The effect of delay in rehabilitation on outcome of severe traumatic brain injury.

BACKGROUND: Expeditious care within minutes of severe injury improves outcome and is the driving force for development of trauma care systems. Transition from hospital care to rehabilitation is an important step in recovery after trauma-related injury. We hypothesize that delay in the transition from acute care to rehabilitation adversely affects outcome and diminishes recovery after traumatic brain injury (TBI).
METHODS: After institutional review board approval, the trauma registry of our regional level I pediatric trauma center was queried for all children with severe blunt TBI (initial Glasgow Coma Scale score </=8) that required inpatient rehabilitation. Records were stratified as severe TBI (Glasgow Coma Scale [GCS] scores 3, 4, 5) and moderate TBI (GSC scores 6, 7, 8). Intensity of acute care was defined by need for mechanical ventilation and length of intensive care unit stay. Outcome was defined by functional independence measurement (FIM) scores at time of transfer to inpatient rehabilitation. Linear regression was used to compare time in days between discharge from intensive care and admission to inpatient rehabilitation (delay) to rehabilitation efficiency (RE), defined as the ratio of FIM score improvement to length of stay for inpatient rehabilitation. Functional improvement was determined by analysis of FIM score improvement (DeltaFIM) between initiation and completion of inpatient rehabilitation.
RESULTS: Between January 2000 and December 2006, 60 children (38 males, mean age, 11.2 years; 22 females, mean age, 10.6 years) with blunt TBI and an initial GCS score of 8 or lower required resuscitation, comprehensive critical care, and inpatient rehabilitation. Mean length of stay in the intensive care unit was 11.1 +/- 7.4 days. Fifty-two children required an average of 9.4 +/- 6.8 ventilator days. Delay ranged between 0 and 24 days (mean, 4.1 days) and was significantly correlated with RE and DeltaFIM (correlation coefficient = -0.346, P = .0068). For children with the highest potential for salvage (GCS scores 6, 7, 8), RE correlation increased to -0.457 (P = .011), whereas those with most severe injury (GCS scores 3, 4, 5) demonstrated a weaker correlation that was not significant. For children with most severe injury (GCS scores 3,4,5), the correlation of DeltaFIM was significant (-0.38; P = .035); however, RE was not.
CONCLUSIONS: These data demonstrate the price of delay of comprehensive rehabilitation, especially for the most vulnerable TBI children with best potential for salvage. The "golden hour," which has become the mantra for continued refinement of systems of emergency and trauma care, must progress without interruption to the "golden day," during which comprehensive critical care seamlessly transitions to timely and aggressive rehabilitation to effect the greatest functional recovery.