The State Implementation and Scaling-up of Evidence-based Practices (SISEP) Center is a national technical assistance center funded by the U.S. Department of Education’s Office of Special Education Programs. Through this subcontract, the UW SMART Center has a subcontract to develop a micro-credentialing program on implementation science (IS) for educators, and to develop and convene a national community of practice of educators focused on application of IS.
Targeted Condition: Trauma/Traumatic Brain Injury (TBI)
Noninvasive tracking of intracranial pressure to improve care of traumatic brain injury
Following severe cases of traumatic brain injury (TBI), the brain can swell, leading to elevations in intracranial pressure (ICP). Patients who develop high ICP following severe TBI are more likely to have poor neurologic recovery from their injury, and control of ICP likely contributes to improved outcomes. ICP detection and management is typically guided by invasive monitors placed through the skull and into the injured brain. These devices are highly accurate and reliable, but they are also expensive and expose the patient to rare but potentially serious risks. This is problematic because as few as one-third of patients are found to have elevated ICP, even when the best available evidence is used to guide their placement.
Using ultrasound to measure optic nerve sheath diameter (ONSD) could be an inexpensive, noninvasive and reliable means of monitoring ICP. Located behind the eye, the optic nerve sheath surrounds the nerve carrying visual signals to the brain. Increases in intracranial pressure are transmitted into this conduit, causing it to dilate. Ultrasound-measured ONSD has been shown to correlate with ICP in many neurologic conditions, including TBI, but it has not been systematically evaluated as a screening or a monitoring tool.
This study will routinely measure ONSD in patients undergoing invasive ICP monitoring for severe traumatic brain injury at Harborview Medical Center. The goal is to determine whether ONSD measurement with ultrasound can be combined with readily available clinical data to improve the prediction of elevated ICP, and to assess whether it can be used to monitor ICP during a patient’s hospital stay. If successful, ONSD measurement could have a significant impact on TBI care in both high and low resource settings.
Opioid prescription and use following traumatic brain injury
Traumatic brain injury (TBI) is common in the United States with 2.87 million emergency department visits related to TBI per year. Chronic pain is a frequent complaint following TBI, with more than half of patients reporting pain. Individuals with TBI are often prescribed opioids for pain following their injury, but unfortunately may be especially vulnerable to post-injury alcohol and drug use problems.
Despite increased opioid prescriptions and risk factors for this population, there are no clinical practice guidelines for opioid prescription following TBI and limited published research. The project seeks to address this knowledge gap by using routinely collected clinical data from several different data sources to examine when and how opioids are prescribed following TBI in a community-based population.
This complete picture of opioid prescription following TBI may reveal trends of higher opioid prescription for specific subpopulations or areas of healthcare. Through understanding the trajectory of opioid prescription following TBI, we will be able to identify the scope of the problem and the most appropriate time points for intervention. Ultimately this project will provide the foundation for new approaches to reduce opioid prescription in the clinical management of TBI.
Harnessing the ECHO Model to help Washingtonians with Traumatic Brain Injury (TBI)
Traumatic brain injury (TBI) is a major cause of disability in Washington state and throughout the US. TBI increases the risk and complexity of multiple behavioral health conditions including post traumatic stress disorder, depression, anxiety, irritability, anger/aggression, substance misuse and cognitive impairment. In addition, TBI impairs a person’s ability to manage their health care and increases the risk of unemployment, long-term functional impairment, and caregiver burnout. Successful TBI recovery can depend in large part on access to and engagement in behavioral health treatment. Unfortunately, TBI-focused community resources are scarce and fragmented. Treatment of post-TBI symptoms often falls to community providers who have little support and are under-prepared to manage these complexities. This burden disproportionally affects rural providers who have little access to specialist care at academic centers.
The purpose of this project is to create and assess the use of the ECHO (Extension for Community Healthcare Outcomes) model to provide education and support by experienced TBI experts to community providers who treat persons with TBI. The ECHO model uses both a virtual educational lecture series and patient case discussion to improve provider preparedness to treat patients and improve patient outcomes. We will launch a monthly to bi-monthly program that will train providers from a variety of disciplines and settings in identification and evidence-based behavioral health treatments, web technologies and mobile technologies, and provide detailed case consultation. We will assess the success, reach and impact of our TBI ECHO by collecting and comparing attendee experiences, clinical information and patient outcomes.
This project received two years of additional funding from the Washington State Department of Social and Health Services.
Improving resilience and recovery from traumatic events using the ECHO model
Most adults in the US experience a traumatic event at some point in their lives. Trauma is linked to the development of mental health disorders, increased suicidality, work and relationship impairment and increased physical health conditions. Effective treatments exist, but many people don’t receive these treatments because of a lack of providers who are trained in evidence-based, trauma-focused treatment, especially those in rural or underserved areas.
This project aims to build, implement and test an ECHO (Extension for Community Healthcare Outcomes) model for disseminating evidence-based, trauma-focused care, both psychotherapy and pharmacotherapy approaches, to providers working with underserved communities in Washington state. The team will evaluate the impact and reach of the training model, with the goal of expanding the ECHO approach to improve trauma-informed mental health care throughout Washington.
Improving access to cognitive rehabilitation treatment following mild traumatic brain injury
More than a million people in the US sustain a mild traumatic brain injury (mTBI) every year, and many report difficulties with attention, memory and other thinking abilities months and even years following their injury. A promising treatment option is cognitive rehabilitation, but the full-length (20 hours), in-person intervention is not feasible for many people due to time and financial constraints.
This study will evaluate a brief (6 hours), virtual cognitive rehabilitation intervention developed for individuals with persisting cognitive difficulties after mTBI. We will evaluate several outcomes related to improving patient care including treatment satisfaction, feasibility of this intervention when using telehealth and preliminary effectiveness. The proposed treatment aims to provide the same clinical impact of traditional cognitive rehabilitation while reducing burden and increasing access.
Brain Injury Rehabilitation: Improving the Transition Experience (BRITE)
Moderate to severe traumatic brain injury (TBI) is a common cause of long-term disability. Persons with TBI receiving care in inpatient rehabilitation facilities (IRFs) are at risk for rehospitalization, poor community reintegration, family stress, and other unfavorable outcomes. In a six-center randomized pragmatic comparative effectiveness study, we compare the effectiveness of two methods for transition from IRF to the community. The Rehabilitation Discharge Plan (RDP) includes patient/ family education and referrals for continued care. The Rehabilitation Transition Plan (RTP) provides RDP plus individualized, manualized care management via phone or videoconference. 900 patients will be randomized, with caregivers also invited to participate. Assessed outcomes include societal participation, quality of life, caregiver well-being, and use of healthcare resources at 6-months and 12-months post-discharge.
Validating a non-invasive imaging method to measure astroglial water transport in brain health and disease
We aim to determine the accuracy and specificity of Arterial spin labeling (ASL) — a non‐invasive perfusion technique used in MRI to track cerebral blood flow — in measuring vascular and glial‐dependent water transfer to establish whether it is a valuable clinical tool in Alzheimer’s disease. This simple and safe technique, already approved for use in a clinical setting, has potential to circumvent current invasive approaches in human subjects at risk for AD‐related dementias.
Does the microbiome play a role in adverse outcomes following mTBI and PTSD?
The proposed research will be a preliminary investigation into the potential association between microbiota abundance, hormone levels, peripheral inflammation and current symptoms (psychiatric and cognitive) in Veterans with and without a history of mild traumatic brain injury (mTBI). This work has the potential to form a new line of research that could ultimately provide new treatment options for individuals who have persisting symptoms following mTBI.
Disseminating a user-friendly guide: Advancing the science of intervention adaptation and improving access to evidence-based psychological treatment
Adaptation of evidence-based practices and programs (EBPs) is a necessary component of the implementation process. EBPs must be adapted to function with the constraints of real-world practice settings, providers’ expertise, and patients’ needs. The science of intervention adaptation is hungry for well-defined methods of EBP adaptation to guide decision making. A how-to guide for EBP adaptation titled MODIFI: Making Optimal Decisions for Intervention Flexibility during Implementation, is under development with NIMH funding (F32 MH116623). MODIFI will be disseminated via multiple strategies locally, nationally, and internationally. Dissemination of MODIFI will improve the practice of intervention adaptation by providing practitioners with a how-to guide that is (a) evidence-based, (b) usable, and (c) supported by the expert consensus of implementation practitioners and researchers.
