Prof. Anthony B Ward. North Staffordshire Rehabilitation Centre Stoke on Trent

Transcription

1 Prof. Anthony B Ward North Staffordshire Rehabilitation Centre Stoke on Trent

2 Major Trauma 16,000 cases per year in England Commonest cause death under 40 years 3rd commonest loss life- years For every death, 3 patients with severe disability 30% hospital deaths avoidable in UK Comptroller & Auditor General. National Audit Office Trauma System Network, TSO. 2011

3 Trauma System in England & Wales Centrally funded system based around rehabilitation Specifically focused on moving patients from hospital to community settings to continue (specialised) rehabilitation System created with participation of all phases of trauma care Pre- hospital Emergency care Critical care & acute definitive care Rehabilitative care early, post acute and long term Regional hub and spoke services Appointment of regional & local directors of trauma care & trauma rehabilitation Comptroller & Auditor General. National Audit Office NICE Guidelines 2007

4 New Trauma Network Trauma system across English regions Established major trauma centres 5 year aim Save 600 lives/year Each trauma centre: 10% decrease mortality Regional trauma network: 15% decrease mortality Comptroller & Auditor General. National Audit Office Trauma System Network, TSO. 2011

5 Model for Rehabilita>on of Long Term Condi>ons Acute Services Post- acute Services Long- Term Services Intensity Rehabilitation in Hospital (ARU*) Post-acute rehab (in-patient and day clinic) Time Intermittent rehabilitation (in-patient or day clinic) Community based rehabilitation (out-patient rehab services) Intermittent rehabilitation (in-patient or day clinic) Gutenbrunner C. Annales de PRM * ARU = Acute Rehabilitation Unit

6 ACUTE CARE ITU Neurosurgery Orthopaedics Neuropsychiatric service more complex needs NEUROLOGICAL REHABILITATION INPATIENT UNIT highly complex needs TERTIARY UNIT (e.g. neurobehavioural unit) Emerg. Dept. less complex needs DGH ward Hospital Acute brain injury Supported discharge Hospital at home Early community rehabilitation Community reintegration Enhanced participation DEA supported return to work Multi-disciplinary multi-agency Brain Injury Team Community REHABILITATION MEDICINE SPECIALIST COMMUNITY SERVICES Collin C, Ward A B. Rehabilitation Medicine 2011 & Beyond. RCP London Integrated care planning Long term support Single point of contact Join health and social service planning Multi-agency care

7 Admission of Significant Trauma Pa>ent ISS 15 Major Trauma Centre MTC Emergency Department & Critical Care Specialised Services Neurosurgery, T&O Cardio- thoracic Maxillofacial, Plastics, etc. Injury ISS<9 ISS 9-14 Trauma Unit, TU Emergency Department & HDU Local Hospital ± some specialised services Local Emergency Hospital LEH Minor Injuries Centre 1 o care follow up

8 North Staffordshire Model Major Trauma Rehabilita>on Emergency Dept. Critical Care Unit (Trauma) Post- Acute Rehabilitation Community Rehabilitation Trauma Team Leader Trauma Coordinator (acute) x 2 Trauma Coordinator (rehabilitation) x 2 Complexity of Needs Level 1 Rehabilitation Service RCS Level 2 Rehabilitation Service Specialised Community Rehabilitation Service Consultant in RM (Acute) (Hyper)Acute Rehabilitation Service Rehabilitation Prescription Community Rehabilitation Service

9 Rehabilita>on Service Commissioning Level 1 Level 2a Level 2b Level 3a Level 3b Consultant in RM, 3 o service pop. 1.3 million Complex cases high dependency Complex cases medium dependency Cognitive behavioural services Consultant in RM, 2 o service pop. 250, ,000 Part Consultant in RM, 2 o service pop. 250, ,000 Non- specialised, community based other physician/gp Non- specialised, community based nurse & therapist run

10 UK Rehabilita>on Outcomes Consor>um Data Defini>on (BSRM 2010) UKROC Data reporting requirements Commissioning Currency SPECIALISED Full Dataset Full Dataset Level 1 Multi-level weighted tariff 5 tier Level 2a Multi-level weighted tariff 5 tier Level 1a: Tertiary services High physical dependency Level 1b: Tertiary services Physical / cognitive/behavioural Level 2a: Extended catchment - Mixed caseload Minimum dataset Level 2b 3 or 5-tier tariff NON-SPECIALISED Level 2b: Local specialist rehabilitation services (e.g. complex stroke rehab None Standard per diem HRG rates (reference costs) NON-SPECIALIST Level 3a: Other specialist services (e.g. stroke rehab) Level 3b: Generic rehabilitation services Complexity of caseload Pa>ents requiring rehabilita>on

11 Process of Transfer Response to need to free MTC facilities Joint rehabilitation plan between acute staff & RM staff Automatic pathway to step down location for rehabilitation Inpatient, Level 1 (NSRC, Haywood Hospital) or level 2 centre Ambulatory care, via early supportive discharge team & eventually CRT Process patients with complex needs separately & transfer from ITU & trauma wards to Level 1 rehab centre (NSRC) Significant communication, cognitive problems Via neuropsychiatry unit, if appropriate

12 Admission to Major Trauma Centre (ISS) 15 Rehab Prescription required TARN minimum dataset TARN dataset Scheme for Rehabilita>on Prescrip>on Pathways & Outcome Measurement BSRM. January 2013 RCS ET M score 3 Category C or D needs RR & R (Level 3) pathway Level 3 rehab pathway Within 48hrs Start rehab planning RCS-ET Checklist of complex needs R point Discharge from record Assessment of severity & outcome for TARN dataset RCS ET M score 4 (Hyper) Acute rehab setting Home discharge: At 6/12 Follow up TARN outcome assessment GOS- E WH O- Quol (o r EQ5- D ) Return to work Benefits Category A or B needs Level 1 or 2 pathway Likely - Category A or B patient Confirm complexity Expedite referral RCS ET M score 5 Post Acute Level 1 or 2 rehabilitation NPDS - cost efficiency FIM/FAM - outcome Community Rehabilitation

13 Admission Criteria to Post- Acute RM Beds l Trauma survivors Medically stable incl. tracheostomies on air Able to participate in rehabilitation programme With potential to be motivated to participate & able to engage Patients in whom there are clear rehabilitation goals l Depends on facilities/personnel RM team needs skills to manage acute patients l Clear documented criteria for each hospital Ward AB, et al. J Rehabilitation Med 2010; 42 (5): Gutenbrunner C, Ward AB, Chamberlain MA. White Book on PRM in Europe. 2007

14 Hyper- Acute RM Team RM specialists integral part of multi- disciplinary team Set up rehabilitation prescription Ensure prevention of complications in acute unit Problems addressed mostly at impairment level Identify patients requiring rehabilitation Move to Level 1 or 2 inpatient rehabilitation services Ambulatory rehabilitation Ensure safe discharge of patients bound for home Education of Acute ward staff Ward AB, et al. J Rehabilitation Med 2010; 42 (5):

15 Specialist Centre Inpa>ent Criteria 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 Those severely disabled people with needs only met by a MPT practising inter- disciplinary rehabilitation Those with complex needs, i.e. requiring >2 professionals working within a team

16 Ac>vi>es Providing rehab therapy for patients with complex problems requiring an input from 2 multi- professional team members Preventing preventable complications & providing treatment for them Providing triage for further definitive rehab programmes which may prevent the need for further rehabilitation Educating patients and carers acute care staff practicalities & principles of RM treatment

17 Team Skills Set out in White Book on PRM in Europe Rehabilitation assessments Clinical skills & assessment tools for functional diagnoses Rehabilitation plan PRM rehabilitation interventions Multi- professional rehabilitation teamwork Prognostication Multi- disciplinary rehabilitation cooperation Follow up Gutenbrunner C, Ward AB, Chamberlain MA. White Book on PRM in Europe. 2007

18 Discharge from Post- Acute Rehabilita>on Se^ng Medical/therapy needs & patient goals dictate pathway Level 2 stand alone rehab centre Ambulatory specialist rehab Return to acute care Community longer term non- complex rehab Specialist interventions Medical problems - complications (ICP, infection, etc) Community hospital/ dom. interventions

19 ABI Mobilisa>on Care Pathway Individual pathways for patients problems Requires good organisation & written plans Mobility & dexterity functions Sensation, special senses Continence, swallowing, pain Communication, cognition, behaviour, mood change Complications immobility, tissue viability, epilepsy, infection ADL Part of goal setting process not easy!

20 TARN Data Odds Ra>o Survival 1,6 1,4 1,2 1 0,8 0, ,4 0, / / / / / /13 Years

21 West Midlands Overview Hyper acute rehabilitation operational model Rehabilitation coordination Trauma units and other providers in pathway Rehabilitation prescription Data collection Ball A. 2012

22 Early support discharge teams Input from specialist rehab teams Acute inpatient rehabilitation team MTC Trauma Units / LEH Rehab outreach from MTC Community Rehab Team (CRT) Early Discharge Support Teams COMMUNITY SPECIALIST REHAB UNIT Fast stream inpatient rehab team Community assessment teams (CAS) Intermediate care hospital & nursing/ resi- dential home Slow stream inpatient rehab teams Ball A. 2012

23 Hyper- Acute Rehabilita>on Core Staffing Consultant in Rehabilitation Medicine (CRM, 2 x 0.5 WTE) 6 clinical sessions (PAs) 2 admin sessions 4 on- call sessions (weekend cover) Rehabilitation Coordinator (RC): 2 x WTE Admin Staff: 0.5 WTE (Rehab data input and secretarial support) 1.0 WTE Tarn data coordinator Therapy staff as per national rehabilitation guidelines Ball A. 2012

24 Hyper- Acute Rehabilita>on Opera>onal Plan Overall supervision and responsibility CRM Smooth transition of care RC working both at MTC & specialist rehabilitation unit (Level 1 & 2) Weekend coordination Senior therapy staff working shifts, support via Consultant RM on call Communication and handover Friday pm + Monday am between weekend and weekday teams Daily between RC & Acute Care Coordinators / Critical Care Outreach

25 Role of Rehabilita>on Coordinator Close liaison with acute care coordinator See every major trauma patient within 24 hours of admission Initiate and document rehabilitation plan Oversee and assist therapy team with delivery Identify key worker for each patient Attend MDT meetings (both sites) Rehabilitation prescription (72 hours before EDD) Coordination with all receiving centres

26 Role of Trauma Rehabilita>on Consultant (CRM) Confirm rehabilitation plan within 24 hours Assess every multiple trauma patient within 72 hours Chair MDT and goal planning meetings Sign off rehabilitation prescription Prognostication and advice to other specialties

27 WARD ROUND Consultant A MONDAY PM ITU Neuro Trauma Unit, Ortho Trauma Unit, Outlying Neuro & Major Trauma Patients MDT CASE CONFERENCE Consultant A & Consultant B TUESDAY AM WARD ROUND Consultant B THURSDAY AM ITU Neuro Trauma Unit, Ortho Trauma Unit, Outlying Neuro & Major Trauma Patients CRM RC Admin staff Where appropriate: Neurosurgical Registrar Ortho Trauma registrar ITU Registrar Senior Nursing staff CRM RC Admin staff Neuro physio & OT Neuropsychologist Nursing staff Other therapy & nursing staff (ITU) as appropriate to be coordinated by rehab admin staff CRM RC Admin staff Where appropriate: Neurosurgical Registrar Ortho Trauma Registrar ITU Registrar Senior Nursing staff

28 Role of Trauma Rehabilita>on Administra>ve Assistant Organise MDT and other meetings Attend ward rounds and meetings Document and disseminate all changes to rehabilitation plan Data entry and updates Production of final Rehabilitation Prescription

29 Rehabilita>on Prescrip>on Evolving document Accompanies patient throughout rehabilitation journey Acute care to community Far superior to existing discharge summaries Regional and national consensus

30 Trauma Rehabilita>on Database Microsoft Access designed by Consultant in RM Simple data input for administrative staff Daily updates with management plans Provision for web- based data entry (currently intranet ) Planned distribution across West Midlands Trauma Network Potential to integrate with TARN database nationally

31 Results 2012/13 University Hospital of North Staffordshire Covers Staffordshire, Shropshire, Cheshire, North Wales million population 354 admissions with major trauma 93% survival of those arriving in hospital (compared to 79% in previous years) 68 category A or B needs requiring admission to Level 1 neurological rehabilitation 258 repatriated to Level 2a/2b rehabilitation centres (mainly for musculoskeletal rehabilitation) Data shortly to be published

32 Further Developments Establishment of full MDT at UHNS for hyper- acute rehabilitation provision Formal links with social services Training and governance of Trust MDT Trauma Directorate? Whole rehabilitation pathway including TU, LEH, community teams.

33 Thank You

34 Early Rehabilita>on Activity under clinical responsibility of RM team Should deliver specialist medical rehabilitation programmes for all trauma survivors during an acute hospital admission Triage for further rehabilitation Should separate those with and without complex needs

35 RM Programmes in Acute Se^ngs Concentrates therapy - therapy input associated with shorter hospital stays & improved outcomes Right environment & right skill mix with trained therapists Optimises patients physical & social functioning Gutenbrunner C, Ward AB, Chamberlain MA. White Book on PRM in Europe. 2007

36 RM Programmes in Acute Se^ngs Identifies & reduces effects & complications of trauma Physical effects - immobility, etc. Cognitive & behavioural deficits Mood changes Others Improves chances of independent living at home & return to work Gutenbrunner C, Ward AB, Chamberlain MA. White Book on PRM in Europe. 2007

37 RM Programmes in Acute Se^ngs Evidence to show that rehabilitation improves chances of independent living at home & return to work

38 Admissions Care Pathway Patient admitted to ITU UHNS Trauma Rehab Coordinator plans Rehab prescription Picked up daily by RM team Return to local facilities Level 2 Centre For I/P with complex problems Neuropsychiatric issues Admit to NBU Return to local facilities Admit to N/ Rehabilitation Unit at NSRC Educate pt & family Community rehab team