European Perspective on Early Brain Injury Rehabilitation Professor Anthony B Ward North 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 Rehabilitation 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 Settings Ward A B, et al. J Rehabilitation Medicine 2010; 42 (5): 417-24.
Specialist Rehabilitation - Acute Phase 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 Here? Rehabilitation is focus for inpatient care – cannot discharge patient Dedicating facilities for this purpose meets healthcare priorities 1 Achieves better clinical outcomes and economic profiles for provider hospital 2 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 Rehabilitation 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.
Acute Physical & Rehabilitation Medicine (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 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 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.
EstablishmentActivityAdvantagesLimitations PRM Beds in Acute Hospital ( ≡ Acute inpatient specialised team) Transfer of pts to PRM beds in acute hospital Rapid transfer to quality PRM care Early rehabilitation principles Requires adequate numbers of dedicated staff Limited nos. of beds and thus pts Potential for bed- blocking Protect against inappropriate admissions Difficult 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 conditions Good liaison team with ac. ward staff Identify patients requiring I/P rehab Education of naïve family care-givers Interact with 1 o care physician Some staff not in PRM team Least specialised format No clinical control – pts under care of other specialists Deal at impairment & activity level Participation issues not addressed
EstablishmentActivityAdvantagesLimitations 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 conditions Closer links between PRM and acute specialists When 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 CentreRapid transfer of patients to fast- track facility in stand alone PRM Centre Pt exposed at early stage to total PRM team & facilities PRM specialist team competence in treating acute conditions Medically stable pts Transfer back if pt deteriorates No formal contact between PRM team & acute specialists Little or no service for patients not transferred
Mobile Team Advise on setting up rehabilitation programmes Prevent complications in acute facility Organise patient’s move to PRM Dept for further inpatient or ambulatory rehabilitation Rehabilitation Medicine specialist integral part of team Good collaboration required with referring specialist and clinical team
Problems addressed mostly at impairment level Aim to improve personal functioning Identify patient requiring inpatient rehabilitation Ensure safe discharge of patients bound for home Education of family members, who may become care-givers for first time Interact with 1 o care physician Mobile Team
Development 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 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 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
North Staffordshire Severe ABI Audit Mobilisation Spasticity Behaviour Mood Communication Ward AB. Audit of NSRC admissions. 2001
North Staffordshire Severe 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% dysphasic Ward AB. Audit of NSRC admissions. 2001
Spasticity Management in Early Brain Injury Prospective, DB RCT - 3 parallel treatments Severe brain damage (GCS ≤ 8/15) 253 patients, 35 randomised –Group 1Standard treatment– control –Group 2Lower leg Combicast Gastrocnemius & soleus mm injected with placebo –Group 3 Lower leg Combicast Gastrocnemius & soleus mm injected with BOTOX ®
Results All randomised within 10 days of event Casting (II & III) superior to standard treatment (I) [ p = 0.07] Trend of improvement with Group III (NS) Rescue of Group I patients with Botox ® Recommendations –Active very early intervention with casting valuable –Skilled staff for casting techniques –BoNT-A safe –BoNT-A required for Patients with DAI & brain stem lesions due to anoxia GCS ≤6 Four limb spasticity at one week Verplancke D, Snape S, Salisbury CF, Jones PW, Ward AB. Clin Rehab. 2005; 19 (2): 117-125.
ABI Mobilisation Care Pathway 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 Pathway
ACUTE CARE ITU Neurosurgery Orthopaedics Acute brain injury Hospital NEUROLOGICAL REHABILITATION INPATIENT UNIT TERTIARY UNIT (e.g. neuro- behavioural unit) REHABILITATION MEDICINE SPECIALIST COMMUNITY SERVICES Supported discharge Hospital at home Early community rehabilitation Community reintegration Enhanced participation DEA – supported return to work Integrated care planning Long term support Single point of contact Join health and social service planning Multi-agency care Multi-disciplinary multi-agency Brain Injury Team Neuropsychiatric service more complex needs less complex needs highly complex needs DGH ward A&E Community Collin C, Ward A B. RCP London. 2010 ‘Rehabilitation Medicine 2011 & Beyond’
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 1 o 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
Establish PRM Beds Response to need for urgent rehabilitation ( McLellan DL BMJ 1990) ‘Fast-track’ bed patients identified Nominal bed for 3 weeks’ occupancy Joint rehabilitation plan between acute staff & NSRC staff Transfer patient to standard PRM bed in NSRC Rehabilitation continues Frees up ‘fast-track’ bed for next patient
Discharge from Acute Rehabilitation Setting 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
Outcomes 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 care Shiel 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 discharge Fjaertoft H. Indredavik B. Magnussen J. et al. Cerebrovascular Diseases 2005; 19 (6): 376-83.
Participation After Early Rehabilitation 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
Return To Work/Productivity Everyone’s goal: ultimate success after rehabilitation –Government, courts, individuals & families, rehab teams Can rehabilitation achieve this? –Poor achievement after TBI 1 Complex issues leading to return /sustain work 2 Components go beyond ability to perform work tasks 2 –Discipline of work Getting to workplace –Personal / people skills 1. Shigaki C, et al. Dis & Rehabil 2009; 31 (6): 484-489. 2. Fadyl JK, et al. Dis & Rehabil 2010; 32 (14): 1173-1183.
Level 1 Evidence of Benefits Reduces complications –e.g. physical effects of neurological injury, immobility, etc. Optimises patients’ physical & social functioning Identifies cognitive & emotional aspects of disability –even in absence of physical sequelae Improves chances of independent living at home & return to work Concentrates therapy –More therapy input associated with shorter hospital stays & improved outcomes Right environment & skill mix of trained therapists Turner-Stokes L. Clinical Rehabilitation 2002; 16 (Suppl. 1): 1-60. Stroke Units Trialists Collaboration. British Medical Journal 1997; 314: 1151-1159. Bernspang B, Asplund K, Erikson S, Fugl-Meyer AR. Stroke 1987; 18: 1081-1086. Indrevidavik B, et al,. Stroke, 22: 1026-1031.
Other Evidence & Consensus Independence at six months after early rehabilitation Prompt response on ill effects of immobility & complications Educating ‘acute staff’ of areas where rehabilitation is of major benefit 1 Money spent on rehabilitation recovered with overall savings to system 2 Overall evidence of effectiveness of rehabilitation ± ?cost-effectiveness 1. Didier JP. La plasticité de la fonction motrice. Springer Verlag; 2004. p476. Paris: p 476. 2. Krauth C, et al. Gesundheitsökonomische Evaluation von Rehabilitationsprogrammen im Förderschwerpunkt Rehabilitationswissenschaften Rehabilitation 2005; 44: pp e46-e56.
Outcomes Benefit on patient activities & on preventing unnecessary sedation McLellan DL. British Medical Journal 1991; 303: 355-357. 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 discharge Fjaertoft H. Indredavik B. Magnussen J. et al. Cerebrovascular Diseases 2005; 19 (6): 376-83. Good clinical practice to transfer patients to specialist rehabilitation, when this is the priority of care Shiel A, et al. Clinical Rehabilitation 1999; 13 (1): 76.
Conclusion 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.