Rehabilitation & Patient Pathways Following Major Trauma

Transcription

1 Rehabilitation & Patient Pathways Following Major Trauma Sandy Gill 2013 Roosevelt Scholar Final Report ~ 1 ~

2 Contents 1. Introduction & Overview 3 2. Itinerary 4 3. Findings 5 4. Conclusion 7 Acknowledgements This once in a lifetime opportunity would not have been possible without the help of several people, some of whom I would like to give thanks to here. To the Queen s Medical Centre League of Friends, for sponsoring my Scholarship place. A truly great charity that offers endless support to NUH. To Nottingham University Hospitals NHS Trust (NUH), for being so supportive and forward thinking. To Jenny Leggott (Director of Nursing at NUH), Karen Swinscoe and Daljit Athwal (NUH mentors), for all their ongoing support and encouragement. To Gordon Waine (Roosevelt mentor) and Ellen Burns (secretary), for all their help and advice along the way. To all the American hospitals and families I met along the way, for all your hospitality, generosity and enthusiasm of my project. I hope I can re-pay the favour one day. To my family and friends, for their unconditional support throughout this process. ~ 2 ~

3 1. Introduction Since qualifying as a Physiotherapist in 2008, I have worked at Nottingham University Hospitals; completing my junior rotations and then securing a senior physiotherapist post. I have relished rotating through various specialities within the hospital and at the time of applying for the scholarship, was looking for another challenge to not only further my career, but also travel. The Queens Medical Centre successfully became the East Midlands regional level 1 trauma centre in Over 500 patients were treated and 44 extra lives saved in its first year. My project idea was fuelled by my interaction with these patients following life changing injuries. Patients that are victims of major trauma are mostly young, working-aged people. I noticed that there was a gap in provisions for rehabilitation for this patient cohort. Elderly patients can go for a period of rehabilitation before we, as medical professionals, deem them safe for home. But where were the young patients supposed to go? And who was following them up once they were home? After talking to a 33 year old patient, a year on following a motorbike accident, he told me he struggled to know what to do with himself after being discharged from hospital and was still not back at work. In my opinion, not enough was being done to support this patient population, with minimal functional rehabilitation, return to work support and long-term follow up. Further strengthening my case, the Department of Health had conducted the Next Steps Review in which rehabilitation was highlighted as the worst performing aspect of the trauma care pathway and tackling major trauma was set as a key priority for the NHS. This combined with Nottingham University Hospitals ambition of becoming a national lead in the development of major trauma services, ensured my project was pertinent to a wide audience. The USA has had regional trauma centres, with centralisation of specialist services for many years. Anecdotally, America is known to be more aggressive with their rehabilitation and I wanted to see what their patient pathway was following major trauma; bringing back best practice. ~ 3 ~

4 2. Itinerary I set out planning my project by conducting a literature search around my project themes and subsequently contacted large level 1 trauma centres across the US. From October 2013 to January 2014, I visited the following places: - San Francisco, California: Bothin Burns Centre - Seattle, Washington: Harborview Medical Centre - Los Angeles / Nevada: Site seeing- Grand Canyon - Orlando, Florida: Progress in Rehab Research Conference - Philadelphia, Pennsylvania: PENN Medicine, Regional Trauma Centre - Boston, Massachusetts: Massachusetts General Hospital, Regional Trauma Centre, Spaulding Rehabilitation Hospital - Orlando, Florida: Institute for Healthcare Improvement Conference - New York City: Sightseeing historical US sites - San Francisco, California: San Francisco General Hospital, Institute for Global Orthopaedic Trauma I was very fortunate to be able to organise home stays through my contacts at the hospitals in every city I visited. This enabled me to see real American life and experience the history and culture of the cities. ~ 4 ~

5 3. Findings It is difficult to sum up all my findings in this report, as simply being in the American healthcare environment, I absorbed so much, beyond the scope of my project. Although there were many similarities, the largely privatised American healthcare system is so different to that of the English system, contrasts were vast. In respects to the major trauma patient pathway, from entering the emergency department to initial stabilisation, the processes were very similar to the UK. I had the opportunity to observe trauma calls where patients are bought in to the emergency department in various different hospitals. The nature of the injuries was striking to me. I was aware of the problems with guns in America, but I perhaps underestimated it. The sheer number of gunshot related injuries really shocked me. Most major trauma wards were full of various gunshot injuries, from gang related violence to accidental shootings. It was fascinating to see how the trauma teams dealt with these injuries; sometimes numerous patients with multiple gunshot wounds at the same time. At one particular centre, the trauma team came together after each trauma call in resus and had a de-brief session there and then, discussing what went well and what could have gone better. This was a great example of in the moment feedback and, although it was a high pressure situation, the staff found it a useful learning tool. When therapist s assessed a patient, their focus was always on discharged. There was a resoundingly large emphasis on function and premorbid activity levels. There was a fast turn over from the acute hospital setting, with patients being transferred to numerous different rehabilitation options. Rehabilitation started very early, mostly on intensive care whilst the patient was still intubated and ventilated. The patients were kept lightly sedated to allow rehab to commence early, often with therapist s timing treatment with sedation holds. Once able to be transferred, depending on insurance coverage, the patient could be sent to the following destinations: Acute rehab ward an allocated ward within the hospital for medically-stable patients who needed more rehab input ~ 5 ~

6 Acute rehab hospital a community based hospital where the patient would receive 3 hours of therapy a day including PT, OT and speech language therapy. Skilled Nursing Facility (SNIF) a community based setting for patients that needed ongoing nursing care and could not tolerate 3 hours of therapy a day. They would typically receive an hour a day here. Long-term Acute Care (LTAC) for patients with ongoing care needs. Often took patients who were slower to wean off ventilators. These numerous options allowed continuous flow of patients between them; i.e. patients could be progressed from a SNIF to an acute rehab hospital or vice versa. This also eased pressure on the acute hospital beds whilst allowing the patient to rehabilitate in an appropriate environment. The acute hospital still had ownership of the patient and often used tele-conferencing to follow up with the patient s progress. There were various factors that I observed that enabled a more efficient service. The use of technology throughout the hospital, including online medical records, often minimised delays. There were nurse specialist roles throughout the trauma units, which allowed effective communication and management of the patients without having to wait for the medical team who are often held up in surgery or clinics. Close working relationships between the Physio and Occupational therapists allowed a more multi-disciplinary approach to patient rehabilitation. The use of assistants to transport patients between the ward and in-patient rehabilitation gym s allowed the therapists to see more patients away from the ward setting, focusing on functional outcomes. All of these elements, whilst existing in the NHS, could be enhanced to improve efficiency. In addition to my project findings, culture and attitudes of staff were very different. I was very impressed by all grades and backgrounds of staff knowing their hospitals statistics and what their hospital was famous for. I wondered how many people would know how many beds we have at NUH or how many nurses we have off the top of their heads. They seemed proud of their organisation and respective departments; a culture we could do with more of in the NHS. ~ 6 ~

7 4. Conclusion Giving justice to this experience in this short report is extremely difficult. On the whole, I have grown so much as a person and learnt a great deal. Whilst I witness some innovative care, it was surprisingly reassuring that our practice is not that different. To provide comparable care with a system that is not under the financial constraints like the NHS, not under the constant scrutiny of the press and that is free at point of contact to all our citizens makes me very proud. I was astounded at the cost of healthcare in the US and it made me very grateful to have the NHS. Since my return, I have been very well supported by my employer (Nottingham University Hospitals). I have been given support to formulate my findings into possible implementations that would benefit the patients and the hospital. Currently, I am working on a project on how to introduce early rehabilitation for major trauma patients. From my observations and subsequent research, it has been documented that lower sedation levels on intensive care can lead to increased early rehabilitation, leading to better outcomes for the patient, as well as reducing their length of stay in hospital. We are conducting a service evaluation audit to see where our current practice is in-line with current research. If appropriate, a trial will be conducted to lower sedation levels to assess if this facilitates earlier rehabilitation on intensive care. I hope to write up this trial as part of a master s research project. I am also disseminating my findings as wide as possible through presentations and attending conferences; campaigning for improved access to rehabilitation services following major trauma. Rehabilitation, in my opinion, is currently seen as an add-on in the NHS. It must be an integral part of the patient s pathway to ensure better outcomes. Whilst we have made major breakthroughs in pre-hospital and emergency care, more focus is needed on rehabilitation to give patients a better quality of life. This topic s importance is growing now, with the department of health recently highlighting rehabilitation as the worst performing element of the major trauma patient pathway. ~ 7 ~

8 Prevention Initial Contact Pre Hospital Assessment Acute Trauma Care Acute/ Specialist Rehabilitation Community / Generalised Rehabilitation Patient Pathway (Trauma Audit & Research Network 2012) The Roosevelt Scholarship has truly been a once in a life time opportunity for me, not only professionally but personally. I would never have envisaged myself where I am now when I applied, and for that I have the whole process to thank. It has enabled me to have a unique insight into various major trauma centres across the US, as well as make international contacts for future collaborations. The concept of supporting young people in their career as well as developing them as individuals is invaluable, and I feel very fortunate to be a part of it. I will continue to support this scheme through the Roosevelt Alumni and look forward to the new opportunities that are constantly arising. ~ 8 ~