Transcript Slide 1

Northern Trauma System
Regional Conference 2014
High quality trauma care
from
‘Roadside to Recovery’
The Role of Specialist Rehabilitation in
Polytrauma Management
Dr James Graham (Consultant Radiologist)
Dr Rachel Reaveley (SPR in Neurological
Rehabilitation)
Objectives
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By the end of this case presentation we will
have covered…
Radiology of the case
Specialist Rehabilitation Interventions
 How the specialist rehabilitation process worked
from acute referral through to outpatient review and
inpatient admission
 Summary of causes of dizziness in the rehabilitation
setting
 Assessing the psychological impact of poly-trauma in
the context of concurrent head injury
 Reflect together on potential gaps in the service
Case History
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50 year old driving instructor
High speed head on collision 10/10/12
Brought to MTC
Trauma CT
Trauma CT
Trauma CT
Trauma CT
Case History - summary
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50 year old driving instructor
High speed head on collision 10/10/12
Right haemo-pnuemothorax and lung contusion with rib fractures – 712
Left pneumothorax
Jejunal perforation and terminal ileum mesenteric injury- requiring
laparotomy, repair and end ileostomy
Complications – chest sepsis, need for high inotropic support, abnormal
kidney function, LFTs & amylase – 19 days in ICU
A few days later…
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Gradual clinical deterioration
Lactate 1.3
 Amylase 439
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WCC 20
 CRP 116
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Bilirubin 63
 ALP 335
 ALT 282
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Follow up CT
Follow up CT
Gastric appearances
Angiogram
Endoscopy
What Happened next?
Rehabilitation Assessment &
Planning
 First seen by Rehabilitation Consultant on
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General Surgery Ward 21/11/12
Referred by Head Injury Sister – small
frontal contusion
Dizziness
Nausea
Back pain
? Change in personality
Dizziness and nausea
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When moving from sitting to standing and from
lying to sitting
Documented drop in BP on standing
Contributory factors
Medications – opioids
Fluid depletion (nausea)
Coeliac axis injury – damage to autonomic
nerve supply to splanchnic bed
? BPPV
Benign Paraoxysmal Positional
Vertigo
Orthostatic Hypotension
Coeliac Plexus
Kambadakone A et al. CT-guided Celiac Plexus Neurolysis: A Review of Anatomy, Indications, Technique,
and Tips for Successful Treatment. RadioGraphics 2011; 31: 1599-1621
Sir Roger Bannister. Autonomic Failure. A Textbook of Clinical Disorders of the Autonomic Nervous System.
Second Edition.
Rehabilitation Medicine Review
as Outpatient May 2013
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Dizziness - diagnosed with BPPV – treated
with Epley’s manoeuvre
Nausea and vomiting improved - Awaiting
surgical reversal of ileostomy
Significant back pain – remained under
surgical review with plan for follow up
physiotherapy – referral made to health
psychology to support through this.
Low mood – body image issues
Character change
Epley’s Manouvre
People involved/pending
procedures
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Mr B Griffiths – General surgery – awaiting
ileostomy reversal
Mr G Wynne Jones – Orthopaedics
Mr Waldron – ENT Sunderland
Sister Hastie – Head Injury
GP – commenced sertraline for low mood
Dr J Lawson - Falls & Syncope Service
Mr Jenkins - Urologist UHND – admitted with
urinary sepsis shortly after discharge from RVI
– 4x unsuccessful TWOC as inpatient
Out patient Review: May 2013
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Assessment of frontal brain injury vs
mood disturbance: Subtle changes in character
 Loss of sense of humour
 Concrete thinking
 Short term memory impairment
 Easily provoked by loud noises and crowds
 Lack of initiation
Rehabilitation Actions & further
Progress
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Ileostomy reversal – health psychology at RVI
requested to provide peri-operative support
Complicated by further sepsis/leakage
requiring readmission via UHND
On-going back pain – waiting for orthopaedic
review and physiotherapy
Continued family concerns around change in
personality (short term memory and increased
irritability)
Referred to neuropsychology as outpatient (
long waiting list….)
In Patient Admission to WGP Cognitive
Assessment Bed February 2014
Increasing concern about ongoing depressive
episodes with psychological trauma- type
symptoms post RTA
Psychology and Psychiatry Input
Changes in cognition reported largely explained by
mood disorder
 Concrete thinking
 Slowness in mental speed both associated with
depression
 Anxiety also may have contributed to underperformance
 Cognitive assessment noted only very mild
problems in verbal abstract reasoning. Working
memory unimpaired
Other Therapies
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OT assessment:
 independent with route finding, money handling and
road safety.
 independent and safe at problem solving in the
kitchen. Written instructions for more complex tasks
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SALT assessment
 Cognitive communication skills largely intact,
however some reading comprehension difficulties
 With prompting to slow down his reading rate and
check his responses, accuracy improved
Limitations of current processes
‘We’ve had no help at all since being at home”
Comment from patient’s wife at first rehab OP review
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Lack of co-ordinated follow up on discharge from
MTC unless head injury severe enough to require
ongoing inpatient follow up or community therapies
needed specific to TBI
Predictable problems – ongoing dizziness and need
for Dix Hallpike. Catheter issues – reassurance of
empty bladder/UTI prevention/onward referral
Mood disorder - psychological complications can be
significant following trauma. Services to address
these issues currently very limited – differences
between psychological trauma and brain injury effect
Summary
Interesting case of patient with multitrauma and complications
 Long period of rehabilitation including
inpatient stay required
 Illustrates that not all changes in behavior
following head injury are related to injury
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Thank you!
Northern Trauma System
Regional Conference 2014
High quality trauma care
from
‘Roadside to Recovery’
Transforming Trauma
Rehabilitation
Recommendations for the North East
Region
Sharon Smith
Paula Dimarco
35 NHS | Presentation to [XXXX Company] | [Type Date]
Overview of talk
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Purpose of project
Background of project
Best practice pathway
Key findings
Recommendations
Purpose of project
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On behalf of NE SHA
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Provide information and recommendations
Develop a best practice pathway
Support commissioning for development of rehabilitation
services following major or serious trauma
The Project
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Regional steering group
Two work streams, JCUH and RVI
Review of MSK and neurological rehabilitation
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Map of current pathway
Data collection and analysis
Stakeholder consultations
Identify models of best practice
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Gap analysis
Best practice pathway
Key findings
No consultants in Rehabilitation Medicine
in MSK and insufficient within neurotrauma
National Standards Recommend:
• 6 WTE per million population
• No single handed consultants
Current Regional Provision:
• 3.8 WTE in level 1 Services
• 3 WTE in level 2 services all working single
handed
There is a 2/3 Shortfall on the national standards.
Lack of communication, co-ordination and
leadership across the pathway leading to
disjointed care and inadequate
management of patients
• RVI has head injury nurse specialist
• JCUH has acquired brain injury coordinator
• No formal coordinated MDT rehab specifically for
TBI at either MTC
• No coordinator for MSK at either MTC
• Rehabilitation needs to be well planned across
the whole pathway, including TUs and community
services
No specialist inpatient beds for MSK
rehabilitation resulting in longer lengths of
stay in acute beds or transfer to
inappropriate settings
• Case example:
• 55 year old male – MSK polytrauma including ITU
stay
• MTC also patient’s local hospital
• NWB for 6 months, remained on an acute ortho
ward
• Transferred to intermediate care at 7 months –
little experience of younger patients and ortho
rehab
No specialist community MDT for MSK
rehabilitation leading to sub-optimal
outcomes and longer lengths of
rehabilitation
• If there were community MSK trauma rehab
teams, the outcome of the previous example may
have been somewhat different
Insufficient level 1 and 2 inpatient
rehabilitation facilities for neurotrauma
patients
• BSRM guidelines recommend 60 level 2 beds per
million population
• Currently 47 in the North East and Cumbria
• Level 1 facility is Walkgate Park = 35 beds
Insufficient specialist community teams for
neurotrauma patients
• Only available in 3 areas:
• Northumberland (3 therapies in one team)
• Gateshead (no physiotherapy)
• Cumbria
• Different models at each locality
• All teams work across health and social care
No robust system for data collection to
indicate the number of patients requiring
specialist and non-specialist Recovery,
Rehabilitation and Reablement
• TARN can provide a list of injuries and ISS, but
these don’t tell us what the patient’s rehabilitation
needs are and are retrospective
• UKROC not used by all aspects of the pathway
• Rehabilitation prescription yet to function as a
data recording tool
Lack of vocational rehabilitation resulting
in no focus on reablement, return to work
and social integration
• No vocational rehab for MSK trauma
• Limited for neurotrauma
• All have access to statutory services – not always
appropriate
• Momentum for neuro patients
No standardised or consistent approach to
the use of outcome measures which
makes it difficult to evaluate rehabilitation
• Different emphasis at each stage of rehab,
therefore a variety of outcome measures are used
• No standardised approach
• Work is being undertaken to determine best
outcome measures to use
Recommendations
Recommendations
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Provide additional Consultant level leadership in
rehabilitation in order to promote inter-speciality working
and improve patient management and outcomes e.g.
Consultants in Rehabilitation Medicine/Consultant Allied
Health Professionals.
Recommendations
2. Explore workforce options to improve coordination and
communication across the whole pathway for example
Rehabilitation Coordinators/Facilitators.
3. Devise robust, flexible, fit for purpose systems to collect
data and inform future commissioning and service
provision.
Recommendations
4. Develop specialist rehabilitation inpatient beds for major
trauma MSK patients. This would also ensure the
capacity to provide intensive therapy. Further work is
recommended to identify the number of beds required.
5. Create specialist MDTs which would deliver specialist
rehabilitation for MSK major and serious trauma patients
(inpatient and outpatient/community).
Recommendations
6. Provision of more level 1 and 2 rehabilitation beds for
Neurotrauma patients in line with national
recommendations.
7. Increase the current number of specialist community
teams for rehabilitation of Neurotrauma patients to cover
all areas.
Recommendations
8. Undertake robust and committed service redesign to
deliver a best practice pathway, with particular focus on
strengthening Recovery, Rehabilitation and Reablement
services.
9. Ensure regional implementation of the rehabilitation
prescription process for all major trauma patients across
all services, from injury to re-enablement. This should
include the redesign of the current Rehabilitation
Prescription.
Recommendations
10. Integrate vocational rehabilitation into the trauma
pathway.
11. Undertake further work to develop recommendations for
the use of outcome measures for the trauma
rehabilitation pathway.
Recommendations
12. Develop a Directory of Rehabilitation Services with
identified administrative support to maintain and update.
Implementation of these recommendations requires a
coordinated approach involving commissioners, expert
clinicians and service users.
Mr Yogendra Jagatsinh
MBBS. M.S. (Tr & Orth), MRCS Ed
Consultant in Rehabilitation medicine
 “Amputation : one of the meanest, and yet one of the
greatest operations in surgery;
mean when resorted to where better may be done
great, as the only step to give comfort and prolong
life.”
Sir Willliam Ferguson 1865
“ The principle of a patient receiving specialist care
appropriate for their injuries is fundamental to Networks
of Trauma care. To abandon this at the point at which
rehabilitation is required is illogical and compromise
patient outcomes. It is wrong to assume that specialist
rehabilitation techniques will be carried out on a general
orthopaedic or general surgical ward in DGH”
Regional Network for Trauma
NHS CAG Report
Incidence and Prevalence
• Prevalence=62000; Incidence : 5000/year
• LL=92%, UL=5% & Cong def=3%
• 50% of all amputees are > 65 yrs & 25 % > 75yrs
• Females=30%, median age of males=66 & females = 69
• 50% of all referrals are transtibial amputees
• 72% of all referrals are PVD & 41% of them diabetic
• 60% of UL referrals are < 55 yrs old.
Trauma Amputations
 30% of new amputations
 industrial accidents, farming accidents, or motor
vehicle accidents, which include automobiles,
motorcycles and trains
 War amputations-complicated, multiple
 Younger and active populations
Levels of Amputations
Phases of Rehabilitation
1.
Pre amputation consultation
2.
Healing and Starting Physiotherapy
3.
Visiting the Prosthetist
4.
Choosing an Artificial Limb
5.
Learning to Use your Artificial Limb
6.
Life as a New Amputee
Goals of Rehabilitation
 optimize health status,
 Function
 Independence
 Quality of life of patients
 Participation in society
Post operative Rigid Dressings-Why Use
Them?
• Control edema- that otherwise would
– Delay healing
– Cause pain
– Complicate prosthetic fitting
• Shape the limb for optimal socket fitting
• Protects wound/incision
• Some can allow for early weight bearing
• Get the patient used to the idea of caring for the residual limb
– Never too early to begin educating on volume management
– Training in compliance
• Some can help prevent a joint contracture
• Desensitization
• Can absorb drainage
Pain Management
 Perioperative pain control
 Pain after healing-Bony causes
-Soft tissue causes
 Pain caused by prosthesis-Pressure, friction or skin
tractioning
 Phantom limb pain
 Decrease dependence on narcotic medication
Physical Health
Reduce the risk of adverse effects due to periods of
prolonged immobilization:
a. Decrease contractures
b. Decrease incidence of pressure ulcers
c. Decrease incidence of deep vein thrombosis
Improve physical status (e.g., balance, normal range of
motion especially at the hips and knees; increase strength
and endurance to maximize efficient use of a prosthesis)
Function
 Improve functional status (e.g., independent bed mobility,
independent transfer, wheelchair mobility, gait and safety)
 Improve ambulation (e.g., distance of ambulation, hours of
prosthetic wearing, use of an assistive device, and ability to
ascend/descend stairs)
 Improve quality of life/decrease activity limitation (e.g.,
activities of daily living [ADL], recreation, physical activity
beyond ADL, community re-integration; and return to
home environment)
Energy use in Amputation
Psychological adjustment
 Overwhelming feeling of lack of control
 Feeling of complete change
 Change in body image
 Grieving process-five stages denial, bargaining, anger,
depression and acceptance.
Traumatic amputation
 Co-morbidity from multiple trauma
 Additional injuries of peripheral nerves, disrupted
blood vessels, retained shrapnel, heterotopic
ossification, contaminated wounds, burns, grafted
skin, and fractures.
 Requires modified rehabilitation strategies in the
training of activities of daily living (ADL) and
ambulation.
Rehabilitation and the long-term outcomes of
persons with trauma-related amputations.
 OBJECTIVE: To examine the long-term outcomes of persons undergoing
trauma-related amputations and the role of inpatient rehabilitation in
improving such outcomes.
 PARTICIPANTS: Principal or secondary diagnosis of a trauma-related
amputation to the lower extremity. Spinal cord injury or traumatic brain injury
were excluded.
 RESULTS: 146 patients
9% died during the acute admission and 3.5% died after discharge
87%-Males. 80% <40 yrs age
Health profile (n = 78, 68% response rate) was systematically lower
than that of the general US population for all SF-36 scores.
25 % - severe problems with the residual limb, including
phantom pain, wounds, and sores.
Number of inpatient rehabilitation nights – directly related
to function in their physical roles, increased vitality, and
reduced bodily pain.
Inpatient rehabilitation- improved vocational outcomes.
Pezzin LE et al. Rehabilitation and the long-term outcomes of persons with trauma-related amputations. Archives of
Physical Medicine & Rehabilitation, 01 March 2000, vol./is. 81/3(292-300).
Carlisle Murrison Centre
 Consultant Led Service
 Team of Prosthetic,
physiotherapy,
rehabilitation assistant,
exercise therapist,
Occupational therapist,
Orthotist, Psychologist,
rehabilitation engineer,
Podiatrist –all in one
roof.
Role of Rehabilitation Consultant
 Perioperative consultation-best outcomes
 Issues with pain, sexual function and pain-early period
 Physical complications such as pain, skin disorders,
sweating, infections and venous thromboses,
 psychological complications such as depression and
‘catastrophising’
 Secondary or tertiary prevention is also a key function
with regard to skin and foot pathology, cardiovascular
disease,osteoporosis and drug complications
 vocational rehabilitation,
 provision of wheelchairs,
 special seating,
 orthoses and
 assistive technologies.
This is the opportunity for the us all to take the Rehabilitation
out of the ranks of being a "Cinderella Speciality"