J R Soc Med 2004;97:384-389
doi:10.1258/jrsm.97.8.384
© 2004 Royal Society of Medicine
Mapping rehabilitation resources for head injury
J D Pickard FRCS FMedSci 1
H M Seeley MSc BA 1
S Kirker MD FRCPI 2
C Maimaris FRCS FSAEM 3
K McGlashan MBBS MRCP 4
E Roels MD 4
R Greenwood MD FRCP 5
C Steward BSc MBA 6
P J Hutchinson PhD FRCS 1
G Carroll MSc FFPHM 6
1 Academic Neurosurgery, Addenbrooke's Hospital, Cambridge
2 Lewin Stroke & Rehabilitation Unit, Addenbrooke's Hospital,
Cambridge
3 Accident & Emergency Department, Addenbrooke's Hospital,
Cambridge
4 District Rehabilitation Centre, Colman Hospital, Norwich
5 Regional Neurological Rehabilitation Unit, Homerton Hospital, London
6 East of England Specialised Commissioning Group, Cambridge, UK
Correspondence to: Professor J D Pickard, Academic Neurosurgery, Box 167,
Addenbrooke's Hospital, Hills Road, Cambridge CB2 2QQ, UK E-mail:
jdpsecretary{at}medschl.cam.ac.uk
 |
SUMMARY
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Several reports have pointed to the unevenness in the UK of
services for
rehabilitation after head injury. A study was conducted
in the Eastern Region
of England to define the key stages in
recovery and rehabilitation, by an
iterative process of questionnaire,
interview and consensus conference.
Findings were translated
into a draft set of maps showing current availability
of services
which were revised after feedback. Working groups then developed
a
set of definitions and classification codes for each stage
of rehabilitation
which were likewise disseminated for feedback.
The maps were then redrafted to
correspond with the definitions
together with a flowchart of potential head
injury rehabilitation
services. The definitions were piloted at a regional
neurosurgery
unit and a rehabilitation hospital. Core services for
neurorehabilitation
region-wide were found to be variable and uncoordinated
with
fragmented and inequitable allocation of resources. The definitions
and
mapping system that emerged from this study should facilitate
the design of
care pathways for patients and identify gaps in
the services.
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INTRODUCTION
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Much effort is being devoted to creating service frame-works,
guidelines
and standards for the care of the 500 000 patients
who sustain a head injury
each year in the
UK.
1,2
Four years
ago the Eastern Region Head Injury Group (ERHIG) was established
jointly
by the Academic Neurosurgery Unit at Addenbrooke's Hospital
and
the Regional Services Commissioning Group in response to
national reports on
the management of head
injury.
3–5
A
further impetus to the group's work came from the recommendations
of a
Parliamentary select
committee.
6 Phase I
of ERHIG's work
included a systematic assessment of the pattern of acute
care
and resources for head injury in twenty district general hospitals
and
the two neurosurgery units in the six counties of the Eastern
Region. This
survey indicated that core services were patchily
distributed and needed to be
better coordinated, with clearly
defined responsibilities and care
pathways.
7 Progress
to this
end has been hampered by the absence of a simple overview of
the
rehabilitation process that describes the individual's needs
that can be
readily understood by all concerned—patients,
families, carers, service
providers, planners and commissioners.
In phase II we have addressed
rehabilitation issues for the
whole spectrum of head-injured patients. Here we
describe the
development of a set of definitions and a system for mapping
the
rehabilitation process that will help identify gaps in services,
set criteria
for movement between sectors and allow an individual's
progress to be
audited.
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METHODS
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Mapping the geographical distribution of rehabilitation services
A questionnaire survey, supplemented by service visits, was
conducted to
ascertain the extent of the current head-injury
rehabilitation services in the
Eastern Region. The findings
of the questionnaire survey were translated into
a series of
maps showing the currently available services as related to
each
stage of rehabilitation for acute and community support
after head injuries of
different severity. The first draft of
the maps was disseminated for feedback
and debate at a multidisciplinary
review meeting with external advisers.
Definitions and classification of rehabilitation services
Working groups for acute, early and late rehabilitation after head injury
were formed and a set of definitions and classification of rehabilitation was
collaboratively developed. Each stage was given a clearly defined
classification code, a patient description, location(s) for that stage to take
place (including examples), necessary level of rehabilitation input and
indications for moving between sectors.
These were disseminated to key personnel throughout the Eastern Region for
comment and agreement. The maps were then redrafted to correspond with the
agreed rehabilitation codes and definitions, together with a flowchart of
potential head injury rehabilitation services.
Piloting the definitions
The definitions and classification codes were piloted prospectively at
Addenbrooke's Hospital Neuroscience Critical Care Unit and in the
neurosurgical wards immediately before discharge from neurosurgical care, and
retrospectively at the Colman Hospital in Norwich (inpatient rehabilitation)
for the post-acute stages, to test for adequacy, appropriateness and
effectiveness.
At Addenbrooke's the pilot study was conducted over six months from
April to October 2002. A weekly head-injury ward round was jointly conducted
by neurosurgery and rehabilitation consultants to assess the inpatient
rehabilitation needs of head-injured patients admitted to and discharged from
the neurosciences critical care unit and the neurosurgical wards. Data on each
patient, including postcode and severity of injury, were collected by means of
a proforma and an Access database.
The study at the Colman Hospital covered twelve months from April 2002 to
April 2003, the same information being collected.
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RESULTS
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The iterative process of consultation yielded consensus definitions
for
each component of the rehabilitation service pathway for
head-injured adults
(
Table 1). Codification of the
resultant
definitions then permitted construction of a flow chart
(
Figure 1).
These definitions
for each step in the care pathway allowed
maps to be drawn of the geographical
provision of each component
throughout the Eastern Region
(
Figure 2). Maps 3, 5 and 6
starkly
illustrate the gaps in service provision. The survey revealed
important
deficiencies in the care pathways and continuity of care at
both
acute and late stages of rehabilitation as well as for
specific programme
categories—for example, patients with
severe behavioural disorders.
Distribution and allocation of
resources were found to be fragmented and
uneven—deficiencies
that appeared to be compounded by lack of an overall
structure
and of coordination between acute and community providers.
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Figure 1. Flowchart of potential head injury rehabilitation services (HI=head
injury; rehab=rehabilitation)
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In the six-month study at Addenbrooke's, 130 patients with traumatic
brain injury were admitted, of whom 25 died. The rehabilitation needs of the
remaining 105 patients were assessed prospectively according to the new coding
system and Table 2 lists the
categories of rehabilitation relevant to the 75 survivors. 37 patients were
transferred to inappropriate acute wards despite being ready for a
rapid-access unit (which is not available in the Region). 3 patients should
have been transferred to a slow-stream rehabilitation unit.
14 patients with traumatic brain injury were admitted to the rehabilitation
unit in Norwich, and use of the codes again highlighted delays in discharge
and follow-up and inappropriate provision of care. Of these 14 patients, 8 had
been looked after on non-specialist wards.
The codes proved easy to use and no patient fell outside the
definitions.
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DISCUSSION
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The principles underlying the rehabilitation needs of the victims
of head
injury have been known since the Second World War, when
experience with
military casualties led to great
advances.
8,9
The
UK can boast neurorehabilitation centres of international repute,
but in
general head injury rehabilitation has not matched the
success of the
supraregional system of spinal cord injury centres.
This deficiency has been
deplored by numerous official reports
and editorials from 1945 onwards. Part
of the difficulty results
from the much greater number of head-injured
patients and the
wide range of their disabilities—physical, behavioural
and
cognitive. Moreover, an argument for diversion of resources
demands clear
evidence that rehabilitation is
effective.
10 In
the
opinion of ERHIG, head-injury rehabilitation is neither
intractable nor
unaffordable.
The definitions and maps developed in this exercise are readily understood
and facilitate the design of care pathways for individual patients, service
planning and audit. Our flow chart is an elaboration of the Slinky model of
the phases of rehabilitation, which emphasizes the seamless integration of the
different stages of care, but the reality of the process is much more complex
and three-dimensional than the Slinky model suggests, as emphasized by
Turner-Stokes in the new National Guidelines for Rehabilitation following
Acquired Brain
Injury.11 The
process of agreeing definitions was sometimes tortuous. There was considerable
variation of opinion over what constitutes acute, post-acute and early
rehabilitation, when it should start and what criteria should be used to
decide when it has been completed. Numerical codes proved less contentious
than titles.
The Eastern Region is not alone in the patchy nature of its provision for
rehabilitation for the
head-injured.6,12
The process described in this paper offers a way to identify blocks and delays
in the care pathways and any shortfalls in resources. In subsequent work we
aim to determine the likely numerical and fiscal demands on each component of
the pathway and derive costings based on outcome, along the lines already
achieved for regional acute neurosurgical
care.13
Finally, the model should prove helpful to patients and their families, as
a means to illustrate the long process that may await them and in which they
will have a key part to
play.14,15
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Acknowledgments
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H M Seeley was partly funded by the Eastern Region Specialised
Commissioning
Group; P J Hutchinson is funded by an Academy of Medical
Sciences/Health
Foundation Senior Surgical Scientist Fellowship.
Members of the Rehabilitation Subpanel were: N Burchett (Queen Elizabeth
Hospital, King's Lynn), M Cooper (Headway, Colchester), P Durrant
(Headway, Cambridge), J Evans (Oliver Zangwill Centre, Ely), M Garner (Sue
Ryder Home, Ely), A Gent (BIS UK), R Greenwood (Homerton Hospital, London), S
Kirker (Lewin Rehabilitation Unit, Cambridge), K McGlashan (Colman Hospital,
Norwich), C Noble (Neurorehabilitation Team, Peterborough District Hospital),
P Osuwu (Peterborough District Hospital), H Seeley (Neurosurgery,
Addenbrooke's, Cambridge), A Tyerman (Camborne Centre, Aylesbury), D Wade
(Rivermead Rehabilitation Centre, Oxford), N Williams (OT BI Outreach/Lewin
Unit, Cambridge).
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REFERENCES
|
|---|
- Thornhill S, Teasdale GM, Murray GD, McEwen J, Roy CW, Penny KI.
Disability in young people and adults one year after head injury: prospective
cohort study. BMJ2000; 320:1631
-5[Abstract/Free Full Text]
- Tennant A. The epidemiology of head injury. In: Chamberlain MA,
Neumann V, Tennant A, eds. Traumatic Brain Injury
Rehabilitation. London: Chapman & Hall,1995
- British Society of Rehabilitation Medicine.
Rehabilitation after Traumatic Brain Injury. London:
Royal College of Physicians, 1998:8
- Royal College of Surgeons of England. Report of the
Working Party on the Management of Patients with Head Injuries.
London: RCS, 1999
- Society of British Neurosurgeons. Safe Neurosurgery
2000. London: SBNS, 2000
- House of Commons Select Committee on Health.
Third Report: Head Injury: Rehabilitation, 2001. London:
Stationery Office, 2001
- Seeley H, Maimaris, C, Carroll G, Kellerman J, Pickard J.
Implementing the Galasko Report on the management of head injuries: the
Eastern Region approach. Emerg Med J2001; 18:358
-65[Abstract/Free Full Text]
- Russell WR. Rehabilitation after gunshot wounds of the brain.
Br J Surg War Surg 1947;(War Surg. Suppl.
No. 1) 252-5
- London PS. Some observations on the course of events after severe
injury of the head. Ann R Coll Surg Engl1967; 41:460
-79[Medline]
- McMillan TM, Greenwood R. Head injury rehabilitation. In: Greenwood
R, et al., eds. Handbook of Neurological
Rehabilitation (3rd edn, Chapt 5). Hove: Psychology Press,2003
: 465-85
- Turner-Stokes L, ed. Rehabilitation Following Acquired
Brain Injury. National Clinical Guidelines. London: Royal College
of Physicians & British Society of Rehabilitation Medicine,2003
- Meek C. What happens next? Health Which
October 2002: 22-5
- Pickard JD, Bailey S, Sanderson H, Rees M, Garfield JS. Steps
towards cost benefit analysis of regional neurosurgical care.
BMJ1990; 301:629
-35
- Barnes MP. Organisation of neurological rehabilitation services.
In: Greenwood R, et al., eds. Handbook of Neurological
Rehabilitation, 2nd edn, Chapt 3. Hove: Psychology Press,2003
: 29-40
- Olivier MA. A different viewpoint—who needs rehabilitating?
In: Greenwood R, et al., eds. Handbook of Neurological
Rehabilitation, 2nd edn, Hove: Psychology Press,2003
: 38-9
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SUMMARY
INTRODUCTION
