European Perspective on Early European Perspective on Early Brain Injury RehabilitationBrain Injury Rehabilitation

Professor Anthony B WardNorth Staffordshire Rehabilitation Centre

Stoke on Trent, UK

•Definitions

•Activities

•Experience

•Outcomes

Ward A B, et al. J Rehabilitation Medicine 2010; 42 (5): 417-24.

•Definitions

•Activities

•Experience

•Outcomes

Ward A B, et al. J Rehabilitation Medicine 2010; 42 (5): 417-24.

Definitions – Early Definitions – Early RehabilitationRehabilitation

Timing

Ill defined

Process of rehabilitative treatment occurring within the

first few days/weeks following injury or illness or in

response to complex medical treatment or its

complications

Time limit one month

Ward A B, et al. J Rehabilitation Medicine 2010; 42 (5): 417-24.

Concept

Hospital-based – Following definitive care or resuscitation

Differs from acute care– Interaction of the professionals’ involvement

Patients transfer to programme of specialist care under Physical & Rehabilitation Medicine specialist

Differs from rehabilitation in post-acute settings

Rehabilitation in Acute SettingsRehabilitation in Acute Settings

Ward A B, et al. J Rehabilitation Medicine 2010; 42 (5): 417-24.

Specialist Rehabilitation - Acute Specialist Rehabilitation - Acute PhasePhase

Direct liaison with medical/surgical discipline

Goal-oriented multidisciplinary rehabilitation

Clear medical role to direct the team

Utilise (or have access to) all aspects of rehabilitation activities

Patient under care of fully trained, certified & competent medical rehabilitationists – To ensure a good quality transfer of care – Systems in place for patient assessment & goal setting

Why is Rehabilitation Important Why is Rehabilitation Important Here?Here?

Rehabilitation is focus for inpatient care – cannot discharge patient

Dedicating facilities for this purpose meets healthcare priorities1

Achieves better clinical outcomes and economic profiles for provider hospital2

1. Ward AB. Journal of Rehabilitation Medicine 2006; 38 (2): 81-86. 2. Worthington AD, Oldham JB. Clinical Rehabilitation 2006; 20 (1): 79-82.

Point of Entry for Early Point of Entry for Early RehabilitationRehabilitation

When the priority of care moves from definitive acute treatment to one of rehabilitation

The point that a rehabilitation specialist should take lead for clinical care – Specialty lead will vary according to location – Specialists need to demonstrate competence on whole range of

rehabilitation interventions

Reflected in current Trauma Network initiative

Ward A B, et al. J Rehabilitation Medicine 2010; 42 (5): 417-24.

•Definitions

•Activities

•Experience

•Outcomes

Acute Physical & Acute Physical & Rehabilitation Medicine Rehabilitation Medicine

(PRM) Services(PRM) Services

Right environment & right skill mix with trained therapists

Concentrates therapy – Therapy input associated with shorter hospital stays & improved

outcomes

Optimises patients’ physical & social functioning

Gutenbrunner C, Ward AB, Chamberlain MA. White Book on PRM in Europe. Jnl Rehabil Med 2007; 39 (Suppl), S1-S75.

Acute PRM Services Acute PRM Services

Reduces complications– Physical effects of illness/injury

• e.g. immobility, contracture, pain, tissue viability problems, etc

Identifies secondary cognitive & emotional effects, even in absence of physical features

Improves chances of independent living at home & return to work

Gutenbrunner C, Ward AB, Chamberlain MA. White Book on PRM in Europe. J. Rehabil Med 2007; 39 (Suppl), S1-S75.

Delivery of Early PRM ServicesDelivery of Early PRM Services

1. Transfer patients to PRM beds in acute facility

2. Mobile teams under responsibility of PRM specialist, while patient under care of referring specialist

3. Daily visits to acute wards by specialists from stand-alone rehabilitation facility

4. Encourage PRM centres to take patients very early

Ward A B, et al. J Rehabilitation Medicine 2010; 42 (5): 417-24.

Establishment Activity Advantages Limitations

PRM Beds in Acute Hospital(≡ Acute inpatient specialised team)

Transfer of pts to PRM beds in acute hospital

Rapid transfer to quality PRM careEarly rehabilitation principlesRequires adequate numbers of dedicated staff

Limited nos. of beds and thus ptsPotential for bed- blockingProtect against inappropriate admissionsDifficult if staff numbers inadequate

Mobile PRM Team (≡ Acute PRM liaison team)

PRM team working solely within acute hospital visits pts. under care of other specialists

See larger pt. nos. & many conditionsGood liaison team with ac. ward staffIdentify patients requiring I/P rehabEducation of naïve family care-giversInteract with 1o care physician

Some staff not in PRM team Least specialised formatNo clinical control – pts under care of other specialistsDeal at impairment & activity levelParticipation issues not addressed

Establishment Activity Advantages Limitations

PRM Consultation to Acute Wards

PRM specialist from stand-alone PRM centre visits pts. under care of other specialists

See larger nos. of patients with wide range of conditionsCloser links between PRM and acute specialistsWhen treating nurses & therapists within PRM team

No clinical control –patients under care of other specialists Time & expense to be effective; need to be on site When treating nurses & therapists not within PRM team

Acute PRM Centre Rapid transfer of patients to fast-track facility in stand alone PRM Centre

Pt exposed at early stage to total PRM team & facilitiesPRM specialist team competence in treating acute conditions

Medically stable ptsTransfer back if pt deterioratesNo formal contact between PRM team & acute specialistsLittle or no service for patients not transferred

DevelopmentDevelopment

Define range of patients– Diagnostic categories of admitted patients

• ABI (TBI), stroke, SAH, SCI, post --neurosurgery, MS acute flare, infection• Post joint arthroplasty, amputation, etc

– Age, demographics, etc.

Define team characteristics and expertise

Set out service philosophy & activities

Admission and discharge criteria

Patient InclusionPatient Inclusion

Suitable (diagnostic) categories of admitted patients

Require acute facilities at start of rehabilitation programmes

Require 24hr nursing/medical care for rehabilitative needs

Those with capacity for, require and will benefit from rehabilitation

Severely disabled people with needs only met by a multi-professional team practising inter-disciplinary rehabilitation

Those with complex needs, i.e. requiring >2 professionals working within a team

Clinical ActivitiesClinical Activities

Providing rehab therapy for patients with complex problems – requiring an input from ≥2 multi-professional team members

Preventing preventable complications – & providing treatment for them

Educating patients and carers

Providing triage for further definitive rehabilitation programmes– which may prevent the need for further rehabilitation

Educating acute care staff – Practicalities & principles of PRM treatment

•Definitions

•Activities

•Experience

•Outcomes

North StaffordshireNorth StaffordshireSevere ABI AuditSevere ABI Audit

Mobilisation

Spasticity

Behaviour

Mood

Communication

Ward AB. Audit of NSRC admissions. 2001

North StaffordshireNorth StaffordshireSevere ABI AuditSevere ABI Audit

Mobilisation– 22% unable to mobilise

Spasticity– 4%-42% incidence - preventable problems

Behaviour– Incompletely addressed in UK Rehabilitation Medicine

services Mood

– 32% clinically depressed Communication

– 12% dysphasicWard AB. Audit of NSRC admissions. 2001

ABI Mobilisation Care ABI Mobilisation Care PathwayPathway

Evidence-based – Stoke on Trent audit, 2001– Verplancke D, et al. Clin Rehab. 2005; 19 (2): 117-125.– UK, French & Italian standards & evidence

Adopted by teams

Staff requires continual education – rapid turnover of nursing & therapist staff in acute wards

Individual pathways for patients’ problems

Requires good organisation & written plans– Motor functions, mobility, reaching, dexterity– Sensation, special senses– Continence, swallowing, – Communication, cognition, behaviour, mood change– Complications – immobility, tissue viability, epilepsy

Part of goal setting process – not easy!

ABI Mobilisation Care ABI Mobilisation Care PathwayPathway

Rehabilitation priorities

Admissions Care Pathway

Rehab Coordinator identifies suitable patients

Admit rapidly to Post Acute

Rehab Centre

Admit to NBU

Advise to continue rehab in Acute Ward e.g. spasticity treatment

Educate pt & family about

Skilled nursing facility

No immediate rehab needs

Liaise with 1o care team/GP

For I/P physical rehab

Neuro-psychiatric

rehab

Deal with acute medical/ surgical

issues

Liaise with community rehab team

No need for I/P treatment

Patient admitted to ICU / Neurosurgery / Neurology / Acute Wards

Assessment by PRM Team with Rehabilitation Coordinator

Discharge from Acute Rehabilitation Discharge from Acute Rehabilitation SettingSetting

Community hospital/ dom. interventions

Medical/nursing/therapy needs & patient goals dictate pathway

Stand alone Rehab Centre

Ambulatory specialist rehab

Community non-complex rehab

Specialist interventions

Return to acute care

Medical problems - complications

(ICP, infection, etc)

Training & Accreditation

European Board of PRM recognises specialist training

– Postgraduate curriculum

– Annual knowledge-based examination

– Continuing professional development

– Approval of training sites

UEMS Section of PRM

– Accreditation of PRM programmes

– Position papers & professional standards

•Definitions

•Activities

•Experience

•Outcomes

OutcomesOutcomes

Benefit on patient activities & on preventing unnecessary sedation McLellan DL. British Medical Journal 1991; 303: 355-357.

Good clinical practice to transfer patients to specialist rehabilitation, when this is the priority of careShiel A, et al. Clinical Rehabilitation 1999; 13 (1): 76-79.

Prevention of contracture & reduction of time spent in further I/P

rehabilitation through early spasticity management Verplancke D; Ward AB. Clinical Rehabilitation 2005; 19 (2): 117-125.

Reduction of overall costs by early supported dischargeFjaertoft H. Indredavik B. Magnussen J. et al. Cerebrovascular Diseases 2005; 19 (6): 376-83.

Participation After Early Participation After Early RehabilitationRehabilitation

Reduction in care Social benefits

– Getting out of house– Personal & family relations

Independence– Community mobility

• Driving• Use of enabling technology

Occupational– Work– Informal/voluntary

Collin C, Ward A B. ‘Rehabilitation Medicine, 2011 & Beyond’. RCP London. 2010

ConclusionConclusion

Valuable activity– PRM beds in acute facility– Mobile teams– Daily visits by PRM specialists– Acute facilities in PRM centres

Combination of options according to PRM availability

Set up evidence based care pathways to deliver

Ward A B, et al. J Rehabilitation Medicine 2010; 42 (5): 417-24.

Thank You