Hello, everybody. This is going to be Rolling with the Punches, an interdisciplinary model for treating the neurobehavioral patient. My name is Dr. Seema Desai. I'm an assistant professor at Carolinas Rehab within the Department of Physical Medicine and Rehabilitation. I have no disclosures. We're going to just list the objectives for this lecture today. We want to manage some common neurobehavioral issues that could arise on the inpatient rehab unit. How do we discuss these interventions? How do we de-escalate the patient and track these interventions objectively, and how do we actually develop an interdisciplinary program to improve outcomes and dispositions at your own institution? Let's just start by talking about definitions of agitation. What is the Oxford Dictionary definition of agitation? It's a state of anxiety or nervous excitement. The Merriam-Webster Dictionary version is a state of excessive psychomotor activity accompanied by increased tension and irritability. However, in our rehab world, we do have our own definition, post-traumatic agitation. This is actually a state of confusion during the period of impaired consciousness, which follows your initial injury. This is also termed post-traumatic amnesia. This is typically characterized by these excessive behaviors, emotional unrest, akathisia, impulsivity, disorganized thinking, disinhibition, as well as aggression. Typically, the actual percentage of outcomes or the percentage of agitation is so variable and it's classified differently across settings that it's really hard to get a realistic number of what the percentage is. However, if you look at a variety of studies, this number is anywhere from 11% to 70% in our traumatic brain injury population, either in the acute care setting or in the rehab setting. As a result of this, they do have longer length of stays. There was a recent study done by McKay that showed that agitation actually increases during the early stages of post-traumatic amnesia. What we're seeing most commonly is actually disinhibited behaviors. However, the gradual reduction of agitation is actually seen towards the middle and late phases of PTA. Treatments that improve cognition during these middle and late phases of PTA could actually produce secondary benefits in reducing agitation. One possible explanation for this is that the significant fatigue and reduced arousal that we see during the early stages of PTA may limit the patient's ability to engage with their internal and external stimuli, and that's potentially what could be triggering some agitation. It is really important to be cautious with the interventions that you're including for your patients because they can impede the cognitive recovery and potentially exacerbate agitation with sedating medications. What are some predictors for agitation? Bogner et al. actually showed that infection and lower FEM cognitive scores actually predicted more severe agitation, and this was a prospective study. Another study by Singh actually showed that those with contusions actually had better outcomes than those with intracranial hemorrhages versus those with a diffuse axonal injury. However, the severity of the injury wasn't assessed during these studies, so it's hard to correlate severity with predictors for agitation. But we do know that the more severe agitated behavioral scores that you get, that actually reflects a reduced prospect for good recovery. There's no actually association with age in studies, and we do know that worse outcomes are there for the longer duration of agitation. The question becomes, why do you have worse outcomes? Is it because you're having to use more than one medication due to the severity of agitation? These are questions that haven't necessarily been addressed by research but would be interesting to correlate. I think the most important thing when you're developing a neurobehavioral program is asking yourself, your staff, your therapists, what do you mean by agitation? What is your definition? What are you seeing when you walk into a patient room or you're walking into a therapy gym? So these are just some of the most common things you may encounter. Impulsivity is one of the most common things that caregivers will actually tell you is something that they find most troublesome. And typically, this is stimulus-bound. You'll typically see snap decisions, poor judgment, verbal utterances, and it's closely related to this individual response to a cue in their environment and then attaches this exaggerated response to that cue. Irritability is another very common thing we'll see. The Oxford Dictionary actually has a great definition of this that reflects both your internal subjective feelings, such as anger, and your external behavioral response, which is showing the anger. And this can typically look like increased arguments, impulsive decisions, feeling impatient, and even threatening either your staff or your therapist or even yourself. Aggression is another thing we do see and can be pretty complex because it's this behavior that truly is comprised of sensory, emotional, cognitive, and motor element. It can be verbal aggression, it can be physical aggression, reactive, explosive, periodic, and even non-purposeful. A recent study by Rao did show that verbal aggression is probably the most common form, but I can definitely tell you with some of our more severe patients, we definitely do see more physical aggression as well. And this can look like a variety of things, loud noises, shouting, cursing, threats to not only their self but to others, and clear threats of potential violence. Another kind of thing I want to loop in with everyone is that everything is truly connected with the brain. So the type of brain injury and the brain that's injured individually and interactively affect all of these domains, your cognition, your emotion, your behavior, and the sensory motor function. So a disturbance in any one of these domains is actually going to affect function in one or more of the other domains. So collectively, these factors and interactions between them do produce a lot of potential post-traumatic neuropsychiatric symptoms, anywhere from depression, anxiety, communication issues, apathy, fatigue, headaches. So these are all things that you need to keep in mind when you're treating a patient with agitation. Another example of this is how behavior and cognition are connected. So, for example, if you have damage to the prefrontal circuit, not only are you going to have poor judgment, but you're going to have impaired problem solving, impulsivity, impaired judgment, insight, problems with your memory. So these are things to keep in mind, like the previous slide. Everything is truly connected when you're treating a patient. Other things you want to consider, medications, or is your patient on any sedative medications? Are they on anything over-the-counter that could be contributing or reacting to their other medications on their MAR? Alcohol and illicit substances, are they in an overdose? Are they actively going through withdrawal? Delirium, electrolyte disturbances, metabolic disturbances, sepsis, infections, UTIs, pneumonia, encephalitis, their sleep-wake cycle, very important to keep track of. Seizures or epilepsy, are they having subclinical seizures? Pain, including musculoskeletal issues, even spasticity, and metabolic disorders as well, vitamin deficiencies and thyroidism. What are some non-pharmacological interventions that you can do? So a low-stimulation environment, and by that, it really doesn't just mean low stimulation when you're walking into a room, but that stimulation has to be variable based on the type of patient you're encountering. So you may need to protect your patient from themselves or others by getting a floor bed or a one-to-one sitter, maybe even a locked ward if that's available. We typically don't like to use restraints, so if you are trying to prevent a patient from pulling at their peg side or their trach, you can put a mitt on them, bed alarms, seat belts for their wheelchair, and tolerating restlessness when possible, so letting them pace their room or letting them pace up and down the unit, if it's a locked unit with a sitter, can also help. And reducing cognitive confusion, so it's really important when you're walking into a room that only one person is speaking with the patient at a time. You're keeping your staff consistent. You want to simplify all your communication, presenting only one idea to the patient at a time. And then how do you actually objectively measure your outcomes? So there are several different scales, the overt behavioral scale, which Dr. Harik will speak more to, and the agitated behavioral scale are probably the two most common that you'll encounter that are also able to easily integrate with EMR systems. So the overt behavioral scale is actually adapted from the overt aggressive scale, and it includes other behavioral domains. It looks at sexual behavior, wandering, initiation, and allows for frequency so you can actually determine if your interventions are working. The agitated behavioral scale is also another one that you can also use with frequency, but you do need to make sure when you're integrating it in with your EMR, you not only train your therapists, but you train your nurses so that this can be actively used and used frequently so that you can determine if your interventions are actually working. The overt agitation severity scale and the overt aggressive scale can also be used, but they have less domains, so typically you'll want to use something that has more domains. And these are my references, and I will turn it over to Dr. Falco to give you some real-world decisions to help build a program. All right. Well, hello, I'm Dr. Christopher Falco. I am an assistant professor of PM&R and brain injury medicine here at UT Health McGovern Medical School in Houston. I'm an attending physician at Tier Memorial Hermann Hospital, and specifically I am the medical director of the Tier Neurobehavioral Program. So to build on Dr. Desai's presentation, I wanted to go through some actual case examples and just highlight some important points, some important factors that we always want to take in consideration when trying to determine both the non-pharmacologic and pharmacologic interventions for our patients. So we're going to start with this specific case, a case of a 22-year-old male who experienced a severe TBI and polytrauma from a motor vehicle collision and underwent hemicraniectomy. His injury was three weeks ago. His initial GCS was three. Early imaging revealed a left subdural hemorrhage and some DAI. He has multiple other traumatic injuries, which have led to restrictions. He must wear the helmet to and out of bed. He's non-weight-bearing on the left upper and the left lower extremities. And throughout the documentation, you see mention of quote-unquote agitation. And as you dive deeper, you get more information. You identify that the specific behaviors that they were referring to involved pulling of lines and tubes and patient placed in four-point restraints, very common types of behaviors we see in our patients who were still just going through the early post-traumatic confusional state. But now the patient has been transferred to your acute inpatient rehab, and he's now your responsibility. So what are some of the important considerations that we will want to factor in? First and foremost, it's absolutely critical, as Dr. Desai mentioned, that we identify and try to quantify the behaviors. And having terminology that everyone on the team, from the physician all the way down to the PCAs, the techs on the front line, making sure that everyone has a similar terminology that they are using and will allow effective communication, because communication absolutely is the key, like with any patient population, but in particular in this one. But yeah, being able to identify, quantify the behaviors, and how do we label them? Is the patient simply restless, confused, and impulsive? Or are they starting to trend on the more complicated end of the spectrum? Are they combative, irritable, or developing some aggression? How frequent are the behaviors? How disruptive are the behaviors when they occur? Obviously, if they're happening with great frequency, or even when they're not frequent, if they're happening, or if they're becoming rather disruptive when they are happening, even if infrequent, obviously that may push you to act and change your treatment plan sooner rather than later. Are they provoked versus unprovoked? This is a critically important factor as well. And as Dr. Desai mentioned on one of the last slides there, how do we measure and track the behaviors? And how do we know that what we're doing is actually helping? Obtaining a thorough history is critical. And of course, we want to know what their past medical history entails, but a psychiatric history, social history, substance abuse history can provide some critically important information that oftentimes gets either completely missed or underlooked and greatly underappreciated and helping to explain why the patient could be experiencing such severe behavioral issues. The patient's mental status is super important, you know, depending on their level of arousal and how confused and disoriented they are. What kind of language comprehension deficits may they be experiencing? What's their attention like and their memory? Do they have any carryover whatsoever? Do they have insight into their deficits? Can they self-regulate or are they redirectable? All of these components of the mental status become really important because you're going to tailor your treatment plan accordingly. You're going to need to meet the patient kind of where they are, obviously. What current medications are they on? Very frequently, as any physiatrist who works with brain injury patients regularly can attest to, very frequently patients show up from the acute care setting on a number of sedating and cognitively impairing medications, which, you know, as I tell patients and families when I'm first meeting them, I'm sure these medicines were necessary and appropriate at one point, but now that you're here and you're in this controlled environment that we can provide in our dedicated neurobehavioral unit, we can start safely weaning off of these meds and just see how the behavior evolves from there. But yes, you know, identifying medicines that could be potentially problematic from either a sedating standpoint to just an overall cognitive standpoint, anything that may delay the speed of their recovery would be important to identify. And then any other considerations, you know, a number of considerations from infectious things, again, things that Dr. Desai pointed out, you want to make sure we're not missing any metabolic issues, infectious issues, making sure that nursing staff is bundled in care at night so as to minimize disruptions and ensure that their sleep patterns are as optimal as possible, countless other considerations that we'll want to factor in. So in this specific, getting back to our case example of our 22-year-old, let's go through these one by one and see where this patient's at. So from a behavior standpoint, he's demonstrating impulsive behavior. He's frequently trying to get out of bed. The specific behaviors we're seeing are a lot of just non-purposeful movements. He's frequently changing positions. This seems to be worse at night. He's frequently trying to remove the helmet when they do have him up out of bed. He gets a little bit combative with any hands-on care. When the nurses try to give him a tube feed or changing his brief, he starts pushing and getting more restless. But importantly, he's not demonstrating anger, irritability, or any unprovoked aggression. This is a lot of just confusion, restlessness, again, very straightforward post-traumatic confusional state. For his history, we'll say it's very benign. No significant past medical, social, psych history, all very unremarkable. His current mental status, he's poorly aroused at times during the day. When you can engage him to answer any questions, you find that he's only oriented to person. Overall, cognitive assessment is greatly limited by poor arousal and poor attention, so you really can't get too much. He doesn't appear to have any insight. He's not even really responding to redirection. So clearly, in the early stages of the post-traumatic confusional state. His current medication list reveals a number of important things that any physiatrist can recognize may be potentially problematic, specifically the clonidine, the famotidine, the clonidine, the gabapentin, the levotiracetam, lorazepam, butypine, and risperidone, all of which have the potential to be somewhat sedating, cognitively impairing. And then other considerations. Again, we're wanting to know what his sleep is doing, what his sleep patterns. Is he in pain, possibly? Again, he's got multiple traumatic injuries, and he's probably confused enough to where he's not maintaining those weight-bearing restrictions all the time. So is he experiencing significant pain? Is there a possibility of an underlying infection? Is his bladder full of urine, and he's retaining and not able to empty? Or is he constipated? All of these things we'll want to look for. So for this specific patient, let's identify these things. Let's go through them. From a sleep standpoint, again, he's got poor arousal during the day. He's not sleeping well at night. So of course, we're going to do something for that. We're going to add the trazodone, try to get some better sleep. In addition, we identify that he's getting his heparin injections Q8 hours. So he's getting them at 1 a.m., 2 a.m. sometimes in the middle of the night. So even if he happened to be asleep, we're poking him and waking him up. So again, trying to bundle care, maybe retiming the heparin to be given maybe at 10 p.m., no later than 10 p.m., etc. From a pain standpoint, he's not at a point where he can really communicate effectively to us whether he's in pain. So you can safely assume he could be. It's very reasonable to maybe put him on some scheduled acetaminophen just to see if that helps, assuming his liver function tests are agreeable. You're going to check a urinalysis. You're going to look for constipation and check his bladder volumes. Again, rule out all that bowel-bladder stuff. Rule out any metabolic and possible contributing factors. But then as far as specific medication changes, you know, first and foremost, we're going to want to try to get him off of any of those cognitively impairing meds. You know, the antipsychotics and the benzos, top priority, of course. You know, the antipsychotics very likely could be contributing or if not straight up causing his restlessness, leading to an akesthesia type of picture. And the benzodiazepines, as we all know very well, are causing further cognitive impairment and potentially worsening delirium. So we're going to start with those and then along the way, try to wean him off the other potentially sedating meds as well, the clonidine, gabapentin, levotiracetam. What about medications that we could add potentially to help with mood? In this particular case, you know, again, his mood doesn't seem to be the issue. He's not demonstrating any specific mood disorder. He's still just in the very early stages of the post-traumatic confusional state. There really isn't a major role for any mood-altering medications. This is certainly something we're going to want to monitor closely as he continues to evolve. And as he clears more cognitively, he very likely could develop a mood disorder. But for now, there isn't really any major need for that type of intervention. And then lastly, what about medications to help his mental status or cognition? You could consider a neurostimulant such as amantadine, try to get that daytime arousal a little bit better, especially if the earlier interventions, you know, the sleep meds and the bundling care, pain medicine, if that hasn't led to quick, significant improvement in his sleep at night, and that doesn't directly translate to improved arousal, that would be a very reasonable thing to try next. However, oftentimes in these cases, if we simply do those simple interventions, get the sleep better, get them off the sedating meds, oftentimes the arousal and the cognition just kind of falls into place from there. And there isn't a major role for a neurostimulant or a cognitive enhancer necessarily. And frequently we will, you know, for a variety of reasons, consider a neurostimulant. But in this specific case at this specific time, not necessarily a top priority. Okay, so that was case one. Now, case number two is actually, I'm going to present the exact same case with the exact same vignette, all this information, this is the exact same slide as we saw with case one, but we're gonna present it with varying degrees of behavior escalation. So for case number two, same patient history. However, this patient's behaviors are a little bit more problematic, just a little. He too is impulsive, frequently trying to get out of bed and removing the helmet. But what's different for patient number two compared to patient one, he is demonstrating frequent irritability. He's demanding to go home very often. And he's not just a little bit combative, he's highly combative with any hands-on care. And even starting to trend towards aggression where he's actually striking and lashing out at the staff. So definitely a notch above patient number one from a behavior standpoint. Again, his history is quote unquote benign, nothing that really stands out, any big red flags necessarily. His current mental status, just like his behaviors are a notch above patient one, his mental status is a notch above. For the better, he's consistently awake and alert. His arousal is good throughout the day. He is also oriented to only person, but he is frequently engaged and able to answer questions when he's willing to participate. You perform an O-log, he scores 12 out of 30. So clearly still very impaired, clearly still in post-traumatic amnesia. And when you do attempt to do a cognitive assessment, you don't get a whole lot, again, because patient is likely, or is mostly just refusing to cooperate, but you do identify obvious deficits in memory, attention, insight, clearly just very, very poor executive functioning. His current medication list compared to patient one is a little more straightforward. You may notice there is no antipsychotics on his MAR, there's no benzodiazepines. He is on the clonidine, gabapentin, levotriacetam like patient one, but overall just a cleaner med list. And again, we're gonna wanna factor in all those other considerations that we referred to. So how are the treatments going to differ for patient two compared to patient one? We're actually gonna start with a very similar approach. We're gonna initially focus on sleep, bundling care, a lot of non-pharmacologic interventions to try to address the behavior. We're gonna schedule acetaminophen for pain, we're gonna look for infectious stuff and bowel and bladder stuff, of course. All that is gonna still hold true for this patient. Where it starts to vary a little bit from patient one. And this specific patient, you know, again, he's not on the super problematic benzos antipsychotics that could be worsening his restlessness and confusion. However, again, the main thing with this patient is probably the irritability. And again, you noted he's on levotriacetam. And of course, as you all know, as most people, most physiatrists, brain injury physiatrists especially know, levotriacetam can be notorious for causing a very severe irritability syndrome. And so in this particular patient, you know, he doesn't appear to have any major risk factors for post-traumatic seizures. He hasn't had seizures to date. He doesn't have any whopping contusions, depressed skull fractures, et cetera. So it would be very reasonable, very appropriate to start weaning off the levotriacetam and aggressively wean them off as very frequently that alone, even without any other interventions can significantly help improve the irritability and overall behavior. In addition to weaning off the levotriacetam, it would also be very reasonable to consider, you don't necessarily have to right off the bat, but at some point along the line and potentially very, very early, consider an SSRI or an SNRI or another antidepressant of choice. SSRIs are usually a safe way to go. This may also, in addition to helping with the irritability, this may also combat any future mood disorder that he will be likely at high risk for, as we discussed in patient number one. And then as far as medications to help facilitate a more rapid cognitive recovery in their mental status, which, you know, again, as Dr. Desai alluded to, very frequently the behaviors get worse early on, you know, as they progress through the stages of post-traumatic, you know, as they progress through the post-traumatic and the confusional stages. But as long as we find a safe avenue to get them through that stages, as long as we can get them safely to the point where they clear PTA, very frequently the behavior just improves in parallel with the cognitive recovery. And so, yes, putting them on cognitive enhancers such as the Dinepazil or potentially a neurostimulant like methylphenidate, which could help attention and mood and potentially irritability to a degree, you know, these would be very reasonable things to try as well. But the main focus here is, you know, again, address the low-hanging fruit, get the Keppra off the board as soon as possible, put them on an SSRI if necessary, get their cognition better, and everything should likely fall into place from there very nicely. All right, now the last case, case number three. And again, exact same patient, same vignette, nothing's changed here, but again, further escalation in this patient's behavior. So patient number three, also impulsive, just like the previous patients, but his behavior goes far beyond that. He is demonstrating severe irritability, constant irritability. He's yelling profanities. He's verbally aggressive towards the staff. He's not becoming physically aggressive towards other individuals yet. However, he is demonstrating some physical aggression towards objects. He's throwing objects and potentially causing damage around the unit, walking around and breaking things. His history is pretty unremarkable from a past medical standpoint, and there's no formal psychiatric illness in his history. However, you get some very critically important, helpful information from his family, which indicates that, you know, he, talking to the patient's parents, he is always, quote unquote, their problem child. You know, he dropped out of school early on, in the ninth grade. He was never a good student. He got into trouble. He ran into the wrong crowd. He was incarcerated for drugs and armed robbery, and he has a pretty extensive history of alcohol and IV drug abuse, even at his young age of 22. So clearly, compared to patient one and two, a lot more problematic on the psychosocial end. His mental status, he's awake, alert. He's actually mostly oriented. He's maybe a little bit off on time concepts, but he's otherwise fully oriented. His cognitive assessment is very limited by lack of cooperation, but he does clearly seem to be recalling specific events from not just previous hours in the day, but from previous days. So you have a high suspicion that he's probably out of post-traumatic amnesia. He does have poor insight into what cognitive deficits he does have, but again, he does seem to be out of the PTA period. His current medication list is similar to patient two, not on anything super complicated or concerning, with the exception of maybe the levotiracetam. Again, the other medical considerations that we'll want to factor in. So how are we going to approach patient three? Just like patient one and two, we're still going to do all this. I mean, sleep is critical, regardless of what other behavior things the patient is experiencing. If the patient's not sleeping well at night, you're certainly going to have the potential for worsening behavioral issues, regardless of what behaviors you may be seeing. So we're going to do that. We're going to address pain. We're going to address bowel, bladder infections, et cetera. But what about the cognitive impairing meds? What about meds to help his mood and to help cognition and just behavior in general? This is where there's a lot of options. You can go in a variety of different directions. What specific direction do I think we need to go in for patient number three? Well, that's where the collateral information and the past history really becomes even more critically important. And the fact that this patient had, what sounds like very possibly a pretty significant underlying personality disorder at baseline, and maybe has always had problems with authority, and maybe that's part of the problem with him being in the hospital and feeling out of control. This is again, far more exotic than just your typical post-traumatic confusional state that the behaviors that go along with that. And so when we start to see this level of behavior difficulty, this is where we're going to need to get into the more hardcore medication management. Of course, as we all know, the typical classes of medications that we're going to be using to try to control post-traumatic agitation, there's a lot of options, the beta blockers such as propranolol of course are widely studied and have good evidence, although in actual practice, not something that I personally use a lot of, it's not my usual first line treatment for a number of reasons. One, what evidence does exist suggests that it requires very high doses. A lot of our patients, unfortunately a lot of our patients with really severe post-traumatic agitation issues are going to be our younger adults who have perfectly healthy hearts so they can tolerate a high dose of a beta blocker if necessary. But my preference is usually start with an SSRI, potentially a catecholaminergic stimulant and potentially at the exact same time. I'm a big fan of an SSRI plus amantadine. That seems to be a winning combination for many of my patients. I find that it gets a nice leveling of the mood stuff as well as facilitating the cognitive recovery and you get to avoid the potential adverse cognitive effects that go along with some of the other more complicated classes of medications, such as the mood stabilizers and of course the atypical antipsychotics. We will use those very frequently. If the patient has, in this patient, patient number three here, maybe he would be the type that we would jump straight to a mood stabilizing agent, such as a valproic acid, because he does have that very complicated psychosocial history. Maybe he was the type of patient that needed a mood stabilizer all along for some underlying personality disorder or psych disorder that was never formally diagnosed. But the key take home here is that it really depends on the specific behaviors, how the patient seems to be responding to what interventions have been tried, both pharmacologic and non-pharmacologic, taking into account just a wide variety of other factors and then just formulating a treatment plan that makes sense for you and for your comfort level. And that's really the key. I mean, there's a lot of reasonable options. There is no right or wrong. That's why there's no clear guidelines for this patient population and for this specific post-traumatic agitation problem, but just identifying interventions that seem reasonable and again, knowing how to track, how do you know that your intervention is working or not? That's kind of the key. And that's a nice segue into the next portion of the talk with Dr. Harik. How do you know if your treatment is actually working? My name is Dr. Lindsay Harik. I am a clinical neuropsychologist at TR Memorial Harmon. I'm the clinical director of the Neurobehavioral Program alongside Dr. Falco. I have no disclosures. I am going to go into, in a moment, some of the metrics that you'll want to pay attention to to understand whether or not your program is working. Before that, just sort of the nuts and bolts of what these programs look like. So the basic programmatic components included here. For us, like I mentioned earlier, we have kind of a co-leadership between medicine and psychology and we have specialized staffing. We have a particular physical space where we house this unit, et cetera. But really, I want you to pay attention to the procedures listed on this slide and note that the vast majority of our procedures are focused on enhancing communication. That's going to be a theme you'll get throughout my portion. Doing whatever you can to enhance the quality and efficacy of the communication that you're receiving from all these different team members. The philosophy of care in these programs is not vastly different than in a standard brain injury program. That said, we are emphasizing a couple of things more specifically, which is providing the safest and least restrictive environment possible. That includes reducing the use of physical and chemical restraints as much as we can in a safe manner. We are including family caregivers as an extension of the clinical team by providing education and support from day one. We understand that these individuals are going to be really, really important in the long-term outcome for these patients and so we try to get them up to speed and on board and ready to work as soon as possible. We're focusing on promoting positive behaviors as well as minimizing the negative impact of challenging behaviors. And note, you are not eliminating challenging behaviors by any stretch, that should not be your goal. You do want to minimize the negative impact of these behaviors. And you're going to spend some additional time with things like rapport building, demonstrating goodwill, doing some bargaining with these patients to earn some trust and to develop that rapport because as has been alluded to, especially in the case examples, it might be a bit of a rocky road. So it's worth putting the time in upfront. Now, the metrics for understanding whether or not your program is effective. You're going to pay attention to a few things and some of these have already been mentioned in the previous presentations or previous portions. But first, you're going to see a reduction in the use of chemical and physical restraints, even further than what you would have initially. So we're going to see less use of the mitts, for example, although not technically a restraint. You're going to see far less need for any medication that might be used for a sedative. You're going to see a return to normal or a normalization as much as possible of the sleep and wake cycles. That's relevant because it means that there's been the removal ideally of stimuli and other things that might be increasing agitation through the day that's making it harder to get good sleep. You're seeing, as has been alluded to, clearance from that post-traumatic amnesia or confusional state, and you're seeing improvements in functional status. And then principally, you're seeing a decrease in the number and severity of behavioral escalations, and I'll talk in a moment about how you might go about measuring that. One thing that's really important to note in these types of programs is the importance of communication and staffing. It's really important and a worthwhile investment to invest heavily in staff education and training early on. A staff member who feels empowered, who feels efficacious, who feels that they have a good sense of how to manage this very challenging patient population not only is going to do good, safe work, but the data that you are able to garner from that individual through their documentation or the report they provide you is going to be of a higher quality. And so it's very much, in terms of the decision-making you're doing as a physician, you need to be able to rely on the report from the number of the individuals in your team. And so ensuring that you have high-quality or highly reliable data is really important. What's your stimulus value? Another way of asking is, what's reinforcing about you? When you have success in these patient interactions and convincing this patient who wants to leave that they should stay, what was it about the way you interacted that allowed that patient to say, yes, I'll stick it out? So, and then finally, making sure that you are informing and educating the non-clinical staff in your setting. We certainly have had it be the case that these behavioral escalations can occur anywhere in our setting. And so it's really important to make sure that, for example, the maintenance and the food services staff and the admin staff are all aware of what to do when a behavioral escalation occurs. Another important component when you're trying to bring this to your setting is understanding what type of behavioral sampling you want to do. I'm not gonna go into too much detail on this slide, but understanding that you have a couple of different ways of approaching how you're gonna collect these data. Is it more important to understand the trend throughout the day, or is it more important to understand the frequency of a behavior? Depending on the observation tools and the measurement tools you use, you can kind of pick and choose what's gonna be more and less important in your setting. In our setting internally, we've developed something called the Behavior Observation Tool. And I'm gonna show this just because it gives you an example of something you might consider implementing in your own setting. On the left side, you can see different types of behaviors, and this is not an exhaustive list necessarily of the behaviors you would like to know about, but it's a really good start. And the rater can just identify yes or no, that type, that behavior occurred in my encounter with the patient. They then have the option to, in a free text box, describe the situation. And so in this example, the patient became escalated when he was told to wear his helmet. He had a craniectomy and he didn't have neplasty yet. And he's becoming escalated and he's saying, the doctor told me I only need to wear it in the hallway. The patient impulsively got up and went into the bathroom without the helmet. These are the things we're seeing in this encounter. And then below that, the staff member has the ability to indicate what did I do to try to intervene on this behavior? And was it helpful? Was it successful or not? And finally, this particular staff member said, you know what, the only thing that worked with this patient is that I had to tell them I would get in trouble if they didn't wear the helmet. So that's a really important kind of rich data point that other staff members can look to when they're interacting with that patient and an example of the importance of communication. How to adapt this to your setting. I'm belaboring the point of educating and investing in your staff because that's probably the most important resource that you have for this type of program. If you think about your nursing staff, you know, for those who are sitting with these patients as one-to-ones for eight hours a day or 12 hours a day, it's quite a lot to ask. And you can imagine that it would be rather draining. And so it's really important to empower and invest in these staff members and say, you know what, you have permission to step away for a moment if you need to process all that's going on and to have a human reaction to working with this population for a number of reasons. And your nursing staff really are the most valuable players in these programs. And so investing in training them and making them feel empowered. Really important to select your measurement tools carefully. Don't go crazy and picking all kinds of different scales. Think about the level of sophistication of your staff. Think about how much time you realistically have to, or they have rather to document and things like that and let that guide which tools you're choosing to use. Identify what barriers might exist in your setting to effective and frequent communication. And as was alluded to earlier, helping your staff, kind of coaching them to answer the question, if I were to walk into the room, what would I see? Try to get away from some of the lingo. Try to get away from some of the semantics and just describe more objectively what I might see if I were to walk into the room. And as physicians, of course, your time is highly valuable. You're getting lots of communication from different team members about what they're observing. And I will tell you for myself, I would rather have perhaps a little bit too much communication on the front end about what behaviors are being observed and things like that rather than trying to address the behavior ad hoc after an escalation has happened, after something really significant has happened behaviorally and then trying to clean it up afterward. There's a number of reasons why that's just far less effective and potentially detrimental for the ongoing admission. So emphasizing communication on the front and then doing your job to kind of sift through that and categorize that. Taking a moment to think about your setting, what are the strengths and limitations, be it the physical space, the length of stay of your patient, the acuity of your patient population? What access do you realistically have in terms of training your staff? Do you have high turnover? How much time am I going to spend training certain staff members that may not need as much? And then finally, doing your best to garner administrative support. So that means really making the financial or business case as to why you need additional staff members to provide one-to-one supervision. As was alluded to earlier, we understand now, both anecdotally and through literature, that patients who remain agitated for longer are going to have poor outcomes, are going to need to be in the hospital longer. They have increased rate of potentially kind of secondary and tertiary injuries as well as readmission. So again, spending some time and money on the front end is probably going to be the more prudent and effective thing to do, but it is in some cases on you to make that case to your administration. So I know I worked through that really quickly, but thank you for your attention today. And do please, I think our contact information will be available, so please reach out if you have questions. Thank you so much.

neurobehavioral patients

agitation

rehab world

traumatic brain injury

non-pharmacological interventions

cognitive confusion

behavioral escalations

staff training