|Year : 2018 | Volume
| Issue : 2 | Page : 72-94
Minimum technical standards and recommendations for traumatic brain injury rehabilitation teams in sudden-onset disasters
Bhasker Amatya1, Vandana Vasudevan2, Nina Zhang2, Seema Chopra2, Irina Astrakhantseva2, Fary Khan1
1 Department of Rehabilitation, Royal Melbourne Hospital; Australian Rehabilitation Research Centre, Royal Melbourne Hospital; Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
2 Department of Rehabilitation; Australian Rehabilitation Research Centre, Royal Melbourne Hospital, Parkville, Victoria, Australia
|Date of Web Publication||11-Jan-2019|
Department of Rehabilitation, Royal Melbourne Hospital, Australian Rehabilitation Research Centre, Royal Melbourne Hospital, Department of Medicine, University of Melbourne, Parkville, Victoria
Source of Support: None, Conflict of Interest: None
Current advances in disaster response and management have improved survival rates of disaster victims, resulting in overwhelming number of survivors with injuries relative to mortality. These include complex and long-term disabling injuries, such as traumatic brain injury (TBI), spinal cord injury, peripheral nerve injury, musculoskeletal injuries and others. Despite lack of accurate data on TBI in sudden-onset disasters (SODs), it remains a common neurological consequence of armed conflict worldwide. TBI is complex and survivors often have long-term physical, cognitive and behavioural disabilities, residual neurological deficits, medical complications and lifestyle consequences. These necessitate comprehensive interdisciplinary management, including medical, surgical and rehabilitation. The goal of rehabilitation in disaster settings is to improve functional independence and successful reintegration into the community, with an emphasis on patient education and self-management. Rehabilitation of TBI survivors should commence from early-response phase during disasters to minimise disability, prevent secondary injury and should be continued long-term in the community. Specialized rehabilitation teams in any SODs are deployed based on the skill-base and response required to meet specific local needs at the request of host health authorities. These interdisciplinary teams (specialized cells) need to be integrated into emergency disaster response and management plans. This report extends the previously published guidelines for WHO Emergency Medical Teams (EMTs) to establishe minimum standards for development and deployment of TBI specialized rehabilitation team in SODs. Overview of rehabilitation input for TBI survivors by EMT type, and specific recommendations and considerations for the management of the TBI victims for EMTs are provided. These include: deployment decision-making process; elements of making rapid assessment of existing TBI care capacity; leadership & operational support; outreach services; medical and surgical input; human resources, skill mix, team competencies and team configuration; equipment including consumables and pharmacological supplies; discharge & referral; data collection, management and health care records; and exit strategy.
Keywords: Disaster, rehabilitation, standards, traumatic brain injury
|How to cite this article:|
Amatya B, Vasudevan V, Zhang N, Chopra S, Astrakhantseva I, Khan F. Minimum technical standards and recommendations for traumatic brain injury rehabilitation teams in sudden-onset disasters. J Int Soc Phys Rehabil Med 2018;1:72-94
|How to cite this URL:|
Amatya B, Vasudevan V, Zhang N, Chopra S, Astrakhantseva I, Khan F. Minimum technical standards and recommendations for traumatic brain injury rehabilitation teams in sudden-onset disasters. J Int Soc Phys Rehabil Med [serial online] 2018 [cited 2019 Jul 22];1:72-94. Available from: http://www.jisprm.org/text.asp?2018/1/2/72/249854
| Foreword|| |
The rehabilitation of individuals who have suffered from traumatic brain injury can be a complex process. This predominately relates to managing a variable combination of medical, physical, cognitive, behavioral, and emotional symptoms stemming from the widespread impairment of neuronal function caused by the brain trauma. These problems not only affect the individuals involved in terms of limiting their activities and participation in daily life, but also have a direct impact on families, friends, and work colleagues. The multidisciplinary team of doctors, nurses, and therapists involved in the acute care and rehabilitation of people with traumatic brain injury must be highly organized and work in a structure that can prioritize treatments and engage in realistic goal setting with patients and their family.
This is a complicated process in a standard working environment, but becomes much more difficult in the face of a disaster situation where routine management procedures are disrupted and the available resources are often limited. Furthermore, there can be significant disruption of the family support structures available to the individual and access to past medical records. The patients' situation in the postacute phase of disaster relief can be further compromised by the addition of symptoms of posttraumatic stress disorder.
These minimum technical standards and recommendations for traumatic brain injury specialized rehabilitation teams in disaster settings management have been produced by Professor Fary Khan and her team from the Royal Melbourne Hospital in Australia supported by an advisory group including national and international experts in the acute and rehabilitation management of people with traumatic brain injury and/or expertise in disaster relief situations. The Royal Melbourne group has now completed training in disaster relief and has gained clinical experience by having been directly involved in a number of relief efforts after natural disasters in neighboring countries.
As a rehabilitation physician who has specialized in traumatic brain injury rehabilitation for over 30 years, I found the guide comprehensive, well written, and structured for use in the field. The practical experience of the authors and their advisory panel gives this prescriptive guide to managing the acute and rehabilitation treatment of traumatic brain injury in a disaster situation the credibility to be a useful tool in this stressful situation to guide the emergency medical teams and health-care workers through the process of treating this complex condition.
John Olver AM MBBS, MD (Melb), FAFRM (RACP)
Medical Director, Rehabilitation
Victor Smorgon Chair of Rehabilitation
Monash University - Epworth HealthCare
| Working Team|| |
- Dr. Bhasker Amatya (Lead)
- Dr. Vandana Vasudevan (Technical Lead)
- Dr. Nina Zhang
- Dr. Seema Chopra
- Dr. Irina Astrakhantseva
- Prof. Fary Khan (Coordinator).
(All working team members are members of the Rehabilitation Medicine Society of Australia and New Zealand (RMSANZ)).
The authors would like to acknowledge Advisory Group Panel Members for their support, assistance, and technical advice during the process of developing this document. The authors would also like to extend their gratitude to all the individuals and organizational bodies who reviewed this document over the course of its development. Particular thanks are due to ISPRM and the RMSANZ.
- Dr. Alaeldin Elmalik, Rehabilitation Consultant, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Ms. Lauren Fletcher, Speech and Language Therapist, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Prof. Mary P Galea, Physiotherapist and Neuroscientist, Department of Medicine (Royal Melbourne Hospital), University of Melbourne, Parkville, Victoria, Australia
- Prof. Rodney Judson, Trauma Consultant, Trauma Services, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Ms. Marlena Klaic, Occupational Therapists, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Mr. Matthew Lowe, Nurse Unit Manager, Rehabilitation Services, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Dr. Melinda Truesdale, Emergency Medicine Specialist, Emergency Services, Royal Melbourne Hospital, Parkville, Victoria, Australia.
- Prof. Ian J Baguley, Brain Injury Rehabilitation Service, Westmead Hospital, Sydney, New South Wales, Australia
- Dr. Vaidya Bala, Victorian Brain Injury Services, Victorian Rehabilitation Centre, Glen Waverly, Victoria, Australia
- Dr. Raju Dhakal, Spinal Injury Rehabilitation Centre, Kathmandu, Nepal
- Dr. Steven Faux, St. Vincent's Hospital, Darlinghurst, NSW, Australia
- Prof. Peter Feys, Rehabilitation Sciences and Physiotherapy, Universiteit Hasselt, Belgium
- Dr. Sumitha Gounden, Rehabilitation Department, Orange Health Service, Orange New South Wales, Australia
- Dr. Wouter De Groote, Department of Physical and Rehabilitation Medicine, St Jozef, Bornem, Belgium
- Prof. Andy Haig, Physical Medicine and Rehabilitation, The University of Michigan
- Prof. Jorge Lains, International Society of Physical and Rehabilitation Medicine (ISPRM), Centro de Medicina de Reabilitação da Região Centro, Rovisco Pais, Tocha, Portugal
- Prof. Jianan Li, Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Prof. John Olver, Epworth HealthCare, Melbourne, Victoria, Australia
- Dr. Farooq Rathore, Department of Rehabilitation Medicine, PNS Shifa Hospital, Karachi, Pakistan
- Prof. Jan Reinhardt, Institute for Disaster Relief and Reconstruction, Sichuan University-Hong Kong Polytechnic University, Sichuan, Chengdu, China
- Prof. Taslim Uddin, Faculty of Medicine, Department of Physical Medicine and Rehabilitation, BSM Medical University, Bangladesh
- Dr. Shaun Xiong, Rehabilitation and Spinal Services, Christchurch, New Zealand
- Prof. Nathan Zasler, Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia, and University of Virginia, University of Virginia, Charlottesville, Virginia, USA.
- Disaster Rehabilitation – Special Interest Group, Rehabilitation Medicine Society of Australia and New Zealand (RMSANZ)
- Disaster Rehabilitation Committee (DRC), International Society for Physical and Rehabilitation Medicine (ISPRM).
Administrative support and funding
The development and publication of this document was made possible through internal support from the Department of Rehabilitation, Royal Melbourne Hospital.
| Background|| |
Sudden-onset disasters (SODs) (such as earthquakes, hurricanes, floods, fire, and storms) are escalating worldwide, with considerable destruction and significant human casualties. Advances in disaster management have improved the survivor rates of disater victims, resulting in an overwhelming number of survivors with injuries relative to mortality. These include complex and long-term disabling injuries, such as brain and/or spinal cord injury, peripheral nerve injury, burns, and trauma/musculoskeletal injuries.,, These problems necessitate comprehensive interdisciplinary management, including medical, surgical, and rehabilitative support in the acute phase and in longer-term in the community.,
Traumatic brain injury (TBI) is defined as “a traumatically induced structural and/or physiological disruption of brain function due to an external force, indicated by new onset or worsening of at least one of the clinical signs, immediately following the event. These include any period of loss or reduced level of consciousness; any loss of memory for events immediately before or after the injury; any alteration in mental state at the time of the injury (confusion, disorientation, slowed thinking, etc.); neurological deficits (weakness, imbalance, praxis, etc.) that may or may not be transient; or an intracranial lesion.” TBI can be categorized as “closed” or “penetrating” based on damage to the skull and meninges. Its severity ranges from concussion to minimal conscious state (MCS) and can de classified into mild, moderate, and severe based on the extent of damage to the brain [Table 1].,
TBI is a multifaceted and complex pathophysiological process that originates with an acute primary injury, which can progress over time resulting in a variety of secondary injuries. Many TBI survivors often have long-term physical, cognitive, and behavioral disabilities; residual neurological deficits; medical complications; and lifestyle consequences,, which may limit their activities of daily living and participation. It is estimated that 40% of those hospitalized with nonfatal TBI sustain impairments that lead to long-term disability. Based on the WHO International Classification of Functioning, Disability and Health (ICF) framework, the impact of TBI may include impairments (e.g., motor/sensory dysfunction, pain, spasticity, and memory impairment), which in turn limit activity (mobility, self-care, and behavioral changes) and participation restriction (e.g., impaired social and coping skills, apathy, unemployment, interpersonal relationships, driving, etc.). Issues of psychosocial adjustment can progress over time with significant economic impact in terms of delayed return to work and/or normal activities, health service utilization, and caregiver burden.,
The global incidence of TBI is estimated to be between 100 and 300/100,000 population, with mild injuries accounting between 70% and 90% of all TBIs. Approximately 2.2 million emergency department visits and 50,000 deaths occur annually due to TBI in the United States (US) alone. It is a leading cause of death and disability in young people (aged 30 years and below). In Australia, lifetime cost per incident for severe TBI is estimated to be approximately $4.8 million. TBI is the most commonly documented neurological consequence of armed conflict worldwide; however, there are no accurate epidemiological data of TBI in natural disaster settings. In SODs, severe TBI is often sporadic because of low survival rates. A recently published review reported that TBI was the most common nonorthopedic injury reported in earthquakes, followed by thoracic and abdominal injuries. Another review estimated the mean incidence of TBI at 16.7% of total injuries per event. These data may be underestimated and need to be interpreted with caution, as many mild TBI cases may be missed during disasters, as focus is more on visible motor injuries, and not on cognitive emotional and behavioral changes.
Medical rehabilitation is “a set of interventions designed to optimize function and reduce disability in individuals with health conditions (disease [acute or chronic], disorder, injury, or trauma) in interaction with their environment.” Overall, the primary aim of medical rehabilitation, specifically in SODs, is complex and includes assessment of injury patterns and management; needs and resource requirements (including long term); establishment of patient triage, discharge, referral, and tracking systems; collaboration with other health-care service providers; coordination with emergency response systems, host health system, and government managers; education of local health-care providers; and data collection/management.,, The goal is to improve functional independence and enhance participation with an emphasis on patient education and self-management. The interdisciplinary team includes rehabilitation physicians, nurses, and allied health professionals.
The overriding objective of brain trauma care has now extended beyond survival and acute management to successful reintegration of the patient into home and community. The WHO minimum standards for rehabilitation recommendations for managing patients with TBI following SODs are provided in [Box 1].
TBI rehabilitation focuses on comprehensive assessment for neurological and functional limitations and individualized treatment program for specific functional goals with ongoing monitoring of outcomes. Rehabilitation should commence from early-response phase of any disasters for timely/early diagnosis and treatment of disaster survivors to minimize impairments/complications and prevent secondary injury. TBI survivors need support for acquisition of essential skills for maximum return to their previous level of functional independence, regardless of whether specific impairments can be eliminated. Further rehabilitation interventions educate survivors to adapt to disabilities or to make modifications appropriate for their needs during their long-term recovery. There is evidence that comprehensive rehabilitation programs for trauma survivors (including TBI) improve functional outcomes and quality of life.
In many disaster-prone countries, there is a lack (or limited and/or still in infancy stage) of sufficient rehabilitation capacity and specialized services to treat complex injuries such as TBI., The situation is much worse in a large-scale disaster, when local health infrastructure (including rehabilitation resources) can be destroyed or overwhelmed by the influx of new victims. Shortages and/or lack of skilled health-care workforce can further hinder comprehensive management., Hence, in disasters, many countries depend on global humanitarian and medical assistance, reflected by the growing number of emergency medical teams (EMTs) responding to many disasters worldwide., Specialist TBI teams integrated into a disaster response and management plan optimize early diagnosis and management of TBI and prevent early complications. These skills need to be shared with local rehabilitation and health-care providers through mentoring and educating/training.
| Emergency Medical Team for Traumatic Brain Injury|| |
Specialized care teams
Specialized care teams are defined by the WHO as: “national or international teams embedded into EMTs or a national facility to provide specialist care” (rehabilitation teams may fall into this category). Specialized care teams are deployed based on the assessment of quality and services and respond to meet specific needs at the request of the host Ministry of Health (MoH). Specialized care teams adhere to the same guiding principles and core standards as other EMTs as described in the WHO core guidelines “Classification and Minimum Standards for Foreign Medical Teams in Sudden Onset Disaster” and “Emergency medical teams: minimum technical standards and recommendations for rehabilitation” [Box 2]. EMT rehabilitation referral pathway for TBI survivors is detailed in [Figure 1].
|Figure 1: Emergency Medical Team rehabilitation referral pathway for traumatic brain injury|
Click here to view
| Scope|| |
This guidance extends the minimum standards proposed in the “EMT Classifications and Minimum Standards” document and builds on the previous work, the “Minimum Standards and Recommendations for Rehabilitation.” It establishes minimum standards for the development and deployment of TBI specialized rehabilitation team and can be used as evidence in the EMT verification process [Annex 1].
An overview of rehabilitation input for TBI survivors by EMT type and specific discharge considerations in the WHO EMT Rehabilitation Guidelines is detailed in [Annex 2]. The standards are for use in the context of SODs, such as earthquakes and are also applicable to conflict situations, characterized by a significant increase in TBI cases. The recommendations provided in this document are based on the currently available TBI clinical practice guidelines from the rehabilitation perspective.,,,, It is recommended that EMTs support local capacity (rather than provide definitive care) and leave a legacy of trained staff after their departure. This guidance includes the following:
- Deployment decision-making process
- Elements of making rapid assessment of existing TBI care capacity
- Leadership and operational support
- Outreach services
- Medical and surgical input
- Human resources, skill mix, team competencies, and team configuration
- Equipment including consumables and pharmacological supplies
- Discharge and referral
- Data collection, management, and health-care records
- Exit strategy of the EMTs.
| Deployment Decision-Making Process|| |
Following a SOD, a specialized TBI team deployment will be made following a request from the host MoH and assessment from the EMT Coordinating Cell (EMT-CC). As aforementioned, new TBI cases occur frequently in natural disasters and are more common following an earthquake. Therefore, in disasters (specifically high-magnitude earthquakes), it is desirable for specialized cells to declare their availability for a rapid deployment. The host MoH or national trauma center can request support of a TBI specialized care team following a rapid assessment of the estimated number of cases and mapping of the existing capacity in the host country. TBI specialized care teams must coordinate with local teams to avoid service duplication or usurping the existing local services. As such, it is advisable that disaster-prone countries should have regular mapping of trauma and injury centers, including TBI care capabilities, as part of their preparedness activities and disaster management plans. Any decision to deploy a TBI specialized care team will involve verification by the local MoH regarding the status of trauma services in country and the expected number of TBI victims resulting from the disaster. TBI cases should be differentiated from other injuries to enable effective management, as the majority of severe TBI cases require comprehensive multidisciplinary management in specialized facilities. Following a disaster, the MoH should rapidly assess the situation, engage with services, and request international assistance and the level of support needed. Preference should be given to local and/or regional specialized care teams. The length of the deployment needs to be agreed with the MoH (and any local partner organization), prior to deployment. This guidance establishes that EMT TBI specialized care teams must be adequately prepared to provide not just human resources, but also operational and medical supplies and meet all EMT standards for life support. [Figure 2] provides flowchart for deployment decision-making for EMTs.
Type of deployment
The following four scenarios for the type of deployment are considered as possible examples:
- Scenario A: Local TBI specialized/trauma center/s or specialized TBI rehabilitation center/s remain intact, but short-term surge in capacity is requested in the form of staffing to meet increased patient numbers and/or outreach to other medical teams
- Scenario B: Local TBI specialized/trauma center/s or specialized TBI rehabilitation center/s is intact or partly functioning, but surge capacity is requested for inpatient and/or outreach services in the form of additional equipment (including beds) and staffing
- Scenario C: Local TBI specialized/trauma center/s or specialized TBI rehabilitation center/s is damaged or not functioning, but surge capacity is requested to establish a 20-bed inpatient facility alongside an existing tertiary hospital or rehabilitation center. Outreach services in the form of additional equipment (including beds) and staffing may also be part of this activity
- Scenario D: No specialized TBI, TBI rehabilitation center, or rehabilitation expertise exists in the host country/region and support is requested to establish a 20-bed facility alongside an existing tertiary hospital or rehabilitation center. Outreach services in the form of additional equipment (including beds) and staffing may also be part of this activity.
For all four above-mentioned scenarios, it is possible for a TBI specialized rehabilitation cell to offer outreach services to support patient cases who are outlying in nonspecialized centers and who are medically unstable and in need of admission or are waiting for bed space. This service aims to reduce the secondary complications following TBI, thereby reducing the length of stay in hospital and improving coordination between TBI specialized services and trauma hospitals. It is recommended that outreach services include national health-care workers (including community health-care/rehabilitation workers) as well as international staff to promote a good liaison and efficiency. Outreach visits must only be carried out at the invitation of the hospitals to be visited.
Outreach Teams' Terms of Reference
- Provision to provide medical advice and support to local health-care staff in managing TBI cases
- Assistance with identification and triage of TBI cases
- To train family members in essential skills such as mobility, skin care, and positioning to limit pressure ulcer development, bowel/bladder care, diet, etc.
- Make a rapid assessment of identified specialized TBI and/or trauma care centers on the spot.
Medical and surgical input
Early diagnosis and treatment is a priority in all TBI incidents, to manage the acute primary injury and to minimize the development of secondary injuries. Overall, most causes of the mortality from brain injury (65%) are due to secondary brain damage resulting from hypoxia and hypotension. Neurosurgery can be available following a SOD either provided by the local or EMT neurosurgeons. Neurosurgery is a technically demanding specialty requiring expensive resources and, in many developing countries, the availability of this is scarce.,
Surgical treatment of intracranial mass lesions can be basic (burr hole) or advanced (including craniotomy, craniectomy, and treatment of intracerebral hematoma). The aim is to timely decompress space-occupying lesions and thereby to prevent secondary brain injury. In addition, TBI specialized care teams may have the capability to offer the deployment of team members (if requested), specifically neurosurgeons, to embed into a tertiary facility (national or Type 3 EMT), and to advise on the acute management of TBI. This would include:
- Advice on decision-making regarding surgical versus conservative management
- Support for the host facility surgeons in operative management as clinically indicated
- Review outcomes of surgery and advice on the suitability for transfer to rehabilitation settings or return to surgery for further procedures.
The length of deployment is likely to be shorter than that of the specialized rehabilitation team. It would be linked directly to the team; however to ensure rehabilitation is available from the earliest outset. Specific equipment and consumables/instruments for deployment is recommended in [Table 2].
|Table 2: Specialized traumatic brain injury rehabilitation equipment and consumables|
Click here to view
Any exit strategy should be coordinated with the host MoH, EMT-CC, and local TBI rehabilitation services. For Scenarios A and B described above, discussions with the host center about the need for medium term support would ideally be initiated at or before 6 weeks of deployment. This could be better formulated if outcomes of rapid assessment on the existing TBI care are available and further communication plan is set up for ongoing support.
| Technical Standards|| |
Traumatic brain injury Specialized care team
Qualification and experience
Length of stay
Common complications following traumatic brain injury
Recommended general competencies within the traumatic brain injury specialized care team
Recommended specific competencies within the traumatic brain injury specialized care team
| Rehabilitation Equipment, Consumables, and Pharmacological|| |
[Table 2] lists the equipment and consumables for TBI specialized cells/teams to support a 20-bed unit for 2 weeks. The quantity of equipment is provided as a guide only and, if patient numbers exceed 20, additional equipment and consumables will be needed correspondingly. The lists are not exhaustive and do not include equipment necessary to support patients with severe TBI or ventilated patients.
[Table 3] lists the minimum medications needed for a 2-week period, names may vary from country to country and specialized teams may wish to add to this table to reflect the best practice in their place of work.
|Table 3: Commonly recommended pharmacological agents for specialized care teams for traumatic brain injury management in disaster settings*|
Click here to view
It is recommended that any remaining surplus equipment, consumables, and medication are handed over to support the ongoing center's needs at the end of the deployment, provided that staff present are competent in using the equipment, consumables, and medication prescription. Assistive device requirement will be based on the need assessments, as their provision requires early, careful consideration and referral to local services where these exist.
| Discharge and Referral|| |
Recommendations for optimal patient care
- Specialized care teams should adhere to the WHO minimum standards of care
- TBI teams should plan for discharge and community reintegration from early stages of care to identify service gaps, which should be communicated to the host MoH
- EMTs should endeavor to discharge patients only when they are medically stable and when they can safely access their discharge destination (as housing may be inaccessible) and only when they have adequate support to cope
- Patients who continue to require care should be appropriately referred to a step-down facility or a local service provider and community rehabilitation services
- Specialized care teams should handover to the local coordinating cell an updated list of all patients who require rehabilitation follow-up after discharge
- All patients should be referred for follow-up as close to their home as possible
- Specialized care teams should maximize opportunities to prepare patients and their families and care providers for discharge by providing education and functional retraining. This can relieve pressure on over-stretched service provider.
| Information Management|| |
Data collection, documentation, and reporting
The number of patients with newly diagnosed TBI is included in the daily reporting forms for EMTs and submitted to the host MoH coordination cell, with any additional data as required. The ICF Brief core set should be used to identify patient-reported problems for “body functions and structures;” “activity and participation,” and “environmental and personal factors” components, where possible [Appendix 3].
EMT-CC standard paperwork for daily reporting form, patient referral form, and exit form should be used.
Documentation should include a classification and tracking of pressure ulcers and wounds; monitoring/documentation of vital observations, fluid, continence, and cognitive and behavioral management.
| Conclusion|| |
SODs result in significant loss of life and long-term physical impairments including TBI. The overriding objective of TBI care has now extended to successful reintegration of the patient into the community. TBI rehabilitation focuses on a comprehensive assessment of neurological and functional limitations and individualized treatment program for specific functional goals with ongoing monitoring of outcomes. Rehabilitation of TBI survivors should commence from early-response phase of any disasters for timely/early diagnosis and treatment of the survivors to minimize impairments/complications and prevent secondary injury. Specialized rehabilitation teams in any disasters are deployed based on the response to meet specific needs required at the request of the host health authorities. These teams should be multidisciplinary and need to be integrated into a disaster response and management plan and their skills need to be shared with local rehabilitation and health-care providers through mentoring and educating/training. Specialized rehabilitation teams need to adhere to the WHO guiding principles and core standards as other EMTs. This report extends the WHO's “Minimum Standards proposed in the EMT Classifications” and “Minimum Standards and Recommendations for Rehabilitation” documents and establishes minimum standards for the development and deployment of TBI specialized rehabilitation team.
Glossary of terms
A coordination cell is mandated to support (not replace) the host MoH (or equivalent national authority) in coordinating all responding EMTs to best meet the excess health-care needs resulting from the emergency or from damage to the existing capacity. The coordination cell matches available resources to identified needs, ensuring optimal resource use and maximum collective outcomes.
Emergency medical team
EMTs are groups of health professionals and supporting staff outside their area of origin (nationally or internationally), who provide health care specifically to populations affected by emergencies. They include governmental (both civilian and military) and nongovernmental teams. EMTs respond to SODs to treat trauma and surgical cases. Their value in other types of emergencies, such as communicable disease outbreaks, has been demonstrated more recently.
- EMT Type 1: Outpatient emergency care
Outpatient initial emergency care of injuries and other significant health-care needs
- EMT Type 2: Inpatient surgical emergency care
Inpatient acute care, general, and obstetric surgery for trauma and other major conditions
- EMT Type 3: Inpatient referral care
Complex inpatient referral surgical care including intensive care capacity.
An umbrella term for impairments, activity limitations, and participation restrictions resulting from the interaction between people with health conditions and the environmental barriers they encounter (based on the ICF).
A serious disruption of functioning of a community or a society causing widespread human, material, economic, or environmental losses, which exceed the ability of the affected community or society to cope using its own resources.
A set of interventions designed to optimize functioning and reduce disability in individuals with health conditions [disease [acute or chronic], disorder, injury, or trauma) in interaction with their environment.
A serious disruption of functioning of a community or a society causing widespread human, material, economic, or environmental losses, which exceed the ability of the affected community or society to cope using its own resources.
Specialized care team
Specialized care teams are national or international teams embedded into an EMT or a local hospital to provide specialist care. They adhere to the same guiding principles and core standards as EMTs.
A step-down facility is an inpatient unit with a mandate to provide interim care for medically stable patients while they are prepared for discharge into the community.
Disasters that occur with little or no warning, meaning there is insufficient time for the complete evacuation of the at-risk populations.
Traumatic brain injury
A traumatically induced structural and/or physiological disruption of brain function due to an external force, indicated by new onset or worsening of at least one of the clinical signs, immediately following the event.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| Appendices|| |
| References|| |
Vos F, Rodriguez J, Below R, Guha-Sapir D. Annual Disaster Statistical Review 2009: The Numbers and Trends. Brussels: Centre for Research on the Epidemiology of Disasters; 2010.
Reinhardt JD, Li J, Gosney J, Rathore FA, Haig AJ, Marx M, et al.
Disability and health-related rehabilitation in international disaster relief. Glob Health Action 2011;4:7191.
Khan F, Amatya B, Gosney J, Rathore FA, Burkle FM Jr. Medical rehabilitation in natural disasters: A review. Arch Phys Med Rehabil 2015;96:1709-27.
Amatya B, Galea M, Li J, Khan F. Medical rehabilitation in disaster relief: Towards a new perspective. J Rehabil Med 2017;49:620-8.
Rathore MF, Rashid P, Butt AW, Malik AA, Gill ZA, Haig AJ, et al.
Epidemiology of spinal cord injuries in the 2005 Pakistan earthquake. Spinal Cord 2007;45:658-63.
Scottish Intercollegiate Guidelines Network. SIGN 130 Brain Injury Rehabilitation in Adults: A National Clinical Guideline. Edinburgh: SIGN; 2103.
Khan F, Baguley IJ, Cameron ID 4: Rehabilitation after traumatic brain injury. Med J Aust 2003;178:290-5.
Brasure M, Lamberty GJ, Sayer NA, Nelson NW, MacDonald R, Ouellette J, et al
. Multidisciplinary Postacute Rehabilitation for Moderate to Severe Traumatic Brain Injury in Adults. (Prepared by the Minnesota Evidence-based Practice Center under Contract No. 290-2007-10064-I.) Publication No. 12-EHC101-EF. Rockville, MD: Agency for Healthcare Research and Quality; 2012.
Regens JL, Mould N. Prevention and treatment of traumatic brain injury due to rapid-onset natural disasters. Front Public Health 2014;2:28.
Access Economics. The Economics Costs of Spinal Cord Injury and Traumatic Brain Injury in Australia. Canberra: Victorian Neurotrauma Initiative; 2009.
Winker PA. Neurological rehabilitation. In: Umphred DA, editor. Traumatic Brain Injury. 5th
ed., Ch. 17. Missouri: Mosby Elsevier; 2007. p. 532.
World Health Organization. International Classification of Functioning, Disability and Health (ICF). Geneva: World Health Organization; 2001.
Sloan S. Acquired Brain Injury Slow to Recover Program: Report of the therapy review program. Melbourne: Prepared for Victorian Government Department of Human Services ABI: STR Program by Osborn Sloan & Associates Pty Ltd.; 2008.
Cassidy JD, Carroll LJ, Peloso PM, Borg J, von Holst H, Holm L, et al.
Incidence, risk factors and prevention of mild traumatic brain injury: Results of the WHO collaborating centre task force on mild traumatic brain injury. J Rehabil Med 2004;43 (Suppl):28-60.
Centers for Disease Control Prevention; National Center for Injury Prevention and Control; Division of Unintentional Injury Prevention. Report to Congress on Traumatic Brain Injury in the United States: Epidemiology and Rehabilitation. Atlanta, GA: Centers for Disease Control Prevention; 2014.
Brain Injury Association of America. Facts about Traumatic Brain Injury; 2011. Available from: http://www.biausa.org
. [Last accessed on 2017 Sep 12].
Mateen FJ. Neurological disorders in complex humanitarian emergencies and natural disasters. Ann Neurol 2010;68:282-94.
World Health Organization. Emergency Medical Teams: Minimum Technical Standards and Recommendations for Rehabilitation. Licence: CC BY-NC-SA 3.0 IGO. Geneva: World Health Organization; 2016.
MacKenzie JS, Banskota B, Sirisreetreerux N, Shafiq B, Hasenboehler EA. A review of the epidemiology and treatment of orthopaedic injuries after earthquakes in developing countries. World J Emerg Surg 2017;12:9.
Missair A, Pretto EA, Visan A, Lobo L, Paula F, Castillo-Pedraza C, et al.
A matter of life or limb? A review of traumatic injury patterns and anesthesia techniques for disaster relief after major earthquakes. Anesth Analg 2013;117:934-41.
World Health Organization. Rehabilitation in Health Systems. Licence: CC BY-NC-SA 3.0 IGO. Geneva: World Health Organization; 2017.
Rathore FA, Gosney JE, Reinhardt JD, Haig AJ, Li J, DeLisa JA, et al.
Medical rehabilitation after natural disasters: Why, when, and how? Arch Phys Med Rehabil 2012;93:1875-81.
Wade D. Rehabilitation – A new approach. Part four: A new paradigm, and its implications. Clin Rehabil 2016;30:109-18.
Cicerone KD. Participation as an outcome of traumatic brain injury rehabilitation. J Head Trauma Rehabil 2004;19:494-501.
Zhang X, Reinhardt JD, Gosney JE, Li J. The NHV rehabilitation services program improves long-term physical functioning in survivors of the 2008 Sichuan earthquake: A longitudinal quasi experiment. PLoS One 2013;8:e53995.
Amatya B, Khan F. Overview of medical rehabilitation in natural disasters in the Pacific Island countries. Phys Med Rehabil Int 2016;3:1090.
Khan F, Amatya B, Rathore FA, Galea MP. Medical rehabilitation in natural disasters in the Asia-Pacific region: The way forward. Int J Nat Disaster Health Secur 2015;2:6-12.
Khan F, Amatya B, Mannan H, Burkle FM Jr., Galea MP. Rehabilitation in Madagascar: Challenges in implementing the World Health Organization disability action plan. J Rehabil Med 2015;47:688-96.
Rathore FA, New PW, Iftikhar A. A report on disability and rehabilitation medicine in Pakistan: Past, present, and future directions. Arch Phys Med Rehabil 2011;92:161-6.
Centre for Research on the Epidemiology of Disasters. The Human Cost of Natural Disasters: A Global Perspective. Brussels: Centre for Research on the Epidemiology of Disasters; 2015.
Norton I, von Schreeb J, Aitken P, Herard P, Lajolo C. Classification and Minimum Standards for Foreign Medical Teams in Sudden Onset Disaster. Geneva: World Health Organization; 2013.
Colorado Division of Workers' Compensation. Traumatic Brain injury medical treatment guidelines. Denver Colorado Division of Workers' Compensation, Department of Labor and Employment: Division of Workers' Compensation; 2013.
Management of Concussion/mTBI Working Group. VA/DoD clinical practice guideline for management of concussion/Mild traumatic brain injury. J Rehabil Res Dev 2009;46:CP1-68.
Wheeler S, Acord-Vira A. Occupational Therapy Practice Guidelines for Adults with Traumatic Brain Injury. Bethesda: American Occupational Therapy Association, Inc.; 2016.
Zasler ND. Brain Injury Medicine: Principles and Practice. 2nd
ed. New York: Demos Publishers; 2013.
Chesnut RM, Marshall LF, Klauber MR, Blunt BA, Baldwin N, Eisenberg HM, et al.
The role of secondary brain injury in determining outcome from severe head injury. J Trauma 1993;34:216-22.
Khan F, Amatya B, Mannan H, Rathore FA. Neurorehabilitation in developing countries: A way forward. Phys Med Rehabil Int 2015;2:1070.
Mock C, Lormand JD, Goosen J, Joshipura M, Peden M. Guidelines for Essential Trauma Care. Geneva: World Health Organization; 2004.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]