BACKGROUND/RATIONALE:
The nature of modern warfare is resulting in new and complex patterns of blast-related injuries. Blast-related injuries are often "polytraumatic" meaning that they result in impairments in more than one body system or organ. Individuals with polytraumatic and blast-related injuries have complex rehabilitation needs. New structures and processes of care are needed to maximize their functional and psychosocial outcomes. Recognizing this, Congress passed Public Laws 108-422 (section 302) and 108-447 and the Secretary of Veterans Affairs designated four Polytrauma Rehabilitation Centers (PRCs), located in Minneapolis, MN, Palo Alto, CA, Richmond VA, and Tampa, FL, to provide specialized rehabilitation treatment and expand clinical expertise in this area throughout the VA. To plan for future programming and meet the needs of patients with polytrauma, research is needed identifying the high priority problems among PRC patients, as well as characterizing rehabilitation outcomes.

OBJECTIVE(S):
(1) Describe the demographic and clinical characteristics, treatment needs and outcomes of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) service members treated for combat injuries at one of the four newly designated Polytrauma Rehabilitation Centers (PRCs), and (2) Identify variations in patient characteristics, treatments and outcomes across the four PRCs.

METHODS:
Design: Observational study of all OEF and OIF service members treated for war-related injuries at one of the four PRCs during the first four years of the Global War on Terror. Procedures: Trained MA and PhD level chart reviewers extracted from the VA electronic medical records patient socio-demographic characteristics, injury date, etiology and types, as well as impairment and treatment information. Outcomes were extracted from VA administrative databases. Outcomes included the Functional Independence Measure (FIM) Cognitive and Motor Gain scores and Length of Stay (LOS). Analyses: Pearson's chi-square, Fisher's exact and Wilcoxon's rank-sum tests were used to determine whether the injuries and impairments differed by mechanism of injury and PRC site. Multiple regression analyses were used to identify predictors of Cognitive and Motor FIM Gain and LOS.

FINDINGS/RESULTS:
Of the 566 active duty service members treated at a PRC during the first four years of the GWOT, 188 were injured in Iraq or Afghanistan. The modal war injured patient was a White male Army service member deployed to Iraq from active duty status and admitted to a PRC from a Military Treatment Facility. Almost all PRC patients had primary brain injuries. Most of the 188 PRC patients sustained injuries to more than one body structure or system and more than half of the PRC patients had impairments in at least five areas of functioning with cognitive problems and pain being the most common. Fifty four percent of the 188 war injured patients had blast-related injuries and blasts impacted more body systems and/or organs than other mechanisms of injury. Soft tissue, eye, oral/maxillofacial, otologic and penetrating brain injuries were more common in blast injured patients than in those with war injuries of other etiologies. Four patients died within the year following discharge, three of whom had blast-related combat injuries. The models predicting Cognitive FIM Gain, Motor FIM Gain and LOS explained 44%, 38% and 66% of the variance in the respective outcomes. Admissions level of functioning accounted for the largest portion of the variance in Cognitive and Motor FIM Gain and LOS, with those who are most dependent at the time of admissions making the greatest gains and having the longest LOS. Mechanism of injury did not predict functional outcome. Although, those with blast injuries had lower median lengths of stay, some blast injured individuals had extremely long lengths of stay. Controlling for other covariates, there were no variations in functional outcomes by PRC site. However, one site had shorter LOSs than the other three.

IMPACT:
Findings confirm the clinical complexity of the patients for whom the Polytrauma System of Care was developed. Blasts appear to produce a unique constellation of injuries. However, functional outcomes as measured by the FIM did not vary by mechanism of injury. There were very few variations by PRC site. Findings have implications for provider screening practices and education.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Carlson KF, Nugent SM, Grill J, Sayer NA. Accuracy of external cause-of-injury coding in VA polytrauma patient discharge records. Journal of rehabilitation research and development. 2010 Nov 9; 47(8):689-97. [view]
2. Sayer NA, Chiros CE, Sigford B, Scott S, Clothier B, Pickett T, Lew HL. Characteristics and rehabilitation outcomes among patients with blast and other injuries sustained during the Global War on Terror. Archives of physical medicine and rehabilitation. 2008 Jan 1; 89(1):163-70. [view]
3. Sayer NA, Cifu DX, McNamee S, Chiros CE, Sigford BJ, Scott S, Lew HL. Rehabilitation needs of combat-injured service members admitted to the VA Polytrauma Rehabilitation Centers: the role of PM&R in the care of wounded warriors. PM & R : the journal of injury, function, and rehabilitation. 2009 Jan 1; 1(1):23-8. [view]
4. Lew HL, Cifu DX, Sigford B, Scott S, Sayer N, Jaffee MS. Team approach to diagnosis and management of traumatic brain injury and its comorbidities. Journal of rehabilitation research and development. 2007 Jan 1; 44(7):vii-xi. [view]

Conference Presentations

1. Sayer NA, Friedemann-Sanchez G. Characteristics and needs of patients with severe combat injuries from OIF/OEF: what VA managers and providers need to know. Poster session presented at: VA HSR&D National Meeting; 2007 Feb 21; Arlington, VA. [view]
2. Sayer NA, Chiros C, Scott S, Sigford B, Prickett T, Lew H, Clothier B. Predictors of Functional Improvement during Acute Inpatient Rehabilitation among Combat-Injured Service Members. Paper presented at: VA HSR&D National Meeting; 2007 Feb 21; Arlington, VA. [view]

DRA: Health Systems, Acute and Combat-Related Injury
DRE: none
Keywords: Operation Enduring Freedom, Operation Iraqi Freedom
MeSH Terms: none