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Screening And Evaluation Of Possible Traumatic Brain Injury

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timetowinarace

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VHA DIRECTIVE 2007-013

1. PURPOSE: This Veterans Health Administration (VHA) Directive establishes policy and procedure for screening and evaluation of possible traumatic brain injury (TBI) in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans. 2. BACKGROUND a. TBI is a common form of injury in service men and women serving in OEF and/or OIF. Details on the screening and management of TBI can be found in the Employee Education System Veterans Health Initiative (VHI) module (see par. 5). As experience with this condition in OEF and OIF veterans accumulated, it became clear that screening for possible TBI in OEF and OIF veterans could contribute to ensuring that cases are identified and treatment implemented. b. In response to this need, VHA established a task force including members with expertise in Physical Medicine and Rehabilitation, Neurology, Psychiatry, Psychology, Primary Care, Prevention, and Medical Informatics to develop a screening tool and evaluation protocol. Although TBI is a significant public health problem, currently there are no validated screening instruments accepted for use in clinical practice. Therefore, the task force reviewed existing literature on screening for TBI, examined the efforts of individual military Medical Treatment Facilities and Department of Veterans Affairs (VA) Medical Centers that had implemented TBI screening locally, consulted with the Defense and Veterans Brain Injury Center (DVBIC), and considered data on the natural history of TBI. Based on these efforts, the task force developed a screening instrument to assist in identifying OEF and OIF veterans who may be suffering fromTBI, and a protocol for further evaluation and treatment of those whose screening tests are positive. c. A national clinical reminder, VA-TBI Screening, was built incorporating this screening instrument. The reminder has several elements, as follows: (1) The first step of the reminder is to identify possible OEF and/or OIF participants based on whether date of separation from military duty or Active Duty status occurred after September 11, 2001. Similar to the OEF/OIF Post-Deployment Screening Reminder, the initial questions address location of deployment. The definition of OEF and/or OIF participant is the same as used for the OEF/OIF Post-Deployment Screen with OEF which includes service in: Afghanistan, Georgia, Kyrgyzstan, Pakistan, Tajikistan, Uzbekistan, the Philippines, and an “other” category; and OIF which includes service in Iraq, Kuwait, Saudi Arabia, Turkey, and an “other” category. The screening is done once for all individuals who report deployment to THIS VHA DIRECTIVE EXPIRES APRIL 30, 2012

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VHA DIRECTIVE 2007-013 April 13, 2007 2 OEF-OIF Theaters, to be repeated if the date of separation has changed due to repeat deployment. The reminder recognizes if screening was completed prior to the most recent date of separation. (2) The reminder then asks whether the patient has already been diagnosed as having TBI during OEF or OIF deployment. Positive answers can be based on patient or caregiver self-report or health records from VA or non-VA sources. Positive answers lead to an option to order a referral for follow-up if the patient does not have current follow-up and wants assistance. (3) For those who confirm OEF or OIF deployment and do not have a prior diagnosis of TBI, the instrument proceeds using four sequential sets of questions. If a person responds negatively to any of the sets of questions, the screen is negative and the reminder is completed. If the patient responds positively to one or more possible answers in a section the next section will open in the reminder to continue the screening process. The four sections are: (a) Events that may increase the risk of TBI. (B) Immediate symptoms following the event. © New or worsening symptoms following the event. (d) Current symptoms. (4) If a person responds affirmatively to one or more questions in each of the four sections, the screen is positive and arrangements for further evaluation is offered. The reminder prompts the user to place a consult for further evaluation, or documents refusal. d. Not all patients whose screen is positive have TBI. It is possible to respond positively to all four sections due to the presence of other conditions, such as: Post-traumatic Stress Disorder (PTSD), cervico-cranial injury with headaches, or inner ear injury. Therefore, it is critical that patients not be labeled with the diagnosis of TBI on the basis of a positive screening test. Patients need to be referred for further evaluation. e. The VHA task force also developed a defined protocol for completing the additional evaluation by a specialized team. It includes the completion of a twenty-two itemneurobehavioral symptom inventory. (1) When any symptom is positive, the protocol provides recommendations on physical examination, diagnostic testing, and recommendations for initial treatment interventions and referral pathways for persistent symptoms. (2) It is possible that patients may have co-existing diagnoses, such as PTSD and TBI, and these must be appropriately evaluated. Given the expertise required to establish a diagnosis of TBI and implement appropriate treatment, the protocol must be completed by Component II Polytrauma Network Sites or Component III Polytrauma Support Clinic Teams existing within the VHA Polytrauma System of Care (see Att. A). If there is no Component II or Component III

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VHA DIRECTIVE 2007-013 April 13, 2007 3 Team at the medical center, the medical center has the option of having the evaluation completed by a specialist with appropriate background and skills, such as a neurologist, who has also had training in the evaluation protocol. f. Between 24 and 59 percent of patients with traumatic spinal cord injury (SCI) have a concomitant TBI. The SCI system of care has the extensive multidisciplinary expertise needed to provide the required evaluation and care. Screening and evaluation are handled by the SCI team for patients followed in the SCI system of care and the initial treatment is provided by SCI Center personnel. 3. POLICY: It is VHA policy that all OEF and OIF veterans receiving medical care, within VHA, must be screened for possible TBI; those who, on the basis of the screen, might have TBI must be offered further evaluation and treatment by clinicians with expertise in the area of TBI. 4. ACTIONa. Veterans Integrated Service Network (VISN) Chief Information Officer. The VISN Chief Information Officer is responsible for ensuring that all medical centers install patch PXRM*2.0*8 which installs the VA TBI Screening clinical reminder and reminder dialog. This patch was made available April 2, 2007. b. National Director for Primary Care. The National Director for Primary Care is responsible for ensuring that: (1) Screen captures and training material for the current version of the VA TBI Screening reminder are posted at http://vista.med.va.gov/reminders/index.html . (2) The reminder is kept up to date and modified, as needed, in the face of advancing clinical knowledge. NOTE: Any updates in the reminder will be implemented using a national IT patch. c. National Director for Physical Medicine and Rehabilitation. The National Director for Physical Medicine and Rehabilitation is responsible for: (1) Maintaining a defined protocol for evaluation of those who might have TBI, based on responses to screening. This protocol must include initial treatment interventions and must be posted at the Physical Medicine and Rehabilitation TBI website at: http://vaww1.va.gov/rehab4veterans/page.cfm?pg=20 . (2) Providing training materials in the protocol for Component II and Component III polytrauma team members and any other specialists who will be completing the protocol. (3) Working with each VISN Chief Medical Officer to develop clear referral protocols, identifying which Component II or III team(s), or other specialists, are to complete the secondary specialty evaluation for each VA medical center.

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VHA DIRECTIVE 2007-013 April 13, 2007 4 d. SCI Center Chief. Each SCI Center chiefs is responsible for ensuring that their staff has been trained in completing the evaluation protocol and for making it available at their SCI Center. e. Facility Director. Each Facility Director is responsible for ensuring that: (1) The National VHA TBI Screening clinical reminder is assigned at the “system” level, or “division” level at all divisions, in the Computerized Patient Record System (CPRS). It is to be available to all users and must be “locked” so that it is not removable by individual users. (2) The reminder is completed for all OEF and OIF veterans who present at the facility for medical care, regardless of the clinic in which they are seen, or the reason for presentation (see Att. B for a flow chart demonstrating the process). (3) When a veteran screens positive for possible TBI, the findings are discussed with the patient by an appropriate clinical staff member and further evaluation is offered. Consults for further evaluation must be submitted, but only after discussion with and agreement by the patient. The clinical staff member must document refusal by the patient within the progress note (using the clinical reminder dialog) if further evaluation is declined. (4) A medical center service is clearly identified for initial management of the consults generated by positive screens. Generally this service is located at the facility; however, it is acceptable for the service to be located at another facility, such as one where the covering Component II or III polytrauma team is located. (5) The identified service initiates contact with the referred patient within 1week, to assist in arranging the recommended evaluation. If initial contact effort is unsuccessful, follow-up efforts must include at least two telephone calls 1 week apart followed by a certified letter. These efforts and any refusals by patients to participate in the recommended evaluation must be documented in the progress notes of the patient’s health record. (6) The patient with possible TBI is offered a comprehensive evaluation by a Component II or a Component III polytrauma team. For sites that do not have a Component II or Component III team and wish to complete the evaluation protocols locally, other specialists such as neurologists can be identified to complete the evaluation protocols locally after completing training. For patients in the SCI system of care, the evaluation protocol is done by a designated SCI team. (7) All staff at the facility involved in completing the evaluation protocol have completed the recommended training on the evaluation protocol. 5. REFERENCES: Veterans Health Initiative (VHI) teaching module, “Traumatic Brain Injury,” found at http://www.va.gov/vhi/

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VHA DIRECTIVE 2007-013 April 13, 2007 5 6. FOLLOW-UP RESPONSIBILITY: The National Director for Primary Care (11PC) and Chief Consultant for Rehabilitation are responsible for the contents of this Directive. Questions should be referred to (202) 273-8558 (Primary Care) or (202) 273-8484 (Rehabilitation). 7. RECISSIONS: None. This VHA Directive expires April 30, 2012. Michael J. Kussman, MD, MS, MACP Acting Under Secretary for Health DISTRIBUTION: CO: E-mailed 4/13/07 FLD: VISN, MA, DO, OC, OCRO, and 200 – E-mailed 4/13/07

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VHA DIRECTIVE 2007-013 April 13, 2007 A-1 ATTACHMENT A VETERANS HEALTH ADMINISTRATION (VHA) POLYTRAUMA SYSTEM OF CARE 1. COMPONENT I: Polytrauma Rehabilitation CentersFour regional Polytrauma Rehabilitation Centers (PRCs) provide acute comprehensive medical and rehabilitation care for the severely injured. They maintain a full team of dedicated rehabilitation professionals and consultants from other specialties related to polytrauma. These PRCs, serving as resources for other facilities and assisting in the development of care plans, are located at Richmond, VA, Tampa FL; Minneapolis, MN; and Palo Alto, CA. 2. COMPONENT II: Polytrauma Network SitesTwenty one Polytrauma Network Sites (PNS) provide specialized, post-acute rehabilitation services in consultation with the PRCs in a setting appropriate to the needs of veterans, service members, and families. There is one PNS in each of the twenty-one VHA Networks, including one at each of the four Component I PRC sites. Each PNS has a dedicated interdisciplinary teamwith specialized training, providing proactive case management for existing and emerging conditions, and identifying resources for Department of Veterans Affairs (VA) and non-VA care. 3. COMPONENT III: Polytrauma Support Clinic TeamsPolytrauma Support Clinic Teams (PSCT) are local teams of providers with rehabilitation expertise who deliver follow up services in consultation with regional and network specialists. They are located at many, but not all, Medical Centers that do not have a Component I or Component II center. PSCTs assist in the management of stable polytrauma sequelae through direct care, consultation, and the use of telerehabilitation technologies, as needed. 4. COMPONENT IV: Polytrauma Points of ContactPolytrauma Point of Contacts (PPOC) are present in facilities that do not have Component I, Component II, or Component III services. Facilities that do not have the necessary services to provide specialized care must have a designated PPOC to ensure that patients are referred to a facility capable of providing the Component of services required. PPOCs commonly refer to the PNS and PSCTs within their network.

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VHA DIRECTIVE 2007-013 April 13, 2007 B-1 ATTACHMENT B FLOW CHART FOR SCREENING AND EVALUATION OF POSSIBLE TRAUMATICBRAIN INJURY (TBI) IN OPERATION ENDURING FREEDOM (OEF) AND OPERATION IRAQI FREEDOM (OIF) VETERANS

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VHA DIRECTIVE 2007-013 April 13, 2007 C-1 ATTACHMENT C FREQUENTLY ASKED QUESTIONS REGARDING TRAUMATIC BRAIN INJURY IN OPERATION ENDURING FREEDOM (OEF) AND OPERATION IRAQI FREEDOM (OIF) VETERANS 1. Do patients who are coming only for compensation and pension examinations, but are not receiving any medical care within the Veterans Health Administration (VHA), need to have the screen completed?No. Patients who present solely for compensation and pension exams do not need to have the screen completed. These patients are not being seen in VHA for medical care, but are being seen only for a specified disability assessment at the request of Veterans Benefits Administration (VBA). 2. Do active duty military personnel who served in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) need to have the screen completed?No. The screen is not mandated for such patients. Screening is optional. Follow-up of positive screens for this population may require referral back to their usual source of care in the military health system, depending upon the authorization received for VHA care. 3. Is screening to be done only in Primary Care or only in the “nexus clinics?” No. Screening is required for all patients receiving medical care within VHA, not just primary care or the nexus clinics. Patients seen in Dental, Emergency Room, or Urgent Care, and any other specialtyclinic; or receiving inpatient care are to have the screen performed and the reminder completed. 4. Can patients with positive screens be referred to local non-VA practitioners or clinics for further evaluation? All evaluations for positive screens are to be done by designated specialists who have completed training in the evaluation protocol. Most commonly these are VHA Component II or Component III teams, or Spinal Cord Injury (SCI) teams. They have the multidisciplinary skills to complete the thorough evaluation required, and have been trained in the evaluation protocol. For medical centers that do not have a Component II or Component III team, it is possible to identify other staff specialists, such as neurologists, to have received, or will receive, training in the use of the evaluation protocol. Data is collected systematically on the results of the evaluations as well as the screens. NOTE: This allows VHA to understand the breadth of the TBI problem in the OEF and OIF veterans, and allows VHA to continuously improve its services. 5. Are only physicians and other practitioners with independent privileges allowed to complete the screens and submit referrals?No. Other clinical staff members are allowed to perform the screens and complete the reminder. However, this staff needs to have completed the Veterans Health Initiative (VHI) Traumatic Brain Injury(TBI) module. They need to understand the basics of TBI and what the evaluation protocol involves, so that they can respond to veterans questions knowledgeably and accurately. NOTE: Medical Centers can allow such clinical staff members to submit referral consults through approved standing orders approved by the medical staff.

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Thanks Time,

Wow what an abundance of great info. Another example of what I am learning from hadit. You wont find this kinda stuff in the waiting room at VA. Thanks for you research and posting.

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  • HadIt.com Elder

Screening for TBI should include ALL veterans. Exspeally Vietnam & Desert storm.

I believe TBI may also be caused by expermental vaccines.

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Guest Vietnam Tanker

Allan, I too believe that all Vet's should be covered and It is my feeling that the VA TBI team is also of that thought. My primary Care Doc submitted my medical history to the team in Tampa and the team called me to schedule a screening exam this month, this is all due to a GSW (gun shot wound) to the head in Nam in 1968, so it looks to me like they are at least trying to do a study of known wounded from the Vietnam Era. JMHO

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