Specialized Early Treatment for Persons With Disorders of Consciousness: Program Components and Outcomes

Objectives: To describe a specialized early treatment program for persons with disorders of consciousness (DOC) that includes family education; to identify rates of secondary conditions, imaging used, and selected interventions; and to evaluate outcomes. Design: A single-center, retrospective, pre-post design using electronic medical record data. Setting: A Commission on Accreditation of Rehabilitation Facilities accredited, long-term acute care hospital that provides acute medical and inpatient rehabilitation levels of care for people with catastrophic injuries. Participants: Persons (N=210) aged 14 to 69 years with DOC of primarily traumatic etiology admitted at a mean +/- SD of 41.0 +/- 27.2 days postinjury; 2% were in coma, 41% were in the vegetative state, and 57% were in the minimally conscious state. Interventions: An acute medical level of care with >= 90 minutes of daily interdisciplinary rehabilitation and didactic and hands-on caretaking education for families. Main Outcome Measures: Coma Recovery Scale Revised, Modified Ashworth Scale, and discharge disposition. Results: Program admission medical acuity included dysautonomia (15%), airway modifications (79%), infections (eg, pneumonia, 16%; urinary tract infection, 14%; blood, 11%), deep vein thrombosis (17%), pressure ulcers (14%), and marked hypertonia (30% in each limb). There were 168 program interruptions (ie, 139 surgeries, 29 nonsurgical intensive care unit transfers). Mean length of stay +/- SD was 39.1 +/- 29.4 days (range, 6-204d). Patients showed improved consciousness and respiratory function and reduced presence or severity of pressure ulcers and upper extremity hypertonia. At discharge, 54% showed sufficient emergence from a minimally conscious state to transition to mainstream inpatient rehabilitation, and 29% did not emerge but were discharged home to family with ongoing programmatic support; only 13% did not emerge and were institutionalized. Conclusions: Persons with DOC resulting primarily from a traumatic etiology who receive specialized early treatment that includes acute medical care and >= 90 minutes of daily rehabilitation are likely to show improved consciousness and body function; more than half may transition to mainstream inpatient rehabilitation. Families who receive comprehensive education and hands-on training with ongoing follow-up support may be twice as likely to provide care for medically stable persons with DOC in their homes versus nursing facility placement. (c) 2013 by the American Congress of Rehabilitation Medicine