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New Assessment Aims to Improve Safety at Home for People with Traumatic Brain Injury

Shepherd Center develops new patient-centered tool to assess risk and inform changes.

The human brain is an incredible machine. It helps orchestrate our every move, thought and emotion – often seamlessly. But in people recovering from traumatic brain injury (TBI), there may be lapses in this complex coordination that increase the likelihood of potentially harmful situations and poor decisions. In fact, unintentional injuries are the leading cause of death following TBI once a patient has discharged from the hospital.

“Most of these events are preventable, so we need be able to anticipate and plan for potential risks after patients leave the rehabilitation setting,” said Ron Seel, Ph.D., the O. Wayne Rollins Director of Acquired Brain Injury Research at Shepherd Center.

Under Dr. Seel’s leadership, Shepherd Center has developed a dynamic assessment tool to gauge and predict the risk of someone having unsafe events after returning home. The Safety Assessment Measure (SAM) has been developed with input from caregivers and patients for more than a year, and researchers have studied its use with 155 patients with TBI.

SAM asks caregivers 99 items about how well the person with TBI performs everyday activities to predict the overall risk of unsafe events especially related to: 1) carrying out activities; 2) walking mobility; 3) wheelchair mobility; 4) judgment; 5) health decision-making; and 6) self-control. The research team is still testing scales that assess safe operation of a motor vehicle and taking care of children.

Higher scores on SAM scales indicate a greater likelihood of an unsafe event; lower scores are associated with lower risk. But this assessment goes beyond simply assigning a score or likelihood of something happening. The SAM scales and items flag areas of concern to guide decisions about additional rehabilitation, logical next steps as goals, if home or behavioral modifications are needed, how much supervision is needed and what activities are deemed safe.

While other scales are available, Dr. Seel says they don’t provide as complete a picture of someone’s risk for harm after TBI.

“It’s important because this tool not only tells us the likelihood that something unsafe could happen, but based on a person’s severity of risk, it also gives very specific information for what activities should be the focus of therapy and what activities might be beyond their reach currently,” Dr. Seel explaied. “It’s a great example of personalized medicine, and it’s grounded in patients’ and families’ real-world experiences.”

Improvements have been made to make the report more user-friendly – in part, to help save time and maximize any therapy patients might receive after discharge.

“It means therapists and coaches have much more information at their disposal from the beginning,” Dr. Seel said. “Instead of spending lots of time on assessments, they can walk in with a feel for what the person can do, their challenges, what kind of assistive devices they use and the like.”

Other institutions are taking note. In 2014, Shepherd Center was awarded a grant from the Emory Center for Injury Control to translate the paper-and-pen research version of SAM into a Web-based program that can be completed online. The new electronic version will reduce the number of items respondents need to answer for each safety scale. It will also be center stage in an upcoming randomized controlled clinical trial called Safe@Home – made possible by a $600,000 grant from the National Institute on Disability, Independent Living and Rehabilitation Research.

This study will enroll up to 130 dyads of patients and family members to evaluate whether using the SAM – coupled with 10 in-home visits for prevention education and skills training – compared to usual care can improve a person’s independence in activities, while also reducing the number of unsafe events.

“Families want their loved one to be safer, and patients want to do more activities,” Dr. Seel said. “It’s their mindset, so we’ve included two outcomes. If effective, we will consider whether this type of program can eventually be delivered remotely and to individuals living alone.”

The goal is to expand SAM to help predict risk for injury in people with spinal cord injury, stroke and neurologic diseases, Dr. Seel noted.

Common Unsafe Events

Some of the more common unsafe events experienced by people recovering from TBI include:

  • Falls while walking or doing a wheelchair transfer
  • Inappropriate behavior or judgment in social situations
  • Incidents using motorized equipment
  • Property loss due to mismanaging money or other valuables

How the Safety Assessment Measure Works

Someone with a moderate level of risk has a 30 percent chance of an unsafe event, such as a fall. If that person is sleeping well, the risk of falling goes down, but if they consume any alcohol, the risk goes up. At this level of risk, it might be reasonably safe for the person to walk on even surfaces, but he or she might need to take extra care walking up and down stairs – making sure to hold the railing or having someone walk behind them – and avoid carrying things while walking. In this case, the individual might benefit from balance and endurance training, Dr. Seel noted.

Written by Amanda Crowe, MA, MPH

About Shepherd Center

Shepherd Center provides world-class clinical care, research, and family support for people experiencing the most complex conditions, including spinal cord and brain injuries, multi-trauma, traumatic amputations, stroke, multiple sclerosis, and pain. An elite center recognized as both Spinal Cord Injury and Traumatic Brain Injury Model Systems, Shepherd Center is ranked by U.S. News as one of the nation’s top hospitals for rehabilitation. Shepherd Center treats thousands of patients annually with unmatched expertise and unwavering compassion to help them begin again.