Acquired Brain Injury Rehabilitation Services: The Southern Picture

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NATIONAL REHABILITATION HOSPITAL
Acquired Brain Injury Rehabilitation
ServicesThe Southern Picture
Dr. Nicola Ryall Consultant in Rehabilitation
Medicine 28 September 2006
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Acquired Brain Injury Data

• Common
• HIPE 11,000 admitted with ABI (underestimate)
• Increasing survivors
• 75 18-35 years
• 75 are men
• 40 due to RTA(UK stats)
• 250-375 survivors/250,000 pop(UK stats)

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Sequelae 1

• Physical
• Paralysis
• Ataxia/incoordination
• Sensory deficits
• Visual/Auditory
• Dysphagia
• Epilepsy
• Headache, fatigue, pain etc.

• Communication
• Expression/Reception
• Dysarthria
• Dyslexia
• Dysgraphia

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Sequelae 2

• Cognitive
• Memory
• Attention
• Perception
• Problem- solving
• Insight
• Safety-awareness
• Self-Monitoring
• Social judgement

• Behavioural/Emotional
• Emotional lability
• Poor Initiation
• Mood change
• Adjustment problems
• Aggressive outbursts
• Disinhibition
• Inappropriate sexual behaviour
• Poor motivation
• Psychosis

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Role of Rehabilitation

• Neural plasticity accounts for some of the
  recovery but this can be facilitated by timely
  and appropriate rehabilitation
• Rehabilitation reduces disability and improves
  integrationmaximal benefit in first 3-6 months

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Slinky Model (RCP, BSRM 2003)
Acute care/neurosurgery Ward based therapy
Reduced Impairment and pathology
Goals outcomes
Post-acute in-patient Specialist Rehabilitation
Hospital
Improved activity (reduced disability
Community based rehabilitation Day centre/out
patients Out-reach/Home based Vocational
rehabilitation
Home
Enhanced participation
Longer term community support Specialist
care/care management Review/ drop-in clinics
Re-assess as required
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Expected Outcomes (BSRM,1998)

• Mild TBI survivors unable to maintain
  pre-accident performance
• 30-40 of survivors have good recovery
  (moderate disability) within 6-12 months
• MDT Rehabilitation reduces length of stay by 30
• lt1 in 6 return to work within 5 years

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Rehabilitation Services

• Patchy and poorly integrated
• ill-understood and sub-optimally used
• inefficient and inappropriate deployment of
  services
• ineffective treatment
• sub-optimal outcomes for patient and carer with
  poor user satisfaction
• unreasonably heavy demands on GP, community
  nursing and social services
• problems are self-perpetuating

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Size of problem?

• 6 DATHs1Younger Disabled Unit
• gt17,500 acute bed-days were spent by young
  patients over five years.
• For an individual patient, the average waiting
  time in an acute hospital was almost two years
  (627 days) from onset of disability.

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National Rehabilitation Hospital

• Republic
• 119 beds
• 34 (ABI)
• 5 consultants

• UK International
• 254 beds (rehab)
• 360 (ABI)
• 16 27..74..450

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Waiting for admission.

• 203 patients waiting admission
• 44.8 awaiting brain injury rehabilitation
• Average waiting time gt 6 months
• 20 of adults from RTAs
• 50 of children from RTAs
• 3 HDU beds.18 months wait

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Waiting for discharge

• 10-15 of NRH beds delayed discharges
• No protected funding to unblock beds
• 12,000,000 spent in last 15 months year on
  crisis intervention
• 78 of recommendations not followed through in
  community.2000
• Most of rest dissatisfied

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New funding since 2001

• 0

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Rehabilitation Strategy 2002

• 0

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Since April 2006.

• 0

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NTPF

• 0

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New Hospital

• 235 beds
• No guarantee of funding
• Significant delays to date

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Is it all doom and gloom?

• Despite limited resources we still achieve good
  outcomes
• Deliver and lead up-to-date rehabilitation
• We work hard at developing ideas to improve our
  care and service delivery
• Majority of patients discharged home
• But poor community resources

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What we need

• National Strategy on Development and Delivery of
  Rehabilitation Services
• Coordinated care across the continuum of care
  from acute to community
• Relevant, Accessible, Acceptable, Equitable,
  Efficient, Effective

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• Thank you