Jennifer Lemke RN, CRRN Anju Deut-Aggarwal, B.A. Psych, B...

Jennifer Lemke RN, CRRN

Anju Deut-Aggarwal, B.A. Psych, B.S.T

Toba Miller RN, MScN, MHA, GNC(C), CETN(C)

Brain Injury Statistics Present our Rehabilitation Program and

Identify team members Case Presentation Define Errorless Learning Describe how errorless learning was utilized Share our success

1.3 million survivors living with Brain Injury 1 in 26 Canadians living with Acquired Brain

Injury #1 cause of death or disabler for those under

44 years of age ( Ontario Brain Injury Association www.obia.ca)

> 18,000 Ontarians will suffer an brain injury this year

Every hour 6 Canadians will suffer a brain injury

1 of every 10 people will know some one with a brain injury

( Ontario Brain Injury Association www.obia.ca)

1.7 million Americans sustain a traumatic brain injury each year

> 3.1-5.3 million children and adults live with a lifelong disability as a result of traumatic brain injury

Economic cost is estimated at 60 Billion Dollars

(US department of health and human services centers for disease control and prevention. www.cdc.gov/TraumaticBrainInjury)

12 bed inpatient unit (8 Acquired Brain Injury

and 4 Behavioural Service) Treatment programs to assist with deficits in

planning, memory, attention, perception, learning and judgement as well as physical deficits

Assist patients to gain control over behavioural challenges associated with their brain injury

Help patients become more independent in the areas of employment, education, meaningful daily activities and relationships with family and others

Physiatrist Rehabilitation therapists Rehabilitation nurses Clinical psychologists Occupational therapists Physiotherapists Speech language

pathologists

Admission coordinator Social Workers Manager Recreational therapy Respiratory therapists Pharmacist

Physician specializing in Rehabilitation that provides necessary medical care and supervises care

Collect, analyze and interpret data on behaviours, which serves as a baseline upon which treatment plans are developed and outcomes are evaluated

Work with the team to develop and conduct individualized, realistic treatment plans and implement cognitive behavioural strategies

Implements individualized strategies according to cognitive, behavioral or physical deficits

Recognizes the client’s resources and abilities in all aspects of care

Acts as an advocate for clients and their significant supports

Assist clients and their significant supports in adapting to the physical, emotional and cognitive changes related to disability and chronic illness

Assess and develop treatment plans to assist with depression, anxiety, pain and changes in memory and thinking

Assess and develop treatment plans to assist with activities of daily living such as dressing, bathing, homemaking

Provide assistive devices to facilitate return to home

Assess and develop treatment plans to assist in return to work

Work with clients and their significant supports by evaluating and developing a plan to restore strength, endurance, movement and physical abilities affected by injury or disability

Assess and treat difficulties in communication- reading, writing, understanding and speaking

Assess and treat swallowing deficits

Collaborates with physician to determine client’s appropriateness for admission

Communicates admission information with team

Collaborates with the patient and their family regarding discharge options

Provides family counseling and support

Oversees the program and provides clinical and administrative support

Specializes in caring for clients with respiratory difficulties

Assist in transition to community

Assist clients and their significant supports in adapting to leisure activities and promoting active community living

Reviews medication regime throughout hospitalization

Provides support for clients and their families and assist with transition to community pharmacist

Provides assessment, treatment and counselling for clients and their significant support for nutritional needs

44 year old married male Motor vehicle collision Glasgow Coma Scale at scene 4/15

Injuries : Right Subarachnoid Haemorrhage Left Frontal Hemorrhagic Contusion Left Frontal and Right Temporal Lacerations Right Temporal and Left Frontal skull

fractures extending into the Left Orbit

Other Injuries and Complications: Pneumocephalus Bilateral Pneumothoaraces Pneumomediastinum Optic Nerve Abnormalities with significant

Visual Deficits Bilateral optic nerve shear injuries Fractured Ribs

Acute Hospital Course Bilateral Chest Tubes Tracheostomy Percutaneous Endoscopic Gastrostomy

(PEG)Tube Deep Vein Thrombosis and Pulmonary

Embolus IVC filter placement

Acute Hospital Course Mechanical Ventilation Pseudomonas Pneumonia Hyperglycaemia Hydrocephalus Ventricular Peritoneal Shunt Placement

Admitted to

Acute Inpatient Rehabilitation

Key Deficits: Disorientation to person/place/time Post Traumatic amnesia Confabulation Visual Hallucination Legal blindness Agitation Aggression Severe cognitive deficits

Burden: objectively is the amount of time and the number of tasks involved in care giving and subjectively is the caregiver’s emotional feelings, attitudes and overall perception of care giving responsibilities

The severer the deficits in the patient’s cognition and self care abilities the greater the burden on the care giver

(Watson,R, Modeste, N, Catolico, O, Crouch, M, (1998) The Relationship

Between Caregiver Burden and Self-Care Deficits in Former Rehabilitation Patients. Rehabilitation Nursing, Vol. 23, No. 5, 258-262)

At admission client required 2-4 staff members for all activities due to safety concerns, disorientation and visual deficits

Burden to significant family to large for client to return to home at this time

Orientation and self care identified by team and family as barriers to discharge

Team decision to set up an Errorless Learning Program to improve orientation and increase independence

Implementation of care treatment plans to communicate with staff and provide framework for consistency

Collaboration with family

Is the process of learning a procedure without allowing the individual to make any mistakes

The information to be learned is presented in the same way each time and any opportunity to guess is eliminated

Each task is broken down into specific components

Repetition/Consistency is the key Often very time intensive Family/care taker carryover into learning

process very important

Implicit versus Explicit Memory Implicit Memory: is a form of information recovery which

happens automatically without the knowledge of the subject Explicit Memory: subject intentionally tries to remember the

information requested as well as the context when the information was learned

(Bier, N.. Vanier. M., Meulemans, T. (2002). Errorless Learning: A Method to Help Amnesic Patients Learn

New Information. Journal of Cognitive Rehabilitation, 12-18)

Research shows that clients with significant deficits in explicit memory respond positively to Errorless techniques and the severer the memory dysfunction the better response as there is no interference by the explicit memories

(Kessels, R.P.C. de Hann, E.H.F, (2003) Implicit Learning I Memory Rehabilitation: A Meta-Analysis on Errorless Learning and Vanishing Cues Methods. Journal of Clinical and Experimental Neuropsychology, Vol. 25, No. 6, 805-814)

Consistency and repetition is of great importance Important to provide ongoing feedback Specific set of instructions for staff to facilitate

consistency Visual support for clients when required Withdrawing supports as performance improves

The Rehabilitation Centre

Behavioural Rehabilitation Service

Treatment Plan

Date: xxxxxxxxx

Target Behaviour: Confusion / Disorientation

Goal: Increase orientation and decrease length of confusion and disorientation (PTA).

Operational Definition:

Confusion / Disorientation is defined as disturbed awareness of ones environment in regard to time,

place, and or person.

Rational for addressing this goal:

There is research suggesting that reality orientation may help reduce the amount of time a client is

in Post Traumatic Amnesia. The method used in this treatment plan was reviewed in a research

article entitled “Effect of an integrated reality orientation program in acute care on post-traumatic

amnesia in patients with traumatic brain injury”.

Treatment procedure: (see Orientation Sequence Handout on his bulletin board)

An Orientation Sequence will regularly be verbally reviewed with Client.

In part of the orientation sequence to assist in decreasing Client’s confusion/ disorientation priming

Client before his scheduled activity will be added to the orientation sequence.

Procedure:

Each staff member orients the patient when they first approach him and whenever appropriate

during their interactions with him.

Given his ongoing level of disorientation do not continuously reorient him when is behaviour or

verbalizations indicate that he is disoriented. Continuous orientation as been noted to lead to

increased agitation. Do not however agree with any false information but simply refrain from

commenting.

Regular visitors are asked to follow the Orientation Sequence when they first speak to the patient

and whenever appropriate during their visit.

Requires commitment by team and significant support as time consuming in beginning of process

Development of scripts and tools to assist staff in consistency

When completing routine it is important to prompt client when they are about to make an error so that errors are not built into the memory

Labelling of client’s space provides prompts for client and helps staff and family maintain consistency

Data was collected during each routine and tabulated into graphs for comparison over 5 weeks

Client’s need for prompts showed a decrease during process

Client was able to independently perform ADL in a controlled environment

Orientation to place and situation improved Topographical orientation to facility

improved

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HC Prompting for Morning Routine July 9- August 15, 2009

Verbal Prompts

Physical Prompts

Linear (Verbal Prompts)

Client able to transition to a residential program

Program consists of 6 private rooms in a home-like atmosphere

Provides community based life skills to facilitate community reintegration and independent living

Although this client continues to have severe cognitive and visual deficits the client has been able to successfully return to his home environment with his family

He is completely independent in activities of daily living but continues to require assistance with instrumental activities of daily living

He continues physiotherapy twice per week and intermittent speech and occupational therapy.

He also participates in and Acquired Brain Injury day program twice a week.

Jennifer Lemke RN, CRRN jlemke@ottawahospital.on.ca

Anju Deut-Aggarwal, B.A. Psych, B.S.T aaggarwal@ottawahospital.on.ca

Toba Miller RN, MScN, MHA, GNC(C), CETN(C) tmiller@ottawahospital.on.ca