Discharge Management for Traumatic Brain Injury

Original Editor - Wendy Walker

Top Contributors - Wendy Walker, Rachael Lowe, Naomi O'Reilly and Kim Jackson  

General Principles of Good Practice for Discharge

Discharge Form
Discharge planning should involve, from the outset, the patient and their family/carers, and the rights and wishes of the patient should be listened to and respected.

If possible, it is considered useful that the discharge occur in the morning, providing the afternoon and evening hours for the individual to settle into their new environment before going to sleep.

For patients returning home, adaptations may need to be provided prior to discharge.

Planning for Discharge

A formal discharge meeting should be arranged, involving (but not limited to) hospital nursing staff, medical social worker, rehabilitation staff (including physiotherapist, occupational therapist, speech and language therapist if relevant), social services staff, close family members, patient, carers (if appropriate). In many hospitals, there is a named professional who has overall responsibility for discharge planning.

In some cases the person may be able to go on a trial visit home for a day and/or overnight before actually being discharged.

Information Provided on Discharge

The hospital should provide information on:

  • Symptoms of complications that could require urgent treatment
  • Activities to avoid, and for how long (eg. driving)
  • Prescriptions and medications
  • Cognitive changes which may be expected, and suggestions on their management
  • Ongoing rehabilitation requirements
  • Any special dietary requirements (eg. soft diet, or thickened fluids) if the patient has problems with swallowing
  • Contact details for key professionals
  • If appropriate, details on how to manage incontinence/urinary catheter


Return to Work

People who have suffered mild to moderate TBI may be able to return to the work they were involved in before their brain injury. Return to work is an important measure of integration into the community. One author reports that individuals with brain injury who fail to return to work have a lowered subjective wellbeing when compared to those who succeed in returning to work[1].

Studies show that only 30% of people with moderate TBI and 80% of people with mild TBI successfully return to work[2],

Barriers to returning to work:

  • Cognitive impairment
  • Loss of motivation
  • Fatigue
  • Lack of support provided in the work environment
  • Inadequate communication between medical professionals and the employer/manager with the result that the employer does not know how to support the person with TBI[3]

Sequelae which commonly occur late in TBI, after Discharge

Heterotopic Ossification

This build up of new bone at the joint has been found to occur in between 10% and 20% of patients with moderate to severe TBI[4].

The most common sites is the hip, followed by the elbow[5].

Pituitary Dysfunction

Pituitary dysfunction, leading to neuroendocrine dysfunction, is a recognised but potentially underdiagnosed complication of TBI[6][7]. It is often labelled Post-traumatic hypopituitrism.

This can result in "neurobehavioural sequelae" including concentration difficulties, fatigue, anxiety and depression[8].

One study[9] specifically looked at the time of onset of pituitary dysfunction, and concluded: "The risk of developing endocrine dysfunction after TBI increased during the entire 5-year follow-up period."

There is more information on neuroendocrine dysfunction in TBI on the Medical Complications in TBI page.

Resources

Headway have useful information about returning to work after brain injury.

The document Brain Injury; a guide for employers by Headway has detailed information on the topic.

Headway also produce information on Self Employment after Brain Injury and Voluntary Work after Brain Injury.

References

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  1. Cicerone, K.D. Cognitive Rehabilitation for traumatic brain injury and stroke: Updated review of the literature from 1998 through 2002 with recommendations for clinical practice. America: Archives of Physical medicine and rehabilitation, 2000;92,(4),1596-1615.
  2. Vuadens,P. & Arnold,P & Bellmann,A. Return to work after a traumatic brain injury- Vocational Rehabilitation. Pari: Springer Paris; 2006.
  3. Law, M., Baum, C.M. & Dunn, W. Occupational performance assessment. In C.H Christiansen, C.M Baum & J. Bass- Haugen (Eds.). Occupational therapy: performance, participation & well being (3rd edition). Thorofare New Jersey: Slack Incorporated; 2005.
  4. Hsu JE, Keenan MA. Current review of heterotopic ossification. UPOJ 2010; 20: 126-130
  5. Mavrogenis AF, Soucacos PN, Papagelopoulos PJ. Heterotopic Ossification Revisited. Orthopedics. 2011Jan;34(3):177
  6. Chin Lik Tan, Seyed Alireza Alavi, Stephanie E Baldeweg et al. 2017 The screening and management of pituitary dysfunction following traumatic brain injury in adults: British Neurotrauma Group guidance. Journal of Neurology, Neurosurgery & Psychiatry, vol 88, Issue 11. Nov 2017.
  7. Agha A, Sherlock M, Phillips J, Tormey W, Thompson CJ Eur J Endocrinol. 2005 Mar; 152(3):371-7
  8. Amir M. Molaie, and Jamie Maguire. Neuroendocrine Abnormalities following Traumatic Brain Injury: An important contributor to Neuropsychiatric Sequelae. Frontiers in Endocrinology 2018;9;176.
  9. Wei-Hsun Yang, Pau-Chung Chen,a, Ting-Chung Wang. Endocrine dysfunction following traumatic brain injury: a 5 year follow-up nationwide-based study. Scientific Reports. 2016;6;32987