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Rehabilitation Outcomes for Veterans with Polytrauma Treated at the Tampa VA
Returning soldiers from Iraq and Afghanistan who have sustained polytrauma have a combination of complex physical and mental morbidities that require extensive therapy and rehabilitation. This study examined the effect of rehabilitation on 116 polytrauma patients with service-connected injuries treated at the Tampa VA; improvements in functional and cognitive abilities were measured using the Functional Independence Measure (FIM™) scores and healthcare costs for rehabilitation treatment were also assessed. Intensive rehabilitation therapy increased functional ability in this cohort with an average improvement in total FIM scores of 23 points. Total inpatient costs for these patients exceeded $4 million in approximately 3 years. Rehabilitation nurses face challenges providing quality care to this target patient population, including characterizing war-related polytrauma, providing surveillance, coordinating care, synchronizing care for patients with multiple injuries, and conducting evidence-based pain management.
Every war has its distinctive injury patterns. During World War II, 1 in 3 wounded soldiers died; in the present Iraq conflict the rate is 1 in 8 (U. S. Department of Defense, 2008). Since the onset of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) in Afghanistan, approximately 35% of all casualties present with neurotrauma evidenced in spinal cord injury (SCI) and traumatic brain injury (TBI), which is the most common combat outcome (DePalma, Burris, Champion, & Hodgson, 2005; Gibbs, Waller, & Walt, 2005). Between July and November 2003 the Defense and Veterans Brain Injury Center (DVBIC) at Walter Reed Army Medical Center screened 155 patients who had returned from Iraq; 62% had sustained a TBI (DVBIC, n.d.). Many of these injuries are caused by blasts from improvised explosive devices (IEDs), rocket-propelled grenades, land mines, artillery, mortar shells, booby traps, and aerial bombs (Scott, Vanderploeg, Belanger, & Scholten, 2005). As of June 2008, more than 4,000 U.S. military personnel had died in Iraq and more than 31,000 had been wounded in combat in OIF and OEF (U.S. Department of Defense, 2008).
Improvements in retrieval, neurosurgery, intensive care, and knowledge gained in trauma care in the past few decades have enabled many soldiers to survive polytraumatic injuries who previously would have died. Although survival rates have improved, the growing population of wounded servicemembers has resulted in vast societal consequences.The changing nature of warfare and battlefield medicine presents new challenges for the Department of Defense and Veterans Administration (VA) healthcare delivery systems. Compared to previous deployments, more war-wounded soldiers are returning from OIF and OEF with complex, multiple injuries. The patterns combine easily observable manifestations, such as amputations, spinal cord injuries, and musculoskeletal injuries, with hidden manifestations including brain injuries; eye injuries; hearing and balance dysfunction; lung, liver, and kidney injuries; and emotional adjustment problems. The way in which polytrauma combines these complex physical and mental morbidities (Brown et al., 2004; Machamer, Temkin, & Dikmen, 2003; Nolan, 2005) results in unpredictable clinical outcomes (Granger et al., 1996; Hammond et al., 2004) and requires extensive therapy and rehabilitation.
The James A. Haley Veterans Administration Medical Center (VAMC) in Tampa, FL, provides care to 142,000 veterans in Central Florida and has been recognized as a Center of Excellence in Rehabilitation and Spinal Cord Medicine. The Tampa VAMC is one of four healthcare facilities recently designated by the VA as a level 1 polytrauma rehabilitation center to treat and coordinate rehabilitation programs for OIF and OEF soldiers with severe combat-related injuries.
The Physical Medicine & Rehabilitation Service (PM&R) coordinates the Tampa VAMC Polytrauma Program. The goals of this program are to (1) identify veterans with polytrauma; (2) provide postacute medical assessment; (3) provide medical, rehabilitative, and psychological treatment services; (4) monitor short- and long-term patient outcomes; and (5) begin a research agenda to enhance the understanding of polytrauma and its treatments. This interdisciplinary team includes a physician, an advanced registered nurse practitioner who specializes in rehabilitation medicine, several rehabilitation therapists, an audiologist, a speech pathologist, a psychologist, and a social worker. Staff members from other disciplines provide further support, and patients enrolled in the program have access to the full range of medical and support services within the hospital through a system of referrals.
The VA is at the forefront of treating polytrauma patients returning from OIF and OEF. Because these conflicts are relatively recent and still ongoing, little has been published concerning this patient population. The research questions addressed in this article include (1) What are the demographic and injury characteristics of patients from OIF and OEF admitted to PM&R at the Tampa VAMC? (2) What are the inpatient fiscal outlays for these patients? and (3) What is the effect of rehabilitation on improvement in functional and cognitive abilities as measured by the Functional Independence Measure (FIM)?
From June 2003 through October 2006, more than 150 returned servicemembers from OIF and OEF with combat-related injuries were referred to PM&R at the Tampa VAMC. Complete data for 116 of the 150 soldiers were collected. Most patients were referred from military treatment facilities such as the Walter Reed Army Medical Center, but some also arrived from other VAMCs. Most OIF and OEF veterans treated at the Tampa VAMC PM&R exhibited aspects of polytrauma (e.g., blindness, orthopedic complexities, burns, problems with hearing, mental health disorders). As part of its contractual agreement with the DVBIC, the Tampa VAMC PM&R maintains a database of all wounded veterans admitted for care that includes demographic and discharge characteristics, mechanism of injury, health utilization, and discharge summary.
Characteristics of the Wounded
Table 1 summarizes characteristics of OIF and OEF patients admitted for treatment. Patients were overwhelmingly male (95%) and ranged in age from 18 to 49, with an average age of 27. The most frequent cause of injury was motor vehicle accidents in combat theatres followed by combat-related blast injury from IEDs and indirect fire such as from mortars. It was not possible to determine whether any of the motor vehicle accidents were the indirect result of combat operations. Most patients had acute symptoms stabilized while being treated in military hospitals, so the primary diagnosis for admission to the Tampa VAMC was rehabilitation. Almost 75% (85) of patients were discharged to their homes, while 11% (13) were transferred to an acute unit in another hospital and 9% were discharged to subacute care facilities, rehabilitation centers, skilled nursing homes, and transitional living facilities.
Inpatient Healthcare Utilization and Costs
The VA uses the Decision Support System (DSS), a national automated management information system based on commercial software that integrates data from clinical and financial systems for both inpatient and outpatient care. The software is interfaced to transport data into the system from Veterans Health Information Systems and Technology Architecture, an integrated outpatient and inpatient information system, and to various other VA administrative and financial information systems. All VAMCs have a local DSS database that provides care details and associated costs of treatment. The Tampa VAMC DSS was used to determine inpatient healthcare utilization and associated costs with initial treatment of returning OIF and OEF patients with different causes of injury as outlined in Table 2. The median value (the middle value of the cost data when arranged in descending order) is presented rather than the mean (the total costs divided by the number of patients) because the underlying cost distribution is very asymmetrical and the median is a better reflection of the average.
Computed costs are comprehensive and include inpatient expenses such as physician services, medications, tests and imaging, procedures performed, and prosthetics and therapy, but do not include subsequent outpatient visits. Total inpatient costs for this patient cohort exceeded $4 million in little more than 3 years. Median cost per patient was $25,000. Median length of stay at the Tampa VAMC was 27 days; the shortest stay was 3 days and the longest stay exceeded a year (504 days). Complications from bullet wounds resulted in higher rehabilitation costs than those from other injuries and required the longest length of stay (median 35 days).
Effectiveness of Rehabilitation on Health Outcomes
The FIM was used to determine the effectiveness of rehabilitation on functional and cognitive outcomes for OIF and OEF patients admitted with polytrauma. The FIM score is the most commonly used outcome measure for quantifying functional status. The FIM is an 18-item seven-level ordinal scale used as a standard measurement index of functional disability and rehabilitation outcomes. FIM scores for each category range from 1 to 7 (7 = complete independence, 1 = total assist). Adding the points for each item yields a possible total score range of 18 (lowest) to 126 (highest) and indicates the level of independence. The main drawback of the FIM is floor and ceiling effects, calculated as the percentage of the sample scoring the minimum and maximum possible scores, respectively. When scores cluster at the bottom and top of the scale range, the FIM has a limited ability to discriminate between subjects. Evaluation of the metric properties of the FIM has been reported extensively (Dodds, Matrin, Stolov, & Deyo, 1993; Heinemann et al., 1997). FIM scores for VA patients are recorded in the Function Status Outcomes Database (FSOD).
FIM scores were calculated at the time of initial admission into the Tampa VAMC and at discharge. Improvements in each domain were computed. Paired t tests were used to determine the statistical significance of disability score changes assuming unequal variances. Rehabilitation resulted in a marked decrease in disability with an average improvement in total FIM scores of 23 points (Table 3).The improvement in each domain was statistically significant (p < .01). The domain of self-care registered the largest point increase.
Implications for Rehabilitation Nurses
Nurses have provided rehabilitation care to war- injured veterans since the days of Florence Nightingale in the Crimean War. The science of rehabilitation nursing has progressed to offer soldiers from OIF and OEF a wide array of rehabilitation interventions and programs. The mission of rehabilitation nursing is to promote seamless, comprehensive care for persons who sustain war-related polytrauma. Rehabilitation nurses face five key challenges in providing quality care to this target patient population.
Characterizing War-Related Polytrauma
Polytrauma is a new phenomenon that is not well-defined and has a clinical course that varies widely. Rehabilitation nurses need to work as part of an interdisciplinary team to more clearly define war-related polytrauma and develop a taxonomy to name and organize the patterns, etiology, signs, symptoms and complications of polytrauma into groups that share similar characteristics.
After patients with polytrauma have been admitted into the VA healthcare system, continued systematic surveillance of health status helps ensure that subtle and delayed manifestations of polytrauma, such as pain or posttraumatic stress disorder (PTSD), are identified (Aziz & Kenford, 2004; Corson, Gerrity, & Dobscha, 2004; Starr et al., 2004). Surveillance, defined as systematic collection, analysis, and interpretation of health data for planning, implementing, and evaluating health services (Centers for Disease Control and Prevention, 1986), helps clinicians fully understand the natural history of polytrauma, in part by drawing on a significant body of evidence from other traumas and chronic conditions. Evidence-based methods for surveillance include (a) targeted medical screenings such as identifying individuals who sustained polytrauma through registries and then screening them for known sequelae such as PTSD, concussion, and hearing problems using standardized tools (Powell & Rosner, 2005; Sheeran & Zimmerman, 2002a); (b) healthcare provider education for identifying invisible injuries of polytrauma, which has been shown to improve the detection of underidentified problems such as psychosocial stressors (Bingham, Plante, Bronson, Tufo, & McKnight, 1990) and psychiatric disorders (van der Feltz-Cornelis et al., 1997); (c) community outreach including television, radio, and news announcements (Cambron, Hawk, Evans, & Long, 2004) and mass mailings (Kennedy et al., 2005) targeted at different populations; (d) review of existing case records and databases and database mining (Pobereskin, 2001); and (e) cascade testing, which involves identifying individuals who have sustained blast injuries by asking known blast victims for the names of other individuals who were involved in the same incident (in this way, individuals who are not inclined to seek early treatment may be proactively engaged by the VA). A combination of these evidence-based approaches is needed to find patients with war-related polytrauma and treat them in a timely fashion.
Care coordination is the wider application of care and case management principles to the delivery of healthcare services. Care coordination uses health informatics, disease management, and telehealth technologies to facilitate access to care and improve the health of designated individuals and populations with the intent of providing the right care in the right place at the right time. Potential gaps in coordination of care have been identified in the transitions from the military to the VA, as well as from VA-designated polytrauma rehabilitation centers to primary care anywhere within VA. Rehabilitation nurses play a pivotal role in designing and implementing care coordination programs to address these potential gaps.
Synchronizing Care for Patients with Multiple Injuries
The clinical course of polytrauma varies widely and the interaction effect among multiple injuries and impairments is largely unknown. Much of the work in trauma centers will be useful in developing clinical tools to manage the complexity of treating people with multiple injuries and impairments. Similar to caring for individuals with chronic, debilitating illness, it is expected that timing and sequencing care will present challenges across the care continuum. The key to managing a disease condition is understanding the causes and patterns of symptomology and disease expression to ensure the most appropriate services are delivered at the right place and at the right time (Zitter, 1997). Rehabilitation nurses need to be actively involved in developing systems and tools for triage, tracking, evaluation, and feedback across acute care, rehabilitation, and primary care settings.
Evidence-Based Pain Management
Pain is an inevitable consequence of the type and extent of tissue damage associated with polytrauma. Because chronic pain and associated disability are highly prevalent in people with polytrauma, the development and implementation of strategies for early and aggressive treatment of pain have become a national priority. The translation of existing evidence-based practices for use in this unique population will help prevent the transition to chronic conditions for some and reduce the severity of the disability and suffering among those who do develop chronic pain. The Tampa VA Chronic Pain Rehabilitation Program, winner of the prestigious Secretary of Veterans Affairs 2004 Olin E. Teague Award, has a long and distinguished track record using evidence-based pain management practices and developing evidence-based clinical practice guidelines. This track record will provide a foundation for translating evidence-based pain management practices to veterans with polytrauma.
The limited analysis of polytrauma treatment at one VAMC indicates that intensive therapy increased functional ability in polytrauma patients. Future studies using more extensive data from all four level 1 VA polytrauma centers are needed to research the efficacy of specific interventions on appropriate outcomes, especially as they pertain to mental health and functional deficiencies associated with polytrauma. There are unique challenges associated with rehabilitating soldiers from OIF and OEF, not only during acute rehabilitation, but across the continuum of care. Rehabilitation nurses in the military and the VA are working diligently to address these key challenges.
About the Authors
Kris Siddharthan, PhD, is a health services researcher at the VISN8 Patient Safety Center of Inquiry at the James A. Haley Veterans Administration Medical Center (VAMC) in Tampa, FL. Address correspondence to her at firstname.lastname@example.org.
Steven Scott, MD, is chief of physical medicine and rehabilitation service and director of the level 1 polytrauma center at the James A. Haley VAMC in Tampa, FL.
Elizabeth Bass, PhD, is a health economist at the Patient Safety Center of Inquiry at the James A. Haley VAMC in Tampa, FL, and assistant professor in the School of Aging Studies at the University of South Florida.
Audrey Nelson, PhD RN FAAN, is director of the Patient Safety Center of Inquiry at the James A. Haley VAMC in Tampa, FL, and associate director of research in the College of Nursing at the University of South Florida.
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