiatric problems and toward the eventual use of this screening tool to improve TBI referrals and patient outcomes. The GSH TBI-E is intended to help to streamline the available services and support for patients. It will also help to address the lack of public knowledge and awareness about TBI and its consequences.

Section snippets

Sample

Data from 47 adult patients with TBI were gathered primarily from the GSH NSOPD and the HeadsUP! Hub in Khayelitsha township. HeadsUP! is a programme of the ComaCARE Trust that provides brain-injury prevention and support services for TBI patients and their families. A few patients were also assessed in the GSH acute neurosurgical ward, where any patient with a GCS score <14 was excluded. Most participants were young, with 63% between 16 and 35 years old (Table 1). The average age was 35, and

Phase 1

For analysis purposes, the results of phase 1 are incorporated into the results presented for phase 2 (Tables 2 and 3). The questionnaire content remained largely unchanged after the successful first trial. Only minor refinements were made to the wording of the cognitive questions, as it was found that some participants struggled to understand what was being asked of them—possibly because of language and educational barriers. This problem led to the inclusion of more clarity and detail, mainly

Discussion

This study refined the GSH TBI-E so that it can help to 1) identify patients' cognitive, behavioral, and psychological/psychiatric problems in the neurosurgical setting and 2) streamline the available services and support for patients with TBI and their families. This involved collecting data to support the design decisions to be made, along with refining the questionnaire content that best served the algorithm.

Most participants (63%) were between 16 and 35 years old, and 94% were male. This

Conclusions

This study further highlights the prevalence of the cognitive, behavioral, and psychological consequences of TBI and sheds additional light on the particular types of problems and challenges that patients with TBI and health care providers face in this under-resourced South African context. Further research can now be conducted into the clinical validity of the newly adapted GSH TBI-E in the under-resourced NSOPD setting.

Acknowledgments

Special thanks to the ComaCARE Trust and its HeadsUP! programme staff for their assistance with the data collection process and to Professor Graham Fieggen for his support throughout.

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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