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Developing a Polytrauma Rehabilitation Center: A Pioneer Experience in Building, Staffing, and Training
The military operations in Iraq and Afghanistan have resulted in patterns of injury not commonly seen in previous conflicts. Improvised explosive devices are the primary weapon, and exposure to blast is the most common mechanism of injury. Blasts can result in polytrauma injury, in which multiple body systems, including the head and brain, are injured. Nursing and rehabilitation care can be further challenged by other blast sequelae such as pain, amputation, blindness or low vision, hearing impairment, and aphasia. This article describes the process by which one Veterans Affairs Medical Center developed its inpatient rehabilitation service into a polytrauma rehabilitation center to meet the medical and rehabilitation needs of these patients. Special attention is given to the education and training program developed to solidify the membership of the center’s nursing staff in the interdisciplinary treatment team.
The frequent use of exploding devices has changed the casualty patterns of servicemembers injured during Operation Enduring Freedom (OEF) in Afghanistan and Operation Iraqi Freedom (OIF). Blast exposure may cause injury through multiple mechanisms, including profound changes in air pressure, conversion of surrounding materials into projectiles, displacement of affected bodies, and burns and other miscellaneous injuries (Scott, Vanderploeg, Belanger, & Scholten, 2005). Polytrauma has been defined as “injury to the brain in addition to other body parts or systems resulting in physical, cognitive, psychological, or psychosocial impairments and functional disability” (Department of Veterans Affairs [DVA], 2005a, p. 2). Recent research shows that, on average, polytrauma survivors in acute care rehabilitation have sustained 4.2 injuries (Sayer et al., 2007).
Although the injuries can be extremely severe, surviving servicemembers are receiving excellent emergency medical care, including rapid transport out of theater, and survival rates for this conflict are exceeding those of past U.S. military conflicts (Gawande, 2004). Bilmes (2007) estimated the casualty-to-fatality ratio to be as high as 16:1. These odds impose striking demands on postinjury and postdeployment medical care. Veterans Affairs Medical Center (VAMC) rehabilitation services are assuming significant responsibility for helping wounded servicemembers adapt to life after injury.
Even with helmets, blast exposure renders the head vulnerable to closed or penetrating brain injury. Severity can range from mild concussion to profound head trauma. Incidence is difficult to quantify across the continuum of severity because of a lack of uniform data collection and reporting mechanisms, but recent numbers based on a screening of soldiers admitted to Walter Reed Army Medical Center reported brain injury in approximately 60% of them (Defense and Veterans Brain Injury Center, n.d.). Numbers are even higher for wounded members of the military admitted to the VAMC for acute rehabilitation, where 93% of patients admitted were diagnosed with traumatic brain injury (TBI; Chiros et al., 2008). The frequency of brain injury after blast exposure has led some to call TBI the signature wound of OEF and OIF (Zoroya, 2005).
Brain injury and subsequent cognitive impairments impose significant challenges on rehabilitation. Disruption of thinking skills, learning, memory, judgment, communication, or visual-spatial skills can undermine the teaching that is inherent in the rehabilitation process (Humayun, Scott, & Scholten, 2006). For this reason, the Veterans Health Administration (VHA) has established a system of polytrauma rehabilitation care where “treatment of brain injury sequelae needs to occur before, or in conjunction with, rehabilitation of other disabling conditions” (DVA, 2005b, p. 1).
Before the war, a network of TBI rehabilitation services was in place in the Veterans Affairs (VA) system. As the VA has responded to rehabilitation needs resulting from combat injuries, this TBI care system has transitioned into a polytrauma and TBI system of care. This article describes how the Minneapolis VAMC quickly consolidated and transformed its inpatient rehabilitation service into a comprehensive polytrauma rehabilitation center (PRC) where rehabilitation nurses assumed key roles in the polytrauma program. This article specifically addresses how an educational program was created to provide nurses with the necessary skills to function autonomously and become integral members of the polytrauma interdisciplinary rehabilitation team.
VAMC TBI History
VAMC polytrauma rehabilitation is firmly grounded in preexisting TBI rehabilitation services. The Minneapolis VAMC has provided specialized TBI services since 1984, when a multidisciplinary team of rehabilitationists joined together to create both inpatient and outpatient TBI care programs. In 1990 and 1991, a VA Central Office Physicians Task Force was convened to plan for TBI-specific care across the nation, and proposals for regional TBI centers were solicited. The Minneapolis VAMC was one of four programs located in tertiary care facilities to be designated a TBI lead center along with Palo Alto, CA; Richmond, VA; and Tampa, FL. The Minneapolis VA TBI lead center received accreditation from the Commission on Accreditation of Rehabilitation Facilities in 1997 and was designated a VA TBI Center of Excellence in 2001 (Sigford & Stephens, 2005).
A memorandum of agreement authorizing VA treatment of active-duty servicemembers with TBI was developed in the 1980s. In 1992, the VA entered into formal collaboration with the Department of Defense when the four TBI lead centers joined the Defense and Veterans Head Injury Program (now the Defense and Veterans Brain Injury Center), a congressionally funded alliance of military treatment facilities and VA facilities chartered to treat expected Persian Gulf War casualties (Salazar, Zitnay, Warden, & Schwab, 2000). The Defense and Veterans Head Injury Program centers established a national TBI registry and evaluation program beginning in 1993, and a system-wide TBI treatment algorithm was developed by VHA in 1995.
Polytrauma Rehabilitation System of Care
As the frequency, severity, and complexity of polytrauma injuries became apparent, the need for specialized, intensive rehabilitation and coordination of care during recovery and rehabilitation became clear. Congressional legislation, including Public Laws 108-447 and 108-422, called for systematic, comprehensive rehabilitation services, including the 2005 establishment of four VA PRCs colocated with the TBI lead center sites (Sigford, 2008).
Further Challenges for the VA
The medical and rehabilitation needs of severely injured polytrauma patients can be daunting. System demands are even more challenging when placed in the broader context of demographic change. The recent cohort of injured servicemembers is younger and more diverse than has historically been seen on rehabilitation units (Chiros et al., 2008). As can be expected of people in this age range, patients often are in relationships (e.g., newly married, engaged, dating) and may have children. In addition, parents often are actively involved in their care. In extreme situations, the presence of different generations within a family can lead to conflict, especially if critical medical decisions need to be made. Rehabilitation provided to 20-year-olds is inherently different from rehabilitation services provided to older adults, and community reintegration challenges such as return to work or school are changing the nature of rehabilitation outcomes. Finally, many polytrauma patients seen in the VA remain on active-duty status with the military. This relationship has led to a far greater military presence throughout the hospital, including active-duty liaisons being assigned to the PRCs (Friedmann-Sánchez, Sayer, & Pickett, 2008).
Minneapolis PRC Program Creation
According to VHA directive, the Minneapolis VAMC PRC provides acute inpatient rehabilitation services to 13 states across the Midwest (Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Ohio, Oklahoma, Nebraska, North Dakota, South Dakota, and Wisconsin). Upon completion of acute rehabilitation and depending on their military status, home of origin, and need for continued medical care or rehabilitation services, patients eventually transfer their care to facilities closer to home; however, services have been provided across a far broader geographic region when patient and family needs are taken into account.
Creating an Environment of Care
One of the first significant challenges in establishing the Minneapolis PRC was identifying a physical space that could meet the complex inpatient rehabilitation needs of this population. Like many healthcare facilities in the United States in the 1990s, the Minneapolis VA responded to budget constraints by restructuring and consolidating inpatient services via a patient service line approach. This included closing a dedicated acute rehabilitation ward and moving rehabilitation patients either to a mixed-service ward or to the hospital’s long-term care wing (extended care center [ECC]).
Although this diversion of patients into other wards did not directly affect the delivery of allied therapy services, the mergers resulted in significant challenges to rehabilitation nursing care. Also, space limitations and mixed use of the care environment resulted in a suboptimal rehabilitation milieu. Nursing staff cohesiveness became a challenge with the wide variety of approaches practiced by the different services and the demand for cross training and coverage.
The mixed service and rehabilitation ward included a small number of rehabilitation nurses. They often struggled with high patient ratios, and it was not uncommon for their care roster to include patients who were not participating in rehabilitation. Nurses without specialized rehabilitation training found themselves struggling to care for seriously brain-injured rehabilitation patients while caring for acutely ill medical patients. The ward staffing mix included few nursing assistants to help supervise time-intensive rehabilitation in activities of daily living (ADLs). This cross care reduced the nurse’s role to that of an adjunct member of the interdisciplinary treatment team. Therapists struggled to communicate with nursing to facilitate generalization of trained tasks onto the ward, and nurses struggled to participate in team rounds. Often, one nurse would attend the interdisciplinary team rounds, but his or her participation would be hampered by unfamiliarity with the patients and would be limited to relaying written notes between the nursing staff and the therapists.
Upon receipt of PRC status, a multidisciplinary task force comprising representatives from executive leadership, engineering, nursing administration, staff nursing, and voluntary service was established to study space and equipment needs. After consideration of multiple factors including Commission on Accreditation of Rehabilitation Facilities requirements, existing strengths, future expansion needs of other services, staffing models, safety needs, and projected costs, a decision was made to reestablish a separate inpatient rehabilitation unit.
Identified space was renovated and ready for patient use within 12 months. Space reconfiguration allowed for a communal dining room, a washer and dryer unit, and a therapeutic recreation space granting 24-hour access to recreational equipment. Because of the high incidence of vision impairment in the polytrauma population, room design incorporated high-contrast floor tiles and paint on door frames to mark entrances to rooms, contrasting furniture, enlarged counter space surrounding sinks to permit setup of ADL equipment, improved lighting over patient beds, and padding of potential room hazards. The nursing station was redesigned to facilitate interaction between clerical staff and patients in wheelchairs. A family lounge with accommodations for small children, high-speed computer access, a kitchenette, and a large-screen television was established to promote socialization for patients and families. Visiting hours were liberalized to permit maximum family involvement in therapies and on the unit. A transitional apartment, designed to offer a home-like atmosphere in which patients and families could practice skills acquired in therapies, was established to facilitate therapeutic passes and discharge planning. Designs for six private, three semiprivate, and three four-bed rooms were developed. Twelve beds were slated to be opened initially, with others added as nursing staff were hired.
While the space was being reconfigured, nursing care for rehabilitation patients was reviewed and revised to a modified primary nursing care delivery model to promote patient care quality and nursing job satisfaction (Beaty, 2006). Based on national benchmarking data, nursing full-time employees (FTEs) were expected to average a range of 8.2–9.8 patient hours per day. Because of the potential acuity of patient needs, however, variances in nurse-to-patient ratios were anticipated. In addition, given the complexity of the polytrauma care, it was determined that the majority of licensed staff would be registered nurses (RNs), supplemented by a limited number of licensed practical nurse (LPN) positions. It was also recognized that there was an increased need for nursing assistants (NAs) to assist functionally impaired patients with mobility and ADL completion. NAs were also hired to provide one-on-one observation for cognitively impaired patients to ensure safety, offer reorientation and reassurance, and thus eliminate or significantly reduce the need for restraint.
The staff was selected from internal and external applicants based on previous work experiences and their anticipated ability to work effectively in the polytrauma interdisciplinary rehabilitation team. The majority of internal transfers (34%) came from the hospital’s ECC, although two (25%) transferred from the preexisting mixed service and rehabilitation ward. External candidates included 7% with experience and 34% new graduates with no independent experience. The initial staff was hired approximately 2 months before the ward opened and included 13.2 RN FTEs (3 certified rehabilitation registered nurses [CRRNs]), 2 LPN FTEs, and 8.3 NA FTEs. The ward officially opened in February 2006, with a census limited to 12 polytrauma and TBI patients. Nursing and allied health services have now expanded to cover 18 mixed polytrauma and TBI and general rehabilitation beds, and capacity is expected to expand to 24.
The following case description illustrates the enormous complexity of injuries that confront polytrauma teams. The patient—a 22-year-old active-duty Army engineer—sustained a blast injury while attempting to disarm an improvised explosive device in theater. Injuries included a penetrating brain injury with retained metallic fragments, multiple facial fractures, bilateral globe rupture, traumatic bilateral transradial upper-extremity amputations, bilateral pneumothoraces necessitating chest tube placement, and multiple soft-tissue injuries of the neck and extremities. The patient was initially treated in theater, then transferred to Landstuhl Regional Medical Center in Germany and then to Walter Reed Army Medical Center in Washington, DC. The patient underwent numerous surgical procedures including bilateral frontal craniotomy, fixation of facial fractures, extensive ophthalmological debridement and reconstruction, and debridement and closure of bilateral upper- and lower-extremity wounds. The patient had a complicated acute hospital course: gastrointestinal complications necessitating exploratory laparotomy, cerebrospinal fluid leak and recurrent pneumocephalus requiring anterior vault reconstruction, wound infections necessitating intravenous antibiotics, dysphagia requiring percutaneous endoscopic gastrostomy tube placement, and pulmonary embolus and deep vein thrombosis necessitating heparinization. The patient was transferred to our facility 5 months after injury for TBI and cognitive rehabilitation, blindness rehabilitation, and prosthetic training. The patient was married, with three children, and a discharge plan of home with family and in-home services was prepared. Patient problems included mild-to-moderate brain injury, blindness, bilateral upper-extremity amputations, left hemiplegia, neuropathy and pain, posttraumatic stress disorder, depression, anxiety, adjustment concerns, and family stress. Nursing considerations included psychosocial and cognitive issues, safety, mobility, pain management, nutrition, bowel and bladder training, and dependent ADLs and instrumental ADLs. Team goals included assisting the patient with adjustment and compensatory strategies and preventing further medical complications, with ultimate consideration for the patient’s goal of returning home to his family as independent as possible. Such injuries dictated significant changes in the delivery of brain injury care and necessitated modifications in the education and training of polytrauma staff.
Nursing Staff Training and Education
The unique nursing needs of polytrauma patients, coupled with the need to recruit new staff with a wide range of rehabilitation experience and the desired expansion of their role on the interdisciplinary treatment team, mandated the creation of a comprehensive staff training program. This was addressed via a three-tiered, comprehensive training program (Figure 1). Content experts designed the curriculum with consideration for care standards, current research, and prior rehabilitation experience of the new nursing employees.
This program is built on an existing 3-day course, “Introduction to Rehabilitation,” offered to all extended care and rehabilitation RN, LPN, and NA staff who work in the ECC, home health, outpatient clinics, or the acute rehabilitation ward. This introductory course is taught by a rehabilitation-certified nurse educator and content expert guest speakers focusing on basic nursing skills related to the rehabilitation patient (Table 1). After completing the introductory course, all rehabilitation ward staff attend a second class, “Introduction to Polytrauma.” This day-long course is also taught by a rehabilitation-certified nurse educator and focuses on the collaborative efforts used to meet the unique needs of the rehabilitation patient (Table 2). The final tier in staff training is an applied neuroanatomy class offered solely to the rehabilitation ward RN staff. The class is taught by a certified rehabilitation advanced practice nurse, who created the class content and a corresponding study packet. Class content includes cognitive changes in TBI survivors based on area, type, and severity of brain injury (Table 3).
Other Learning and Training Activities
After a 4-week centralized orientation, the nurses arrive on the ward and are paired with a nurse preceptor. The duration of the precepting period is individualized to each nurse’s needs, including hands-on patient care, videotaped resources, journal articles, textbooks, and validation of unit-specific competencies.
Documentation and Assessment Training
The educational components associated with documentation begin with central orientation and continue during unit orientation with specific requirements for the polytrauma patient population. Elements include documentation in the computerized patient record system, the VA’s national electronic record, including polytrauma nurse shift note templates. These templates incorporate assessment of vital signs, infection-control precautions, cognitive status and communication method, safety devices used, behavior and other precautions (seizure, heel, aspiration), pain assessment and reassessment, respiratory status, mobility status, ADLs, nutrition, bowel and bladder, skin integrity and wound care, specialized equipment, sleep patterns, and educational needs. Training also includes medication documentation using the bar-coded medication administration system. Other training elements include documentation of patient progress toward weekly goals, interdisciplinary care plans, Braden skin integrity assessment, Morse fall risk assessment, preprocedure and postprocedure documentation, Situation-Background-Assessment-Recommendation hand-off communication templates for patient change in condition or transfer of care, and admission and discharge assessments. The unit clinical nurse leader saves all applicable templates in an easily accessible, online staff folder. The clinical nurse leader works with individuals or small groups to teach the appropriate information and the best format or template with which to document it.
Veterans Health Initiatives
A series of comprehensive independent study courses have been developed to deliver important education and information connecting “certain health effects and military service, to allow military medical history to be better documented, to prepare healthcare providers to better serve their veteran patients” (DVA, 2007). Licensed nursing staff members complete veterans health initiatives on TBI, traumatic amputation and prosthetics, hearing impairment, visual impairment and blindness, and posttraumatic stress disorder.
Twin Cities Health Professional Education Consortium (TCHP) Classes
TCHP, a collaboration between Minneapolis VAMC, Regions Hospital, and Hennepin County Medical Center, offers continuing nursing education courses to area professionals. TCHP classes offered to rehabilitation nurses include “Evidence-Based Practice,” “Assessment of the Adult Patient,” “Precepting with Competence and Confidence,” “Excelling as a Charge Nurse,” “Building Teams: Your Key to Success,” “Shock and Infection in Critical Care,” “Top Notch Customer Service,” and “Neurological Critical Care.” Additional classes are developed and offered on an as-needed basis (TCHP, n.d.).
Although specific outcomes of the educational campaign are difficult to quantify, two dynamic changes have occurred that testify to the campaign’s success.
Nurse Collaboration and Participation on the Team
Nursing staff are now integral members of the interdisciplinary team and share critical information about patient function and family needs on the ward. A nurse clinical leader attends all rounds, and primary nurses attend whenever possible. Their participation in rounds helps them identify and proactively respond to emerging difficulties, contributes to the writing of team-based goals, and fosters generalization of treatment success outside the clinics. In addition, nursing staff are the prime conduit for the relay of information back to staff on the rehabilitation ward.
Retention and Satisfaction
In the 18 months since the acute rehabilitation ward opened, 29 RNs have been hired, and to date retention is at 83% (24). In the early days of ward operation, four RNs were detailed to the ward based on their seniority status, and two RNs volunteered for a temporary assignment until staffing reached the necessary level. Retention of these six RNs remains at 83% (5/6), and the five nurses have become permanent staff on the rehabilitation unit. In addition, there is 100% retention of four LPNs and 75% retention of our NA staff (18/24). Seven RNs have earned their CRRN accreditation since the opening of the unit, for a total of eight certified polytrauma RNs. Unit patient satisfaction surveys for the past year reveal that 90%–95% rated the quality of nursing care as very good to excellent.
In the short span of 12 months, Minneapolis VAMC has solidified acute polytrauma rehabilitation services through the construction of a dedicated space and a system change that restores nursing to key, peer membership in the interdisciplinary treatment team. The realignment is serving patients well and boosting nurses’ job satisfaction. The nurses’ dedication to rehabilitation, as witnessed by seven RNs’ commitment to pursue CRRN status, is a big source of pride. Causes behind the successful change are assumed to be multifactorial, including logistical changes through the dedicated space; streamlined job responsibilities; increased ability to participate in team rounds; a primary nursing model that allows relationship-building between patients, families, and staff; and the strong presence of NA staff. In addition, we believe that the nursing training and education program is critical for providing skill acquisition necessary to meet the complex nursing needs of polytrauma patients.
As the patient census grows and staff increases, curriculum modifications for new staff and a refresher course for existing staff are planned. Future areas of need include the following:
The first national polytrauma nursing symposium will be held in Minneapolis, MN, in September 2007, bringing 150 nurses together from four polytrauma centers to allow information exchange on successful strategies and analysis of challenges to create seamless transition of care among the centers. Annual or biannual symposia are being discussed for the future. New educational programming, including computer-based, self-paced modules, is planned for both ongoing and refresher staff education. Future efforts will also focus on promoting nursing research in the polytrauma and TBI patient population.
About the Authors
Diane MacLennan, MS RN CRRN, is a TBI/polytrauma nurse case manager at the Minneapolis VA Medical Center Polytrauma Network Site, Minneapolis, MN. Address correspondence to her at email@example.com.
Shawna Clausen, BSN RN CRRN, is the clinical nurse leader candidate at Minneapolis VA Medical Center Polytrauma Rehabilitation Center, Minneapolis, MN.
Nina Pagel, MSN RN CRRN, is a nurse manager at Minneapolis VA Medical Center Polytrauma Rehabilitation Center, Minneapolis, MN.
Jack D. Avery, MA CCC/SLP, is a the polytrauma director of operations at Minneapolis VA Medical Center Polytrauma Rehabilitation Center, Minneapolis, MN.
Barbara Sigford, MD PhD, is the director of physical medicine and rehabilitation at the Minneapolis VA Medical Center, Minneapolis, MN.
Donald MacLennan, MA CCC/SLP, is a speech-language pathologist at Minneapolis VA Medical Center Polytrauma Transitional Rehabilitation Program, Minneapolis, MN.
Rita Mahowald, MSN RNBC, is the former director of staff education at Minneapolis VA Medical Center, Minneapolis, MN.
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