Tackling Post-Acute TBI Care Barriers: A Multidisciplinary Initiative at a Single Institution

Introduction: Moderate to severe traumatic brain injury (TBI) in children presents complex post-acute challenges, including inconsistent care transitions, provider discomfort with behaviors and medications, and variable recovery timelines. Additional barriers include a lack of standardized post-acute guidelines, limited inpatient rehabilitation (IPR) centers, and national shortages of rehab specialists and nurses. To address this, our institution implemented a multidisciplinary care pathway to optimize pediatric post-acute TBI management.


Methods: Goals included early mobilization, timely therapy involvement, delirium screening, medication review, and early IPR referral. A team of critical care physicians, trauma surgeons, advanced practice providers, and physical, occupational, and speech therapists evaluated patients using a standardized tool across five domains: arousal, agitation, cognition, sleep, and pain/spasticity. Medications were adjusted based on family and care team feedback. Both subjective (nursing reports) and objective (modified Rankin Scale, cognitive screening) measures were used.

Implementation involved staff education, daily rounding, and tracking tools. Pharmacologic management focused on reducing benzodiazepine use and selectively using amantadine or other stimulants based on cognitive status. Pathway adherence and discharge disposition were monitored.


Results: In the first year, 38 pediatric TBI patients were identified; 23 survived to discharge. Nineteen patients were evaluated (82.6% compliance) and pathway use increased over time with repeat education and EMR integration. All were seen by rehab services and had nurse-reported updates. Seventeen were discharged home, six to IPR. Patients were predominantly male (59%) and Black (55%). While not statistically significant, evaluated patients had longer ICU stays (15 vs. 10 days), ventilation (10 vs. 7 days), and lower initial Rancho scores (2 vs. 3). Interventions began a median of 10.5 days after admission; 79% showed motor improvement by day 14.


Conclusions: This initiative demonstrates effective implementation of a structured pediatric TBI pathway amid national rehab staffing shortages. Future efforts will target reducing polypharmacy, expediting therapy engagement, and evaluating recovery via Rankin scores.