Acquired Brain Injury Rehabilitation Services:The Southern Picture

Dr. Nicola RyallConsultant in Rehabilitation Medicine

28 September 2006

NATIONAL REHABILITATION HOSPITAL

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)

Sequelae 1…

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

pain etc.

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

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

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 integration…maximal benefit in first 3-6 months

Slinky Model (RCP, BSRM 2003)

Acute care/neurosurgeryWard based therapy

Post-acute in-patientSpecialist Rehabilitation

Community based rehabilitationDay centre/out patientsOut-reach/Home basedVocational rehabilitation

Longer term community supportSpecialist care/care management

Review/ drop-in clinicsRe-assess as required

Reduced Impairment and pathology

Improved activity(reduced disability

Enhanced participation

Goals & outcomes

Hospital

Home

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%

• <1 in 6 return to work within 5 years

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

Size of problem?

• 6 DATHs…1Younger Disabled Unit

• >17,500 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.

National Rehabilitation Hospital

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

• UK International• 254 beds (rehab)

360 (ABI)• 16

27..74..450

Waiting for admission….

• 203 patients waiting admission

• 44.8% awaiting brain injury rehabilitation

• Average waiting time: > 6 months

• 20% of adults from RTAs

• 50% of children from RTAs

• 3 HDU beds….18 months wait

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

New funding since 2001

0

Rehabilitation Strategy 2002

0

Since April 2006….

0

NTPF

0

New Hospital

• 235 beds• No guarantee of

funding• Significant delays to

date

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

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

Thank you