A Fumbled Handoff to Inpatient RehabCommentary by LauraEllen Ashcraft, MSW, and Jeremy M. Kahn, MD, MS
An 18-year-old man with no significant past medical history sustained a traumatic brain injury after a motor vehicle collision while driving intoxicated. The patient was admitted to a regional trauma center and required a decompressive craniectomy (removal of part of the skull bone) due to brain swelling as a result of his injury. He survived, but required prolonged care in the adult trauma intensive care unit (ICU).
His neurologic status remained poor, and he required a tracheostomy due to difficulty weaning from mechanical ventilation as well as placement of a percutaneous endoscopic gastrostomy (PEG) tube for nutrition. After a 3-week hospitalization the patient was transferred to a pediatric acute rehabilitation facility. He was scheduled to return to the trauma center for cranioplasty (repair of the skull defect) in 2 weeks. The plan was for him to continue to be weaned from the ventilator and receive physical and occupational therapy at the rehabilitation facility, likely for a period of several weeks to months.
The patient became increasingly agitated during his rehabilitation stay, and he eventually pulled on and broke his PEG tube. This necessitated a return to interventional radiology at the trauma center for removal of the retained PEG tube bulb. The patient was then admitted to the hospital for cranioplasty. He appeared to be doing well postoperatively and was transferred back to the pediatric acute rehabilitation center on postoperative day 2, which was a Friday afternoon.
The next day (Saturday), he had an acute change in mental status and new onset seizures. He was emergently transferred to the ICU at the pediatric hospital affiliated with the rehabilitation facility—not the adult facility where his surgeries had initially been performed. A stat head CT showed enlarged ventricles and a midline shift, indicating acute hydrocephalus (obstruction of the outflow of cerebrospinal fluid from around the brain). After realizing another surgical procedure would be needed, the patient was then transferred back to the trauma center, where an extraventricular drain was placed. After the procedure, the patient was then transferred back again to the rehabilitation facility, despite concerns on the part of the facility staff about the complexity of the patient's needs.