Return to School Following TBI: Educational Services Received 1 Year After Injury.

BACKGROUND: Many children who experience a traumatic brain injury (TBI) return to school without receiving needed support services. OBJECTIVE: To identify services received and predictors of formal special education services (ie, Individualized Education Plan [IEP]) for students with TBI 1 year after returning to school. SETTING AND PARTICIPANTS: A total of 74 students with TBI recruited from children's hospitals in Colorado, Ohio, and Oregon. DESIGN: Secondary analysis of previously reported randomized control trials with surveys completed by caregivers when students returned to school (T1) and 1 year later (T2). This study reports data collected at T2. RESULTS: While 45% of students with TBI reported an IEP 1 year after returning to school, nearly 50% of students received informal or no services. Male students, those who sustained a severe TBI, and students whose parents reported domain-specific concerns were more likely to receive special education services at 1 year. In a multivariate model, sex remained the only significant predictor of IEP services at T2. CONCLUSIONS: Females and students with less severe or less visible deficits were less likely to receive special education services. While transition services may help students obtain special education for the first year after TBI, identifying students with TBI who have subtle or later-developing deficits remains a challenge.

Management of Return to School Following Brain Injury: An Evaluation Model.

Traumatic brain injury (TBI) affects children's ability to succeed at school. Few educators have the necessary training and knowledge needed to adequately monitor and treat students with a TBI, despite schools regularly serving as the long-term service provider. In this article, we describe a return to school model used in Oregon that implements best practices indicated by the extant literature, as well as our research protocol for evaluating this model. We discuss project aims and our planned procedures, including the measures used, our quasi-experimental design using matched controls, statistical power, and impact analyses. This project will provide the evidential base for implementation of a return to school model at scale.

Preliminary Efficacy of Online Traumatic Brain Injury Professional Development for Educators: An Exploratory Randomized Clinical Trial.

OBJECTIVE: To examine the efficacy of an online traumatic brain injury (TBI) professional development intervention, In the Classroom After Concussion: Best Practices for Student Success. DESIGN: A randomized controlled trial with a sample of 100 general educators, who were randomly assigned to the In the Classroom Web site (treatment group) or the LEARNet Web site (control group). Participants completed the pretest, accessed the In the Classroom or LEARNet site and the posttest and completed follow-up assessments 60 days after posttest. MEASURES: (1) Knowledge of effective strategies for working with students with TBI; (2) knowledge application; (3) self-efficacy in handling situations presented in text and video scenarios, and (4) a standardized self-efficacy measure. RESULTS: On the posttest assessment, In the Classroom educators showed significantly greater gains in knowledge (P < .0001, d = 1.36 [large effect]), TBI knowledge application (P = .0261, d = 0.46), and general self-efficacy (P = .0106, d = 0.39) than the LEARNet controls. In the Classroom educators maintained significant gains in knowledge (P = .001, d = 0.82) and general self-efficacy (P = .018, d = 0.38) but not in TBI knowledge application (P = .921, d = 0.02). CONCLUSION: Given the prevalence of TBI, it is important to develop evidence-based, cost-effective approaches to knowledge transfer and exchange in TBI professional development. In the Classroom is one such approach.

Dry eye symptoms and impact on vision-related function across International Task Force guidelines severity levels in the United States.

BACKGROUND: International Task Force (ITF) guidelines established a grading scheme to support treatment of dry eye disease based on clinical signs and symptoms. The purpose of this study was to assess the impact of dry eye on vision-related function across ITF severity levels using the Ocular Surface Disease Index (OSDI) questionnaire. METHODS: Non-interventional, cross-sectional study of prescription treatment-naïve dry eye patients seeking symptom relief at 10 ophthalmology and optometry practices. Clinicians assessed corneal and conjunctival staining, tear break-up time, Schirmer's test (type I with anesthesia), and best-corrected visual acuity. Patients completed the OSDI questionnaire and OSDI overall and domain (Symptoms, Visual Function, and Environmental Triggers) scores were compared across ITF guidelines severity levels (1-4). RESULTS: Of 158 patients (mean age, 55 years) enrolled, 52 (33%) were ITF level 1, 54 (34%) ITF level 2, and 52 (33%) ITF levels 3/4 combined. No significant differences were observed in most baseline characteristics. Overall OSDI scores (mean [standard deviation]) were 26.5 [20.0] for ITF level 1, 33.8 [17.5] for ITF level 2, and 44.9 [26.1] for ITF level 3/4 cohorts (P < 0.0001). Component OSDI Symptoms, Visual Function, and Environmental Triggers domain scores all worsened with increasing ITF severity level (P ≤ 0.01). CONCLUSIONS: Dry eye disease has significant deleterious impact on vision-related function across all ITF severity levels.

School experiences following traumatic brain injury: A longitudinal qualitative study.

BACKGROUND: This longitudinal qualitative study tracked students with traumatic brain injury (TBI) from hospital discharge through their return to school and then for an average of four years of school. OBJECTIVE: To better understand the experiences of students and parents in the education system following TBI. METHODS: Participants were parents and educators of 21 students with TBI. Interviews were conducted using open-ended questions and students were observed in the classroom. RESULTS: From these data, three themes were identified: lack of student tracking year to year, lack of educator training, and conflicting views between educators and parents about students' needs. These factors ultimately led to parent frustration and eventually conflict and deteriorating relationships between parents and educators. CONCLUSION: The results suggest that improving educator training could positively affect the factors identified and possibly mitigate parent frustration.

Stakeholder Perspectives on the School Experiences of Students With Traumatic Brain Injury: The Effects of COVID-19 Pandemic on Service Delivery.

BACKGROUND: For students with traumatic brain injury (TBI), the COVID-19 pandemic exacerbated challenges they were already experiencing at school. METHODS: This qualitative study employed focus groups and interviews with students, parents, school, and medical personnel to explore the school experiences of students with TBI. Thematic qualitative analyses were used. RESULTS: Key themes from the analysis include (a) incidence of brain injuries decreased; (b) screen time for students with TBI exacerbated symptoms; (c) COVID protocols at school made it difficult for educators to identify and provide accommodations for students with TBI; (d) COVID protocols at school could inadvertently exacerbate mental health difficulties after a TBI; and (e) COVID-related logistics increased the time between an injury and return to school or return to play. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: The results from this study suggest that professional development for teachers supporting students with TBI is needed, especially for online learning environments. Additionally, because mental/behavioral health concerns may arise for students with TBI in online learning environments, school health care providers can work with families to assess a student's mental health, making referrals to appropriate supports. CONCLUSIONS: There is a significant need for professional development and school-wide infrastructure supportive of students with TBI.

Using guided credible history interviews to establish special education eligibility for students with traumatic brain injury.

BACKGROUND: In Oregon in 2019, only 261 students were eligible for special education under the traumatic brain injury (TBI) category. Many students with TBIs are not treated by a medical provider, so the requirement for a medical statement could prevent eligible youth from receiving special education services. OBJECTIVE: This study investigated barriers to using a medical statement to establish special education eligibility for TBI, support for using a guided credible history interview (GCHI), and training needs around GCHI. RESULTS: Among participants, 84% reported difficulty obtaining a medical statement for TBI eligibility determination, and 87% favored the GCHI as an alternative, though they reported a need for training in TBI and GCHI. CONCLUSION: The results support the use of GCHI to establish special education eligibility for TBI and informed Oregon's addition of GCHI to TBI special education eligibility determination.

Back to School: Academic Functioning and Educational Needs among Youth with Acquired Brain Injury.

Youth with a history of traumatic or non-traumatic acquired brain injury are at increased risk for long-lasting cognitive, emotional, behavioral, social, and physical sequelae post-injury. Such sequelae have great potential to negatively impact this population's academic functioning. Consistently, poorer academic achievement and elevated need for educational supports have been well-documented among youth with a history of acquired brain injury. The current paper reviews the literature on neuropsychological, psychiatric, and academic outcomes of pediatric acquired brain injury. A discussion of special education law as it applies to this patient population, ongoing limitations within the field, and a proposal of solutions are also included.

Hospital Readmissions and Mortality Among Intubated and Mechanically Ventilated Adult Subjects With Pneumonia Due to Gram-Negative Bacteria.

BACKGROUND: Ventilator-associated pneumonia (VAP) is one of the most common hospital-acquired infections in ICUs and is associated with significant morbidity and mortality. Gram-negative bacteria cause 55-85% of hospital-acquired pneumonia and are associated with increased mortality. METHODS: This study sought to describe mortality rates and 30-d readmission rates among intubated and mechanically ventilated subjects with Gram-negative pneumonia and to explore associated risk factors for mortality and rehospitalization using data from the 2013 Healthcare Cost and Utilization Project (HCUP) National Readmission Database. The study sample included adults age ≥ 18 y who were hospitalized with invasive, continuous mechanical ventilation; were discharged between February 1, 2013, and November 30, 2013; and had a primary or secondary diagnosis of Gram-negative bacterial pneumonia. Logistic regression was used to identify subject characteristics significantly associated with mortality and readmissions. RESULTS: Using the HCUP projected sample of 32,683 intubated and mechanically ventilated subjects with Gram-negative pneumonia, the mortality rate during the index hospitalization was 24.3%. More than one fifth of subjects (22.9%) who survived the index hospitalization were readmitted within 30 d of discharge. Among subjects with readmissions, 18% occurred within 3 d of discharge, 39% occurred within 7 d of discharge, and 65% occurred within 14 d of discharge. Subjects with prior hospitalization within 30 d of the index hospitalization had a higher risk of readmission with an odds ratio of 1.70 (95% CI 1.48-1.94). CONCLUSIONS: Mortality was high and readmissions were substantial among intubated and mechanically ventilated subjects with Gram-negative pneumonia.

A quasi-experimental study examining the effects of online traumatic brain injury professional development on educator knowledge, application, and efficacy in a practitioner setting.

Background: Each year ∼700 000 U.S. children ages 0-19 years sustain a traumatic brain injury. Children who experience brain injury are at risk for impairments in executive function, processing speed, cognition, memory, attention, and behavior which can lead to school failure. However, few teachers or other educational professionals receive training on effectively working with students who have traumatic brain injury (TBI). The purpose of this study was to examine the efficacy of an online traumatic brain injury professional development intervention, In the Classroom after Concussion: Best Practices for Student Success.Methods: This quasi-experimental study examined the effects of online traumatic brain injury professional development (In the Classroom after Concussion: Best Practices for Student Success) on educator knowledge, knowledge application, and self-efficacy in a practitioner setting with a sample of 81 educators from all professional backgrounds. Participants completed the pretest, accessed the In the Classroom training and posttest, and completed follow-up assessments 30 days after the posttest. Measures: (1) knowledge of effective strategies for working with students with TBI; (2) knowledge application; (3) self-efficacy in handling situations presented in text and video scenarios, and (4) a standardized measure of educator self-efficacy.Results: On the posttest assessment, educators showed significant gains in knowledge (p = 0.001, r = 0.62), knowledge application (p = 0.001, r = 0.63), and self-efficacy (p = 0.008, r = 0.29). At 30-day follow up, educators maintained significant gains in knowledge (p = 0.001, r = 0.62) and self-efficacy (p value = 0.008, r = 0.28), but not in knowledge application.Conclusion: Given the prevalence of traumatic brain injury, it is important to develop evidence-based, cost-effective approaches to knowledge transfer and exchange in traumatic brain injury professional development. In the Classroom is one such approach.Implications for rehabilitationWithout training in TBI, educators will be poorly prepared to monitor students' post-injury challenges and to address learning and behavioral challenges as they occur.Given the prevalence of TBI, it is important to develop evidence-based, cost-effective approaches to knowledge transfer and exchange in TBI professional development. In the Classroom is one such approach.

Establishing Consensus for Essential Elements in Returning to Learn Following a Concussion.

BACKGROUND: Returning to learn following a concussion is the process of managing a student's recovery during the school day by implementation of academic supports with varying intensity. Due to a lack of consensus or even guidance on Return to Learn, this paper set out to establish cross discipline consensus on some essential elements of Return to Learn using a Delphi method. METHODS: Sixteen national organizations participated in a Delphi process to reach consensus on overarching themes of Return to Learn focused on: returning a student to school, composition of the school-based concussion management team, progress-monitoring, educational safeguards, neuropsychological testing, and legislation. Two rounds of questionnaires were disseminated via email using a Delphi process. Consensus was established during round 2. RESULTS: Twelve national organizations were able to reach consensus and endorse 13 essential elements of Return to Learn following a concussion. CONCLUSIONS: There continues to be limited research on concussion Return to Learn leading to confusion in the field. In this paper, we demonstrate consensus on a number of essential elements, from a wide variety of professional disciplines who participate in the care of students following a concussion, as a starting place for some guidance on Return to Learn.

Hospital to school transition following traumatic brain injury: A qualitative longitudinal study.

BACKGROUND: The transition from hospital to school is regarded by researchers as a key factor in the educational success of students with traumatic brain injury (TBI). OBJECTIVES: The objective of this study is to look closely at what transition services consist of, how they are delivered, and how they are received by educators. METHODS: Parents and educators of 21 students with TBI participated in a qualitative study of the delivery of transition services and implementation of hospital recommendations. RESULTS: This paper presents two themes that emerged from interview and observational data collected over a 7-year period: 1) provision of hospital-school transition services is inconsistent and 2) teachers lack sufficient awareness of and training in TBI to implement hospital transition recommendations. Regardless of the type and quality of transition support, most educators in the students' schools remained unaware of the students' needs and how to meet them. CONCLUSION: Recommendations include more consistent and specific communication between hospital and school for all students with TBI, long-term tracking of the injury in student files, and increased training of educators in how to meet the needs of students with TBI.

A call for implementing preferred practices for brain injury screening in youth to improve transition.

BACKGROUND: It is vital to engage in systematic screening to identify and serve children who may have sustained an acquired brain injury (ABI) - either traumatic or non-traumatic, so they can be successfully transitioned between environments and life stages. This is particularly important for children and adolescents given the impact an ABI can have on learning and social functioning over the course of the neurodevelopmental process. A pattern of repeated, undiagnosed mild brain injuries may lead to mood or behavior disorders, learning problems. Despite increasing awareness of brain injury as a public health issue, there has not been implementation of systematic screening practices in schools or other public health settings similar to other conditions (e.g., vision disorders, Autism Spectrum Disorders). OBJECTIVES: What is needed to address this lack of systematic screening for ABI is a rationale for systematic screening for ABI in children and adolescents, including examining successful models of screening for other disorders and conditions. METHODS: A review was conducted of available ABI screening methods, including a description of the available screening tools for pediatric ABI, along with supporting research findings. RESULTS: A comparison was made of these pediatric ABI screening tools, looking at the purpose of the tool, the populations and settings in which the tool can be used, the time and cost for administering the tool, the evidence basis in the literature supporting the tool, and the types of outcomes that can be attained from using the tool. CONCLUSION: Recommendations are made for procedures for systematically implementing ABI screening in pediatric settings including schools, primary care providers, mental health, and juvenile justice systems to improve the access to brain injury services and affording more successful transition of adolescents into the adult roles.

Evaluating Outcomes in Patients with Overactive Bladder within an Integrated Healthcare Delivery System Using a Treatment Patterns Analyzer.

BACKGROUND: Overactive bladder (OAB) is a relatively common disease that has been linked to a variety of comorbidities, reductions in quality of life, and increased healthcare costs. Antimuscarinic agents are the standard of care among pharmacologic treatments for OAB, but these drugs are linked to high levels of anticholinergic burden, especially in the elderly. OBJECTIVE: To demonstrate how efficient data analysis can be used to identify gaps in care as a result of improvement strategies for OAB within an integrated healthcare delivery system setting. METHODS: We developed an OAB treatment patterns analyzer, a clinical outcomes software analysis program, to identify gaps in care, high anticholinergic burden, and potential quality improvement initiatives. Deidentified pharmacy and medical claims data from an integrated delivery network were imported into the OAB treatment patterns analyzer. Patients with a diagnosis of OAB who were continuously enrolled in the network between January 1, 2009, and December 31, 2013, were identified and were imported into the analyzer. The analyzer used National Drug Code; International Classification of Diseases, Ninth Edition, Clinical Modification; Current Procedural Terminology; and UB-92 codes to measure treatment patterns, comorbid conditions, anticholinergic burden, concomitant use with anticholinesterases, costs, and healthcare resource utilization. RESULTS: Of 157,710 members in the integrated delivery network population, 7309 patients met the study eligibility criteria. Of patients taking medications for OAB, 85% were nonadherent and 73% discontinued treatment within 1 year. Among 1147 patients in the integrated healthcare delivery system who were using medications for OAB, 39 (3.4%) patients were concomitantly taking anticholinesterase drugs and an antimuscarinic agent. The per-month plan-paid cost per member was $318.67. Of all the patients with OAB within the population, the rates of all-cause office visits, emergency department visits, and hospitalizations were 81%, 6%, and 4%, respectively. The rate of clinically relevant anticholinergic burden was 16%, with higher rates among patients with dementia who were also receiving a branded (20%) or generic (24%) antimuscarinic drug. CONCLUSION: In patients using medications for the treatment of OAB, the rates of medication persistence and adherence were poor. Antimuscarinic medications may place certain patient populations at risk for increased anticholinergic burden. Data included in the analyzer can be used to implement member-specific strategies to prevent poor outcomes and reduce associated healthcare costs and utilization.

Variations in State Laws Governing School Reintegration Following Concussion.

OBJECTIVE: We sought to examine the prevalence, scope, and specificity of provisions governing school reintegration in current state concussion laws. METHODS: State concussion laws as of May 2016 were independently assessed and classified by 2 trained coders. Statutes were classified as "Return-to-Learn" (RTL) laws if they contained language mandating institutional action at the state, district, or school level related to academic reintegration of youth who have sustained a concussion. All statutes classified as RTL laws were further analyzed to determine scope, required actions, and delineation of responsibility. RESULTS: RTL laws were uncommon, present in only 8 states. Most (75%) of these laws held schools responsible for RTL management but mandated RTL education for school personnel was less frequent, present in only one-quarter of the laws. None of the RTL laws provided guidance on support of students with persistent postconcussive symptoms, and only 1 recommended an evidence-based standard for RTL guidelines. CONCLUSIONS: Our review of state concussion laws indicates scant and vague legal guidance regarding RTL. These findings suggest an opportunity for legislative action on the issue of RTL, and reveal the need for better integration of laws and research, so that laws reflect existing best-practice recommendations and remain current as the evidence base develops.