A REHABILITATION AND CARE SERVICE FOR YOUNG ADULTS WITH ACQUIRED BRAIN DAMAGE IN GREATER GLASGOW

T M McMillan, University of Glasgow and Greater Glasgow NHS Board

May 2002

The Vision

A comprehensive service that identifies people in need, deals with the wide range of types of problem that can occur after acquired brain damage (ABD), deals with the wide range of severity of problems and offers an accessible service and at the time that people need it. The service will cover a range of inpatient and community settings. It is a service mainly for young adults with ABD, covering a wide range of problems, severity and recovery patterns. Services for children, adolescents and older adults are referred to but need to be developed as further pieces of work and integrated with the young adult service.

Accident & Emergency Admission: It is anticipated that about 2,500 people per annum who are less severely injured will be admitted to Accident & Emergency with traumatic brain injury (TBI) for up to 48 hours. During this time they might be in post traumatic amnesia (confused and disorientated) but are rapidly recovering or there may be an issue as to whether they are confused as a result of alcohol or drugs: A period of recovery and monitoring is required in order to discount the possibility that they have sustained a more severe brain injury. Should it be clear that the injury is more severe then they should be passed to the appropriate acute service or to an early management unit. It is anticipated that for Glasgow two such units are required associated with the main A&E sites. 

Early Management and Rehabilitation: This is for patients soon after injury who are medically stable. It refers to people who may still be confused and disorientated, may be agitated or wandering or may be in prolonged coma. Often these people require a period in hospital during which they recover rapidly; all will subsequently require inpatient rehabilitation. There needs to be assessment of their needs and signposting to the next appropriate stage in rehabilitation. Some will benefit from early rehabilitation at this stage although they will often fatigue rapidly and not be capable of intensive rehabilitation. About 500 cases per annum in total might be admitted. However some of these will self-discharge or be discharged because they are not in post traumatic amnesia when acute medical treatments end. The principle is that they should be moved on when they have sufficiently recovered and are capable of benefiting from intensive rehabilitation, or can be discharged to home, or require specialist rehabilitation.

Inpatient Physical Rehabilitation: This is provided by the Physical Disability Rehabilitation Unit (PDRU) at the Southern General Hospital; there are normally up to six to eight patients with traumatic brain injury at any time; in addition there may be some young stroke patients. The emphasis is on physical rehabilitation. The PDRU does not admit patients who do not require intensive physical rehabilitation, who have a moderate or severe behaviour problem or who cannot cope with intensive rehabilitation. Length of admission will vary but might range for most cases between six and 12 weeks. 

Inpatient Psychosocial Rehabilitation: This is a subgroup of patients who have had severe brain injury, require help in adjusting to psychological (i.e. cognitive or emotional) effects and may have difficulty with day to day living tasks (e.g. dressing, cooking and so on). They may require some degree of physical rehabilitation although this is not the main source of their needs. These patients are usually referred to the Central Scotland Brain Injury Rehabilitation Centre (Scotcare) near Wishaw; as this unit is in the independent sector all of these cases are first assessed by the Health Board who then monitor progress. The average number of admissions in the past three years is 19.

Challenging Behaviour: This can range from provocative outbursts, embarrassing behaviour, verbal tantrums to threatening behaviour and actual violence. Some units (such as Scotcare) are prepared to manage challenging behaviour if it is not severe (i.e. violence where physical restraint is not required and there are not high levels of disruption to other patients). The only specialised unit for dealing with severe challenging behaviour in Scotland is the Robert Ferguson Unit in Edinburgh; the median bed use here over the past five years by Glasgow residents has been three with duration of stay to 12 months. The number of beds required by Greater Glasgow for treatment after traumatic brain injury is likely to be around three per annum. However there is in addition a need for the services of such a unit for people with brain injury from other causes (alcohol related, brain infection, cerebral anoxia).

Of 10 people discharged in the past four years; three have been discharged to home with support, five to nursing homes, two to Scotcare. A further three have finished treatment but cannot be discharged and one of the two discharged to Scotcare was readmitted to RFU. Those who cannot be discharged represent people who remain dangerous, and the frequency of antisocial behaviour is markedly higher if not in a “milieu” designed to manage difficult behaviour. Hence there is a need for continuing care.

Minimally conscious or responsive/near to Vegetative State: This refers to patients who are in a vegetative state (no evidence for cognitive functioning), who are in a low awareness state or where cognitive ability is unknown because of severe physical impairment. These cases are also small in number. Many die within the first 12 months, but some survive for many years. They tend to block acute beds in general wards for many months and are then discharged to nursing homes where they receive no rehabilitation. It is proposed to create a specialist unit of three beds which will carry out repeated assessment, will give appropriate nursing care, can provide any treatments that might possibly be considered effective (such as sensory stimulation), will liaise with and counsel relatives and will given an informed opinion with regard to prognosis and needs. Currently such a service is being developed at the Central Scotland Brain Injury Rehabilitation Centre (Scotcare).

Slowstream Rehabilitation: A small number of patients remain severely physically disabled more than six months post injury and although they show signs of change, this is slow and likely to be over a lengthy period of time. Where disability is severe these cases are often discharged to home with extensive care packages or extensive care from relatives or are placed in nursing homes. What is needed is the option of low intensity long-term rehabilitation and Consultant monitoring. A recent review of nursing homes in Glasgow has made recommendations in this regard. For example that there could be two or more specialist nursing homes, (with some parallels to a US Rehabilitation Care Home model), where there is regular review by consultants in rehabilitation medicine and some ongoing rehabilitation.

Long Term Physical Disability: Where physical disability persists beyond the inpatient phase there are three community physical disability teams who can offer treatment in the person’s home. The case load of these teams is largely MS and stroke and a relatively small proportion is traumatic brain injury (perhaps 5%).

Psychosocial and Emotional Problems: Hitherto there has been no specific service to deal with the large proportion of people with ABD who make a near perfect recovery from physical disability. It is widely recognised that a significant number of these people have persisting changes in personality and ongoing cognitive and emotional problems. These changes can be severely debilitating, can result in marital break up, loss of employment and social isolation. A community treatment “hub” has been commissioned and will open in the Autumn of 2002 in Govanhill to specifically deal with this group of patients. It will not provide physical therapy but will provide group and individual based packages for the “walking wounded”. It has been designed to admit around 100 new cases of acquired brain damage each year and will offer a time limited programme with client centred goal planning at its core. 

It will also offer a brief intervention service (normally by telephone) for about 200 people with minor brain injury per annum who were admitted to hospital. Previously rehabilitation of minor brain injury has largely been neglected. It is thought that most will recover within a period of three months post injury although some will remain disabled for longer. There is evidence to suggest that education and advice at an early stage can prevent the development of later handicap. The treatment centre will also offer liaison with other services who deal with brain injured people, training of less specialist staff (e.g. in Nursing Homes) and research.