Impact of Intensive Hyper-Acute Neurological Rehabilitation

Purpose

There is strong evidence to support the provision of specialist and intensive rehabilitation programmes (BSRM 2014) and that the highest level of neurological recovery occurs within the first three months post injury (Broeks et al 1999, Feys et al 2000). However, clinical data from our patient cohort showed patients were not commencing rehabilitation until after this time window due to delays in access to specialist rehabilitation, specifically our local district general patients would wait on average 87.3 days, and patients awaiting repatriation to local hospitals would wait 35 days from being medically stable before transfer. On analysis of our patient caseload, 70% of the caseload had a Rehabilitation Complexity Score of more than 10 indicating a complex specialist service as determined by Turner- Stokes et al (2007), however our staff to patient ratio fell significantly short of the recommendations for this level of service. Funding for this service type traditionally comes from NHS England. It was hypothesised that these delays and service parameters impacted on patient’s functional outcome and on the wider health economy.

This service pilot aimed to examine whether provision of specialist rehabilitation to neurological patients receiving hyper-acute neurosciences care would result in clinically significant functional improvements and reduce length of stay, and transfers to specialist facilities.

75% achievement
of GAS goals
Estimated £3 million
combined savings for the CCG and Trust per annum.

Approach

The pilot intervention consisted of a virtual interdisciplinary team resourced in line with BSRM guidelines providing intensive rehabilitation to category A/B patients during and on discharge from neurosciences wards. The rehabilitation approach given was individualised to each patient depending on their presenting condition. All data utilised was managed in accordance with trust data protection guidelines and consent for participation obtained. Ethical approval was not required as this was a service initiative to support improved patient wellbeing and hospital flow.

To analyse impact on hospital related outcomes, a baseline group, identified through hospital records of patients requiring specialist rehabilitation during winter 2012/13, was identified to control for external economic factors. The comparative group was all patients who received pilot intervention during winter of 2013/14.

The patient related outcomes collected and analysed where Rehabilitation Complexity Scale (RCS), Functional Independence Measure (FIM) and Functional Activities Measure (FAM), Northwick Park Dependency Scale (NPDS) and Goal Attainment Scale (GAS).

The hospital outcomes collected and analysed were average length of stay (LoS) and delay (LoD), and the number of referrals to specialist consortium facility.

Outcomes

During 3-month period, 33 patients received the pilot intervention, 82% of vocational age and 65% were male. This was comparable to the 34 baseline patients. 89.7% of patients treated had an RCS score of 10 or more indicating high level of complexity.

RCS had average reduction of 2.39 points and NPDS Care dependency by average of 6.69 points between admission and discharge. 75% of patients’ GAS goals were achieved or overachieved and the FIM/FAM had an average overall improvement of 24.14 points, with greatest improvement in motor and cognitive functions. This is above the level of clinically significant change.

The hyper-acute rehabilitation pilot reduced the average LoS by 27.60 days and average LoD by 24.90 days, indicating a significant improvement in patient flow. There was a 10% increase in discharges home and 37% reduction in referrals to specialist consortium beds.

Cost and savings

The project was costed as approximately £1.2m per annum, with £35k non-recurrent start up costs. The projected combined savings for the CCG and Trust were estimated as approximately £3m. These savings were attributed from internal flow, improved patient outcomes and prevention of secondary complications, reduced transfer and transfer dependency level to specialist beds and improved staff retention and satisfaction.

Implications

The provision of hyper-acute neurological rehabilitation produced clinically significant changes for patients, which are in line with existing specialist rehabilitation services. In addition, it had significant impact on the hospital related outcomes supporting patients in receiving the right care at the right time.

This was a service initiative to evaluate an alternative care model for service users within Barts Catchment area. Therefore, it is not possible to translate the findings to other clinical areas, however it does raise questions for future research into the potential benefit of alternative models of care.

Top three learning points

  1. Patients were able to tolerate high intensities of therapy while still within the acute Neurosurgical service and the importance of this type of service for patient care
  2. Leadership for a service like this can come effectively from a consultant therapist working in collaboration with medical peers.
  3. The positive impact delivering this service had on both patients and staff satisfaction, and with economical benefits.

Fund acknowledgements

Funding for the pilot was granted by Barts Health NHS trust from winter pressures funds.

Additional notes

This work was presented at Physiotherapy UK 2018.

For further information about his work contact Kelly Saunders

References:

British Society of Rehabilitation Medicine (2014) ‘Rehabilitation for patients in the acute care pathway

following severe disabling illness or injury: BSRM core standards for specialist rehabilitation’

Broeks, J.G. Lankhorst, G.J. Rumping, K. Prevo, A.J.H (1999) ‘The long-term outcome of arm function after stroke; Results of a follow-up study’ Disability and Rehabilitation 21 (8): pp. 357-364

Feys, H. De Weerdt, W. Nuyens, G. Van De Winckel, A. Selz, B. Kiekens, C. (2000) ‘Predicting motor recovery of the upper limb after stroke rehabilitation: Value of a clinical examination’ Physiotherapy Research International 5 (1): pp. 1-18

Turner-Stokes, L. Disler, R. Williams, D. (2007) ‘The Rehabilitation Complexitity Scale: a simple, practical tool to identify ‘complex specilized’ services in neurological rehabilitation’ Clinical Medicine 7 (6) pp. 593 - 599