Acute Care, Disability, and Rehabilitation   
 

Public Health Burden

Each year, Americans make 30 to 40 million emergency department (ED) visits for injuries. While the majority of injured patients are treated and released, many are admitted to inpatient trauma units and later receive rehabilitative services. The most favorable patient outcomes result when acute care and subsequent rehabilitation begin as early as possible and when they focus on returning patients to their baseline or an optimal level of functioning. Trauma systems are designed to match trauma patients with the acute care and rehabilitative facilities they need, but in many parts of the United States, trauma systems are not fully operational or do not exist at all. Where these systems are lacking, as many as 30% to 40% of deaths among trauma patients are due to preventable problems in clinical care, including missed diagnoses and treatment delays. Follow-up studies have shown as much as a 50% reduction in preventable trauma deaths after trauma systems are introduced.

Injuries are a major cause of disability in the U.S. Central nervous system injuriesóthose to the brain and spinal cordóare most likely to result in serious, long_term disability. Each year, an estimated 80,000 Americans sustain traumatic brain injuries (TBI) that result in disabilities; an estimated 5.3 million Americans live with TBI-related disability. Although physical impairments from the injury may contribute to TBI disability, cognitive deficits are the hallmark, frequently resulting in secondary conditions such as depression and other adverse outcomes such as the inability to work. An estimated 200,000 people in the U.S. live with spinal cord injuries (SCI), and this number increases annually by as many as 11,000 individuals. Secondary conditions such as pressure ulcers are a common cause of lost productivity among people with SCI.

Other important disabling injuries include limb injuries, back injuries, eye injuries, and burns. Injuries to the lower extremities constitute the leading cause of trauma admissions among adolescents and young adults, accounting for 235,000 hospitalizations each year. In addition to their high incidence, lower extremity injuries often result in significant impairment and loss of function.

Injured patients may suffer a variety of psychosocial effects, including post-traumatic stress disorder, depression, misuse of alcohol and other drugs, and difficulties returning to the routines of pre-injury work and social lives. Screening and intervention programs may reduce the frequency and severity of these consequences and may also decrease the number of ED and trauma center visits for future injury. In one study, for example, screening and intervention for alcohol problems among patients hospitalized for trauma reduced hospital admissions for injuries by 48% for the following three years. To prevent adverse outcomes, pre-existing injury risk factors, such as excessive alcohol use, must be addressed in a comprehensive way, including during acute care and rehabilitation.
 

The Injury Centerís Niche in Acute Care, Disability, and Rehabilitation

CDCís Injury Center maintains close ties with practitioners and researchers working in acute care and rehabilitation, as well as with public health professionals working in injury prevention and control. These relationships help foster cooperation and strategically advance a broad-based, multidisciplinary approach to injury. The Injury Centerís multidisciplinary orientation also provides unique opportunities to catalyze and coordinate innovations in clinical preventive services in acute care and rehabilitation facilities. It recently developed a research program on clinical preventive services for alcohol problems in EDs and brought together federal partners and experts in alcohol research, emergency medicine, and trauma care to set a research agenda for this emerging field.

The Injury Centerís partnerships with state health agencies, academic injury research programs, and health care practitioners provide a vital foundation for establishing and maintaining population-based surveillance systems and conducting outcomes research. More comprehensive and timely information about injury incidence, causes, and outcomes in defined populations can help guide injury prevention programs as well as efforts to improve treatment and rehabilitation for those injuries that do occur. With its focus on population-based surveillance and research, the Injury Center is positioned to lead the development and dissemination of appropriate case definitions, data elements, and data collection methods. Activities involving evaluation of community- and clinic-based interventions, community services, and systems of care also distinguish the Injury Centerís work from that of many other agencies.

Although lead federal responsibility for trauma care systems resides with the Health Resources and Services Administration (HRSA), the Institute of Medicine (IOM) report Reducing the Burden of Injury: Advancing Prevention and Treatment specifically recommends that the Injury Center collaborate on new trauma outcomes research. The Injury Center staff has extensive experience working with public and private sector organizations responsible for trauma care system planning and development at the local, state, and national levels. This experience positions the Injury Center to help set research priorities, provide technical assistance for research programs, and facilitate translation of new findings into practical methods for evaluating trauma care systems.

The Injury Centerís research and programs in the area of disability and rehabilitation are designed to inform efforts to reduce the impact or prevent the development of secondary conditions and other adverse outcomes of TBI and SCI. Findings from Injury CenterĖfunded TBI surveillance provide crucial information to guide primary prevention efforts, not only for TBI but for many other injuries as well.

Many of CDCís injury research activities can support the work of other federal, state, and local agencies. The Injury Center collaborates with agencies involved in trauma care and disability prevention, including HRSA, the National Institute for Disability and Rehabilitation Research (NIDRR), the National Center for Medical Rehabilitation Research at the National Institutes of Health, and the Social Security Administration. All research activities should include interaction among related organizations and agencies to develop case definitions and enhance the ability to generalize across agenciesí studies.

 
The Injury Centerís Research Priorities in Acute Care, Disability,
and Rehabilitation

Every research priority in this agenda is important. After considering input from experts in the field, Injury Center staff identified the eight most important priorities, those that warrant the greatest attention and intramural and extramural resources from the Injury Center over the next three to five years. They are designated with asterisks.
 

Priorities

A.* Develop and evaluate protocols that provide onsite interventions in acute care settings or linkages to off-site services for patients at risk of injury or psychosocial problems following injury.

Clinical preventive services for patients treated in emergency departments, hospital trauma units, and other acute care settings can help reduce the risk of injury and mitigate the effects of injuries that do occur. Such services might include instruction in the proper use of safety restraints and screening and interventions for alcohol problems, intimate partner violence, or child maltreatment. For injured patients, ED visits and inpatient hospital admissions for trauma care may provide crucial opportunities for early identification of and intervention for post-traumatic stress disorder and other psychosocial problems that can follow or be exacerbated by injury.

Decision makers are often reluctant to fund preventive clinical services because they believe the investment needed to implement a single service in one clinical setting is too high. Research should demonstrate the effectiveness and value of such services and examine ways to implement multiple services simultaneously to amortize operational costs.

B.* Measure the benefits and costs of trauma care systems.

Despite evidence that trauma care systems save lives, many areas of the U.S. lack trauma system coverage. New methods of measuring morbidity, quality of life, functional status, and cost will help define the benefits and costs of trauma care systems, including determining which patients benefit most from trauma care systems and at what costs. In all aspects of trauma care, these new approaches to studying outcomes and costs will likely yield insights that influence policies and practices at the national, state, and local levels. They can be applied in ongoing efforts to monitor and improve system performance and may be useful in research conducted about specific clinical interventions.

C.* Identify risk factors and develop and evaluate interventions for secondary conditions following TBI or SCI, particularly among patients who have not received treatment or rehabilitation at state-of-the-art facilities.

Secondary conditions of TBI and SCI result in reduced capacity to perform daily activities, lost work productivity, and decreased quality of life. Secondary conditions range from medical conditions resulting from the injury, such as pressure ulcers among people with SCI, to behavioral changes, such as alcohol and substance abuse. Much of the research about the incidence and risk factors for secondary conditions of TBI and SCI has been conducted by researchers from NIDRRís Model Systems project, which focuses on a relatively small subgroup of patients treated by specialized Model Systems facilities. Research should increase understanding about the risk factors for secondary conditions among all persons with TBI and SCI, especially those who do not have access to state-of-the-art information and care.

The relationship between treatment for secondary conditions and longer-term outcomes of TBI and SCI is not well understood. Additional research is needed to develop more effective rehabilitation methods that include treatment or management of secondary conditions and to evaluate the costs and benefits of these approaches.

D.* Identify methods and strategies to ensure that people with TBI and SCI receive needed services.

People disabled by an injury often do not receive the help they need. A CDC-funded follow_up study of TBI in Colorado found that one year after injury, about one third of people with a disability said they had not received any services since their discharge from the hospital. According to a 1998 General Accounting Office report, people who have cognitive or behavior problems, but not physical problems, resulting from TBI are among those most likely to have unmet service needs. Without treatment, people with behavior problems are the most likely to become homeless, be committed to mental institutions, or be sentenced to prison. A recent study showed that people with TBI who received the services they needed reported a better quality of life. Research should increase understanding of the gaps between needed and available services for people with TBI and SCI and should identify strategies to close those gaps.

People with "mild" TBI may not even be diagnosed with a TBI, making it even more difficult for them to get assistance. Research should explore the possibility of adapting case identification methods to help link people with TBI and SCI to services. To that end, the Injury Center has already funded two small, pilot projects to investigate the feasibility of using state-based TBI surveillance to identify people hospitalized with TBI who may need help finding out about services. Studies should investigate specific methods for linking people to information and services, such as evaluating the usefulness of toll-free telephone numbers that serve as single points of entry to the service delivery system. Studies should also describe the spectrum of rehabilitation services and trends in service provision, and they should evaluate access to medical, rehabilitation, and social services to prevent disabling outcomes and secondary conditions.

E.* Develop and evaluate methods of using point-of-care clinical information systems to report injuries and other acute health problems to public health agencies.

As electronic clinical information systems enter the mainstream of acute care practice, new opportunities arise to use clinical data for public health surveillance of injuries and other acute health problems. However, methods of using point-of-care clinical information systems in this manner are not well developed and require evaluation. Research should identify the point-of-care data to be recorded and reported, resolve questions about terminology and classification systems, guide decisions about linking disparate systems, and evaluate the benefits and costs of new approaches to public health surveillance of injuries and other acute conditions. Findings from this research can help establish and maintain relevant data standards. For example, in emergency and trauma care, standards would include data elements, clinical vocabularies, and coding systems that convey information about the nature, severity, treatment, and outcomes of injuries.

Point-of-care clinical information systems can facilitate surveillance of access to acute care. Diversions of patients transported by ambulance have increased in recent years in many metropolitan areas in the U.S. When a hospital places its emergency department on diversion, patients transported by ambulance must be taken to another hospital for emergency care. Prolonged patient transports and resulting treatment delays cause dissatisfaction among patients, practitioners, and health care managers. They also may lead to worsening clinical outcomes. More systematic and population-based research is needed to evaluate the impact of diversions on patient care in defined geographic areas. Research about emergency department diversions can be aided by Web-based reporting systems that enable hospitals to communicate their diversion status to other hospitals and to health agencies. Linking data from these systems to patient outcome data can provide an important measure of the magnitude and consequences of ambulance diversions.

F.* Develop and apply methods for calculating population-based estimates of the incidence, costs, and long-term consequences of SCI and nonhospitalized TBI.

Developing methods to identify and characterize people with TBI and SCI is an essential first step to conducting surveillance and outcome studies. Such methods are lacking for some subgroups of people with TBI, particularly those with "mild" TBI. Research should focus on increasing uniformity of case identification methods to improve the comparability of national-level data for people with TBI. Increased collaboration among federal agencies is crucial to such research. Considering available resources and the language in the TBI Act Reauthorization for 2000, case identification of people with "mild" TBI, including those who do not receive medical care, should receive highest priority.

The Injury Center conducts population-based surveillance to develop nationally representative estimates of the incidence, prevalence, nature, and causes of injuries that result in long-term disability. This activity includes conducting population-based follow-up studies to identify and track the long-term outcomes of disabling injuries. Research should investigate the unique outcomes and special needs of specific subgroups of TBI and SCI populations, such as those injured as a result of violence. Better information about outcomes could improve estimates of the true burden of disability for individuals with "mild" TBI by helping to document long-term problems resulting from these injuries. Research should also identify the service needs of people with TBI and SCI, providing useful information for injured persons, service providers, and policy makers.

The direct medical costs and indirect costs associated with disabling injuries are not well documented; however, this information is important to guide decisions about resource allocation and other policies. For TBI, the study most often cited was published 10 years ago. Research should provide comprehensive, up-to-date information about the direct and indirect costs of TBI and SCI. In addition, research should estimate the costs associated with secondary conditions such as pressure sores, depression, and alcohol abuse.

G.* Determine the impact of TBI on special populations.

The majority of population-based studies of TBI outcomes have focused on adults generally. Documenting the true impact of disability from TBI requires additional research on populations that have not been well studied to date, including children and youths, working adults, institutionalized individuals, victims of intimate partner violence, and people within school systems and the criminal and juvenile justice systems. Some subgroups within the adult TBI population, for example people in prisons, are difficult to locate and are often lost to follow-up. Considering available resources and language in the TBI Act Reauthorization of 2000, determining the prevalence of TBI and related disability among children, youths, and people in institutions should receive highest priority.

H.* Determine the incidence, causes, nature, biomechanics, and outcomes of limb injuries.

The few studies to date about limb injuries have shown that these injuries result in substantial disability and affect oneís ability to return to work. In fact, only about 50% of people who were working before being injured return to work within six months. The extent of physical impairment is one key factor that influences disability, but other factors exist about which data are limited. Research using population-based studies is needed to describe accurately the public health burden of limb injuries and to suggest appropriate interventions to prevent these injuries and resulting disability. In addition to epidemiologic studies, research about the biomechanics of injuries to the extremities, such as fractures and dislocations, is necessary to devise prevention strategies.

I. Develop and evaluate interventions to improve patient safety in health care settings using strategies that have helped prevent and control injuries.

The IOM report To Err is Human: Building a Safer Health System has spurred new efforts to monitor and improve patient safety. The report highlights injuries in health care settings that are amenable to systematic surveillance, epidemiologic study, and targeted interventions to prevent them or control their effects. Although the Injury Center is not a lead federal agency for efforts to improve patient safety, its expertise and experience in developing, disseminating, and evaluating countermeasures for a wide range of injury problems provides a powerful injury-prevention paradigm appropriate to the problem. For example, much has been learned about preventing falls and suicides in community settings that can be extended to health care facilities. The Injury Centerís partnerships with professional associations, community groups, national coalitions, prevention specialists, injury researchers, and state and federal health agencies will be advantageous in building support for and disseminating interventions to improve patient safety.

J. Develop and evaluate interventions for reducing disability due to "mild" TBI.

People with "mild" TBI, especially those who are not hospitalized, frequently receive little information about the potential impact of their injuries and may not even be diagnosed by health professionals. Some clinical psychologists report that early counseling and intervention can reduce the likelihood of long-term problems. For example, early training in adaptive strategies to cope with memory problems may minimize an injuryís impact. Identifying appropriate interventions and documenting their effects will support the development of a service infrastructure for people with "mild" TBI.

K. Develop and evaluate injury and disability interventions using biomechanical and computer models.

Knowledge of injury tolerance and injury mechanisms for the most prevalent and disabling injuries among children and adults of different sizes should be applied to the design of injury and disability prevention strategies. These strategies should be evaluated using biomechanical models, "crash dummies," and computer simulation and models.

L. Determine how the environment affects disability from TBI and SCI.

Physical and social factors in the environment may contribute to the risk of disability among people with TBI and SCI. According to the 1991 IOM report Disability in America, physical risk factors are primarily the product of the built or human-made environment, for example, the lack of stair ramps or inadequate transportation. Social factors are a function of the opportunities and expectations that may interfere with a personís ability to get a job; the presence of discriminatory attitudes about the capabilities of people with disabilities is one example. The relationship between these factors and disability among people with TBI and SCI has not been well studied.

M. Investigate the long-term effects of TBI and SCI on the health and longevity of people with disability from these injuries.

Early research suggests that people with disabilities may have shorter life spans and poorer health overall as they age than do people without disabilities. Specific research about the relationship between injury-related disability and long-term health effects is needed to guide interventions to reduce the likelihood of these adverse outcomes as persons with disabilities age. Research should include longitudinal studies of people with TBI- and SCI-related disabilities, as well as studies of older adults who sustain these injuries.

 

 

 


This page last reviewed September 07, 2006.

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