VA's Directive 2010-012, TBI Secreening and Evaluation

Department of Veterans Affairs
VHA DIRECTIVE 2010-012
Veterans Health Administration
Washington, DC 20420
March 8, 2010
SCREENING AND EVALUATION OF POSSIBLE TRAUMATIC BRAIN INJURY IN
OPERATION ENDURING FREEDOM (OEF) AND OPERATION IRAQI
FREEDOM (OIF) VETERANS
1. PURPOSE: This Veterans Health Administration (VHA) Directive updates policies and procedures 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 injury found in servicemembers serving in OEF and OIF. Details on the screening and management of TBI can be found in the Employee Education System Veterans Health Initiative (VHI) module (see paragraph 5). As occurrences of this condition in OEF and OIF Veterans increased, screening for possible TBI in OEF and OIF Veterans could contribute to ensuring that individuals with TBI are identified and treated.
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 (MMTF) 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 from TBI, and a protocol for further evaluation and treatment of those whose screening results are positive for possible TBI.
c. A national clinical reminder, VA-TBI Screening, was built incorporating this screening instrument. This reminder has the following elements:
(1) The first step of the reminder is to identify possible OEF and OIF participants based on whether date of separation from military duty or active duty status occurred after
September 11, 2001.
(a) Similar to the "OEF/OIF Post-Deployment Screening Reminder," the initial questions address location of deployment.
(b) The definition of an OEF or OIF participant is the same used for the “OEF/OIF Post-Deployment Screen," which includes service in Afghanistan, Georgia, Kyrgyzstan, Pakistan,
THIS VHA DIRECTIVE EXPIRES MARCH 31, 2015
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Tajikistan, Uzbekistan, or the Philippines. OIF participation includes service in Iraq, Kuwait, Saudi Arabia, or Turkey.
(c) The screening is done once for all individuals who report deployment to OEF and OIF Theaters, and is 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 may 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.
(a) The four sections are:
1. Events that may increase the risk of TBI.
2. Immediate symptoms following the event.
3. New or worsening symptoms following the event.
4. Current symptoms.
(b) 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 opens in the reminder to continue the screening process.
(4) If a person responds positively to one or more questions in each of the four sections, the screen is positive, the clinician discusses the results of the screen with the patient, and arrangements for further evaluation are offered. The reminder prompts the user to place a consultation for further evaluation or documents refusal.
d. Not all patients who screen 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 a comprehensive evaluation to substantiate the diagnosis.
e. The VHA task force has developed a defined protocol for completing the additional evaluation by a specialized team. The Comprehensive TBI Evaluation is a comprehensive evaluation which includes the origin or etiology of the patient’s injury, assessment for neurobehavioral symptoms (using the 22-question Neurobehavioral Symptom Inventory), a targeted physical examination, and a follow up treatment plan. An electronic template for documentation of this evaluation has been developed and deployed. The diagnostic conclusion
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regarding the occurrence of a TBI must be documented using this template. All TBI evaluations must be completed using the Comprehensive TBI Evaluation template. This application is hosted and supported by the VHA Support Service Center (VSSC) and is accessible using the Computerized Patient Record System (CPRS) Tools menu. NOTE: Reference documentation, including instructions for installing the template are available at http://vaww.rehab.va.gov/PMR/Comprehensive_TBI_Evaluation.asp. NOTE: This is an internal Web site and is not available to the public.
(1) The treatment algorithm available through VA's Web site at: http://vaww.rehab.va.gov/PMR/Comprehensive_TBI_Evaluation.asp provides guidance on physical examination, diagnostic testing, and recommendations for initial treatment interventions and referral pathways for persistent symptoms. NOTE: This is an internal Web site and is not available to the public.
(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 Level II Polytrauma Network Sites (PNSs) or Level III Polytrauma Support Clinic Teams (PSCT) existing within the VHA Polytrauma System of Care (see Attachment A). If there is no Level II PNS or Level III PSCT at the medical center, the medical center has the option of determining an alternate plan and team that meets the intent of this Directive. This may include having the evaluation completed by a specialist with an appropriate background and skills, such as a physiatrist, neurologist, or neuropsychiatrist who has also had training in the evaluation protocol and in directing an interdisciplinary rehabilitation treatment team. Alternate plans are to be reviewed with the Veterans Integrated Service Network (VISN) Chief Medical Officer (CMO) and the national Director of Physical Medicine and Rehabilitation.
f. Between 24 and 59 percent of patients with traumatic spinal cord injury (SCI) have a concomitant TBI as reported in literature. The SCI system of care has the extensive multidisciplinary expertise needed to provide the required evaluation and care. TBI 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 Veterans who, on the basis of the screening may have TBI, must be offered further evaluation and treatment by clinicians with expertise in the area of TBI.
4. ACTION
a. 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.
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(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 must be implemented using a national Information Technology (IT) patch.
b. National Director for Physical Medicine and Rehabilitation. The National Director for Physical Medicine and Rehabilitation is responsible for:
(1) Maintaining a defined protocol for the comprehensive Second Level Evaluation of those who might have TBI, based on responses to screening. This protocol must:
(a) Include initial treatment interventions, and
(b) Be posted at the Physical Medicine and Rehabilitation TBI Web site at: http://vaww.rehab.va.gov/PMR/TBI_Clinical_Reminder.asp. NOTE: This is an internal Web site and is not available to the public.
(2) Providing training materials in the protocol for Level II PNSs and Level III PSCT and any other specialists who will be completing the protocol.
(3) Working with each VISN CMO to develop clear referral protocols, identifying the Level II PNSs or Level III PSCT(s), and approving alternate plans and recommendations for other specialists, who are to complete the Second Level Evaluation for each VA medical center.
c. VISN Director. The VISN Director is responsible for ensuring that:
(1) The direction and standards to ensure that the screening and evaluation of possible TBI in OEF and OIF Veterans is fully implemented.
(2) Expectations are established and commitments reinforced at all levels of the
organization.
(3) Adequate resources are allocated for implementation.
(4) Performance for TBI screening program is monitored.
d. Chief Medical Officer (CMO). The CMO is responsible for:
(1) Working with the National Director for PM&R to develop clear referral protocols, and identifying the Level II PNSs or Level III PSCT(s), and approving alternate plans and recommendations for other specialists, who are to complete the Second Level Evaluation for each VA medical center.
(2) Ensuring that all clinical activities for utilizing the TBI Screening and Evaluation Tool meet or exceed the standards set by the VISN Director.
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e. VISN Quality Management Officer (QMO). The VISN QMO is responsible for:
(1) Monitoring the effectiveness of the TBI Screening and Evaluation Tool as part of the VISN’s QM and PI program.
(2) Ensuring that “lessons learned” and “strong practices” are identified and communicated.
(3) Representing the interests of the VISN in all VHA Central Office interactions on Quality Management issues regarding the implementation of the TBI Screening and Evaluation Tool.
f. Veterans Integrated Service Network (VISN) Chief Information Officer (CIO)
(1) The VISN CIO is responsible for ensuring that all medical centers have installed patch PXRM*2.0*8, the VA TBI Screening clinical reminder and reminder dialog.
(2) The VISN CIO is responsible for ensuring that all medical centers install the current version of the Comprehensive TBI Evaluation. This application is hosted and supported by the VSSC and is accessible using the CPRS Tools menu. NOTE: Reference documentation, including instructions for installing the template is available at http://vaww.rehab.va.gov/PMR/TBI_Clinical_Reminder.asp. NOTE: This is an internal Web site and is not available to the public.
g. 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 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 reason for their visit (see Attachment B for a flow chart demonstrating the process).
(3) The patient with possible TBI is offered a comprehensive evaluation by a PNS or a PSCT polytrauma team. For sites that do not have a PNS or PSCT team and wish to complete the evaluation protocols locally, an alternate plan and team that meets the intent of this Directive, including other specialists such as physiatrists, neurologists, or neuropsychiatrists, must be identified to complete the evaluation protocols after completing training. NOTE: For patients in the SCI system of care, the evaluation protocol is done by a designated SCI team.
(4) The provider reviews all screens with the patient regardless of method of completion to ensure proper patient understanding and response accuracy. NOTE: The screen may be completed face-to-face, or in writing.
(5) 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. Consultations for further evaluation must be submitted with agreement by the patient. The clinical staff
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member must document the discussion of screening results with the patient and any refusal of further evaluation by the patient within the progress note (using the clinical reminder dialog).
(6) 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 Level II PNSs or Level III PSCTs is located.
(7) The facility's alternate plan and team composition meets the intent of this Directive, if the facility is not a Level II PNS or Level III PSCT and the facility does not refer to a Level II PNS or Level III PSCT.
(8) Requests for alternate plans and team to complete the comprehensive evaluation and treatment are directed to the National Director for Physical Medicine and Rehabilitation through the VISN CMO.
(9) The identified service initiates contact with the referred patient within 5 working days to assist in arranging the recommended evaluation. NOTE: It is strongly recommended that, in addition to calling the Veteran by telephone, a letter is sent to the patient indicating that a consultation has been received, and provides information on how to schedule an appointment upon receipt of the letter to facilitate contact efforts.
(a) If the initial effort to contact the patient by telephone is unsuccessful, follow-up efforts must include at least two additional telephone calls within 14 days of the positive screen. Calls must be completed on different days of the week and different times of the day.
(b) If contact by phone is not successful after three attempts, a certified letter must be sent to the patient providing contact information should they desire to schedule an appointment. This letter must be sent within 14 days of the positive screen.
(c) These efforts and any refusals by patients to participate in the recommended evaluation must be documented on the consult request in the patient’s health record.
(10) The clinical team responsible for completing the evaluation documents any appointments that were cancelled by the patient or "no shows," and must document all attempts to reschedule the patient for completing the evaluation. If the patient cancels or is a "no show" for three appointments, the consultation can be closed out. Any consult closeouts must include a notation sent to the referring provider to resubmit a consultation to the team should the patient be interested in future evaluation services.
(11) The patient with possible TBI is seen for the Comprehensive TBI Evaluation within
30 days of the initial positive screen regardless of the facility or specialty team responsible for completing the evaluation. The Comprehensive TBI Evaluation includes: the origin or etiology of the patient’s injury, assessment for neurobehavioral symptoms (using the 22-question Neurobehavioral Symptom Inventory), a targeted physical examination, and a comprehensive follow up treatment plan. All TBI evaluations must be completed using the Comprehensive TBI
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Evaluation template. This application is hosted and supported by VSSC and it is accessible using the CPRS Tools menu. NOTE: Reference documentation, including instructions for installing the template are available at http://vaww.rehab.va.gov/PMR/Comprehensive_TBI_Evaluation.asp. NOTE: This is an internal Web site and is not available to the public.
(12) All staff at the facility involved in completing the evaluation protocol have completed the recommended training on the evaluation protocol.
(13) VA and non-VA inter-facility transfers are timely and follow policy outlined in current VHA policy.
h. SCI Center Chief. Each SCI Center Chief is responsible for ensuring that their staff has been trained in completing the evaluation protocol and for making it available at their SCI Center.
5. REFERENCES: Veterans Health Initiative (VHI) teaching module, “Traumatic Brain Injury,” found at http://www.va.gov/vhi/.
6. FOLLOW-UP RESPONSIBILITY: The Chief Consultant for Primary Care (11PC) and Chief Consultant for Rehabilitation (117) are responsible for the contents of this Directive. Questions are referred to (202) 461-7444.
7. RECISSIONS: VHA Directive 2007-013, dated April 13, 2007, is rescinded. This VHA Directive expires March 31, 2015.
Robert A. Petzel, M.D.
Under Secretary for Health
DISTRIBUTION:
E-mailed to the VHA Publication Distribution List 3/2410
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ATTACHMENT A
VETERANS HEALTH ADMINISTRATION (VHA)
POLYTRAUMA SYSTEM OF CARE
1. Level I: Polytrauma Rehabilitation Centers
Four regional Polytrauma Rehabilitation Centers (PRC) 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 in Richmond, VA; Tampa FL; Minneapolis, MN; and Palo Alto, CA.
2. Level II: Polytrauma Network Sites
Twenty 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 Level I PRC sites. Each PNS has a dedicated interdisciplinary team with 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. Level III: Polytrauma Support Clinic Teams
Polytrauma 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 Level I or Level II center. PSCTs assist in the management of stable polytrauma sequelae through direct care, consultation, and the use of telerehabilitation technologies, as needed.
4. Level IV: Polytrauma Points of Contact
Polytrauma Points of Contact (PPOC) are present in facilities that do not have Level I, Level II, or Level 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 Level of services required. PPOCs commonly refer to the PNS and PSCTs within their network.
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ATTACHMENT B
FLOW CHART FOR SCREENING AND EVALUATION OF POSSIBLE TRAUMATIC BRAIN INJURY (TBI) IN OPERATION ENDURING FREEDOM (OEF) AND
OPERATION IRAQI FREEDOM (OIF) VETERANS
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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 (C&P) 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 active duty military personnel. 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, Urgent Care, or any other specialty clinic, 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 Level II or Level 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 are not designated as a Level II Polytrauma Network Sites, or Level III Polytrauma Support Clinic Team, it is possible to determine an alternate plan and team that meets the intent of this Directive. This may include non-VA practitioners, or other VA staff specialists, such as neurologists, who have received, or will receive, training in the use of the evaluation protocol. Polytrauma Point of Contact or Level IV facilities wishing to complete the Traumatic Brain Injury (TBI) Second Level Evaluation locally must ensure that their alternate plan and team composition meets the intent of this Directive. Requests for alternate plans and teams need to be directed to the National Director for Physical Medicine and Rehabilitation through the Veterans Integrated Service Network (VISN) Chief Medical Officer (CMO). Data is collected systematically on the results of the evaluations as well as the screens. NOTE: This allows VHA
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to understand the breadth of TBI related issues in 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) 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.
6. If I see a non-OEF or OIF Veteran in my clinic who may have had a TBI, can this Veteran also receive a comprehensive evaluation?
Yes. Signs and symptoms of TBI are similar whether the injury is sustained in combat or non-combat situations. If you think a non-OEF or OIF Veteran has sustained a TBI, you should send a consult requesting evaluation and treatment to the same rehabilitation team that completes the comprehensive evaluation for OEF and OIF Veterans.