What are the discharge instructions for a patient with a Traumatic Brain Injury (TBI)?

Discharge Instructions for Traumatic Brain Injury (TBI) Patients

Patients with TBI should receive standardized discharge instructions in both written and verbal formats, with clear guidance on warning signs requiring immediate return to the ED, activity restrictions, and expected recovery timeline.

Format and Delivery of Discharge Instructions

• Instructions must be written at a 6th-7th grade reading level 1
• Provide instructions to both patient AND immediate caregiver 1
• Use appropriate formatting for low literacy (12+ point font, wide margins, left-justified text) 1
• Verbal review of instructions is essential as 23% of TBI patients cannot recall any discharge instructions 1

Warning Signs Requiring Immediate Return to ED

Instruct patients to return immediately for:

• Repeated vomiting
• Worsening headache
• Problems remembering/confusion
• Focal neurologic deficit
• Abnormal behavior
• Increased sleepiness or loss of consciousness
• Seizures 1

Activity Restrictions and Return to Normal Function

1. First several days after injury:

   • More restrictive physical and cognitive activity 1
   • Avoid activities that could risk re-injury

2. After initial days:

   • Gradually resume activities that don't worsen symptoms
   • Monitor symptom expression closely 1
   • May require 2-3 days off work or school 1

3. Progressive return:

   • Gradually reintroduce non-contact aerobic activity that doesn't exacerbate symptoms
   • Return to full activity only when patient has returned to pre-injury performance and remains symptom-free with increasing physical exertion 1

Postconcussive Symptoms Education

Provide a written list of potential postconcussive symptoms that may develop:

• Chronic headaches
• Dizziness/balance problems
• Nausea
• Vision problems
• Increased sensitivity to noise/light
• Depression or mood swings
• Anxiety/irritability
• Memory problems
• Difficulty concentrating
• Sleep difficulties
• Chronic fatigue 1

Inform patients that:

• Most symptoms resolve within 1-3 months 1
• Up to 58% may have persistent symptoms at 1 month post-injury 1
• Patients experiencing these symptoms should refrain from strenuous mental or physical activity until symptom-free 1

Follow-up Instructions

• Provide clear clinician follow-up instructions 1
• Refer to a TBI specialist if postconcussive symptoms persist beyond 3 weeks 1
• Explain that home observation with frequent waking is NOT recommended for patients with negative CT scan or low risk for neuroimaging 1

Injury Prevention Education

Include information about:

• Seatbelt safety
• Alcohol safety
• Helmet use 1

Special Considerations

For Patients with Negative CT Scan

• Patients with a negative head CT scan and normal clinical examination can be safely discharged from the ED 1
• These patients have a very low rate of developing delayed intracranial pathology 1

For Patients with Higher Risk

• Consider more cautious discharge planning for patients with bleeding disorders, anticoagulant therapy, previous neurosurgical procedures, or significant neurological disease 1

Common Pitfalls to Avoid

1. Inadequate discharge instructions: Many institutions fail to include all critical monitoring factors in their discharge instructions 1

2. Inappropriate reading level: Most discharge instructions are written at too high a reading level for patients to understand 1

3. Failing to identify postconcussive symptoms: Evaluating for headache, nausea, and dizziness in the ED can identify patients at 50% risk of developing postconcussive syndrome 1

4. Unnecessary wake-up instructions: Frequent waking for neurological checks is not supported by evidence for patients with negative CT scans 1

5. Insufficient follow-up planning: 9% of TBI patients are discharged without any follow-up recommendations, and 28% are only told to "return to ED as needed" 1