Rehabilitation Following Major Trauma in Greater Manchester

Transcription

1 Rehabilitation Following Major Trauma in Greater Manchester Dr Krystyna Walton Consultant in Neurorehabilitation Director Greater Manchester Major Trauma Rehabilitation

2 Major Trauma Rehabilitation in the UK A relatively new concept Regional Networks for Major Trauma, NHS Clinical Advisory Group Report, September 2010 Major Trauma Networks live from April 2012

3 New Major Trauma Centres to save up to 600 lives every year April 2, 2012

4 Mortality after Head Injury Effect of Neurosurgical Care Trends in head injury outcome from 1989 to 2003 and the effect of neurosurgical care: an observational study. Patel HC, Bourama O, Woodford M, King AT, Yates DW, Lecky FE. Lancet 2005 Oct 4; 366(9464):

5 Results: non-surgical lesions case mix adjustment Model predicting death adjusted for age, RTS and ISS B S.E Sig O.R 95% CI Non-neuro centres the age, injury severity, and presenting physiology adjusted odds of death are 2.4 times greater in patients treated in a non-neurosurgical centre compared to those treated in a neurosurgical centre

6 Trauma Centres in England Many patients need a personalised rehabilitation programme taking many months to help them return to an active life. From April, every major trauma patient will be given a rehabilitation prescription which describes their recovery plan in detail. Secretary of State for Health, Andrew Lansley, April 2012

7 The Rehabilitation Prescription

8 Key reports Regional Networks for Major Trauma, NHS Clinical Advisory Groups Report, September 2010 Management of People with Spinal Cord Injury, NHS Clinical Advisory Groups Report, August 2011

9 The principle of a patient receiving specialist care appropriate for their injuries is fundamental to Networks of Trauma Care. To abandon this principle at the point at which rehabilitation is required is illogical and compromises patient outcomes. It is wrong to assume that specialist rehabilitation techniques will be carried out on a general orthopaedic or surgical ward in a district general hospital. Regional Networks for Major Trauma NHS Clinical Advisory Groups Report September 2010

10 CAG Recommendations A Network Responsibility, with a Trauma Network Director of Rehabilitation Acute & specialist rehabilitation must be delivered early along the pathway Clinical Lead for Rehabilitation in every Major Trauma Centre (Consultant in Rehabilitation Medicine) Adequately skilled & resourced MDTs in all services Personal prescription for rehabilitation for all trauma patients

11 Major Trauma Centre Rehabilitation Responsibilities 1. Early identification of rehabilitation needs 2. Ensuring that patients are transferred to a service which can meet the individual s needs 3. Planning & co-ordination of the rehabilitation pathway

12 Interpretation varies across England as to what constitutes specialist rehabilitation & how it should be provided

13 Levels of complexity Rehabilitation Level 3 Level 2 Level 1 Generic, not led by a Consultant in Rehabilitation Medicine Specialist, led by Consultants in Rehabilitation Medicine 2a 50% of patients with very complex needs 2b 35% of patients with very complex needs Specialist, led by Consultants in Rehabilitation Medicine 85% of patients with very complex needs

14 Implementation across Trauma Variable Networks in England Standards differ

15 Implementation across Trauma Variable Networks in England Standards differ Rehabilitation pathways Variable initial commitment by MTCs Transformation of PCTs to CCGs, lack of knowledge in CSUs Absence of infrastructure for non-neuro rehabilitation Very limited access to vocational rehabilitation

16 Implementation across Major Trauma Networks in England Influences on implementation 1. National directive NHS England Service Specification for Major Trauma Centres & for Complex Rehabilitation National guidance via the NHS

17 Implementation across Major Trauma Networks in England How implementation can be influenced 1. National directive NHS England Service Specification for Major Trauma Centres & for Complex Rehabilitation National guidance via the NHS 2. Professional Advice BSRM Core Standards Rehabilitation in the Trauma Pathway, January 2013 Peer review

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19 Hyper-acute Rehabilitation Step down from ICU/HDU No longer under direct care of parent acute (usually surgical) speciality Need to be close to parent specialty Still medically unstable Under direct care of a Consultant in RM

20 Hyper-Acute Rehabilitation Unit Medical leadership Consultant in Rehabilitation Medicine Dedicated acute rehabilitation team Expertise Governance Mobile Rehabilitation Team Experienced therapy team, but day-to-day care by treating team ownership of the process Patient remains under care of referring consultant Unable to promote ethos of rehabilitation Pressures on acute neurosurgical & orthopaedic beds Outreach from post-acute Rehabilitation unit Generally unsatisfactory Usually for advice & listing for transfer Not part of the treating team Absence of rehabilitation ethos Risk of repatriation or inappropriate discharge, because of pressures on acute specialist beds

21 Hyper-acute/early Rehabilitation Unit in or close to MTC/TU Medical leadership Consultant in Rehabilitation Medicine Dedicated acute rehabilitation team Expertise Governance Mobile Rehabilitation Team Experienced therapy team, but day-to-day care by treating team ownership of the process Patient remains under care of referring consultant Unable to promote ethos of rehabilitation Pressures on acute neurosurgical & orthopaedic beds Outreach from post-acute Rehabilitation unit Generally unsatisfactory Usually for advice & listing for transfer Not part of the treating team Absence of rehabilitation ethos Risk of repatriation or inappropriate discharge, because of pressures on acute specialist beds

22 North West England s Trauma Systems 1. North Cumbria 2. Lancs & South Cumbria 3. Mersey & Cheshire 4. Greater Manchester 5. Children s Trauma System

23 Major Trauma Rehabilitation in Greater Manchester

24 Trauma in GM Reference Slide Only

25 Greater Manchester Major Trauma Centre Collaborative (MTCC) Salford Royal Hospital Neurosciences Spinal surgery Head & neck surgery Acute neurorehabilitation Spinal injuries pathways Manchester Royal Infirmary Vascular Eye Hospital Amputee rehabilitation beds South Manchester University Hospital (Wythenshawe) Vascular Plastics & burns Cardiothoracic Prosthetics (DSC) + NWAS

26 Greater Manchester Neurosciences Centre Neurorehabilitation Pathway What we have had since 2001 Established pathways for Neurorehabilitation Acute Neurorehabilitation 20 dedicated beds at SRFT Patient flow issues a major problem for a number of reasons??? Provision for MSK rehabilitation

27 SRFT Major Trauma Rehabilitation Process

28 Patient added to Major Trauma provider list on EPR on admission TAU patients, 5 days/week MDT rehabilitation review with Consultant in Rehabilitation Medicine TAU patients, daily review by Consultant in Ageing & Complex Medicine, x2/week MDT review involving Consultants in Neurosurgery & Rehabilitation Medicine All other patients (Critical Care, Neurosurgery, Spinal Unit, orthopaedics etc) 3 days per week (Mon, Wed, Fri) MDT rehabilitation outreach with Consultant in Rehabilitation Medicine

29 R point identified & patient transferred or listed for appropriate rehabilitation service; no patients with Level 1 or 2 rehabilitation needs are repatriated Outreach Neurorehabilitation MDTs for tracheostomy & spasticity management Assessment by Consultant in Ageing & Complex Medicine where required

30 Older adults Large number of patients admitted with fall/collapse 25% TAU admissions >65yrs old 14% TAU admissions >75yrs old Challenges Frail Polypharmacy Comorbidities

31 Old is not the same as elderly

32 Integration with Elderly Care / Complex Medicine at SRFT GM Major Trauma Network

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34 Rehabilitation Prescription 1. The rehabilitation prescription sets out a check-list of simple standards of process that should ensure the best outcome for patients. 2. Prescription for specialist rehabilitation must be completed by a Consultant in Rehabilitation Medicine

35 Rehabilitation Prescription Document

36 The Rehabilitation Prescription & Best Practice Tarrif

37 Major Trauma Rehabilitation on TAU 18 bedded Trauma Assessment Unit 12 Major Trauma Rehabilitation beds (TRU) Daily Rehabilitation ward rounds Mon-Fri Twice weekly MDT ward rounds on TAU Neurosurgery, Neurorehab, Ageing & Complex Medicine TAU immediate transfers to Trauma Rehabilitation if bed available

38 Hyper-Acute Neurorehabilitation (C2) 20 beds, 25 30% Major Trauma; caters for the most complex patients Experienced team, service established in Consultants in Rehabilitation Medicine, 2 ST3 or higher doctors, CMT 1 or 2, Clinical Fellow (CMT 1 equivalent) High nursing levels Therapy levels in accordance with BSRM guidance Therapy space on the ward Consultant Neuropsychologist based on C2 Up to 8 complex tracheostomy patients Up to 7 patients requiring 1:1 supervision Severe challenging behaviour management

39 Major Trauma Inpatients at SRFT Between 55 & 65 patients Usually 6 or 8 patients in Critical Care patients on TAU 4-6 patients in neurosurgical beds 3 5 in orthopaedic beds 19 to 23 patients in specialist rehabilitation beds in level 1a Hyper-Acute (TRU & C2) 3 5 in Level 1 post-acute Neurorehabilitation

40 Musculo-skeletal Injuries CMFT UHSM SRFT 65% MSK injuries 5% MSK with neuro injury 20% spinal fracture without cord injury MSK rehabilitation, dedicated team with RM consultant MDT Major Trauma Clinic Community outreach 71% MSK injuries 4% MSK with neuro injury 10% spinal fractures without cord injury MSK rehabilitation, dedicated team with RM consultant 50% multiple MSK injuries, 30% also have brain or spinal cord injury injury 40% have spinal fractures without cord injury Access to Level 1 & 2 rehab beds at SRFT Co-ordinated neurorehab pathway Follow-up only if had IP rehabilitation GM Major Trauma Network

41 Rehabilitation in the Greater Manchester MTCC Specialist & non-specialist early rehabilitation Dedicated hyper-acute & post-acute neurorehabilitation beds Dedicated trauma rehabilitation beds (Level 1 & 2) Delivery of the Rehabilitation Prescription in the MTCC Network of post-acute neurorehabilitation

42 Principles A co-ordinated approach in the MTCC Trusts, & across the Network A continuum of care with rehabilitation being available in acute care (incl ICU/HDUs), involvement in ongoing care & reconstruction, as well as in dedicated inpatient facilities Pathways of care should be patient centred & flexible to meet changing needs Services should work collaboratively & flexibly across Gtr Manchester to ensure patients are cared for in the most appropriate environment to meet their individual needs GM Major Trauma Network

43 The Future SRFT to be principle receiving site by April 2017 Improvements (developments) in MSK rehabilitation Roll out of the Rehabilitation Prescription outside the MTC

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