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Northern Trauma System Regional Conference 2014

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Northern Trauma System Regional Conference 2014 High quality trauma care from Roadside to Recovery – PowerPoint PPT presentation

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Title: Northern Trauma System Regional Conference 2014


1
Northern Trauma System Regional Conference 2014
  • High quality trauma care from
  • Roadside to Recovery

2
The Role of Specialist Rehabilitation in
Polytrauma Management
  • Dr James Graham (Consultant Radiologist)
  • Dr Rachel Reaveley (SPR in Neurological
    Rehabilitation)

3
Objectives
  • 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

4
Case History
  • 50 year old driving instructor
  • High speed head on collision 10/10/12
  • Brought to MTC

5
Trauma CT
6
Trauma CT
7
Trauma CT
8
Trauma CT
9
Case History - summary
  • 50 year old driving instructor
  • High speed head on collision 10/10/12
  • Right haemo-pnuemothorax and lung contusion with
    rib fractures 7-12
  • 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

10
A few days later
  • Gradual clinical deterioration
  • Lactate 1.3
  • Amylase 439
  • WCC 20
  • CRP 116
  • Bilirubin 63
  • ALP 335
  • ALT 282

11
Follow up CT
12
Follow up CT
13
Gastric appearances
14
Angiogram
15
Endoscopy
16
What Happened next?
17
Rehabilitation Assessment Planning
  • First seen by Rehabilitation Consultant on
    General Surgery Ward 21/11/12
  • Referred by Head Injury Sister small frontal
    contusion
  • Dizziness
  • Nausea
  • Back pain
  • ? Change in personality

18
Dizziness and nausea
  • 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

19
Benign Paraoxysmal Positional Vertigo
20
Orthostatic Hypotension
21
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.
22
Rehabilitation Medicine Review as Outpatient May
2013
  • Dizziness - diagnosed with BPPV treated with
    Epleys 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

23
Epleys Manouvre
24
People involved/pending procedures
  • 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

25
Out patient Review May 2013
  • 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

26
Rehabilitation Actions further Progress
  • 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.)

27
In Patient Admission to WGP Cognitive Assessment
Bed February 2014
  • Increasing concern about ongoing depressive
    episodes with psychological trauma- type
    symptoms post RTA

28
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
    under-performance
  • Cognitive assessment noted only very mild
    problems in verbal abstract reasoning. Working
    memory unimpaired

29
Other Therapies
  • 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
  • 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

30
Limitations of current processes
  • Weve had no help at all since being at home
  • Comment from patients wife at first rehab OP
    review
  • 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

31
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32
Summary
  • Interesting case of patient with multi-trauma and
    complications
  • Long period of rehabilitation including inpatient
    stay required
  • Illustrates that not all changes in behavior
    following head injury are related to injury

33
Thank you!
34
Northern Trauma System Regional Conference 2014
  • High quality trauma care from
  • Roadside to Recovery

35
Transforming Trauma Rehabilitation
  • Recommendations for the North East Region
  • Sharon Smith
  • Paula Dimarco

NHS Presentation to XXXX Company Type Date
35
36
Overview of talk
  • Purpose of project
  • Background of project
  • Best practice pathway
  • Key findings
  • Recommendations

37
Purpose of project
  • On behalf of NE SHA
  • Provide information and recommendations
  • Develop a best practice pathway
  • Support commissioning for development of
    rehabilitation services following major or
    serious trauma

38
The Project
  • Regional steering group
  • Two work streams, JCUH and RVI
  • Review of MSK and neurological rehabilitation
  • Map of current pathway
  • Data collection and analysis
  • Stakeholder consultations
  • Identify models of best practice
  • Gap analysis

39
Best practice pathway
40
Key findings
41
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.

42
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

43
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 patients 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

44
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

45
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

46
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

47
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 dont tell us what the patients
    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

48
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

49
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

50
Recommendations
51
Recommendations
  • 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.

52
Recommendations
  • Explore workforce options to improve coordination
    and communication across the whole pathway for
    example Rehabilitation Coordinators/Facilitators.
  • Devise robust, flexible, fit for purpose systems
    to collect data and inform future commissioning
    and service provision.

53
Recommendations
  • 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.
  • Create specialist MDTs which would deliver
    specialist rehabilitation for MSK major and
    serious trauma patients (inpatient and
    outpatient/community).

54
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55
Recommendations
  • Provision of more level 1 and 2 rehabilitation
    beds for Neurotrauma patients in line with
    national recommendations.
  • Increase the current number of specialist
    community teams for rehabilitation of Neurotrauma
    patients to cover all areas.

56
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57
Recommendations
  • Undertake robust and committed service redesign
    to deliver a best practice pathway, with
    particular focus on strengthening Recovery,
    Rehabilitation and Reablement services.
  • 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.

58
Recommendations
  • Integrate vocational rehabilitation into the
    trauma pathway.
  • Undertake further work to develop recommendations
    for the use of outcome measures for the trauma
    rehabilitation pathway.

59
Recommendations
  • 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.

60
Amputation Rehabilitation
  • Mr Yogendra Jagatsinh
  • MBBS. M.S. (Tr Orth), MRCS Ed
  • Consultant in Rehabilitation medicine

61
  • 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

62
  • 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

63
Incidence and Prevalence
  • Prevalence62000 Incidence 5000/year
  • LL92, UL5 Cong def3
  • 50 of all amputees are gt 65 yrs 25 gt 75yrs
  • Females30, median age of males66 females
    69
  • 50 of all referrals are transtibial amputees
  • 72 of all referrals are PVD 41 of them
    diabetic
  • 60 of UL referrals are lt 55 yrs old.

64
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

65
Levels of Amputations
66
Phases of Rehabilitation
  • Pre amputation consultation
  • Healing and Starting Physiotherapy
  • Visiting the Prosthetist
  • Choosing an Artificial Limb
  • Learning to Use your Artificial Limb
  • Life as a New Amputee

67
Goals of Rehabilitation
  • optimize health status,
  • Function
  • Independence
  • Quality of life of patients
  • Participation in society

68
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

69
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

70
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)

71
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)

72
Energy use in Amputation
73
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.

74
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.

75
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 lt40 yrs
    age
  • Health profile (n 78,
    68 response rate) was systematically lower than
    that of the general US population for all SF-36
    scores.

76
  • 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).

77
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.

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79
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

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84
  • vocational rehabilitation,
  • provision of wheelchairs,
  • special seating,
  • orthoses and
  • assistive technologies.

85
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87
This is the opportunity for the us all
to take the Rehabilitation out of the ranks of
being a "Cinderella Speciality"
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