1. Acquired Brain Injury Rehabilitation Services: The Southern Picture Dr. Nicola Ryall Consultant in Rehabilitation Medicine 28 September 2006 NATIONAL REHABILITATION HOSPITAL

2. 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)

3. Sequelae 1… Physical Paralysis Ataxia/incoordination Sensory deficits Visual/Auditory Dysphagia Epilepsy Headache, fatigue, pain etc. Communication Expression/Reception Dysarthria Dyslexia Dysgraphia

4. 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

5. 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

6. Slinky Model (RCP, BSRM 2003) Acute care/neurosurgery Ward based therapy Post-acute in-patient Specialist Rehabilitation Community based rehabilitation Day centre/out patients Out-reach/Home based Vocational rehabilitation Longer term community support Specialist care/care management Review/ drop-in clinics Re-assess as required Reduced Impairment and pathology Improved activity (reduced disability Enhanced participation Goals & outcomes Hospital Home

7. 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

8. 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

9. 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.

11. National Rehabilitation Hospital Republic 119 beds 34 (ABI) 5 consultants UK International 254 beds (rehab) 360 (ABI) 16 27..74..450

12. 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

13. 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

14. New funding since 2001 0

15. Rehabilitation Strategy 2002 0

16. Since April 2006…. 0

17. NTPF 0

18. New Hospital 235 beds No guarantee of funding Significant delays to date

19. 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

20. 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

21. Thank you