Inclusion, delivery, assessment, and outcomes in longitudinal research on sleep disturbance and agitation in TBI-rehabilitation: lessons learned and future considerations.

PURPOSE: This article presents some issues for consideration before scaling from a pilot study to a larger investigation in longitudinal observational studies of traumatic brain injury (TBI) rehabilitation. MATERIALS AND METHODS: We present a case to discuss protocol improvements in longitudinal TBI-rehabilitation studies. The case was a pilot study conducted at two university hospitals in Denmark investigating 1-year outcomes related to sleep disturbance and agitation during neurointensive care. We included patients with moderate and severe TBI determined by the Glasgow Coma Scale, sleep disturbance was assessed using actigraphy, and agitation was assessed using the Agitated Behavior Scale. RESULTS: Patients (n = 29) were more severely ill and had poorer six-month outcomes in Eastern vs. Western Denmark. Recovery was similar at one-year follow-up. Protocol improvements were needed in relation to inclusion criteria, intervention delivery, patient assessment, and follow-up outcomes. CONCLUSION: In TBI-rehabilitation studies, we suggest adding the severity of disease score to the initial GCS score and a delirium detection score to the ABS score. Actigraphy should not be used during deep sedation. Established procedures should be in place along all stages of the study protocol, including preparation and periodic assessment of study nurses to optimize data quality.

Sleep and agitation during subacute traumatic brain injury rehabilitation: A scoping review.

BACKGROUND: Sleep disturbance and agitation are frequent conditions during the subacute period of recovery in moderate to severe traumatic brain injury (TBI). Clarity is needed regarding the association between the two conditions to improve fundamental nursing care. AIM: The aim of our scoping review was to identify the evidence for potential associations between sleep disturbance and agitation during subacute inpatient rehabilitation of adult patients with moderate to severe TBI. DESIGN: We conducted a five-step scoping review. METHODS: Sources of evidence were PubMed, CINAHL, PsycINFO, Cochrane, and Web of Science databases. Eligibility criteria were as follows: English or Scandinavian language articles describing sleep and/or agitation during inpatient rehabilitation of adult patients with moderate to severe TBI and published in the period 2000-2019. RESULTS: We identified 152 articles of which we included six. The included articles were all affiliated with the USA using quantitative methodology. The association between sleep disturbance and agitation is highly complex, with disturbed sleep affecting cognitive and emotional functions. Sleep disturbance was associated with posttraumatic amnesia (PTA)/posttraumatic confusional state, cognitive function, and agitation. Our review suggested a bidirectional association between these symptoms during early TBI rehabilitation. We inferred that improved sleep might be a contributing factor to the resolution of PTA, cognitive impairment, and agitation. CONCLUSION: The association between sleep disturbance and agitation is still undetermined, but we assume that improved sleep may protect against neuropsychiatric problems in patients with moderate to severe TBI. Larger controlled interventional studies are needed to provide the evidence of modifiable factors for improving sleep during inpatient TBI rehabilitation. Owing to the current lack of publications, it is probably too early to perform a systematic review on the topic. RELEVANCE TO CLINICAL PRACTICE: We recommend systematic implementation of sleep hygiene during inpatient rehabilitation of patients with TBI to reduce PTA, agitation, and long-term neuropsychiatric problems.

Nursing roles and functions addressing relatives during in-hospital rehabilitation following stroke. Care needs and involvement.

RATIONALE: In the last decades, length of stay of in-hospital rehabilitation of patients with stroke has been significantly reduced. Health authorities expect relatives to be at disposal to convey the knowledge of everyday life and to provide emotional as well as practical support in relation to the patient. Caregivers require nurse assistance, support and to be seen as an essential partner in the care giving process. However, the nurses do not perceive that teaching of relatives is a task they should routinely undertake. This might indicate an ambiguity between the relatives' expectations and the actual contribution from nurses. AIM: This study describes nurses' experienced roles and functions addressing the relatives of patients with stroke during in-hospital rehabilitation. METHODOLOGICAL DESIGN: A phenomenological hermeneutic approach influenced by Paul Ricoeur. In a secondary analysis focus group, interviews of 19 randomly selected nurses from three different hospital settings were interpreted in three levels. The study was conducted in accordance with the ethical guidelines for nursing research in the Nordic countries. FINDINGS: The nurses expressed that they address the patient and the relatives and support the interaction between the patient and the relatives. Four themes occurred: the changed lives of relatives; shared life after stroke; noncooperating relatives; time for the relatives. CONCLUSION: Nurses experience their roles and functions addressing relatives after stroke as crucial, challenging and multifaceted. They acknowledged care needs of the relatives in their own right by addressing the relatives' vulnerability during in-hospital rehabilitation characterised by an existential threat to the physical as well as the shared life. The focus on the needs of relatives considering their expected future role was experienced as conflicting with restricting time frames and a healthcare system focusing on the individual patient.

Effects of music during daytime rest in the intensive care unit.

BACKGROUND: Sleep is essential to the recovery of patients in the intensive care unit. Patients in the intensive care unit frequently experience poor sleep, characterized by sleep deprivation, sleep fragmentation and abnormal sleep architecture. Factors affecting sleep are multifactorial. AIM: To investigate the effects of music on self-reported quality of sleep during daytime rest among patients in the intensive care unit. STUDY DESIGN: A randomized controlled trial. METHODS: The study was conducted between February and April 2016 in two Danish multidisciplinary intensive care units. The study sample consisted of 37 patients (19 in the control group and 18 in the intervention group) who complied with the criteria of inclusion for the study. Patients were randomly assigned to either an intervention group or a control group. The intervention group listened to music for 30 min during daytime rest while the control group rested without music. The Richards-Campbell Sleep Questionnaire was used to measure the subjective quality of sleep. RESULTS: Significant differences in the mean scores of the subjective quality of sleep were found between the intervention group and the control group (p < 0·02). Significant differences were also found between groups in three items of sleep scores: sleep depth (p < 0·02), awakenings (p < 0·00) and the overall perceived quality of sleep (p < 0·01). The perceived noise level score was higher in the intervention group compared with the control group, although not statistically significant (p < 0·67). CONCLUSION: Listening to music during daytime rest improves subjective sleep in patients in the intensive care unit. Furthermore, there are indications that listening to music reduces the subjective experience of noise in some patients. RELEVANCE TO CLINICAL PRACTICE: The result of this study implies that music can be an effective practice for nurses to improve sleep among patients in the intensive care unit.

Post-ICU symptoms, consequences, and follow-up: an integrative review.

AIM: To determine the symptoms seen in patients after discharge from an intensive care unit (ICU) and the follow-up programmes offered to help patients deal with the problems that arise after an ICU stay. BACKGROUND: An increasing number of people are discharged from an ICU to continued treatment, care and rehabilitation in general hospital wards, rehabilitation facilities and at home. A prolonged stay in an ICU is associated with stressful memories that have long-term physical, mental and social consequences for health-related quality of life. We therefore conducted a data search to identify the programmes that have attempted to cope with these consequences. DATA SOURCES: Searches of six online databases were conducted in December 2013. REVIEW METHODS: Qualitative or quantitative, original, empirical studies on symptoms and consequences associated with ICU stay and the follow-up programmes offered were reviewed. Excluded were studies in ICU patients younger than 18 years published in languages other than Scandinavian or English. We analysed original empirical studies according to symptoms, consequences and follow-up programmes and added a category 'new ideas'. This was done to identify any possible evolution in the programmes offered to patients after ICU care. The review of the literature and the critical analysis were summarized in a figure in order to join the different parts together into a logical, coherent whole. CONCLUSIONS: Patients discharged from an ICU are heterogeneous, with a wide array of physical, mental and social problems. They and their close relatives can benefit from returning together to the ICU or participating in follow-up programmes. Little is known about the specific effects of the different types of follow-up. RELEVANCE TO CLINICAL PRACTICE: ICU staff as well as other professionals should prepare patients and relatives for the fact that they may need various types of help for many months after discharge from the ICU, and an overview of national and local opportunities for help should be offered.

Nursing Roles and Functions in the Acute and Subacute Rehabilitation of Patients With Stroke: Going All In for the Patient.

BACKGROUND: The description of nursing roles and functions in rehabilitation of patients with stroke remains sparse. AIM: The aim of this study was to describe the experienced roles and functions of nurses during in-hospital rehabilitation of patients with stroke. METHODS: Within a phenomenological hermeneutic approach, 19 nurses working with in-hospital rehabilitation of patients with stroke participated in three focus group interviews during 2013. FINDINGS: The nurses' experiences were described in two themes: (a) the nurse's role and function in relation to the patient's needs 24/7 and (b) the nurse's role and function in the interdisciplinary team. Getting to know the patient as a person was essential to the nurses to care for the patient's basic needs; these must come first working with rehabilitation and always include the relatives. Recognition of the team members' individual skills with focus on the patient's needs must be the center of attention. CONCLUSION: An interdisciplinary rehabilitation program actively needs to include the patient by integrating the patient's perspective in the goals as well as in daily rehabilitation. In the team, nurses had the role of coordinator and the patient's voice.

Testing a reality orientation program in patients with traumatic brain injury in a neurointensive care unit.

PRIMARY OBJECTIVE: The aim of this study was to examine the effect of a systematic reality orientation program (RO) introduced in a neurointensive care unit on duration of posttraumatic amnesia (PTA) and outcomes of patients with traumatic brain injury (TBI). RESEARCH DESIGN: This study used a quasiexperimental, prospective design. METHODS AND PROCEDURES: Twenty-four patients (intervention) with a significant TBI classified as moderate-to-severe injuries as measured by scores of less than 12 on the Glasgow Coma Scale underwent an RO program compared with a similar group of 38 patients (control) who received a conventional rehabilitation program. The Rancho Los Amigos Score was used to assess the cognitive level 24 hours after the end of sedation, and the Galveston Orientation and Amnesia Test was used daily to assess orientation and duration of PTA. The Glasgow Outcome Scale Extended was then used as an indicator of clinical outcome after 12 months. MAIN OUTCOMES AND RESULTS: The preliminary results indicated that patients who received the RO had a higher mean of the Glasgow Outcome Scale Extended (SD = 1.53) than those receiving the usual care (SD = 1.35) despite that the groups differed significantly (p = .01) in PTA duration. CONCLUSION: Patients with TBI may benefit from early assessment and systematic RO nursing intervention. The RO may facilitate patients with PTA to regain orientation and interact with their surroundings in the neurointensive care unit to optimize the recovery. However, further studies with focus on timing, intensity, and duration are needed to evaluate the influence of an early RO approach on PTA and outcomes in patients experiencing TBI.

Nursing roles and functions in the inpatient neurorehabilitation of stroke patients: a literature review.

Stroke is a major cause of morbidity and mortality in the world. In the United States, it was estimated that approximately 750,000 patients had a stroke annually. Denmark, with a population of 5.5 million, had about 12,500 cases of hospitalizations from stroke in 2009. Despite the patient's obvious need for complex nursing care and a common recognition of the nurse's central role in rehabilitation after a stroke, a description of their specific contributions appeared sparse. Therefore, a literature review was conducted using the matrix method. The purpose was to explore the nursing roles and functions identified in empirical research and to discern any possible evolution in the nursing roles and functions during a span of years. The rehabilitation literature related to inpatient rehabilitation after stroke during the period from 1997 to 2010 was reviewed. The total number of identified citations was 1,529. After screening for relevancy, 134 eligible articles remained. Of these, 30 articles were extracted into a table and formed the basis for the conclusion. We found that four nursing roles and functions described in 1997 still accommodated central aspects of the current nursing practice but also emerging changes reflecting a development in the nurses' responsibilities and contributions in conducting rehabilitation after a stroke. These changes seemed mainly to be shaped instigated by changes in the (1) patient role, (2) increasing interdisciplinary teamwork, and (3) focus on rehabilitation efforts conducted in the patient's environment.

A critical review of the literature on early rehabilitation of patients with post-traumatic amnesia in acute care.

AIMS AND OBJECTIVES: To identify the effect of early rehabilitation of patients with post-traumatic amnesia in patients with traumatic brain injury, to review and critically assess evidence related to the timing of intervention and to identify the effect on outcome of a specific neurological rehabilitation in acute care. BACKGROUND: Up to 70% of patients with traumatic brain injury will experience post-traumatic amnesia. Although duration of post-traumatic amnesia is correlated negatively with outcome for patients with traumatic brain injury, there is limited evidence relating to what influence timing and effect may have on enhancing early rehabilitation patient outcomes. DESIGN: A critical literature review. METHODS: Searches for systematic reviews were undertaken in Medline, CINAHL, Cochrane, PSYC INFO and Neurotraume databases. The efficacy of intervention and timing was classified based on a hierarchy of study designs for questions about health care interventions based on soundness of design. RESULTS: Six reviews and 11 original studies were included and comprised the review. Many studies used weak designs and small sample size, thus limiting their ability to control confusing variables and outcomes. Few studies included papers with the information about timing and effect of early post-traumatic amnesia intervention. Only one study showed an effect of a reality orientation programme in acute care. Although there was no significant detail reported on the possibility of reducing the post-traumatic amnesia period, the study showed clinical relevance. CONCLUSION: This review highlights the limited evidence of the effect of early rehabilitation of patients with post-traumatic amnesia. Future research should be conducted to identify the effectiveness of early intervention. RELEVANCE TO CLINICAL PRACTICE: Although nurses are treating patients with post-traumatic amnesia without systematic assessment, the limited evidence available does little to direct nurses as to the best approach to start early rehabilitation of post-traumatic amnesia to promote good outcomes.

[Dysphagia--an overlooked problem in neurorehabilitation]. / Dysfagi--et overset problem i neurorehabiliteringen.

INTRODUCTION: The purpose of this study was to evaluate the management of dysphagia in patients with traumatic brain injury (TBI) and adjoining disorders during multidisciplinary neurorehabilitation in phase I and II in Denmark and abroad. MATERIALS AND METHODS: The study was conducted as structured interviews at six outstanding international neurorehabilitation institutions and as a national questionnaire survey including five phase I neurointensive wards and two phase II neurorehabilitation institutions. RESULTS: Data from the study visits showed that the international clinics received patients with cuffed tracheostomy tubes, had 24-hour medical support, and semiintensive monitoring. Patients were treated by multidisciplinary teams and all were clinically and instrumentally examined for dysphagia. Data from the Danish questionnaire survey showed that the two neurorehabilitation institutions did not receive patients with cuffed tracheostomy tubes. Both institutions had 24-hour medical support, multidisciplinary teams and monitoring of saturation. Clinical and instrumental examinations of dysphagia were not systematic procedures in either phase I or II. CONCLUSION: The study demonstrates the need for clinical guidelines on the examination and treatment of dysphagia in patients with TBI and adjoining disorders within neurorehabilitation in phase I and II in Denmark. There is also a need to clarify the management of dysphagia in patients with cuffed tracheostomy tubes.