1

KOSCHI Assessment Following Paediatric Head

Injury

Carol Hawley PhD

Warwick Medical School

University of Warwick

UK

• Background to the development of the KOSCHI

• Early use of the KOSCHI

• Data sources for assessment

• Scoring strategies

• Case examples

2

Development of KOSCHI

• Marion Crouchman and Lucille Rossiter, Paediatric Neurosciences, Kings College Hospital, London, UK (1998)

• Found the GOS for adults did not allow for developmental changes in children after TBI

• Set out to provide a robust, simple description of outcome after paediatric TBI in the short, medium or long term

A Practical Outcome Scale For Paediatric Head Injury (Crouchman et al, 2001)

• Developed as a specific paediatric adaptation of the original adult Glasgow Outcome Scale (GOS)

• Expands the 5 category GOS to provide increased sensitivity at the milder end of the disability range

• GOS ‘persistent vegetative’ was redefined as ‘vegetative’

• Good recovery was divided into two categories to acknowledge the long-term importance of relatively minor sequelae in a developing child

3

Inter-rater Reliability (Forsyth)• As part of the development we carried out an inter-

rater reliability exercise

• 6 observers with professional interests in child head injury

• 2 paediatric neurologists

• 2 clinical nurse specialists

• 1 psychologist/health economist

• 1 medical social worker with specialist experience in the field

• Independently assigned KOSCHI categories to 90 child survivors of head injury using one page clinical discharge letters

Inter-rater Reliability Results• General agreement between 5/6 observers. One

observer (Ob 2) consistently rated children as more disabled than other observers

• Excluded Ob 2 from the final inter-rater reliability

• Overall Kappa statistic (5 observers) = 0.58

• Agreement worst in categories 3b: Severe b (0.33) and 4a: Moderate a (0.28)

• Best agreement 2: vegetative (0.88), 3a: Severe a (0.63) and 5b: Full (intact) recovery (0.66)

4

3b or 4a? (Crouchman et al, 2001)

• 3b: “Implies a continuing high level of dependency, but the child can assist in daily activities. E.g. can feed self or walk with assistance or help to place items of clothing. Child is fully conscious but may have a degree of post-traumatic amnesia.”

• 4a: “The child is mostly independent but needs a degree of supervision/actual help for physical or behavioural problems. Such a child has overt problems. E.g. 12 year old with moderate hemiplegia and dyspraxia insecure on stairs or needing help with dressing.”

First large scale study to use the KOSCHI (Hawley et al, 2004)

• North Staffordshire (UK) Head Injury Register (brain injury nurse)

• Contains details of all children admitted to hospital for ≥24 hours with head injury

• We looked for all children aged 5-15 years at time of injury and admitted with head injury between November 1992 and December 1998

• Identified 986 children

5

Postal Survey (Hawley et al, 2004)

• 974 parents of head injury survivors (age 5-15) were sent a detailed postal questionnaire

• 40 untraceable

•

• 526 parents responded (523 living in the community)

• 57% overall response rate

• 63% response rate for those injured� 2 years ago

•

• Injured Children : Males = 70% Females = 30%

• Mean Age of Child at Time of Injury = 9.8 years

• Mean time between injury and Q follow-up = 2.3 years

• Mean Age of Child at follow-up = 12 years

• (same proportions for responders and non-responders)

Definition of Injury Severity

• Mild = GCS 13 - 15 (unconscious less than 15 mins)

• Moderate = GCS 9 - 12 (unconscious > 15 mins and < 6 hours)

• Severe = GCS 3 - 8 (unconscious > 6 hours)

6

Injury Severity (n = 974)

80 83

11 11 9 60

10

20

30

40

50

60

70

80

90

%

Mild Moderate Severe

Responders

Non-Responders

Cause of Injury of Responders (n = 526)

50%

18%

10%

12%

10%

Fall RTA Pedestrian RTA vehicle Hit by Object Other

7

Questionnaire Content

1 Follow-up, therapy, other injuries, information received by parents

2 Changes in child since the injury

3 Current problems/difficulties - incorporating the King’s Head Injury Checklist

4 Return to school

5 Employment since the head injury

6 Effect on parents/family (support required/received)

Outcomes measured using the KOSCHI

• Used definitions as described by Crouchman, Rossiter and Colaco (1998)

• All questionnaires scored by one person experienced in the KOSCHI and who took part in the original inter-rater reliability exercise

• Scored using anonymised questionnaires, without knowledge of injury severity

• All survivors. All community dwelling.

8

• Category Definition

• 1 Death

•

• 2 Vegetative Breathes spontaneously. No evidence of verbal or non-verbal communication or response to commands.

•

• 3 Severe disability A Conscious, totally dependent. May be able to communicate. Requires specialised educational/rehabilitation setting.

•

• Severe disability B Limited self-care abilities and predominantly dependent. May have meaningful communication. Requires specialised educational/rehabilitation setting.

• 4 Moderate disability A Mostly independent for daily living, but needs a degree of supervision/help for physical or behavioural problems. Has overt problems. May be in

specialised rehabilitation/educational setting or in mainstream school requiring special needs assistance. His behavioural problems may have caused him to be disciplined or excluded from school.

•

• Moderate disability B Age-appropriately independent for daily living, but with neurological sequelae frequently affecting his daily life, including behavioural and learning difficulties. He may also have frequent headaches. Likely to be in mainstream school with or without special needs assistance.

•

• 5 Good recovery A Appears to have made a full functional recovery, but has residual pathology attributable to head injury. He may suffer headaches which do not affect his school or social life, and may occasionally have some of the problems listed on the head injury checklist.

•

• Good recovery B The information available implies that child has made a complete recovery. No sequelae identified.

However, determining between 4a and 4b could be difficult

• Moderate disability 4A

• Able to carry out most self-care, but needing support and supervision for these. Likely to have problems with behaviour/learning/communication. Has overt problems. May be in specialised rehabilitation/educational unit or in mainstream school requiring special needs assistance. His behavioural problems may have caused him to be disciplined or excluded from school.

•

• Moderate disability 4B

• Age-appropriately independent for daily living, but with neurological sequelae affecting his daily life, including behavioural and learning difficulties. He may also have frequent headaches. Likely to be in mainstream school with or without special needs assistance.

9

Outcomes (KOSCHI scores) n=526 (1 child Severe 3a, 3 children 3b)

0

5

10

15

20

25

30

35

40

severe moderateA

moderateB

good full

0

8

35

21 21

0

26

38

26

108

35 35

18

4

percent

mild HI moderate HI severe HI

KOSCHI scores 1 year post injury (n=106)

0 0

1713

33

42

29

47

25

37

2017

22

0 00

10

20

30

40

50

percent

severe moderate A moderate B good full

mild HI moderate HI severe HI

10

CLINICAL FOLLOW-UP AFTER DISCHARGE ACCORDING TO KOSCHI OUTCOMES (N =

526. Significant difference: p = 0.006)

100

0

36

64

24

76

0102030405060708090

100

PERCENT

SEVERE DIS MODERATE DIS GOODRECOVERY

FOLLOW-UP NO FOLLOW UP

Deprivation and Outcome• Deprivation was measured using the Townsend

material deprivation score (Townsend et al 1986) using postcodes

• The range is approximately +10 to -10, where the higher positive = more deprived and lower negative = more prosperous.

• There was a significant association between deprivation and KOSCHI outcomes (p = 0.002, 95% CI = -1.3 to -0.3) I.e. more deprived worse outcome.

11

Conclusions and Recommendations

• There was no evidence to suggest a threshold of injury severity below which the risk of late morbidity could be discounted.

• The KOSCHI is a simple measure, with training it is easy to use.

• KOSCHI outcome scores can be obtained from a detailed postal questionnaire.

• Cost effective means of identifying children who are likely to benefit from clinical follow-up after hospital discharge

Use Of KOSCHI To Determine Catastrophic Injury In Youth With Brain Injury Aged <18 Years

• Application for determination of catastrophic impairment (OCF-19) in young persons with TBI aged <18 years

• Automatically qualify if received for in-patient treatment (qualifying facility) with positive CT or MRI,

• Or in-patient treatment for neurological rehabilitation in qualifying facility

• Criterion 5 if above not met

• KOSCHI will be used for children who are not admitted to in-patient rehab or hospital, or who do not have positive imaging

12

Criterion 5 states that a child would meet the definition for “catastrophic” if

• One month or more after the accident, the insured person’s level of neurological function does not exceed category 2 (Vegetative) on the King’s Outcome Scale for Childhood Head Injury;

• Six months or more after the accident, the insured person’s level of neurological function does not exceed category 3 (Severe disability) on the King’s Outcome Scale for Childhood Head Injury;

• Nine months or more after the accident, the insured person’s level of function remains seriously impaired such that the insured person is not age-appropriately independent and requires in-person supervision or assistance for physical, cognitive or behavioural impairments for the majority of the insured person’s waking day.

• KOSCHI not specified here, but to me sounds like 4a or lower.

Data Sources for Assessment

• Use as much information as is available

•Use a range of sources:Interview with childInterview with parentInterview with teachersInterview with health workersUse other assessments where availablee.g.neuropsychological assessments physio assessmentsOT assessments

But, can also score KOSCHI from clinical discharge letters

• Or postal questionnaire incorporating key questions

13

Scoring the KOSCHI• Original KOSCHI incorporated a functional

scoring system using seven categories to measure dependence

• Minimum score of 7 (K2) Max score 20 (K5)

• By totalling the scores you get a KOSCHI rating

• Dependence must be age related

• Good recovery (5a or 5b) can only be allocated to children scoring 20

Not only physical disability and dependency

• A severely behaviourally or cognitively disordered child may be categorised as severely disabled even in the absence of physical sequalae (Crouchman & Rossiter, 1998 in notes to scoring KOSCHI)

14

15

KOSCHI Scoring Algorithm(Rumney et al, 2014)

16

Case Examples

Sarah

• Age 9 (STK1041)

• Severe TBI 10 months ago (GCS 4) Pedestrian v car

• Living at home with full time carers

• No speech, but has limited non-verbal communication

• Dependent on others for self-care and mobility

• Has decreased cognitive function

• Cheerful mood but personality change

• Receiving specialised education outside the home

• Unable to carry out neuropsychological assessments

17

3a, 3b or 4a?(Crouchman et al, 1998 criteria)

• 3a: Severe disability

• Conscious, totally dependent. May be able to communicate. Requires specialised education/rehabilitation setting.

• 3b: Severe disability

• Limited self-care abilities and predominantly dependent. May have meaningful communication. Requires specialised educational/rehabilitation setting.

• 4a: Moderate disability

• Able to carry out most self-care, but needing support and supervision for these. Likely to have problems with behaviour/learning/communication. May be in a specialised rehabilitation/educational unit or in mainstream school with special needs assistance.

Sarah KOSCHI using functional scoring system

• Mobility = 1 (dependent)

• Communication = 2 (coping mechanism)

• Mood/behaviour/personality change = 1 (occasional problems)

• Disinhibition = 2 (not present)

• Danger awareness = 1 (unaware)

• Self-care = 1 (dependent)

• Cognitive/memory/concentration = 2 (decreased)

• Total score = 10 = 3a

18

Andrew• Age 11 (STK1555)

• Severe TBI 9 months ago, GCS 4, RTA pedestrian

• Independent for ADLs but needs prompts for some aspects of self-care

• Severe behavioural problems

• Poor memory and concentration

• Falling behind and having difficulty learning

• In mainstream school, teachers complain he is aggressive, moody and disruptive

• Poor danger awareness ‘fearless’

Andrew KOSCHI using functional scoring system

• Mobility = 3 (normal)

• Communication = 4 (normal)

• Mood/behaviour/personality change = 1 (constant problems)

• Disinhibition = 1 (present)

• Danger awareness = 1 (unaware)

• Self-care = 3 (needs prompts)

• Cognitive/memory/concentration = 2 (decreased)

• Total score = 15 = 4a

19

Scott• Age 7

• Severe TBI one year ago, GCS 8. RTA

• Living at home with parents and carers

• Delayed language development due to TBI

• Receiving rehabilitation within the home (SLT, Physio)

• Unable to walk and uses wheelchair, dependent on others for mobility

• Can feed self with prompts and supervision, but mostly dependent

• Receiving limited educational input from specialist teachers

• Difficulty with concentration and memory

• Occasionally moody and temper tantrums

• Poor awareness of danger, needs supervision for safety

Scott KOSCHI using functional scoring system

• Mobility = 1 (dependent)

• Communication = 3 (delayed language development)

• Mood/behaviour/personality change = 1 (occasional problems)

• Disinhibition = 2 (not present)

• Danger awareness = 1 (unaware)

• Self-care = 2 (predominantly dependent)

• Cognitive/memory/concentration = 2 (decreased)

• Total score = 12 = 3b

20

Fine line between 3a & 3b and 4a

• Some subjectivity

• Good days and bad days?

• When is assessment done?

• Who should do the assessment?

• Child should be assessed on several occasions, taking evidence from different sources and using a range of measures

• Caution – are these behaviours or problems due to the TBI?

Summary• KOSCHI is a useful tool for assessing disability after

paediatric TBI

• Was intended to provide a simple, robust description of outcome in the short, medium or long term

• Intended use was to enable clinicians to describe the rate and extent of recovery

• Not intended to be used to determine financial compensation

• Any health professional experienced in TBI can score, but training needed for consistency of scoring.

• Can be difficult to score ‘borderline’ cases. Dependency is key. Must be age related. If in doubt between two scores take the lower