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Williams OT sponsors the Innovative Service Delivery Award every year for the SA OT association and we just announced the winner for 2018.

We attended the award celebrations on 12/12/18 where we announced the winner as:

Heather Block, Congratulations!

2018 Innovative Service Delivery Award

Heather is a gun. Check out the highlights of her project below that won her the award.

Improving and Standardising the Management of Behaviours of Concern in Acute Traumatic Brain Injury

Heather Block

There is an estimated 22,710 hospitalisations involving traumatic brain injury (TBI) in Australia, with peak incidences occurring predominantly in males aged 16-24 years old (Helps et al, 2008, Marshman et al, 2013). In the early recovery phase of moderate- severe TBI, patients will experience a syndrome of symptoms in their emergence of consciousness, including post-traumatic amnesia and behaviours of concern (Jennett et al, 1981). Behaviours of concern encompass behaviours such as agitation, irritability, physical or verbal aggression, disinhibited behaviour, repetitive behaviour, confusion and disorientation (Kelly, 2010).

From the patient’s perspective, the acute recovery stage of TBI involves periods of restlessness, agitation, emotional lability, disrupted day/night cycle, impaired insight, impulsiveness and aggression, with limited memory recall, orientation and attention to their surroundings. In addition to dealing with an acute traumatic event, family members of patients are often experiencing despair and concern in witnessing their loved one exhibit these complex behaviours. Hospital staff caring for the acute TBI patient are faced with daily challenges in managing these unpredictable and complex behaviours of concern, with risk of injury to themselves, or to the patient. 

Anectodally, across South Australia’s acute trauma hospitals, management of acute TBI behaviours of concern has involved variable use of sedating medications at large doses, variable use of restraints, and frequent security incidents, or Code Blacks, when staff feel under threat or at risk of injury. A consistent approach to identify and standardise the management of behaviours of concern is optimal in order to provide best care to patients with acute TBI. 

Throughout this project, funded by the Lifetime Support Authority, a standardised approach to the identification and management of behaviours of concern in the acute phase of TBI has been implemented across Flinders Medical Centre (FMC) and Royal Adelaide Hospital (RAH).  In planning phase of this project, a systematic review of literature was completed in addition to interstate benchmarking visits to gain evidence and resources used by other acute hospitals and TBI rehabilitation facilities. Working parties were developed, consisting of local experts in the field of TBI, including allied health, nursing, neurosurgeons, rehabilitation consultants, neuropsychiatrists and pharmacists to develop best practice recommendations for standardised identification and management of behaviours of concern in acute TBI.

As a result, a TBI specific assessment tool and protocol was developed to identify and manage TBI behaviours of concern which has been implemented across SA’s acute trauma hospitals. The TBI Behaviour Scale and Record provides an objective, TBI specific assessment and recording tool for severity of behaviours of concern. The TBI – Management of Behaviours of Concern in the acute phase protocol provides a standardised approach to non-pharmacological and pharmacological (medication) interventions based on assessment of behaviours using the TBI Behaviour Scale and Record. Additionally, an Individualised TBI Behaviour Support Plan has been developed to identify patient’s lifestyle factors, routines, supports, and can be used to track patient’s behaviour triggers, warning signs and individualised management strategies.

A multi-disciplinary approach is required for the comprehensive management of behaviours of concern in acute TBI. Occupational therapists play an undervalued role in identifying occupations, habits and routines of value to the TBI patient, and have skills in recommending non-pharmacological behaviour management strategies, such as modifying the environment to a low stimulus setting, providing familiar items and leisure activities, providing reorientation strategies and structured ADL routines. The development of the TBI protocol, particularly use of the Individualised TBI Behaviour Support Plan encompasses the pivotal role of occupational therapy in the emergence of post traumatic amnesia and management of behaviours of concern. Development and implementation of this standardised management approach has diversified the role of OT in TBI behaviour identification and management.

Evaluation of the acute TBI protocol is ongoing. Pilot results completed at FMC indicate that after the use of the TBI protocol, the frequency of ‘code black’ security incidents reduced by 38%. Furthermore, there has been a reduction in the use of restraints for acute TBI patients by 51%. Ongoing evaluation will continue across FMC and RAH, however this preliminary data is suggestive that the implementation of a standardised approach to identification and management of behaviours of concern may improve outcomes for TBI patients, including reduced use of restraints, reduced security incidents, reduced length of stay and earlier access to rehabilitation. 

Heather has developed TBI – Management of Behaviours of Concern protocol.

It is a standardized behaviour scale to avoid a pharmacological behaviour management approach to problematic behaviour. Very quickly. The tool has reduced code black calls on the acute TBI ward by 38% and reduced restraint use by 51%.

A bit about Heather

I’ve been a qualified OT working with acute stroke and ABI patients for 9 years. I have always had an interest in patients with neurological changes, and enjoy working to increase function and independence in the acute (and often traumatic) time of patient’s stroke or ABI. I am curious minded, a dynamic thinking and value evidence based practice; hence I am often reflecting on my work and the role of OT as “how can we improve what we do”, “how can we achieve better outcomes”, “what makes this better for patients, families, and staff”. I was intrigued and excited to be leading this TBI project as I could see the value in improving the care to acute TBI patients with behaviours of concern. During this acute and often traumatic time, I have seen family members in despair to see their loved one demonstrate such out of character, complex behaviours. As an OT, I have seen the difficulty hospital staff have in managing these behaviours of concern in a consistent manner, which impacts on a patient’s ability to participate in therapy, and emergence from post-traumatic amnesia, and places hospital staff at risk of injury.

Throughout this project it’s been great to be able to collaborate with a range of health care professionals across FMC, RAH and Brain Injury Rehabilitation Services, who are passionate about improving clinical care and outcomes to TBI patients. However, at times it has been challenging, with barriers arising to impede the implementation of the TBI protocol. With strong advocacy, clear communication of evidence, and support from staff across FMC, RAH and BIRS, we have been able to achieve a consistent approach to identifying and managing behaviours of concern in acute TBI, which is a huge achievement. It’s even more pleasing to see positive pilot results, and look forward to seeing the final evaluation results and how this impacts TBI patient care.

I believe as OT’s we should push the limits, diversity our role to incorporate many aspects of patient care to enable independence and engagement in ADLs in an innovative manner.

As sponsor of this award, I say, Go OTs!

We are changing the face of health care with our person-centered approach. Keep up the good work and keep sharing your success stories. We are awesome.?

Please make a comment below to show your appreciation for Heather’s great work.