|CHAPTER 5: PHYSICAL AND REHABILITATION MEDICINE IN HEALTH CARE SYSTEMS
|Year : 2019 | Volume
| Issue : 2 | Page : 81-86
5.3 Physical and rehabilitation medicine in health-care systems: Acute rehabilitation
Mohankumar Mariappan, Anthony B Ward
North Staffordshire Rehabilitation Centre, Haywood Hospital, Stoke on Trent, UK
|Date of Web Publication||11-Jun-2019|
Dr. Mohankumar Mariappan
North Staffordshire Rehabilitation Centre, Haywood Hospital, Stoke on Trent
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Mariappan M, Ward AB. 5.3 Physical and rehabilitation medicine in health-care systems: Acute rehabilitation. J Int Soc Phys Rehabil Med 2019;2, Suppl S1:81-6
|How to cite this URL:|
Mariappan M, Ward AB. 5.3 Physical and rehabilitation medicine in health-care systems: Acute rehabilitation. J Int Soc Phys Rehabil Med [serial online] 2019 [cited 2019 Aug 20];2, Suppl S1:81-6. Available from: http://www.jisprm.org/text.asp?2019/2/2/81/259345
| Introduction|| |
The rehabilitation of patients after an acute illness or after trauma should begin as soon after the event as possible. This chapter describes the response through early rehabilitation in acute settings and hence that patients can proceed to further definitive rehabilitation programs. Acute medical rehabilitation is defined as a program of goal-oriented, multidisciplinary rehabilitation under the responsibility of a Physical and Rehabilitation Medicine (PRM) specialist during the first 4 weeks following injury, illness or in response to complex medical treatment or its complications.
PRM is a primary medical specialty responsible for the prevention, medical diagnosis, treatment, and rehabilitation management of persons of all ages with disabling health conditions and their comorbidities, specifically addressing their impairments and activity limitations to facilitate their physical and cognitive functioning (including behavior), participation (including quality of life), and modifying personal and environmental factors.
Since the Declaration of Alma-Ata in 1978 rehabilitation is considered an essential health strategy in primary care which aims to address “the main health problems in the community” by “providing promotive, preventive, curative, and rehabilitative services.”,
Hyperacute rehabilitation refers to the very early stage of rehabilitation for patients who have been moved on from critical care or high dependency units but still have unstable medical conditions, which need specialist care. They may no longer need to be under the direct care of acute medical and surgical teams, etc., but still require these specialties to be immediately available for advice or the management of complications. In the past, such patients have been “repatriated” into nonspecialist, nonrehabilitation beds, often in a different hospital. This is inappropriate because neither their needs for rehabilitation nor for specialist acute care were sufficiently met. It is now evident that PRM specialists have the skills to manage these people effectively and have connections with colleagues in other specialties as well as the skilled support of the members of the PRM team.
| Epidemiology|| |
About 10% of Western Europe's population experience a disability, as described in a British survey. This is importantly highlighted in the World Report on disability. The WHO director stated that there were >1 billion people in the world live with some form of disability, of whom nearly 200 million experience considerable difficulties in functioning. In the years ahead, disability will be an even greater concern because its prevalence is on the rise. This is due to aging populations and the higher risk of disability in older people as well as the global increase in chronic health conditions such as diabetes, cardiovascular disease, cancer, and mental health disorders.
Two important factors have also to be considered are as follows:
- Survival from serious disease and trauma leaves an increasing number of people with complex problems functional deficits
- Many of these people are young at the time of their event/injury and will survive for many decades.,,
Many of these are disabled through neurological and musculoskeletal conditions and account in the UK for 10% and 30% of acute hospital admissions and the third most common reason for attending a family doctor. An estimated 350,000 people across the UK need help with daily living activities because of a neurological condition, and 850,000 people care for someone with a neurological condition.
In 2013–2014, there were 348,934 hospital admissions for an acquired brain injury (ABI) and 130,551 for stroke in the UK, that is, 566 admissions per 100,000 of the population. ABI admissions in the UK have increased by 10% since 2005–2006. In 2013–2014, there were 162,544 admissions for the head injury. Men are 1.6 times more likely than women to be admitted for the head injury. One million people visit emergency departments each year following a head injury.
| Conditions|| |
Typical conditions presenting to acute PRM programs [Table 1].
| Clinical Problems Requiring Attention|| |
There are many issues that need to be addressed when people see a PRM specialist after arriving as an emergency into the hospital. Some of these considered as a direct consequence of the primary problem, such as reduction and fixation of fractures, but others exist in relation to the immobilization and hospitalization of the patient. These problems complications can be broadly divided into general, immobility, systemic, critical care associated and psychological [Table 2].
Acute rehabilitation involves frequent and cooperative working with acute specialties, who still have an important input into the overall management of the patient. In hyperacute neurological rehabilitation centers, these include otorhinolaryngology (especially the tracheostomy team), neurology, neurosurgery, maxillo-facial, orthopedic and trauma surgery, plastic and reconstructive surgery, and radiology and clinical scenarios typically seen requiring medical intervention are bowel management, respiratory distress/desaturation, autonomic dysreflexia, and sepsis.
The description of the assessment and management processes of these clinical problems are beyond the scope of this chapter, but they can be minimized or prevented if PRM principles are applied.
| Rehabilitation Plans and Goal Settings|| |
Specialized rehabilitation is a process of assessment, treatment, and management by which the individual (and their family/carers) are supported to achieve their maximum potential for physical, cognitive, social and psychological function, participation in society, and quality of living. It may be provided along three main (frequently overlapping) pathways and the principles are described in [Table 3]:,
- Restoration of function, for example, those recovering from a “sudden onset” or “intermittent” condition, where patient goals are focussed not only on improving the independence in daily living activities but also on participatory roles such as work, parenting, and other activities
- Disability management, for example, those with stable or progressive conditions, where patient/family goals are focussed on maintaining existing levels of function and participation; compensating for lost function (e.g., through the provision of equipment/adaptations); or supporting adjustment to change in the context of deteriorating physical, cognitive, and psychosocial function
- Neuropalliative rehabilitation focuses on symptom management and interventions to improve the quality of life during the later stages of a progressive condition or profound disability, at the interface between rehabilitation and palliative care.
Despite these clear advantages, variation exists in structural and process characteristics of in-hospital acute rehabilitation and referral to postacute rehabilitation centers among 66 centers treating patients with acute neurotrauma across Europe.
| Models|| |
There are several ways to deliver acute medical rehabilitation. The most efficient for patient care is the establishment of PRM beds in the acute hospital and Mobile PRM team.
The UK model for rehabilitation service provision has three broad levels of rehabilitation service [Table 4].
Tertiary specialized rehabilitation for patients with highly complex needs is commissioned directly by NHS England, whereas local specialist and general services are commissioned by Clinical commissioning groups.
The staff serving an acute PRM unit should reflect those seen in other areas of PRM. This would also be governed not only by the kinds of patients admitted, by the care pathways, and priorities for discharge but also by the national availability of staff. This chapter will, therefore, not give the actual numbers for minimum staffing provision, but they are available from national resources.
| Rehabilitation in Intensive Care|| |
Rehabilitation interventions for patients with severe acute diseases, severe trauma, or complex surgery as well as persons with multimorbidity should start as early as possible. In the early-phase prevention of muscle atrophy, contractures, pressure sores, thrombosis, and pneumonia are of major importance. Respiration therapy is crucial during the weaning phase and can prevent reintubation. In addition, regaining functions and training of activities such as transfers, mobility, self-care, eating, toileting, and other activities are important goals of early rehabilitation. These interventions must be provided in intensive and intermediate care units. In some cases, physiotherapy alone is sufficient, however, in more complex cases, a multidisciplinary rehabilitation team, including PRM physicians, physiotherapists, occupational therapists, speech and language therapists (including dysphagia management), and rehabilitation nurses should be member of such a team (mobile or peripatetic rehabilitation team). After discharge from the intensive care unit (ICU), the complex cases should be transferred to a dedicated early or Acute Rehabilitation Unit (ARU) led by a PRM specialist. Several studies show that such a regimen is effective as it leads to a shorter length of stay in the ICU and better functional outcomes at discharge from the hospital.,,,,,
| Hyper-Acute Rehabilitation Units|| |
Hyper-ARUs are now starting to be established, where an emphasis develops on rehabilitation issues, within the critical care units. The PRM physician is very much part of the critical care service and a co-located and dedicated inpatient service is used to transfer patients at a early stage for the further rehabilitation of patients, who still have unstable medical conditions, which need specialist care, but where the priority is for developing rehabilitation goals. The patients may no longer need to be under the direct care of acute medical and surgical teams, etc., but still require these specialties to be immediately available for advice or the management of complications. They are then transferred to the next stage of the rehabilitation process, once they have become medically stable. The University Hospital of the North Midlands in Stoke on Trent, the UK, is one of the first established units and serves as a template for the development of other similar services. The role of the physician is setting up early goals for rehabilitation, along with guiding the rehabilitation team in the early mobilization of the patient, where possible and working in close connection with the other surgical and medical specialists involved in the patient's care. The service's coordinator also closely liaises with dedicated individuals in the other rehabilitation services further down the pathway.
Assessments of patients take place on arrival and it is not in the remit of this chapter to describe these in detail, but they include vital observations, estimation of the conscious level (Glasgow Coma Scale), a nutritional chart, bowel chart, and a tissue viability risk score. In addition to taking a comprehensive history and physical examination, there should be a review of all imaging, tests, and any neurophysiological studies, especially when care is transferred. For those patients with disorders of consciousness, a Galveston Orientation Assessment Test can be used for the posttraumatic amnesia assessment, and a Coma Recovery Scale can be applied later. Other assessments are available but are used more outside the early phase of rehabilitation.
Outcome measures need to be employed right from the start to determine the progress and the effect of the acute rehabilitation team's interventions. Similarly, it is not possible in this chapter to into these in any detail and their several references to consult. Useful measures in acute settings, however, are as follows:
- The rehabilitation complexity (RCS) extended trauma version adapted for other acute care settings. The RCS outperformed the ISS and the Barthel in its ability to identify rehabilitation requirements in relation to injury severity, rehabilitation complexity, length of stay, and discharge destination
- The functional independence/assessment measure (UK FIM + FAM) is now the standard outcome measure for all hyperacute and acute specialized services in the UK
- The Northwick Park Dependency Scale (NPDS) nursing and Care Needs Assessment (NPDS/NPCNA) are used to provide data on cost-efficiency of the services
- The neurological/trauma impairment set.
The FIM and NPDS both translate to a Barthel score and any of these tools can, thus, provide a common language at the level of the Barthel Index. At 6 months, a follow-up outcome assessment may also include the Glasgow Outcome Scale-Extended (GOS-E), a quality-of-life EQ-5D patient experience, and a return to work activity.
| Ethical Aspects|| |
Good medical practice dictates that PRM specialists should be involved in shared decision-making and be an advocate for persons with disabilities. Common ethical scenarios faced in the acute medical rehabilitation setting are as follows:
- Assessment of mental capacity to consent to treatment/discharge. Capacity should be decision-specific and time-bound. For some, they may have a fluctuating capacity. In some situations, it's best practice to involve multidisciplinary team when doing this assessment. Where there is a lack of capacity, a “Best Interests” decision process should be employed
- The ceiling of care and Do-Not-Attempt Cardiopulmonary Resuscitation decisions. Interdisciplinary liaison, family discussion, and clear documentation of the outcome are essential to respect dignity
- The interface between PRM and palliative care. Approximately 20% of people in hyper-acute rehabilitation phase die of their illnesses. The fundamental aspect of this care is symptom control and to consider the patient's wishes including any spiritual considerations.
| Costs|| |
Recently, two studies of cost-efficiency of inpatient rehabilitation-one for complex neurological disabilities in the UK, and the other for brain injury in Ireland, clearly demonstrated substantial on-going care cost savings produced by rehabilitation with mean weekly cost reductions of £760 or £639 for each highly dependent patient. The cost recovery of rehabilitation was achieved in 14.2 or 15.6 months. These findings extend the benefit of rehabilitation services (including PRM programs) over and above just functional improvement, but also to important cost-savings to both families and third-party payers as well as to society in general.
Direct costs can be classified into following two categories:
- The additional costs encountered by that disabled persons and their families for daily living standards and
- The disability benefits provided by governments. In the UK, estimates range from 11% to 69% of standard income. Expenditure is at about 2% of gross domestic product with the inclusion of sickness benefits.
A recent study has proposed that the cost of the disability is related to two problems. The first is financial. People with a disability may have more difficulty in getting/retaining a job. The second problem relates to social protection systems, which provide services through direct taxation or facilitate the environment, such as preferred parking or employment subsidies.,
PRM services deal with the rehabilitative needs of people with complex needs and they thus consume considerable resources in health care. For instance, stroke patients with spasticity directly cost up to four times as much as those without spasticity.,
Costings for acute rehabilitation are based on a mandated commissioning currency, which has a 5-tier weighted per diem model:
- The commissioning currency in the UK has operationalized through the UK Rehabilitation Outcomes Collaborative dataset
- The currency is the weighted bed day based on a 5-tier structure, in which a set of five weighting factors are applied to the standard per diem rate
- The weighting factors were derived from the relative proportion of nursing and therapy staff time used by patients within the different levels of complexity 1 and hence that higher complexity scores attract a higher weighting
- At the level of an individual episode: the total weighted bed days are derived from the number of days, the patient spent at each of the five levels of complexity, multiplied by the weighting factors for each of the levels
- At a service level, the total annual occupied bed days within each of the five levels are multiplied by their respective weighting factors and summed to calculate the total number of weighted bed days. The total annual cost is then divided by the total weighted bed days to calculate the weighted per diem cost.
Looking at costs internationally, there is information on disability-adjusted life years [Table 5].
|Table 5: The age-standardized disability-adjusted life years per 100,000 by cause in 2004 (WHO, 2009)|
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| Conclusion|| |
Acute medical rehabilitation programs should start as soon as possible from within the critical care setting. Goal-oriented multidisciplinary programs aim not only at preventing complications and reducing the length of hospital stays but also in reintegrating persons with a disability back to the community. The evidence for the benefit of acute medical rehabilitation is supported by numerous cost-effective studies; hence, dedicating the necessary resources is essential for its delivery. Education and awareness to both patients and the carers are key aspects for the success of this phase of rehabilitation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]