Alum Kristen Keech is working to change how patients with disorders of consciousness are treated at hospitals everywhere
Imagine you’re in an accident and are brought to a hospital. The initial tests find that you’re unresponsive and the care team concludes that that not much can be done. But what if that’s not true and you don’t receive potentially beneficial interventions, or worse, care is withdrawn altogether?
Unfortunately, this is a realistic scenario. A 2018 study from the European Journal of Neurology reported that approximately 40 percent of patients with disorders of consciousness, which can include coma, vegetative state and minimally conscious state, are misdiagnosed. A recent study co-led by Mass General Brigham, found that brain scans of unresponsive patients showed evidence of consciousness in 25 percent of them.
Kristen Keech has seen that firsthand.
“We would go into these interdisciplinary meetings and the patient was already written off,” said Keech, an occupational therapist at the Queen’s Medical Center in Honolulu, Hawaii, who graduated from the MGH Institute Post-Professional Doctor of Occupational Therapy program in 2022. “Families were pressured to make life-altering decisions within 24-48 hours. It caused me a lot of moral distress and was the starting point of wanting to advocate for a change.”
Making that prognosis after two days is the norm in many medical centers, according to Keech and other experts, even though it goes against the clinical practice guidelines from several organizations, including the American Academy of Neurology, that recommend waiting until 28 days post injury to make any prognostic statements. Keech was already interested in advocating for patients with disorders of consciousness because of the gaps in care and began to become actively involved in research on these patients. She soon saw a different gap in care for these unresponsive patients.
“There's an immense amount of research coming out that shows that if these folks get the right amount of medical and rehabilitative care, the trajectory is much more positive as far as their recovery of consciousness, along with functional recovery,” explained Keech who soon began educating her colleagues to bring the research into her clinical practice. “I felt empowered by sharing that knowledge with the other disciplines. I had the knowledge to speak up and say, ‘Let’s try an assessment.’ More often than not, I could get a response because I took the time to use available standardized assessments focused on a methodical way of introducing multisensory stimuli to observe for a specific neurobehavioral response and looked at outside factors such as sedation or comorbidities that might cloud the true assessment. I really pivoted from not only being an OT but also an advocate and saying, ‘Let’s give this person a chance.”
Her actions led to change in mindset and practice on her team but there was still more to do. Now empowered, Keech wanted to expand on her quality and process improvement work and figure out how she could make an impact on the lives of patients and families who experience marginalization or decreased access to services. That’s one of the reasons she enrolled in the MGH Institute Post-professional OTD program.
That most of the program was virtual was a key point but her interactions with Sarah McKinnon, interim chair for Occupational Therapy, convinced her the program would fit her needs in other ways.
“When I talked to Sarah, it sounded like it was really going to help me achieve that goal of taking a non-clinical lens to have an impact clinically in the long run,” remembers Keech.
Part of the program involves working with a faculty mentor on an Innovation Project. Keech brought her ideas and passion about implementing clinical changes for patients with disorders of consciousness and worked with Jessica Asiello, an assistant professor in the program, to figure out how to make it happen.
“For the Innovation Project, you work on identifying a problem you see in professional practice and Kristen identified one that many acute care OTs can relate to because unfortunately, a lot of hospitals aren’t implementing the best evidence-based practices for disorders of consciousness,” said Asiello.
Asiello’s mentorship and the step-by-step process helped Keech refine her ideas.
“I am a big picture person and I tend to get excited and ahead of myself,” shared Keech. “The program helped break things down into smaller, achievable processes and goals in order to get to that ultimate outcome.”
Her project, which was recently published in the journal, Brain Injury, resulted in the Conscious Care Model, which Keech said, “developed into something that was articulate, evidence-based, and feasible,” and could be used to, “improve interprofessional care of patients with DoC in the hospital setting,” which Keech has done at Queen’s Medical Center.
Through this model, Keech was able to implement a number of changes on her team that filled some of the existing gaps including informal education so that people knew what was available; early consults for physical and occupational therapy; as well as successfully getting patients into an inpatient rehabilitation or specialty centers on the mainland which did not previously happen. There were also changes made with the IT department on the documentation system to make it more consistent and integrate a better approach to documenting results of evaluations, patient response to treatment, and standardized assessments for that population.
Keech was invited to present on the model at the American Occupational Therapy Association (AOTA) National Conference but was unable to make it, so Asiello presented it on her behalf to a packed auditorium with a few videos of Keech included.
“There was a lot of good discussion that really accentuated the problem and further reinforced the importance of her project,” said Asiello.
The presentation also resulted in several opportunities, and according to Keech is, “continuing to have a positive impact on my career to this day as far as other opportunities outside of my primary role at the hospital.” She started her own company to consult with hospitals on implementing the care model and improving their practice with the entire team. She and Asiello have also partnered with a company to create three continuing education courses on interventions with patients with disorders of consciousness.
Keech was also honored by The National Board for Certification in Occupational Therapy (NBCOT) with the 2024 NBCOT Impact Award. Asiello nominated her for the award, which recognizes practitioners who demonstrate exceptional professional commitment through dedication, hard work, and outstanding OT skills to improve their clients’ overall life satisfaction and their engagements in valued occupations.
That is likely not the last award Keech will earn. She has successfully implemented practice changes at her hospital that are not related to her Innovation Project, including an interdisciplinary Traumatic Brain Injury (TBI) Sleep-Wake Bundle to address the correlation between sleep and next day agitation in individuals with acute TBI. She is also the only OT to serve on the state of Hawaii’s TBI advisory board.
“It’s been successful,” said Keech. “I very much attribute that to the skills that I developed through the IHP PP-OTD program that I didn’t have before. I’m so grateful for that opportunity because it really skyrocketed me into this next level of being an OT and opened my eyes to possibilities of having a larger scale impact on the individuals and families I encounter in my practice. It really helped me pivot and reignite my passion for OT, advocating for patients and really bringing a lot of my goals and passions to life. There is more work and advocacy to be done and I plan to pursue it with the skills the MGH IHP PPOTD equipped me with during my program. “
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