RNs in the Traumatic Brain Injury and Coma Recovery Unit at St. Mary's Hospital for Children, Bayside, NY, transition children and their families from acute care to returning home

by Sandy Keefe, MSN, RN

As director of nursing and assistant vice president of inpatient programs at St. Mary's Healthcare System for Children in Bayside, NY, Linda Mosiello, RN, is proud of the unique nature of the nursing care provided to children on the Traumatic Brain Injury (TBI)/Coma Recovery Unit.

"I remember one time when an experienced nurse unfamiliar with brain injuries was touring the unit," she said. "The nurse remarked the children's behaviors had the 'look and feel of children with psychological disturbances.' She clearly did not understand the unique nature of brain injury."

Unique Approach to TBI

"Children with brain injury may present with variable behaviors that can sway from alert and oriented 1 minute to confused, disoriented and agitated the next," Mosiello explained. "TBI is not a unit a nurse can easily walk into without a full understanding of how to work with this population."

The TBI/Coma Recovery Unit provides a post-acute level of care with an average length of stay of 3-5 months for children with cognitive and physical impairments secondary to a brain injury. Many of these children were born healthy and their admission is secondary to catastrophic illness or injury such as a motor vehicle accident, acute infection, cancer or stroke. All have received intensive acute medical management and are eligible for rehabilitation.

Nurses are an important part of the interdisciplinary rehab team that collaborates to restore children to an optimal level of functioning and help them take back their independence. Nursing care begins with a comprehensive assessment upon admission, and that assessment is updated regularly.

"It means looking at the child's physical status, as well as psychosocial and developmental development," Alex Mirasol, RN, said. "It's a whole unique approach along the spectrum of care."

Parental Involvement

An integral component of the first pediatric TBI/coma recovery program to be certified in New York City, the inpatient unit treats children from a wide geographic area. Many families have sat by the bedside of their critically ill children during the acute phase of care, often at the sacrifice of their home and work responsibilities. The transition to a post-acute center can be challenging for the families as they grieve.

As they develop trust in the TBI team, families learn they can leave the bedside and begin to rebuild their lives. "From the onset, we make every effort to establish a connection with families and get them involved in the plan of care for the child," said Michelle Pierre, RN.

Immediately after the brain injury, parents are often in shock and are consumed by worry about their child's survival. "Once stabilized and transferred to St. Mary's Hospital for Children, the parent's shock has shifted to an overwhelming request: 'Please make him my child again,'" Mosiello said. "That whole transition from the acute-care setting to our post-acute unit is so important. We feel strongly about establishing a partnership with the parents. We'll ask about the child's favorite stories, the songs he likes to hear at bedtime and other details that will help us establish a familiar and home-like environment to promote recovery."

Children who arrive on the TBI unit often are being transitioned off medications. When parents visit, they initially may be dismayed by what they see and express concerns their child is regressing.

"As we discontinue the medications the children were on in the acute-care settings and they start to recover, they may change from a period of sedation to a state of restlessness and agitation," Bency Mathew, RN, said. "We see a lot of behavioral issues during this phase, and parents may say to us, 'My child was never like this.' We sit down with them and explain this pattern is typical of TBI patients coming out of coma."

Parents become part of an interdisciplinary team, meeting with the medical team that includes nurses, behavioral therapists, social workers, physicians, PTs, OTs and speech-language pathologists to discuss how the child is recovering.

Consistency & Flexibility

After many years of working with youngsters who have brain injuries, the seasoned nurses on the unit have achieved a delicate balance in their approach to the children.

"TBI nursing is a combination of consistency and flexibility, planning and problem-solving as a team," said Danielle LaRose, LPN.

How do the nurses determine the right mix of consistency and flexibility? "Nursing is an art," Mirasol said. "There's not one approach that works across the board. As each day goes by on our unit, we have to work as a team to figure out what's best for each child."

Each child has a unique behavioral care plan established by the interdisciplinary team under the direction of behavioral health staff and social workers. "One thing that holds true is the consistency of carrying out that plan," Mosiello explained. "It's not uncommon for a child to present with a new behavior as he recovers, and the team responds by calling an emergency meeting that afternoon to come up with a plan for everyone to deal with that behavior in a consistent manner."

"When we face a novel situation, we as healthcare professionals adapt ourselves to that situation — that's flexibility," said Evelyn Buan, RN. "Flexibility can apply to our work with the parents as well. We may need to work around less-than-ideal home situations we can't change in order to meet the needs of the child."

Complex Nursing Care

The nursing care delivered on the TBI/Coma Recovery Unit is complex, combining aspects of pediatric critical care, behavioral health nursing and rehabilitation nursing.

"Remember, these children were living a normal life at home before an event that caused a coma or brain injury, and now they might have central lines, trachs, G-tubes, TPN [total parenteral nutrition], IVs, PCA pumps to deliver morphine, and multiple other medications," Mathew said. "There's a lot of round-the-clock nursing care required, and a lot of teaching for the parents. They want to know why the child has a G-tube, how long that tube will be in place, and what that means for life at home."

As the children recover, the nursing process is used to continuously re-evaluate and address their needs.

"This is a pain-free hospital not only in terms of physical pain, but emotional pain as well," Mirasol said. "We have a dedicated pain management team that is committed to exploring all aspects of pain relief, including medication, Reiki therapy, aromatherapy, visual imagery, and therapeutic play to help reduce their discomfort."

St. Mary's Healthcare also is proud to be a restraint-free environment. "As these children emerge from coma and have extensive behavioral manifestations, we don't use chemical or physical restraints," Mosiello said. "If a child is at high risk because of those behaviors, we will provide one-on-one observation care rather than use of restraints. We will put a person in place to calm, quiet, distract and support the child as he emerges from coma."

A Sense of Normalcy

As they deliver the compassionate and skilled nursing care that promotes recovery and patient participation in the rehabilitation process, nurses focus on the child within each patient.

"Children with TBIs have complex nursing needs and need a great deal of support with activities of daily living; surrounding all that, we are trying to establish a sense of normalcy in their lives," Mosiello said. "Therapy sessions are worked around their schedule, which includes mealtime, school, homework and recreation, so there is a path to getting back to that perceived sense of normalcy."

Child-life therapists provide carefully crafted activities to provide just the right level of stimulation for each child.

"We try very hard to foster the wonderful feelings of childhood within our patients, and that effort shows in the smiles as they're playing, enjoying aromatherapy, listening to music or joining in a recreational activity," Mosiello said. "We have bowling, movies, swimming, celebrity visits and a host of other events. The trained professionals in our well-structured therapeutic recreation department do an amazing job each and every day."

Children wear regular clothing on the unit rather than patient gowns, and attend an onsite public school if their conditions allow. "We're very proud of our family-centered care, which means we support both the child and his family members," Mathew said.

"Being with these children 12 hours a day is my other life; I may spend more time with them than with my own family on the days I work," she said. "This type of nursing is very personal to me."

Sandy Keefe is a frequent contributor to ADVANCE.