BHQ - CCPC TBI Overview 2019

Traumatic brain injury pathway
Nanthasak Tisavipat, MD
TBI program director
Overview of TBI pathway
Performance Measures
Content and Data management in
TBI pathway
Lesson learn from TBI

pathway
2
Global incidence of traumatic brain injury (TBI)
SEVERITY OF TBI
Severe
Moderate TBI
TBI 8%
11%
Mild TBI
81%
SEAR= Southeast Asia Region Dewan MC, et al. J Neurosurg. 2019; 130: 1080–1097. 3
Epidemiology of TBI: Thailand
4
Epidemiology of TBI in BHQ
• Trauma inpatients 2019 = 906 cases
Eye Trauma
Plastic 18 Burn 286 patients
Spine 28 2% 1 were included
72 3% 0%
8% in TBI pathway
Neuro
General Surgery
301
93
33%
10%
Other
108
12%
Ortho
285
32%
5
• To provide comprehensive and
Mission compassionated neurological care

through integrated multidisciplinary of
health team.
• To provide quality of care and quality of

Goal life of patient with Traumatic Brain
Injury
6
Traumatic Brain Injury Pathway
Objective
• To standardize the clinical care process and ensure the

continuum of care for traumatic brain injury patients.
• To guide the clinical care to all healthcare personnel involved.
• To improve patient safety and reduce the risk that may occur
during the care processes.
• To promote self awareness and quality of life in traumatic
brain injury patients and family in short and long term.
7
Board of Director
BHQ Committee
Communication Workflow
Ethics Joint Executive
Committee Committee
❖ BGH- Bangkok General Hospital
❖ BHT- Bangkok Heart Hospital
❖ WSH- WattanosothHospital
❖ BHN- Bangkok Hospital Huahin
Institutional ❖ BSN- Bangkok Sanamchan Hospital
Review Board Group 1 ❖ BPR- Bangkok Hospital Petchaburi
Executive Committee ❖ BMR- Bangkok Muangraj Hospital
❖ RAH- Royal Angkor Hospital
Clinical Rapid ❖ RPH- Royal Phnom Penh Hospital
Improvement ❖ TCH- Transitional Care Hospital
❖ BIH- Bangkok International Hospital
Committee
Education
Critical Care and Training
Committee
Medical Quality
Committee
Executive Management
Committee Committee
Employee
Anesthesia and Wellness
Surgical Care Committee
Committee
Primary Stroke
Environment of
Pharmacy Therapeutic Acute Myocardial Infarction
Care Committee
and Transfusion
Committee Heart Failure
Diabetic Mellitus Type II Supply
Chain Management
Medical Records Committee
Committee
Low Back Pain
Breast Cancer Information
Management
Infection Control Trauma Brain Injury
Committee
Committee
Total Knee Replacement
8
2 ways communication
BIH Hospital Director
Mr. Michael Mitchell
PCU Director of Neuroscience

Dr.Apichart Pisarnpong TBI Pathway
Program director
Dr.Nanthasak Tisavipat Organization Chart
Program manager
Mrs.Chutikan Suwalapa
Nurse coordinator
Emergency Operating Professional Data supporting

OPD IPD CCD
department room supporting team team
Neuroscienc Total Quality

6D ICU-1 Clinical Nutrition
e Rehabilitation Green Line and Cost
pharmacy therapeutic
team Synergy Co,Ltd Improvement
department department
Center
Orthopedics 7D ICU-7-8
Surgery 6B
4 BIH 9
Journey of TBI pathway
2016; Guideline for the Management
2012; Seizure Prophylaxis 2013; TBI Medical of Severe TBI. 4th Edition.
in Patients with TBI Treatment Guideline
2017; Severe TBI 2017; Seizure Prophylaxis
2007; Guideline for the Management in Patients with TBI
Management of Severe
2014; Head Injury, triage, assessment, 2018; Guideline for
TBI. 3rd Edition.
investigation and early management of head Concussion/ Mild TBI &
injury in children, young people and adults. Persistent Symptoms
2018; ATLS
2008: Clinical policy: neuroimaging and
2014; Severe TBI 2015; ACS TQIP Best Practice
decision making in adult mild traumatic
Management in the management of TBI
brain injury in the acute setting
2012 2013 2015 2016 2017 2019 May 2019

Initiation of TBI CCPC TBI Update TBI CCPC TBI BDMS CoE Update TBI Implement TBI
pathway accreditation protocol recertification neuroscience protocol network
▪ To synergize
▪ To standardize
▪ To analyze
10
Reference guidelines in TBI pathway
▪ Guideline for the management of severe TBI, 4th edition, Brain trauma foundation 2016.
https://braintrauma.org/guidelines/guidelines-for-the-management-of-severe-tbi-4th-
ed#/:guideline/3-hyperosmolar-therapy
▪ Seizure prophylaxis in patients with traumatic brain injury (TBI), Department of Surgical Education,
Orlando Regional Medical Center, Approved 8/27/2012, Revised 7/26/2017.
▪ Severe traumatic brain injury management, Department of Surgical Education, Orlando Regional
Medical Center. Revised 2/6/2013, 2/17/2014, 3/29/2016, 5/4/2017.
▪ Guidelines for Concussion/mTBI and Persistent Symptoms: 3rd Ed., Ontario Neurotrauma
Foundation 2018.
▪ 10th Advanced Trauma Life Support® Student Course Manual, American College of Surgeons., 2018.
11
Updated CPG of TBI Pathway
No Previous Currently Ref.
(Rev.2 2018) (Rev.3 2019)
1 Add definition Dangerous mechanism of Injury The 10th ATLS, 2018.
Criteria
• Death in same passenger compartment
• Vehicle telemetry data consistent with high
risk of injury
2 Mod/Severe TBI Mod/Severe TBI Severe traumatic brain injury management,
• MAP > 70 mmHg • SBP > 100 mmHg Orlando Regional Medical Center, 2017.
3 GCS 3-8 GCS 3-8 Severe traumatic brain injury management,

• PaCO2 35-45 mmHg • PaCO2 35-40 mmHg Orlando Regional Medical Center, 2017.
• PaO2 80-120 mmHg • PaO2 ≥100mmHg
4 • ICP< 20 mmHg • ICP monitoring criteria Severe Traumatic Brain Injury, 4th Edition, BRAIN
• CPP 60-70 mmHg • ICP < 22 mmHg, cerebral perfusion pressure TRAUMA FOUNDATION, 2016.
(Trauma brain, 2016) (CPP) > 60 mmHg Severe traumatic brain injury management,
Orlando Regional Medical Center, 2017.
12
Updated CPG of TBI Pathway
No Previous Currently Ref.
(Rev.2 2018) (Rev.3 2019)
5 None Surgical criteria Severe Traumatic Brain Injury, 3th Edition, BRAIN
• Epidural hematoma TRAUMA FOUNDATION, 2007.
• Subdural hematoma Severe Traumatic Brain Injury, 4th Edition, BRAIN
• Intracerebral hemorrhage/ Traumatic TRAUMA FOUNDATION, 2016.
parenchymal lesions
• Depressed skull fracture
• Refractory intracranial hypertension
6 None Safety discharged for home observation follow Guideline for Concussion/Mild Traumatic Brain
all criteria for mild TBI Injury & Persistent Symptoms 3rd Ed 2018 .
Ontario Neurotrauma foundation
7 None Seizure prophylaxis for severe TBI Seizure prophylaxis in patients with traumatic
- Phenytoin (Dilantin®) brain injury (TBI), Orlando Regional Medical
- Fosphenytoin (Cereneu®) Center, Approved 8/27/2012, Revised 7/26/2017.
- Leveltiracetam (Keppra®)
8 None Tetanus vaccination CDC. Updated Recommendations for Use of
Tetanus Toxoid, Reduced Diphtheria Toxoid and
Acellular Pertussis Vaccine, 2018.
13
Inclusion Criteria Exclusion Criteria
• Age >=15 years old • Penetrating head injury
• Head injury within 72 hours • Unstable hemodynamic (systolic
after accident blood pressure < 100 mmHg or
• With or without multiple cardiopulmonary resuscitation
organs injury (CPR) at arrival)
• Pregnancy
• Current condition with brain
diseases which cannot do self-
care e.g. bed ridden
• Patient or relative refuse care
14
Moderate
- Monitor
Mild - O2 saturation ≥ 95%
Low risk - SBP ≥ 100 mmHg
- Symptomatic treatment - CT brain & C-spine
- Lab and cross matching
- Monitor V/S, N/S
- Pain control
- V/S, N/S q 15 min
High risk
- CT brain +/- C-spine
- Consult neurosurgeon Severe
- Symptomatic treatment - Intubation
- Pain management - Monitor
- Surgery if indicated - O2 saturation ≥ 95%
- SBP ≥ 100 mmHg
-Observe V/S, N/S
- ETCO2 35-40 mmHg
- Multidisciplinary team (avoid hyperventilation)
- Admit if indicated - +/- ABG
- Head of bed
- CT brain & C-spine
- Lab and cross matching
- V/S, N/S q 15 min
V/S= Vital signs
N/S = Neuro-signs 15
From Policy to Documentation
16
Trauma Brain Injury Pathway
Consent form (TH, EN, Japan)
Every TBI patient should consent to enter and benefit of pathway.
17
Integrated care process for TBI patients
Multidisciplinary approach
ER/OPD
nurse
18
Rehabilitation and nutrition assessment for TBI inpatients
19
Discharge planning
1. Patient’s condition and expected discharge date
2. Education for patient, family and caregivers
– Health education
– Home medication
– Necessary procedures such as suction,
percussion, tube feeding
– Daily activity and hygiene
– Safety environment
3. Home rehabilitation program, position, and transfer
4. Neurological observation, follow up plan, and
contact number
20
Discharge Criteria
Mild Low Risk Mild High Risk Moderate & Severe
From • Normal mental status (alertness/behavior/cognition) with clinically improving • Normal and stable vital signs,
hospital post-concussion symptoms after observation until at least 2 hours post-injury neurological signs and clinical signs at
• CT Normal CT scan result or no clinical risk for CT scan least 72 hours
• No clinical indicators for prolonged hospital observation such as: • Normal consciousness
✓ Clinical deterioration • None of abnormal neurological
✓ Persistent abnormal Glasgow Coma Scale (GCS) or focal neurological deficit condition, headache, nausea or
✓ Persistent abnormal mental status vomiting
✓ Vomiting/ severe headache • Readiness of caretaker for continuation
✓ Presence of known coagulopathy of care at home
✓ Persistent drug or alcohol intoxication
✓ Presence of multi-system injuries
✓ Presence of concurrent medical problems
From (2 weeks after discharge) (3 months after discharge) (6 months after discharge)
Pathway • follow up within 2 weeks after • follow up within 2 weeks after • follow up within 2 weeks after
discharge , discharge, discharge ,
• normal vital signs and neuro signs; • normal vital signs and neuro signs; • normal vital signs and neuro signs; none
none of abnormal neuro system none of abnormal neuro system of abnormal neuro system condition,
condition, headache, nausea and condition, headache, nausea and headache, nausea and vomiting;
vomiting; vomiting; Follow up
Follow up for Mild high risk TBI • At 1 month: Depression rescreening
• At 3 month: EuQoL, Fall functional (PHQ9)
assessment (BBS<45), Cognitive • At 3 month: EuQoL, BBS 21
assessment • At 6 month: Modified GOS, BBS
Self-supporting management
TBI booklet
- 3 Languages
- Download from hospital website
22
23
24
Designed discharge summary report

for e-clinical program
Referral report for

referred cases Template of e-mail follow up
25
Cooking class Blenderized diet and swallow training
@Bangkok hospital headquarters @Chiva transitional care hospital
26
Notify
neurosurgeon and
TBI Coordinator if
score < 45
Fall risk assessment Call follow up

Education
within 6 months
Booklet: safety
in the house
27
TBI network training 2019
Learning topics
1. CCPC Traumatic Brain Injury Supporting
Tools and Communication Channel
2. Overview & Experience Form TBI
Program
3. Evidence Base Practice for
Management of Traumatic Brain Injury
4. CCPC Guideline Development &
Algorithm
5. Multidisciplinary Team Approach for
the Best Care of TBI Patients
6. Rehabilitation in Traumatic Brain In
Multidisciplinary Team Approach for the
Best Care of TBI Patients
7. TBI Data Registry and KPIs
28
ICP monitoring teleconference
and workshop 2017 and 2019
29
30
TBI e-learning program & test Number of Percentage of
Department
staffs participation
Passing
Hip and Knee Center 4 100
score Center of Excellent (Neuro) 6 100
Center of Excellent (Ortho) 2 100
Clinical Pharmacy 18 100
Emergency 46 100
ICU 7 & ICU 8 58 100
Imaging 7 100
Intensive Care Unit 1 30 100
Neurology 25 100
Nutrition Therapeutic 11 100
Operating Room 2 100
Operating Room (BIH) 6 100
Orthopedic Surgery 13 100
Rehabilitation II 42 100
Surgery Unit 13 100
Ward 4 BIH 18 100
Ward 6B 15 100
Ward 6D 43 100
Ward 7D 32 100
Grand Total 392 100 31
TBI simulation training
BDMS simulation center
Staffs RN , PN Core Team TBI

- TBI Mild high risk
- TBI Moderate & severe 68%
Year 2019
52%
Year 2018
Cumulative rate of
participation
(Total staffs=284) 32
Yearly CME
TBI Management
33
System & clinical tracer
TBI campaign 2019
34
Hospital-wide
communication
via AMPOS ERM
application
35
Public awareness
“Injuries from fall”
3 Apr 2019
4 scenarios
1. Accident and patient escort
2. Traumatic brain injury
3. Bone fracture repair
4. Rehabilitation
36
Public awareness
• Songkran day
- 7 days campaign during long weekend
- to prevent road traffic accident
37
Public awareness
• The helmet project
– For community
– For staff’s safety
38
Public awareness
CSR: Fall prevention

ชุมชนโรงปูนเหนือและใต้ “ห่ างไกล ไร้ ล้ม”
39
Public awareness
Traumatic brain injury and
neurosurgery management
Public seminar
@ Myanmar
@ Laos
@ Cambodia
40
Performance Measures and
Data management in TBI pathway
41
Demographic data of TBI pathway 2012-2019
GENDER
Number of TBI patients 2012-2019 Male
3285
Female
48%
1200 3540
1084 52%
971
NATIONALITY
1000 956 947 930
846 Non-Thai
803 1224
800 18%
Thai
600
SEVERITY 5601
Moderate Severe 82%
79 37
400 1% 1%
288
Mild low-
200 risk
3082
Mild high- 45%
0 risk
2012 2013 2014 2015 2016 2017 2018 2019 3627
53%
Total 6,825 cases 42

TBI pathway 2017-2019
2017 2018 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 YTD-19
Number of TBI
983 878 83 78 91 75 67 88 81 86 89 88 821
patients
13 7 0 0 0 2 1 0 0 2 0 0 7
Excluded
(1.3%) (0.8%) (0%) (0%) (0%) (2.7%) (1.5%) (0%) (0%) (2.3%) (0%) (0%) (0.9%)
40 25 2 1 2 3 2 0 1 4 3 0 11
AMA/refer
(4.1%) (2.8%) (2.4%) (1.3%) (2.2%) (4%) (3%) (0%) (1.2%) (4.7%) (3.4%) (0%) (1.3%)
930 846 81 77 89 70 64 88 80 80 86 88 803

Included
(94.6% (96.6%) (97.6%) (98.7%) (97.8%) (93.3%) (95.5%) (100%) (98.8%) (93.0%) (96.6%) (100%) (97.8%)
43
TBI pathway 2017-2019
Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- YTD-
2017 2018
19 19 19 19 19 19 19 19 19 19 19
Mild TBI
381 317 38 29 36 20 22 46 29 32 30 35 317
(low risk)
Mild TBI
536 519 43 45 52 50 41 42 51 48 56 52 428
(high risk)
Moderate
12 10 0 2 0 0 1 0 0 0 0 1 4
TBI
Severe TBI 1 0 0 1 1 0 0 0 0 0 0 0 2
Total 930 846 81 77 89 70 64 88 80 80 86 88 803
44
GENDER
Male Top 10 Nationality of Foreigner
1157
45%
JAPANESE 118
Female
1422 CHINA 37
55%
KOREAN SOUTH 32
FRENCH 24
BRITISH 22
NATIONALITY
AMERICAN 20
Non-Thai GERMAN 17
451
17% INDIAN 17
MYANMAR 12
Thai
2128 AUSTRALIAN 11
83%
0 20 40 60 80 100 120
Number of TBI patients
45
Age group Cause of injury by age group 2017-1019
(WHO 2018)
AGE GROUP 15-29 young adult 100% 16 8
50
>=85 30-49 adult 236
109
75-84 141
162 50-64 older adult
292 6% 80% 8
11% 15-29 65-74 youngest-old 31 47
472 75-84 middle-old 60%
65-74 18%
331 > 85 oldest-old 285 266
155 251 153
13% 342
50-64 30-49 40%
503 819
20% 32% CAUSE OF INJURY
20% 145
RTA Accident Assault 194 101
481 561 86 30 1
10
19% 22% 3% 0%
15-29 30-49 50-64 65-74 75-84 >=85
Fall RTA Fall Assualt Other accidents
1451
56%
RTA: road traffic accident
46
Performance Measures and Improvement
Performance Measures Numerator Denominator Metric Time report
1. Door to CT brain read by Number of patients with moderate to Total number of moderate to Percentage Monthly
neurosurgeon within 60 mins in severe TBI who had CT brain read by severe TBI patients who had
moderate to severe TBI neurosurgeon within 60 mins of arrival CT brain
Make new agreement with radiologists 2019:

1=CT trauma body Notify neurosurgeon immediately after
% CT brain is done.
100 100 100 Target > 95 %
100
4=CT trauma body
80 1=Clinical condition 67 67
60 1=Delay notification
40 33 Read by part-time
Direct feedback
radiologist
20
N/A N/A N/A N/A N/A N/A 0
0
Numerator 11 3 0 2 1 0 1 0 0 0 0 0 4
Denominator 11 9 0 3 1 0 1 0 0 0 0 1 476
Performance Measures Numerator Denominator Metric Time
report
2. Percent of cases where Number of patients with a surgical decision to Total number of severe TBI Percentage Monthly
surgical decision to operation operation within 60 mins in severe TBI, who have who have surgery. (Exclude
within 60 mins in severe TBI indication for emergency (Exclude patient GCS = 3 in patient GCS = 3 in brain
brain death condition) death condition)
Reference: NICE
% clinical guideline 176: Triage, assessment, investigation and early management of head injury in children, young people and
adults. 2014. page 23-24
% Target > 90%

100
100
80
Minimal tSAH Multiple injury
60 (urgency/semi-elective) (Need other intervention: abdominal angiography
40 for pelvic artery embolization)
20
N/A N/A 0 0 N/A N/A N/A N/A N/A N/A N/A 0
0
Numerator 1 0 0 0 0 0 0 0 0 0 0 0 0
Denominator 1 0 0 1 1 0 0 0 0 0 0 0 482
3. Percentage of TBI patients who Number of TBI patients who had a Total number of the TBI Percentage Monthly
had fall during first 30 days post fall during the first 30 days after patients who reach 30 days
discharge. discharge from the hospital. post hospitalization.
%
Target 0%
5
Encourage
4
3.41 home program
2 = accident
3 1 = during exercise/activity by PT
2
1 = syncope
1.56
1 0.50
0.35
0.11 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
0
Numerator 1 3 0 0 0 0 1 3 0 0 0 0 4
Denominator 930 846 81 77 89 70 64 88 80 80 86 88 803
49
Fall during first 30 days post discharge
Case Cause of fall Solution Outcome
- Fall during praying - Provided education to patient and caregivers
Male
- Patient refused to do BBS - Advised to use wheelchair, walker and home - No fall
84 yo
assessment before discharge rehabilitation 3 times/week
- Frequent syncope due to - Consulted arrhythmia clinic then urgent
Famale
arrhythmia appointment to place pacemaker at Ramathibodi - No fall
46 yo
- BBS 18/56 (dizziness) hospital (public hospital)
Female - Fall from sofa
- Provided education to patient and caregivers - No fall
43 yo - Cognitive impairment
Advised to
Female - Accident in bathroom - use floor mat in bathroom
- No fall
93 yo - BBS score 25/56 - use bedpan at nighttime
- stay with caregiver all the time
50
Fall during first 30 days post discharge
2 = accident
home
1 = during exercise/activity environment
1 = syncope External adjustment
factors
Refer to
4 cases of fall Consult PM&R for multidisciplinary
within 30 days risk identification
Individual
Internal factors
exercise program
51
4. Percentage of unexpected revisit Number of patients with mild TBI Number of mild TBI patients Percentage Monthly
to hospital within 24 hours in mild revisiting with same diagnosis within (OPD cases)
TBI 24 hours after discharge (OPD cases)
% Target < 5%
5
1 0.4
0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0
0
Numerator 0 2 0 0 0 0 0 0 0 0 0 0 0
Denominator 527 474 41 42 52 45 38 40 44 41 50 48 441
52
Performance Measures Numerator Denominator Metric Time
report
5. Percentage of Cognitive function A number of the in-patient with mild TBI (high Total number of in-patient Percentage Monthly
screening at discharge in in-patient risk) who was done cognitive function screening with mild TBI (high risk)
with mild TBI (high risk) . by occupational therapist prior to discharge. who were discharged.
Reference: State of Colorado, Department of Labor and Employment. Traumatic Brain Injury Medical Treatment Guidelines. 2012; page 22.
Target > 90%
Communicate in pathway monthly meeting
%
100 100 100 100 100
100 94 93 92 93 93 94
88 88
80
60
40
20
0
Numerator 313 258 6 15 14 14 12 7 13 13 14 16 124
Denominator 313 258 6 16 14 15 13 8 14 14 16 16 53
132
Program improvement project:
Reduce in-hospital falls-related TBI

In-hospital falls resulting in TBI(2018-2019)
IN HOSPITAL FALL TBI non-TBI Number of in-hospital falls 2018-2019
2018-2019
10
2018: 15 TBI cases 2019: 17 TBI cases
TBI 8
32 6
6 3 6
27% 6 8
non-TBI 4 3 7 6 4 3 5
4 2 2 6 4 4
87 2 2 2 4 4
2 2 2 3 3 2 2 2
73% 1 1 1 1 1 1 1 1 1 1
0
Oct-18
Oct-19
Feb-18
Feb-19
Apr-18
Jul-18
Jun-18
Sep-18
Nov-18
Apr-19
Jul-19
Jun-19
Sep-19
May-18
May-19
Jan-18
Dec-18
Jan-19
Mar-18
Aug-18
Mar-19
Aug-19
Number in-hospital falls-related TBI in each wards 2018-2019
4
3
2 4 4
3 3 3
1 2 2 2 2
1 1 1 1 1 1 1
0
55
NATIONALITY LEVEL OF FALL PRECAUTION
Severity of falls Indian
Burmese Indonesian
1
High Strict
1 1
1 3% 3% 3%
Arabic 4% Standard
25
5 10
16% 31%
20 Thai Strict
23 21
74% 66%
15 14
10 ACTIVITY BEFORE FALL

Transfering
1 During rehab into/out of bed
5 Moving about in
8
Sitting in chair
1 1 bed
SHIFT
5 3% 3%
1 1 4 7
1 1 Night Morning
0 12% 22%
11 11
34% 35%
Walking
6
19% Toileting/Showering Evening
2018(N=15) 2019(N=17) 13 10
41% 31%
56
Total = 32 cases
Cause of falls 2018: 15 cases
2019: 17 cases Compliance to TBI pathway of In-hospital falls
20
2018 2019
15
100
9
10
80
60 71
5 8
2 40
1 3 40
2 1 2
1 1 1 1 20
0 20 8
0
Film skull/CT Brain Included in TBI Pathway
Year Film skull or CT brain Include in TBI pathway

2018 (15) 3/15=20% 1/13*=8%
2019 (17) 12/17=71% 6/15*=40% 57
2018 2019
Project improvement: reduce in-hospital falls-related TBI
Activity-Knowledge sharing and walk round
58
TBI pathway roadshow: IPSG 6 focus tracer: 2019
October 2019
59
Safety environment and facilities Ongoing Project Motion Sensor Project- 6D,5R
FALL
SIT
STAND
WALK
RUN
TRANSPORT
SLEEP
Push- call for help
BGH BIH
Product & Service

1. Current activity status
2. Motion sensor- fall risk detection
3. Call for help
4. 2 way communication
5. Fall notification
60
Alarm scenario
61
NEXT Plan
From Hospital to Home
62
Lesson learn from TBI pathway
63
Lesson learn from TBI pathway
▪ Positive brain CT scan in mild high risk TBI

▪ BBS evaluate & education program
▪ How to implement to whole network
TBI patients with positive brain CT scan 2018-2019
GENDER
Female Mild TBI (high-risk) with brain CT scan = 970 cases

26
37%
positive brain CT scan = 70 cases
Male AGE GROUP
44
63% >=85 yo 15-29 yo
7 8
75-84 yo 30-49 yo
13
10% 11%
12 CAUSE OF INJURY
19% 17%
assualt
50-64 yo 1
65-74 yo 10 1%
20 14% accident
29% 9
Road traffic 13%
accident
14 fall
20% 46
66%
POSITIVE BRIN CT SCAN
(NUMBER OF LESION)
Epidural hematoma Mild TBI (high-risk) with brain CT scan = 970 cases
5
traumatic SAH 5%
24 Positive brain CT scan = 70 cases
27%
acute SDH Need neurosurgery = 10 cases
38
Brain contusion
43%
22
25%
OPERATION IN TBI CT POSITIVE PATIENT TYPE OF OPERATION

Need operation
10
14% neuro
4
40%
Not required facial
operation 6
60 60%
86%
High-risk criteria of mild-TBI patients with positive brain CT scan
Loss of concious 25
History of coagulopathy, on antithrombotics 25
Dangerous mechanism of injury 15
Diffuse headache 14
Known case of neurological disease 13
Amnesia 10
Suspected skull fracture 4
GCS 13-14 4
poor cooperative/language barrier 3
History of alcohol and/or illicit drug 2
Recurrent vomitting 2
New neurological deficit 1
Post-traumatic seizure 1
0 5 10 15 20 25 30
Fall-risk medication in mild-TBI patients with positive brain CT scan
Antiplatelets 26
ARBs 18
Glucose lowering agents 15 Chronic disease in mild-TBI patients
Calcium channel blockers 15 with positive brain CT scan
Beta-Blockers 9
Sedatives/BZD 8
Antiepileptic drug 8 Endocrine 22
Acetylcholinesterase inh. 7
Thiazide diuretic 5
Herbs increase bleeding CVS 17
5
Anticoagulants 5
Antivertigo drugs 4 Neuromuscular 12
SSRIs/SNRIs 4
Antipsychotic drugs 3
Loop diuretic Renal 1
3
Alpha-1 blocker 3
Antiemetics 2 Liver 1
Muscle relaxants 2
Anticholinergics 2
ACEIs Hemato 1
2
Dopamine agonists 1
Antihistamine 1 0 5 10 15 20 25
Antianginals 1
0 5 10 15 20 25 30
BDMS TBI network
BHQ Variation of severity of TBI
• Surrounding hospital
BPH RPH
• Traffic condition
SVH SNH PTY2
260 beds public
hospital
250 beds 50 beds
university hospital 250 beds private hospital
public hospital
BPH 400 beds
80 beds
private hospital
400 bed
new hospital
80 beds
private hospital
110 beds
private hospital
RPH 400 beds 500 beds
500 beds
69 hospital
private
public hospital
BDMS TBI network
BHQ Variation of severity of TBI
• Surrounding hospital
BPH RPH
• Traffic condition
SVH SNH PTY2 150 beds
166 beds private hospital
private hospital
325 beds
private hospital
BHQ 518 beds

500 beds
military hospital SNH 400 beds
1,200 beds 200 beds
military private hospital
medical school
1,300 beds
medical school
PYT2 260 beds
109 beds
private hospital
120 beds
private hospital
1,200 beds
Supertertiary
public hospital
SVH 275 beds 70
BDMS TBI network
BHQ
BPH RPH
SVH SNH PTY2
71
Q&A
Thank You 72

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Traumatic brain injury pathway

Lesson learn from TBI

Mission compassionated neurological care

• To provide quality of care and quality of

• To standardize the clinical care process and ensure the

PCU Director of Neuroscience

Emergency Operating Professional Data supporting

Neuroscienc Total Quality

2012 2013 2015 2016 2017 2019 May 2019

3 GCS 3-8 GCS 3-8 Severe traumatic brain injury management,

Designed discharge summary report

Referral report for

Fall risk assessment Call follow up

Staffs RN , PN Core Team TBI

CSR: Fall prevention

Total 6,825 cases 42

930 846 81 77 89 70 64 88 80 80 86 88 803

Total 930 846 81 77 89 70 64 88 80 80 86 88 803

Make new agreement with radiologists 2019:

% Target > 90%

Reduce in-hospital falls-related TBI

10 ACTIVITY BEFORE FALL

Year Film skull or CT brain Include in TBI pathway

Product & Service

▪ Positive brain CT scan in mild high risk TBI

Female Mild TBI (high-risk) with brain CT scan = 970 cases

OPERATION IN TBI CT POSITIVE PATIENT TYPE OF OPERATION

BHQ 518 beds

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