Rehabilitation after Acquired Brain Injury. A Northern Perspective.

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Rehabilitation after Acquired Brain Injury.A
Northern Perspective.

• John P McCann.
• Consultant in Rehabilitation Medicine.
• Green Park Healthcare Trust.

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Demographics

• Population 1.7 million
• Stable population base
• Dept. Health Social Services and Public Safety
• Four Area Health Boards
• Regional Medical Services Consortium
• Mixed regional and local commissioning

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Acquired Brain Injury

• Acute onset non progressive brain injury.
• Trauma
• Vascular Accident
• Cerebral Hypoxia
• Toxic/Metabolic Insult
• Infection

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Definitions of Rehabilitation

• Conceptual A process of active change by which a
  person who has become disabled acquires the
  knowledge and skills needed for optimal physical,
  psychological and social function.
• Service The use of all means to minimise the
  impact of disabling conditions and to assist
  disabled persons achieve their desired level of
  autonomy and participation in society.

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Epidemiology of A B I

• Stroke. lt65y.o. 20/100000. N.I. 300
• S A H. 8500/yr. N.I. 200
• Head Injury. 275/100000. N.I. 4000
• Mod-severe. 25/100000. N.I. 260
• 2-4 Severe disability/prolonged
  coma
• 18-22 Good physical recovery.

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N.I. Audit 2003

• 7826 A E attendances.
• 2417 adults admitted.
• 871 children admitted.
• 257 referred to NSU in 6/12 period.
• 195 adults. 62 children.
• 87 adults admitted. 34 NSU/53 RICU.
• 22 children admitted.

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Admissions to hospital.

• District General Hospital 116 (45)
• RICU 53
  (21)
• NSU 34
  (13)
• DGH ICU 15 (6)
• RBHSC 13 (5)
• PICU 9
  (4)
• No Info 15
  (6)

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Background Documentation

• Royal College Surgeons England. Working Party on
  Management of Patients with Head Injuries. June
  1999.
• Royal College of Physicians / BSRM.
  Rehabilitation following acquired brain injury.
  National clinical guidelines. 2003.
• National Service Framework for Long-term
  Conditions. March 2005.

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Principles and organisation of services

• Every patient with ABI should have access to
  specialist neurological rehabilitation services.
• Covering all phases from acute management through
  medium term rehabilitation to long term support.
• For as long as required, which may be life long.

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Prinicples and organisation.

• Specialist neurorehabilitation services for
  persons with ABI should meet published standards,
  and comprise the following.
• A coordinated interdisciplinary team of all the
  relevant clinical disciplines.
• Staff with specialist expertise in the management
  of ABI including a consultant specialist in
  Rehabilitation Medicine.

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Transfer to Rehabilitation

• Patients still in hospital gt 48 hours with
  impaired consciousness or mobility should be
  reviewed as soon as possible by a rehabilitation
  team.
• Severely brain injured patients still in coma
  should be referred to a specialist ABI unit where
  their continued acute care may be supplemented by
  an interdisciplinary rehab. team

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Transfer to Rehabilitation

• Patients requiring post-acute inpatient
  rehabilitation should be transferred to a
  specialist post-acute rehabilitation unit as soon
  as they are medically stable and fit to
  participate in rehabilitation.

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Inpatient Rehabilitation Services

• Regional Acquired Brain Injury Unit
• Thompson House
• Maine Villa
• Spruce House

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Regional Acquired Brain Injury Unit.

• Opened May 2006.
• 25 Beds
• Flexibility of accommodation
• Integrated outpatient service
• Early transfer from acute units
• Working relationships with other providers
• Interdisciplinary team structure

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20 Years a coming

• 1982. Medical Rehabilitation. Report of a
  Working Party.
• 1991. Sloan Report.
• 1994. Business Case for R.R.U. submitted to
  Management Executive.
• 1996. Social Services Inspectorate. Symposium
  and Workshop on TBI.
• 1998. RMSC Report on ABI Rehab.

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• Regional Strategy. 1997-2002.
• Dept. should undertake to resolve with Boards the
  provision of Rehabilitation services for persons
  with T B I.
• Development of locally sensitive hospital and
  community services and establish a Regional
  Rehabilitation Unit.

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Priorities for Action 2001/2002

• Boards and Trusts should finalise a Business Case
  for a Regional TBI Unit by December 2001.
• Agreement that Greenpark should lead development
  of Business Case.
• Sept. 2001 Outline Case submitted
• Dec. 2001 Capital funding announced.

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Thompson House Hospital

• Down and Lisburn Trust
• Young disabled unit
• Slow stream neurorehabilitation
• 6-8 Brain injury rehab beds.
• Low level consciousness patients
• Shares base with community brain injury team

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Maine Villa

• Stand alone within psychiatric unit
• Locked facility
• 10-12 beds
• Challenging behaviour
• No female patients
• Linked to Mourne project
• Limks with community team

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Spruce House

• New build on acute hospital site
• Slow stream rehabilitation and respite
• Limited therapy input
• 6-8 brain injury beds
• Links to community team
• Potential step down facility

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Rehabilitation Service Networks

• These networks should include
• Specialist regional service to meet the needs of
  more complex cases and provide specialist
  training and guidance for other professionals
  involved in the care of patients with ABI.
• Local hospital and community rehabilitation teams

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Rehabilitation Service Networks

• Patients can be transferred between different
  services without any bureaucratic delays.
• There is close communication between local
  hospital, community and regional services to
  provide a seamless continuum of care.
• Patients with complex needs are able to
  regain access to specialised services as their
  needs dictate.

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Rehabilitation Service Networks

• Social services to provide continued support for
  the individual and their family within the home
  setting.
• Voluntary agencies providing support, information
  and activities.
• Specialist brain injury vocational rehabilitation
  services.

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Rehabilitation Service Networks

• Strategic Health Authorities should ensure that a
  managed network of specialised rehab. services is
  planned over a geographical area with
  collaborative commissioning of regional services.

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A Network?

• R A B I U
• Thompson House
• Maine Villa
• Spruce House

• R A B I U
• Mourne project
• Community Brain injury rehab teams in each Area
  Board

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Timing, intensity and duration of treatment.

• Following acute ABI patients should
• Be transferred as soon as possible to a
  rehabilitation programme of appropriate intensity
  to meet their needs.
• Receive as much therapy as they need, can be
  given and find tolerable.
• Be given as much opportunity as possible to
  practise skills outside formal therapy sessions.

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Timing, intensity and duration of treatment.

• After the post-acute phase, continued
  rehabilitation in the community should move
  progressively from formal therapy to a guided and
  supported resumption of chosen activities over
  months and years.
• There should be recognition of the need for
  life-long contact to meet the changing clinical,
  social and psychological needs of patients and
  carers.

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Discharge Planning

• Inpatient rehabilitation should continue while
  the patient requires the facilities, skills and
  therapeutic intensity of a specialist
  rehabilitation unit in order to make progress or
  while thee hospital environment is needed in
  order to maintain safety.
• Patients may be transferred back to the community
  once any specialist rehabilitation and support
  needed can be continued in that environment
  without delay.

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Continuing care and support

• Patients with significant ABI should have long
  term access to an individual or team with
  experience in management of ABI.
• Care services should be provided by skilled
  workers trained in the needs of ABI patients
• Patients with complex needs after ABI should have
  joint assessment by health and social services,
  with ongoing review and re-assessment
• Access to regional services is needed to
  supplement local service provision.

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Outpatient/Community Services

• RABIU
• Mourne Project

• Down Lisburn B.I.T
• UCHT B.I.T.
• N W Belfast. B.I.T.
• S E Belfast. B.I.T
• NHSSB CABIRS.
• SHSSB. A.B.I.T.
• WHSSB. B.I.T

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Vocational Rehabilitation

• CEDAR Foundation.
• Vocational and pre-vocational rehabilitation
  services in each of N.I. Area Health Boards
• Reconnect.
• Provision of services for persons in Greater
  Belfast Area.

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• No man is an Island, entire of itself, every man
  is a piece of the Continent, a part of the
  main.
• Any mans death diminishes me, because I am
  involved in Mankind, and therefore never send to
  know for whom the bell tolls It tolls for thee.
• John Donne Meditation XVII

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Carers and families

• Rehabilitation services should be alert to the
  likely strain on families/carers and, in
  particular the needs of children in the family
• Patients and their families/carers should be
  considered with regard to treatment and care
  options and should be involved in planning of the
  patients specific rehabilitation programme,
  negotiating appropriate goals, and in decisions
  regarding their care.

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Carers and families

• Families of patients with ABI should be offered
  timely
• Information and education about ABI, and local
  and national services and support groups.
• Referral to social services regarding their own
  needs.
• Assistance with the benefits system.
• Support and counselling, which should be
  available long-term, provided by professionals
  experienced in ABI management.

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Carers and families

• And where appropriate
• The opportunity to learn skills, techniques and
  routine necessary to maintain rehabilitation
  games.
• Information about the process of compensation for
  personal injury and approved sources of
  information concerning legal assistance.

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Support Organisations

• Headway Belfast. Social Reintegration and Family
  Support Services.
• Headway Ballymena.
• Headway Londonderry
• Headway EnnisRone
• Headway Southern Region.

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Unresolved Issues

• Minor Brain Injury
• Patients managed within DGH
• Children with ABI
• Transition services
• Step down units
• Community care
• Long term neurobehavioural management

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Future challenges

• Review of Public Administration
• Combined hospital and community Trusts
• Reduction in number of Trusts
• Locality based commissioning
• Service network development
• European expansion

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European matters.

• Increase in size of European Union
• Accession states / economic migration
• Language
• Culture
• No family network
• Longer term placement
• Long term support

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