Disorders of Consciousness in Acute Care: Application of the CRS-R and Respiratory, Swallowing, and Discharge Outcomes at a Level 1 Trauma Hospital.

OBJECTIVE: To exemplify the use of the Coma Recovery Scale-Revised (CRS-R) during critical acute care and to characterize associated functional and rehabilitative trajectories of patients with disorders of consciousness (DoC). Although most research emphasizes postacute assessment and recovery, early rehabilitation in the initial days and weeks after injury remains unexplored. DESIGN: Retrospective, observational cohort study. SETTING: Level 1 Trauma and Certified Stroke Center acute care hospital. PARTICIPANTS: A total of 68 adults admitted with a severe brain injury with an initial Glasgow Coma Scale score of ≤8. MAIN OUTCOME MEASURES: Outcomes were assessed across 3 domains: (1) consciousness, via the CRS-R; (2) respiratory function, including cough categorization, tracheostomy status, and decannulation readiness trials (speaking valve or capping); and (3) swallowing/eating, measured by the Functional Oral Intake Scale (FOIS) and engagement in evaluations for oral diet advancement. RESULTS: Initial CRS-R assessments showed 2.9% (n=2) in coma, 52.9% (n=36) in unresponsive wakefulness syndrome (UWS), 27.9% (n=19) in minimally conscious state minus (MCS-), 13.2% (n=9) in MCS plus (MCS+), and 2.9% (n=2) emerged. By discharge, no patients remained in coma; 2.9% (n=2) were in UWS, 17.7% (n=12) MCS-, 13.2% (n=9) MCS+, and 41.2% (n=28) emerged. Among those emerging, 53.6% did so within 30 days. Tracheostomy was required in 73.5% (n=50); most participated in capping (72%, n=36/50) and speaking valve trials (88%, n=44/50) while cannulated, and 68% (n=34/50) were decannulated. Instrumental swallowing evaluations were completed in 42.6% (n=29), with 39.7% (n=27) discharged on oral diets. Overall, under half (39.7%, n=27) were discharged to specialized or rehabilitative settings. CONCLUSION: Patients with DoC make demonstrable improvements in consciousness, respiratory function, and swallowing during acute care, challenging prevailing assumptions that rehabilitation potential begins later in the recovery trajectory. These findings underscore the importance of initiating structured assessments and interventions early to optimize outcomes and inform discharge planning. Future research should focus on the development and evaluation of standardized screening protocols for identifying DoC in acute care, as well as examining national screening, assessment, and treatment practices.