4RAUMATIC "RAIN )NJURY IN !DULTS
3ERVICE -APPING 2EPORT
Content Page 1. Introduction 3 1.1 Background to the National Managed clinical Network 1.2 Initial focus 1.3 Nature of head injury
2. Service mapping process 7 3. Mapping by NHS Board 9 NHS Ayrshire & Arran 11 NHS Borders 15 NHS Dumfries & Galloway 17 NHS Fife 21 NHS Forth Valley 23 NHS Grampian 25 NHS Greater Glasgow & Clyde 29 NHS Highland 37 NHS Lanarkshire 41 Central Scotland Brain Injury Rehabilitation Centre 45 NHS Lothian 47 NHS Orkney 51 NHS Shetland 55 NHS Tayside 59 NHS Western Isles 63
4. Summary of findings & discussion 65 5. Recommendations 69 6. References 71 7. Appendix 72 i. Steering Group membership
1 2 1. Introduction 1.1 Background to the National Managed Clinical Network
As the human brain controls all our thoughts, feelings and actions, both voluntary and involuntary, when it is damaged the consequences are often variable and complex. Acquired brain injury (ABI) often leads to a mixture of physical, communicative, emotional, and behavioural changes with profound consequences for the individual and their family. The person with such complex disabilities requires expertise traditionally based in medicine, mental health and learning disability services but does not fit neatly into any of these categories and so may be denied access to appropriate treatment. Brain injury rehabilitation needs a specialist approach that can deal with the combination of problems arising from ABI. ABI rehabilitation is patient or family-centred and involves joint working with social work, educational, vocational and voluntary agencies as well as health professionals.
Head injury (or traumatic brain injury) is the paradigm and the inadequacies of services to this group have been recognised and lamented by leaders of the medical profession and the responsible authorities for many decades. During the Second World War attempts were made to establish co-ordinated services initially directed at military personnel but used extensively by civilians (1-3). Pleas were made to maintain these services in peacetime(4) and when rehabilitation medicine was proposed as a specialty in 1974 the Scottish Department of Health report singled out services for head injury as a topic for urgent attention (5). By 1989 there was still patchy and inadequate provision in Scotland (3, 6), which stood in stark contrast to most other Western Countries. In 1991 temporary funding was made available to establish a national tertiary rehabilitation service at three units. Two of these were to provide early in-patient rehabilitation at Astley Ainslie Hospital, Edinburgh and Murdostoun Castle, Bonkle in Lanarkshire; the other at the Royal Edinburgh Hospital was to cater to those with severe challenging behaviour. During the ensuing decade a number of initiatives occurred, particularly the establishment of generic and specialist rehabilitation medicine services in a number of NHS boards with in-patient and out-patient components. There have also been a number of welcome developments outside the health service.
However the Scottish Needs Assessment Programme (SNAP) report of 2000 indicated that the provision of services for brain injured people in Scotland continued to be inadequate and patchy (7). Among their recommendations related to health provision were the following:
% Agreed care pathways are needed by both professional and lay carers. % Agreed standards of care are needed to complement care pathways % Professionals and patients need access to better information (e.g. on care pathways; patient and carer needs; available services; and care standards) % Patients and carers urgently need help with the choices and decisions involved in moving through a complex care system. % Regional centres with expertise in the management of these conditions should be identified as sources of advice and training to extend the availability of their expertise. % The data currently available to allow planning of services need to be improved
3 As part of the review of the SNAP report the National Services Division (a division of NHS National Services Scotland) explored the current tertiary services provided at the Astley Ainslie and Royal Edinburgh Hospitals, Edinburgh. However it was recognised that specialist services of a tertiary nature had also been established in a number of other centres with both hospital and community rehabilitation approaches and that the development of services in Scotland has been erratic over the years. Consequently there were considerable inequalities in access to specialist advice throughout the country and therewasaneedtoaddressthebraininjuryrehabilitation requirements for the whole of Scotland.
Accurate figures/epidemiology are not available for ABI. Even for traumatic brain injury the available epidemiology has limited evidence-base but the Royal College of Physicians suggests 2-4/100,000 of those categorised as moderate or severe head injury will have complex disability. A proportion of those with ostensibly mild head injuries have complex problems and non-traumatic brain injuries (e.g. subarachnoid haemorrhage, brain damage after cardiorespiratory arrest etc) probably account for as many individuals with these difficulties as traumatic cases. Improved acute medical and surgical care has led to reduced death rates from traumatic and non-traumatic brain injury but also increased numbers of survivors with complex disabilities. Thus a conservative estimate would be 8- 10/100,000 or about 400-500 cases annually in Scotland as a whole. It was felt that a National Managed Clinical Network approach would be appropriate to encourage development of services for this population of patients.
A Managed Clinical Network is defined as:
Linked groups of health professionals and organisations from primary, secondary and tertiary care, working in a co-ordinated manner, unconstrained by existing professional and Health Board boundaries, to ensure equitable provision of high quality clinically effective services throughout Scotland (8)
An application for the establishment of a National Managed Clinical Network for Acquired Brain Injury was successful and an MCN manager appointed in December 2006. The Steering group first met in February 2007.
Copies of the application and directions to learn more about MCN’s can be obtained via our website: www.sabin.scot.nhs.uk
4 1.2 Initial Focus
The Steering Group agreed that the initial report would concentrate on the health service provision for people aged 16-65 years with head injuries. More details on the rationale behind this decision are available via our website but a brief explanation follows:
Head injury was chosen as the most common cause of ABI and the most practical starting point for a mapping exercise. The second most common cause is stroke and much work has already been done by local stroke MCNs for this group.
The needs of children, particularly those less than 5 years of age, differ from adults and paediatric services for those with disabilities are longer established and usually greater than those for adults. Elderly people with head injury often have other pathologies that may have caused the injury and complicate subsequent treatment. Thus the initial focus is on those aged 16-65 years but specific attention will be given to transitional ages of adolescence (where children with persisting problems move on to adult services) and 65 years (when care of the elderly services takes responsibility for some cases.)
The patient journey after moderate and severe head injury after Accident & Emergency may involve Intensive Care, Neurosurgery, and in-patient Rehabilitation. Rehabilitation is the transition from hospital to community care and often includes out-patient or community based input from health professionals. Many community health resources are delivered from primary care and will be under the auspices of Community Health Partnerships. The journey does not end there and many other agencies are involved particularly social work, employment and educational and the voluntary sector and the effects of head injury are often life-long.
It was agreed that the initial focus of the managed clinical network should be on health service provision but with full consultation with and involvement of these other agencies. It is envisaged that a future stage of the network’s work will include a shift of attention from the NHS component to the wider aspects and so may evolve from a Managed Clinical Network to a Managed Care Network.
The NMCN decided to begin with four principle objectives:
• Develop standards of care • Map out current services for people aged 16 - 65 with traumatic brain injury • Identify the educational needs of health care groups involved in the care of people with traumatic brain injury • Identify information requirements of patients and carers
This report deals with the second of these objectives - details of the others are available on request and via the website: www.sabin.scot.nhs.uk
5 1.3 Nature of head injury
Determining the epidemiology of head injury is notoriously difficult 9,10. In this document the terms head injury and traumatic brain injury are used synonymously although this is not strictly accurate. For example an abrasion or laceration to the scalp constitutes a head injury but may not be accompanied by any brain damage. These problems are reflected in the International Classification of Diseases (ICD-10) which forms the basis of statistical recording of diagnoses in the NHS. The ICD-10 has ten separate codes that may apply to head injury. These codes are often applied from hospital discharge letters by non-clinical staff. If a scalp laceration is wrongly coded as head injury an overestimate of head injury may result. On the other hand it is estimated that about half of those who suffer head injury also have an extracranial injury. The associated injury may take precedence in terms of medical treatment and be the only injury recorded resulting in an under-recording of head injury.
With these caveats, it is generally accepted that approximately 100,000 people attend hospital in Scotland with head injury each year. Of these about 20,000 will be admitted. These injuries vary in severity. The conventional manner of categorising severity of injury is by the Glasgow Coma Scale (GCS) score after initial resuscitation; duration of unconsciousness; and duration of post-traumatic amnesia (PTA) as summarised in the following table.
Duration of GCS PTA unconsciousness Mild <15 minutes 13-15 <60 minutes Moderate 15mins.-6 hours 9-12 1-24 hours Severe >6 hours 3-8 >24 hours
Estimates for each category attending Accident & Emergency are mild 90%, moderate 5%, and severe 5%.
While all members of society are at risk of head injury, it occurs disproportionately in young men of low socio-economic and educational status from areas of multiple deprivation. Those affected show increased frequency of substance abuse, suicide, psychiatric disorders, physical disability, long-term unemployment and family breakdown. There is a high incidence of mental and physical health problems in carers.
6 2. Service mapping process
2.1 Introduction and Methods
Determining existing services and current care pathways for people with head injury poses several challenges. The patient journey could be considered to extend from long before the injury, taking account of risk factors and prevention, to long after discharge from contact with health services. This exercise looked at the pathway from attendance at Accident & Emergency to discharge to non-NHS community resources. The latter stage is rather diffuse as health professionals may be involved for prolonged periods.
Care pathways necessarily vary widely according to the individual patient. The network was directed to concentrate on people with complex disabilities usually resulting from moderate or severe injuries. However it was recognised that a small proportion of those with ostensibly mild head injuries have complex problems and require consideration.
One of the principal challenges was to decide upon methodology. The NHS, at both national and local level, is a constantly changing organisation. Where local strategies, plans or proposals for head injury services existed and were available, they are mentioned in the report. However the mapping exercise was directed at describing current practice. Consequently a direct approach to clinical staff was chosen and wherever possible this was done by face-to face interview. A semi-structured questionnaire was used that was slightly adapted according to the part of the service being studied.
Five very brief case examples or scenarios were used:
Scenario A: The individual who has no significant physical impairment and is sufficiently orientated to be allowed home but has persisting cognitive impairments.
Scenario B: A patient who is medically stable but has mixed physical and cognitive impartment without major behavioural issues. He requires physical assistance with transfers and all mobility activities and because of mixed cognitive and language difficulties needs supervision in activities of daily living.
Scenario C: An acutely behaviourally disturbed person who, because of cognitive/language impairment, is unco-operative with ward staff, attempts to leave hospital and can be aggressive to staff.
Scenario D: Persisting challenging behaviour in a person who is aggressive to staff but lacks cognitive capacity to comply with the staff or go to the community.
Scenario E: An individual in a vegetative state/minimally conscious state. Medically stable but requires nursing care for all needs and has been in this state for some weeks.
2.2 Current Pathways by NHS Board
The following reports are summaries of the current care pathways in each NHS board area. The mapping exercise took place between July 2007 and July 2008. Changes may have occurred since that period and if we have been informed these are mentioned in the report.
7 We are grateful for those who agreed to be interviewed and their names are listed in each NHS board entry. While the informants have had the opportunity to check the factual details, the report is often a composite of several interviews.
As a number of terms and abbreviations are used throughout the report, the following short section provides an overview and brief glossary.
Emergency Care
The mapping exercise begins in the Accident and Emergency (A & E) department and the terms A & E consultant or Emergency Medicine consultant are used interchangeably. Seriously injured patients may be admitted to an Intensive Care Unit (ICU) or Intensive Therapy Unit (ITU). These are virtually synonymous terms. A High Dependency Unit (HDU) provides similar high levels of acute supportive care.
There are 4 Regional Neurosurgical Centres in Scotland at: Aberdeen: Aberdeen Royal Infirmary Dundee: Ninewells Hospital Edinburgh: Western General Hospital Glasgow: Southern General Hospital
TertiaryTertiary RehabilitationRehabilitation CareCare
The three units designated as part of the national brain injury rehabilitation service in 1991 still accept patients from various NHS boards. Two are based in NHS Lothian and are described on page 51. These are the Scottish Brain Injury Rehabilitation Service (SBIRS) at the Astley Ainslie Hospital and the Scottish Neurobehavioural Rehabilitation Service (SNBRS) [also known as the Robert Fergusson Unit] at the Royal Edinburgh Hospital, Edinburgh. The third is the Central Scotland Brain Injury Rehabilitation Centre (CSBIRC) at Murdostoun Castle, Bonkle, Newmains, Lanarkshire. Although an independent hospital, it is described on page 47 after NHS Lanarkshire.
8 3. MAPPING BY NHS BOARD
9 10 NHS Ayrshire & Arran
Land Area: 3,377 km²
Population: 367,020
Population Density: 109 per km²
Local Authorities: East Ayrshire: 119,570 North Ayrshire: 135,760 South Ayrshire: 111,690
Principal Hospitals: Crosshouse Hospital, Kilmarnock Ayr Hospital, Ayr Ayrshire Central Hospital, Irvine
Crosshouse Hospital, Kilmarnock Serves a population of approximately 220,000 – North & East Ayrshire
A&E Thereare4.5wholetimeequivalent(wte)A&Econsultantswith24hoursmiddlegrade andjuniormedicalstaffing.HeadinjuredpatientsareadmittedtotheA&Eshort stayward for observation and management. This is usually an overnight period with most younger patients being admitted in the evening or during the night. In the great majority of cases length of stay is 24 hours or less with occasional stays of up to 3 days. Those requiring more than 24 hours are usually transferred to a surgical ward. Elderly patients with head injuries are often admitted during the day and discharged home with rapid response team support.
Discharged patients are provided with information about possible complications as described in SIGN Guideline 46 but not covering cognitive disorder. Some are advised verbally to contact the local Headway group.Thereisnoroutineout-patient follow up.
Those identified as having alcohol problems are referred to the Alcohol Liaison Nurse or Psychiatric Liaison Nurse during their stay in the short stay ward.
Neurosurgical liaison is with the Southern General Hospital, Glasgow.
Routine data is collected on head injury admissions.
Post A & E Those patients not transferring for neurosurgery are admitted under the care of one of 7 general surgeons to the ITU, HDU or surgical wards. Occasionally they may go to medical wards if a surgical bed is unavailable.
11 The general surgeon on call on the day of admission is given consultant responsibility for the patient whether they are in the ITU, HDU or the wards and when the patients are returned after neurosurgical admission to Glasgow.
If an individual is fit for discharge but has some ongoing cognitive or neurological impairment (Scenario A) they would be referred to the neurologist. Some cases would be referred to Headway.
The acutely behaviourally disturbed patient (Scenario C) is usually managed with existing staff as difficulties can arise in providing additional staffing. Such staff, when available are not Registered Mental Nurses (RMNs). Liaison psychiatry is available but not readily and the informant could not recall any case being transferred to a mental health facility. The same circumstances apply to those with persisting challenging behaviour (Scenario D). One such case was referred to the Scottish Neurobehavioural Rehabilitation Service (SNBRS) in Edinburgh but the family took him home while awaiting a place.
Those patients requiring rehabilitation (Scenario B) are referred to Scottish Brain Injury Rehabilitation Service (SBIRS) or occasionally to the medical wards depending upon the nature of their disability and their age. Patients have access to generic allied health professionals but this resource is limited. A number of disabled patients remain in surgical wards for months, exceptionally as long as two years.
Patients in a vegetative or minimally conscious state (Scenario E) or with severe disability remain in the ward until placed in a nursing home. This is a very limited resource for the continuing care of young people in Ayrshire.
Ayr Hospital, Ayr
A & E There are 3 A & E consultants and the service principally deals with South Ayrshire but includes some of East Ayrshire. There is also some cross-boundary work with Dumfries & Galloway as road accidents on the routes to Stranraer may be brought to Ayr Hospital.
There is a six bedded observation area where patients may be kept for 24 hours. Those requiring more than 24 hours are transferred to the care of the general surgeons. Occasionally, usually due to social circumstances, individuals will stay in the observation ward slightly longer than one day.
Discharged patients are provided with an information sheet. Occasionally TBI patients are followed up in the A & E clinic. If cognitive problems are detected the individual would not be discharged but admitted to surgical care. (Some elderly individuals with a degree of cognitive impairment might be discharged with rapid response team input). Headway information is provided to selected patients.
Neurosurgery is provided by the Southern General Hospital, Glasgow.
Post A & E Most patients requiring more than 24 hour are admitted under the care of one of 8 general surgeons usually to a surgical ward (Station 2) unless requiring ITU care.
Those discharged from ITU or returning from neurosurgical care would also usually go to Station 2.
12 Acutely behaviourally disturbed patients (Scenario C) are managed on the ward often with extra nurses though not RMN trained. There is limited support from liaison psychiatry. The informant was unaware of SNBRS but recalled one case of chronic challenging behaviour (Scenario D) being taken to Ailsa psychiatric hospital.
Those patients requiring rehabilitation (Scenario B) are usually first seen by the consultant in rehabilitation medicine and then referred either to SBIRS or the Central Scotland Brain Injury Rehabilitation Centre (CSBIRC), Newmains.
Rehabilitation The rehabilitation medicine service provides out-patient services to TBI (and other ABI) cases but there is no in-patient facility. The in-patient rehabilitation unit at Ayrshire Central Hospital, Irvine has single room accommodation with a low ratio of nursing staff to patients so that ABI patients cannot be managed safely. As above, the consultant assesses patients in Crosshouse and Ayr Hospitals and directs those requiring in-patient rehabilitation to SBIRS or CSBIRC.
Out-Patient referrals to rehabilitation medicine come from several medical sources; general surgeons, neurosurgeons, SBIRS or CSBIRC and general practitioners. Those from Headway are channelled through the GP. There are occasional cross-boundary referrals from Inverclyde Hospital. Waiting time to be seen in clinic is 4 – 6 weeks. There is no fixed duration of contact with the service, which is determined by individual need.
Community Service A neuropsychologist, also based at Ayrshire Central Hospital, has been in post for almost a year with the aim of providing psychological assessment, support and care management for people with ABI. This is principally directed at those around 18 months post injury, the earlier period being addressed by the neuropsychologist (0.5 wte) attached to the rehabilitation medicine service. However, she has had requests to assess and advise regarding patients in the acute hospitals. General practitioners have referred people with no physical sequelae of TBI but with cognitive issues (i.e. scenario A). Advice has been given regarding management of acute behavioural disturbance in in-patients (scenario C) and on more persistent challenging behaviour (scenario D). Referrals are accepted from a wide range of medical sources including; psychiatry, from Headway and people can self- refer.
Community Services North Ayrshire Council Social Services provide day services and support to meet the specific requirements of head injured people and their carers at the Dirrans Centre in Kilwinning. The centre, which has an open referral system, is staffed by two occupational therapists, an outreach worker and an escort/support worker. Further support is provided by sessional workers and volunteers. The main aim of the service is to increase an individual’s capacity to live in the community as independently as possible by providing programmes that promote development in the following areas - social physical educational leisure. They also provide information and support to carers and family. The centre, which has 20 places per day and supports 45 service users, is registered with the care commission. Headway Ayrshire has provided a very active and wide ranging service to people with ABI throughout Ayrshire. This includes tailored support and advice for individuals and their carers, with a current client list of almost 700 and on average 70-80 new clients annually. Support starts from hospital visits and includes signposting individuals to appropriate services. In addition the group have run prevention campaigns to school children.
13 Principal funding for this invaluable service came from the Lottery and will not be renewed. Care funds from local authorities are much less and there is a threat of a huge reduction in service unless care funding is increased.
Interviewees Mr Hamar Felsenstein Consultant General Surgeon, Crosshouse Hospital Dr Teresa Hand Consultant in Emergency Medicine, Ayr Hospital Stephanie Kyle Headway Community Support worker Dr Alan Lannigan Consultant in Emergency Medicine, Crosshouse Hospital Nanette Masterton Manager Dirrans Centre North Ayrshire Dr Paul Mattison Consultant in Rehabilitation Medicine Dr Sharon Mulhern Clinical Psychologist in ABI Margaret New Charge Nurse, Station 2 Ayr Hospital Jane Sloan Headway Ayrshire Manager
Reviews, plans and strategies A review of services for people with brain injuries to inform future planning and strategic issues was carried out in 1998. There are no current specific plans for acquired brain injury services. http://www.nhsayrshireandarran.com/uploads/1986/Brain.pdf
14 NHS Borders
Land Area: 4,732 km²
Population: 111,430
Population Density: 24 per km²
Local Authorities: Scottish Borders: 111,430
Principal Hospitals: Borders General Hospital, Melrose
A&E A & E services are provided by 4 orthopaedic surgeons. From November 2008, A & E services will be led by one Consultant in Emergency Medicine. There is no observation ward. Patients requiring admission are admitted under the care of general surgeons principally to surgical wards 7 & 8. CT scanning is available and liaison is with neurosurgery at the Western General Hospital, Edinburgh.
Patients are provided with information leaflets based on SIGN 46 format. There is no specific reference to longer term complications and no routine follow up.
Routine data is collected and in the year 2007 there were 866 attendances recorded.
Post A & E Five general surgeons have the rota for in-patient care of TBI cases, most of whom are admitted to ward 7. Most patients are in for less than 24 hours. Small numbers of younger patients are admitted for a few days or weeks. Longer stays tend to occur in older patients. Quite often elderly patients (e.g. those on clopidogrel) are not accepted for neurosurgery and are managed conservatively in the surgical ward. Patients with mixed cognitive and physical problems (scenario B) may be admitted to the stroke unit (Ward12) under the care of a physician and rehabilitation team. This usually relates to older patients. Occasional patients are referred to the Scottish Brain Injury Rehabilitation Service (SBIRS).
Acute behavioural problems (scenario C) in Ward 7, especially in elderly patients, is a relatively common occurrence and difficulties occur in getting extra nursing -Registered Mental Nurses (RMN’s) or otherwise. The same circumstances apply to those in Ward 12. Liaison psychiatry is available to give advice but often after a delay. Patients are not transferred to a mental health facility.
Ward 12 has referred one case fitting scenario D to the Scottish Neurobehavioural Rehabilitation Service (SNBRS).
Patients with severe disability including those in a vegetative/minimally conscious state (scenario E) would be transferred from ITU to Ward 12.
15 Community Resources Allied health professional input is available in the community. There are community health care teams (generic) in Coldstream and Jedburgh and referrals can be made to clinical psychology but there is no rehabilitation team specifically directed at younger people. However it is felt that communication across professions is good.
Community hospitals (Duns, Hawick, Kelso and Peebles) have 24 hour nursing with occupational therapy and physiotherapy input and can provide continuing NHS care for younger patients with TBI. There is limited access to nursing homecare with the closure of Sue Ryder’s Marchmont.
There are 5 locality social care & health teams within Social Work in the Borders (Duns, Galashiels, Hawick, Kelso, and Peebles). Theseteamsprovideaservicetopeoplewitha brain injury in the community. They undertake assessments and provide services such as home care, day care and respite. The team leader in Kelso is the lead officer in Scottish Borders Council (SBC) for brain injury. Specialist services for this group of patients are provided through a service level agreement between SBC and Momentum, also based in Kelso but with outreach services. Momentum have recently secured additional funding to facilitate the Pathways programme (vocation and education).
Interviewees Elspeth Critchley Social Health Care Team Leader Dr Victoria Dobie Associate Specialist in Emergency Medicine Dr Andrew McLaren Consultant Physician Mr John O Neil Consultant General Surgeon Linda Stewart Community Physiotherapy Service Manager Jamie Thomson Charge Nurse Ward 12 Harry Wood Momentum Borders Manager
Reviews, plans and strategies There are no specific plans for acquired brain injury services
16 NHS Dumfries & Galloway
Land Area: 6,426 km²
Population: 148,300
Population Density: 23 per km²
Local Authorities: Dumfries & Galloway: 148,300
Principal Hospitals: Dumfries & Galloway Royal Infirmary, Dumfries Garrick Hospital, Stranraer
Dumfries & Galloway Royal Infirmary
A&E TwoA&Econsultantsarebasedatthehospitalandprovideacuteassessment.Patients are observed for up to 4 hours and if requiring longer are transferred to a general surgical ward unless needing neurosurgical transfer or admission to ITU.
ThosedischargedfromA&Eareprovidedwith an advice card regarding acute complications. Headway leaflets are available in the department but are not routinely given. However, not infrequently patients are seen in A & E 2 - 3 weeks after discharge, either by self-referral or via the GP if problems persist. They may have a repeat CT scan or be referred to the rehabilitation service. Patients are given the consultant’s secretary’s phone number so that they can arrange to be reviewed.
Neurosurgical services are provided in Edinburgh.
Post A & E There are 6 general surgeons who admit head injured patients to one of two surgical wards. Some patients with concurrent orthopaedic problems might be admitted under orthopaedic surgeons or those with maxillofacial injuries to the maxillofacial ward where there is a single-handed consultant.
The majority of head injured patients are in for 1 – 3 days, occasionally as long as two weeks. Those requiring rehabilitation will be transferred to the rehabilitation ward (Ward 14) sometimes after a delay because of bed availability.
Patients with challenging behaviour (scenario C) are difficult to deal with and there is no specific contingency or liaison psychiatry support.
Rehabilitation There is a general rehabilitation ward (Ward 14) with 23 beds. There are no “ring-fenced” neurological rehabilitation beds the ward taking elderly hip fractures and other diagnostic
17 groups and sometimes accepting “boarders” from other departments. TBI patients are admitted from surgery at Dumfries & Galloway Royal Infirmary but also from neurosurgical units in Edinburgh, Glasgow and Newcastle if they are Dumfries and Galloway residents. A small number of Ayrshire patients are accommodated due to the lack of in-patient services in Ayrshire. Multi-disciplinary rehabilitation is provided including neuropsychology. Medical follow up is provided to those discharged from Ward 14 and all TBI patients are referred to Headway.
The typical length of stay is 1 – 2 months. In a few cases there has been a prolonged stay of more than one year.
There is no provision for extra nursing to deal with behaviourally disturbed patients (scenario C). Occasional patients are transferred to psychiatric care and advice and occasional transfer is arranged with the Scottish Neurobehavioural Rehabilitation Service (SNBRS). The number in both these cases is very small.
Those in a vegetative or minimally conscious state (scenario E) would be referred to and transferred to Allanbank, a private provider of continuing NHS care.
There is a community ABI meeting held monthly to discuss and arrange services to discharged patients.
Neuropsychology There is a 0.5 wte consultant neuropsychologist available for adult ABI. There is no integrated pathway and the service is reactive, receiving referrals from A & E, rehabilitation, general practice and Headway House. [The neuropsychologist is to retire in November 2008 and there is uncertainty as to replacement.]
It is estimated that there are about 60 referrals per year. In-patients are usually seen within a week, out-patients within one month.
Clinics are held in Stranraer, Newton Stewart and Langholm as well as service to Dumfries.
After intervention patients may be referred to Headway
Physical Disability Service This is a single point of contact in the community for all physical disability referrals for Dumfries & Galloway. The Physical Disability Service is a joint venture between the NHS, Local Authority and Capability Scotland.
Referrals come from the rehabilitation service at Dumfries & Galloway Royal Infirmary and from SBIRS. Some are referred from Headway at a later stage, post injury. The wide geographical area of Dumfries & Galloway can prove problematic in terms of providing care packages to less populated areas.
Headway Headway House is joint funded from Health and Social Work and is accessible to patients from throughout the region. It is affiliated to Headway but separate.
Although all ABI cases are accommodated, 70-75% are TBI. Referrals come from rehabilitation, neuropsychology, general practice and self-referral.
18 There are 18 staff mainly part-time. This includes two outreach workers who also see clients in remoter areas and perform the function of care manager to an extent. There is also a vocational worker who can assist with return to employment,
Issues arise regarding distance travelled to attend the centre so there are plans to develop a drop-in centre in Stranraer.
Interviewees Carron Allison Headway Outreach Worker Mr Charles Auld Consultant General Surgeon Mr John Burton Consultant in Emergency Medicine Dr Roger Holden Consultant Physician Geoff Marks Joint Planning & Commissioning Manager Dr John Moore Consultant Neuropsychologist Trevor Muir Manager Physical disability & Community Services Chris Wallace Charge Nurse Community Services
Reviews, plans and strategies There are no specific plans for services for people with ABI, however services to people with a disability, including those with ABI, are referred to in the joint community care plan for 2008-9. These are aimed at achieving more integrated and sustainable services. http://www.nhsdg.scot.nhs.uk/dumfries/files/HCCP%202008%20final%20.pdf
19 20 NHS Fife
Land Area: 1,325 km²
Population: 360,428
Population Density: 272 per km²
Local Authorities: Fife: 360,428
Principal Hospitals: Queen Margaret Hospital, Dunfermline Victoria Hospital, Kirkcaldy Cameron Hospital, Windygates
A & E Seven A & E consultants cover the A & E departments at the Victoria Hospital, Kirkcaldy and Queen Margaret Hospital, Dunfermline. Both hospitals have CT scanners. Trauma cases are taken by ambulance to Queen Margaret Hospital and those seen in Victoria Hospital who require admission are transferred to Queen Margaret Hospital.
Post A&E Neither hospital has an observation facility within the A & E department and those requiring admission are admitted to the orthopaedic wards at Queen Margaret under the consultant care of the A & E specialist. Most admissions are for less than 72 hours.
Neurosurgical care is provided from Edinburgh and those returning after neurosurgery would be admitted to the orthopaedic wards under the care of the consultant orthopaedic surgeon.
Rehabilitation Those individuals requiring rehabilitation are transferred to the Sir George Sharp Unit, Cameron Hospital, Windygates. This has 12 beds for acute/post acute neurorehabilitation and acquired brain injury constitutes almost 80% of admissions. There are also nine beds at Glenrothes Hospital for people, including brain injured, with severe neurological disability.
Patients are accepted from orthopaedics at Queen Margaret Hospital, neurosurgical units in both Edinburgh and Dundee. All patients are seen in the referring unit – the majority within one week of referral.
The average length of stay is of the order of 3 months. Acutely behaviourally disturbed patients (scenario C) would not be accepted into the rehabilitation ward as facilities are unsuitable. Advice would be offered and contact made with the SNBRS. They would also be referring those with longer standing challenging behaviour (scenario D). Individuals in a vegetative/low awareness state (scenario E) are accepted for a period of assessment and
21 may subsequently be transferred to Cameron Hospital or a community placement.
The rehabilitation medicine service also provides out patient rehabilitation programmes. They have close links with the Fife Traumatic Brain Injury Service (FTBIS).
Community Services Fife Council Social Work Service has a specific social rehabilitation resource for head injured clients and their carers, the FTBIS. The team consists of a dedicated manager and 3 full-time equivalent social care workers. This service works closely with Fife Rehabilitation Service to ensure that all rehabilitation programmes are co-ordinated accordingly, to reduce duplication of work-load and enhance individuals’ quality of life.
Additionally, FTBIS direct people to Headway, Momentum and Fife Council’s Supported Employment Service. Health and social work professionals can refer people to Momentum via the Disability Employment Advisor through the Job Centre Plus scheme for vocational advice and assistance.
Interviewees Eddie King Momentum Manager Dr Lanre Osifodunrin Consultant in Emergency Medicine Dr Lance Sloan Consultant in Rehabilitation Medicine Ben Sutherland Lead Nurse George Sharp Unit Elaine Westwater Manager, Fife Council, Traumatic Brain Injury Service (FTBIS)
Reviews, plans and strategies There are no specific plans for services for people with ABI.
22 NHS Forth Valley
Land Area: 2,633 km²
Population: 288,473
Population Density: 110 per km²
Local Authorities: Falkirk: 150,720 Stirling: 88,190 Clackmannanshire: 49,900
Principal Hospitals: Falkirk & District Royal Infirmary, Stirling Royal Infirmary
Accident & Emergency Stirling Royal Infirmary (SRI) and Falkirk District Hospital (FDRI) have A & E departments. All cases of traumatic brain injury requiring imaging are sent to SRI. There are 5 (4.9 wte) consultants in A&E. Patients requiring observations are admitted to the orthopaedics wards (usually ward 28) or occasionally elsewhere. They are under the consultant charge of the general surgeon on call. (7 surgeons and 1 rehabilitation medicine consultant comprise the rota) not the consultant orthopaedic surgeon. The middle grade orthopaedic medical staff and orthopaedic nurses are involved in the patient’s care.
Those individuals requiring neurosurgical care are referred to Edinburgh (unless a Glasgow resident). Those discharged directly from A&E are provided with written information.
Post A&E People admitted to ward 28 (or other surgical wards) for observation are reviewed the following day and may remain for a few days or transfer to rehabilitation at Ward 14, FDRI or to a general surgical ward.
Similarly those returning from neurosurgery at the WGH are transferred to ward 14 FDRI or a surgical ward. A small percentage of such patients are admitted to SBIRS for rehabilitation.
Rehabilitation In-patient rehabilitation Since November 2006 there have been 8 beds designated for neurological rehabilitation in a 28 bed ward (ward 14) at FDRI. These 8 beds are available for ABI cases but are not protected/ring fenced for the purpose – [indeed at the time of our visit, July 2007, the ward was being closed for three months for fiscal reasons]. Patients may be referred from a number of services: orthopaedic, general surgery, neurosurgery, and SBIRS.
There is a consultant in rehabilitation medicine and part-time/sessional commitments from
23 AHPs (occupational therapists, physiotherapists, and speech & language therapists) but no neuropsychology input and AHP staff work on a rotational basis. Patients are admitted within days to weeks of injury and average length of stay is of the order of 2 months. [It is not possible to provide a true average length of stay as the unit has only been active for 8 months]
The unit is designed principally to address the needs of individuals with a mixture of cognitive and physical problems after TBI (scenario B). If a patient is acutely behaviourally disturbed in the rehabilitation or surgical ward the duty psychiatrist might be called but it would be unlikely that the patient be transferred to a mental health facility. Extra nursing would be used and could be a registered mental health trained nurse (RMN). The surgeon would be unlikely to section the patient while this is done in the rehabilitation unit if required Most persisting challenging behaviour would be referred to SNBRS. Vegetative or minimally conscious state patients are uncommon and the informant had little experience of such cases. They would be referred to Marchglen care home or a nursing home.
Out-patient rehabilitation There is a well established Area Rehabilitation Team directed at those aged 16 to 65 years with neurological problems including ABI. Team comprises consultant, associate medical specialist, 5 occupational therapists, 4 physiotherapists, 2 part-time speech & language therapists, 2 nurses, 0.5 psychologists, 5 rehabilitation assistants. It provides an area wide service and estimate ~ 5% of cases are TBI or approximately 15 cases per year. Contact with patient is not for a fixed period – probably averages about 1 year
Community Services Social Work Day Centres: The Whin Centre, Stirling Council and Dundas Resource Centre, Falkirk Council will accept TBI cases.
Forth Valley Headway is based in Falkirk but has an area-wide remit. It principally acts in an advisory role directing people back into the system. It provides a helpline two mornings per week and a programme of activities/outings.
Interviewees Craig Finlayson Charge Nurse Ward 14 FDRI Shiona Hogg Head Occupational Therapist Area Rehabilitation Team Bette Locke Manager Forth Valley Rehabilitation Teams Mrs Ursula Mackintosh Consultant in Emergency Medicine Margaret Petherbridge Policy & Development Officer Falkirk Council Dr Robert Prempeh Consultant in Rehabilitation Medicine Mr Rob Smith Consultant General Surgeon
Reviews, plans and strategies There are no specific plans for services for people with ABI however; there are action points in joint community care plans which relate to ABI and there is ABI joint agency planning group
24 NHS Grampian
Land Area: 8,736 km²
Population: 535,290
Population Density: 61 per km²
Local Authorities: Aberdeen City: 209,260 Aberdeenshire: 239,160 Moray: 86,870
Principal Hospitals: Aberdeen Royal Infirmary Woodend Hospital, Aberdeen Dr Gray’s Hospital, Elgin
Aberdeen Royal Infirmary
A&E Thereare7consultants(5fulltimeand2halftime)with2moretobeappointedinthe near future. There is an observation ward where TBI cases are admitted. The majority have a length of stay of less than 24 hours. The unit operates with a planned length of stay of less than 48 hours but occasionally patients remain for up to a week.
The neurosurgical service is very responsive and rapid transfer is possible. Those requiring extended observation are transferred to the neurosurgical ward.
Those discharged from A & E are provided with information leaflets. There is no routine follow up of TBI but a liberal policy for admission operates
Post A & E/Neurosurgery Four neurosurgeons provide post-acute care of TBI case transferred from the A & E observation ward.
The neurosurgical service covers Grampian, Highland and the Northern Isles with occasional cases from the Western Isles (most of which go to Glasgow).
Many patients are in for short periods (e.g. 24 hours) for observation but some wait longer prior to transfer for rehabilitation or if not considered appropriate for rehabilitation, may remain for as long as 3 months often due to difficulties with finding appropriate accommodation or care packages. It can sometimes prove difficult to repatriate patients to other health board areas.
There is a weekly case conference which the consultant in rehabilitation medicine attends
25 and patients requiring rehabilitation (Scenario B) are discussed. In the event of acute behavioural disturbance (scenario C) on the neurosurgical unit, liaison psychiatry provide useful advice on management but patients are very rarely transferred to a psychiatry unit. Very occasionally patients with persisting challenging behaviour (Scenario D) will be transferred to the Scottish Neurobehavioural Rehabilitation Service (SNBRS).
Individuals in a vegetative/minimally conscious state (Scenario E) may be transferred to long term stay beds at Woodend Hospital but otherwise would wait for a nursing home place which could take months. A post-acute rehabilitation unit for people with brain injury is being established at the Tor-na-Dee care centre, the site of a former convalescence hospital.
Rehabilitation Two of the three consultants in rehabilitation medicine provide rehabilitation for brain injured patients at the Maidencraig Unit, Woodend Hospital. The main source of in-patient TBI referrals is neurosurgery at ARI with occasional referrals from GP sandvery occasionally from orthopaedic or general surgeons. A consultant attends the neurosurgical conference each week. Most patients are seen within one week of referral and transfer depends on bed availability but is usually within 1 to 3 weeks of acceptance. The average length of stay is of the order of 2 months.
Maidencraig Unit has 16 rehabilitation beds. In the event of a patient showing acute behavioural disturbances (scenario C) the liaison psychiatrist and/or neuropsychologist would advise. If sectioning proves necessary the patient might be moved to Dunnottor Ward, Royal Cornhill Hospital. There is no real capacity to increase nursing levels to deal with acute behavioural problems. Neuropsychology is regularly involved in assessment of capacity and often involved in discharge planning of more complex patients with behavioural disturbance. Referrals to the SNBRS are infrequent. Similarly, exceptional cases might be referred to the Scottish Brain Injury Rehabilitation Service (SBIRS) at the Astley Ainslie Hospital for a second opinion.
The neuropsychology department sees both in and outpatients, as well as making home visits and visits to community hospitals and to Dr Grays Hospital in Elgin.
Patients are generally followed up at least for one year in the out patient clinic and some are referred to other services such as Horizons and Momentum.
Dr Gray’s Hospital
A&EandpostA&E Two associate specialists provide alternate days cover for the A & E department. Head injured patients are given a CT scan and then managed with the advice of the neurosurgeons in Aberdeen. There is also a consultant general surgeon available for advice. Those patients admitted are usually managed in the 6 bedded short stay unit. Most cases stay overnight (e.g. 10 to 12 hours) and the maximum stay in the short stay unit is 24 hours. After this time they are transferred to a general surgery bed.
Patients returning from neurosurgery in Aberdeen are usually admitted to one of the medical wards (Ward 7) at Dr Gray’s Hospital.
Community Resources Horizons is joint funded by NHS Grampian and the City of Aberdeen Council. It provides
26 out-patient therapy and a degree of day hospital/day care support for patients including those with neurological disabilities.
Momentum is principally concerned with vocational issues and like most voluntary organisations depends on its funding from annual review and negotiation with its sponsors. Clients are seen within 2 months of referral. However, it may be 3 – 4 months before a space is available in the programme called Pathways, which aims at supported education and offers work placement which can lead to employment. The capacity is 22 clients at any one time.
Other support is provided by the Brain Injury Group, Grampian (BIGG) which is affiliated to Headway
Interviewees Dr Tudor Codreanu Associate Specialist in A&E, Dr Gray’s Hospital Elgin Mr David Currie Consultant Neurosurgeon, ARI Dr Helen Gooday Consultant in Rehabilitation Medicine, Woodend Hospital Mr John Hiscox Consultant in Emergency Medicine, ARI Dorothy Strachan Momentum Manager Dr Fiona Summers Consultant Neuropsychologist, ARI
Reviews, plans and strategies There is a wide range of activity in Grampian related to the development of brain injury services. The report Brain Injury – a call for action 2003 by the Joint Future Brain Injury Group assessed current provision and identified gaps in services.
The Grampian Brain Injury Strategy 2004-2010 was agreed in 2005 http://www.aberdeenshire.gov.uk/about/departments/brain.pdf Joint future – Brain Injury (phase 1) audit 2006 examined current working practice and explored was of improving services within current resources for Aberdeen City.
NHS Grampian has formal planning arrangements for brain injury with Local authorities in Moray and Aberdeen City and arrangements are being discussed with Aberdeenshire. Proposals are also being developed for a Grampian-wide managed Care Network for brain injury.
27 28 NHS Greater Glasgow & Clyde
Land Area: 1,151 km²
Population: 1,192,419
Population Density: 1,036 per km²
Local Authorities: Glasgow City: 581,940 Inverclyde: 81,080 East Dunbartonshire: 104,850 East Renfrewshire: 89,260 Renfrewshire: 169,600 West Dunbartonshire: 91,090
Principal Hospitals: Glasgow Victoria Infirmary Western Infirmary Glasgow Royal Infirmary Gartnavel General Hospital Stobhill Hospital Southern General Hospital Clyde Royal Alexandra Hospital Paisley Inverclyde Royal Hospital Greenock
Outline Approximately two years ago (2006) the Clyde component of NHS Argyll & Clyde was added to NHS Greater Glasgow to form NHS Greater Glasgow & Clyde. For the purpose of this report we describe the Greater Glasgow and Clyde divisions separately. The population served by NHS Argyll & Clyde was 413,503 of which 322,113 were from Clyde, resulting in a population for NHS Greater Glasgow & Clyde of 1,191,584.
Greater Glasgow There are 5 hospitals with A & E departments and the early phase of the patient journey will be described in relation to each. The Regional Neurosciences are based at the Southern General Hospital as is the Rehabilitation Medicine service.
The A & E departments and their approximate catchment areas are as follows;
Glasgow Royal Infirmary: City Centre and East Glasgow Stobhill Hospital: North Glasgow and part of East Dunbartonshire Southern General Hospital: South West Glasgow with considerable numbers for Clyde, Renfrew & Erskine. Also, having a helipad receive search and rescue cases.
29 Victoria Infirmary: South East Glasgow Western Infirmary: West Glasgow & North of River Clyde
Glasgow Royal Infirmary
A & E: Five consultants in Emergency Medicine (4 wte) share the rota. Two consultants do have duties at the Western Infirmary and Stobhill Hospital. The consultants in Emergency Medicine have responsibility for the in-patient care of head injured patients who are usually cared for in 8 beds on an orthopaedic ward close to the Emergency Department. Of those admitted to this ward approximately 80% of head injured patients are discharged within 48 hours and 20% within one week. Occasional cases (1-2 per month) stay in for up to one month. (In times of high incidence there is the capacity to provide short stay observation in an orthopaedic ward). Those requiring to be in hospital for over 4 weeks get transferred to the Physical Disabilities Rehabilitation Unit (PDRU), Southern General Hospital if physical disability is the predominant feature; to the Central Scotland Brain Injury Rehabilitation Centre (CSBIRC) if cognitive or psychosocial problems are most prominent; or to a medical ward within GRI under the care of the receiving physicians from the day of admission. Prior to such transfers there is a case conference to inform the medical team and a Specialist Head Injury Nurse will follow them up whilst in the medical ward. There is also a social worker attached to the head injury team who also follows the patient into the medical ward and post discharge (described as Head Injury Throughcare Project).
With regard to the scenarios, individuals who are able to go home but have some persisting problems (Scenario A) are offered out-patient review in the department. In addition all discharge letters are sent to both the GP and to the CTCBI. Individuals requiring in-patient rehabilitation (scenario B) are referred to PDRU or CSBIRC as described above. There is good support from the liaison psychiatrist for the acutely behaviourally disturbed individual (scenario C) but patients are not transferred to a mental health facility. Additional nursing staff can be used but very rarely RMN staff. Chronic challenging behaviour cases (scenario D) are rare and help is sought from Scottish Neurobehavioural Rehabilitation Service (SNBRS).
Neurosurgical cases go to the Southern General Hospital and some are re-admitted to the head injury beds on the orthopaedic ward if necessary after which they follow the pathway described above.
Stobhill Hospital There is a Casualty Unit at Stobhill with an Associate Specialist in Emergency Medicine supervising the Casualty care of head injured patients. There are close links including consultant care/input from the Emergency Medicine consultants at GRI.
Most moderate and severe cases, not requiring direct transfer to the SGH, will be transferred to GRI. Others requiring admission are taken to a general surgical ward.
Southern General Hospital There are 3.5 wte consultants in Emergency Medicine. There are no observation beds so that patients requiring admission are transferred to orthopaedics, high dependency unit or neurosurgery. There are Head Injury Throughcare social workers to support relatives and facilitate discharge.
30 Western Infirmary There are 3 Emergency Medicine consultants who share on-call cover with GRI. There is no observation area so patients requiring admission are transferred to a general surgery, receiving ward, intensive therapy unit or neurosurgery. From the surgical receiving ward those needing a longer stay will be transferred to Gartnavel General Hospital.
Victoria Infirmary There are 4 wte. Consultants in Emergency Medicine. There is no observation area. An estimated 12 cases per week are admitted to orthopaedic wards under the care of the orthopaedic surgeon.
A recent service development is the appointment in November 2007 of a specialist ABI nurse for the acute hospitals in Glasgow. This post is based at the Community Treatment Centre for Brain Injury CTCBI and is in addition to the specialist nurse at GRI.
Neurosurgery There are 8.5 wte neurosurgeons and the service is provided to NHS Ayrshire & Arran, Greater Glasgow & Clyde, Lanarkshire and Western Isles, in addition to some of Dumfries & Galloway, Forth Valley and Highland.
Patients are admitted for neurosurgery and the average length of stay is one week, exceptionally as long as 3 weeks. All patients go back to the referring hospital including orthopaedics at the Southern General Hospital, Glasgow and Inverclyde Royal Hospital. Most patients return to the referring unit before referral on to local rehabilitation services. Return of patients to their referring hospital is often delayed because of non-availability of beds.
Rehabilitation Three consultants in Rehabilitation Medicine supervise the care of patients in the 26 bed Physical Disability Rehabilitation Unit (PDRU) at the Southern General Hospital. The unit provides specialist neurorehabilitation to people with a range of neurologically disabling conditions including acquired brain injury. There is an estimated 20-30 TBI admissions annually. The PDRU consultants with referrals prioritise those to be admitted, hold a weekly intake meeting; and advise regarding patients not suitable for admission. This includes advice to local therapy teams for patients on their waiting list.
Patients are referred from a wide range of sources: general surgeons, orthopaedic surgeons, neurosurgeons and general practitioners. They also take occasional patients from other health boards such as Lanarkshire, Western Isles and Ayrshire & Arran. The policy is to see referrals within 5 working days. Length of stay for all patients is of the order of 6-7 weeks, with TBI probably a little longer on average.
In the event of a patient developing acute behavioural problems, (scenario C) they are referred to the liaison psychiatrist who provides a good service and occasionally will arrange for the patient to be transferred to a mental health facility. There is the capacity to employ additional nursing staff but not RMN trained. Chronic challenging behaviour cases would not be admitted to PDRU but the consultant would advise the referring unit to contact the Scottish Neurobehavioural Rehabilitation Service (SNBRS) in Edinburgh.
Individuals in a vegetative/minimally conscious state (scenario E) would not be admitted to PDRU but referred to the Central Scotland Brain Injury Rehabilitation Unit (CSBIRU). There is also a 20 bed Young Disabled Unit (YDU) (Ward 53) at the Southern General
31 Hospital which may provide continuing care to such patients.
Extra-contractual Referral Assessment and Monitoring Service Patients who may require rehabilitation for cognitive or emotional problems outwith NHS Greater Glasgow & Clyde (including CSBIRC and SNBRS) are referred to Public Health and then assessed by a Consultant Neuropsychologist. Progress is monitored and continuation of funding is dependent on goal attainment and planning of future goals.
Community Rehabilitation Patients discharged from PDRU with ongoing physical rehabilitation needs are referred to one of the three Community Physical Disability Teams (CPDT): North East (NE), North West (NW) and South (S). These services for those aged 16-65 years also accept open referrals provided the person is registered with a general practitioner in Greater Glasgow. Usually people have to require input from more than one profession. The teams have nursing, physiotherapy, occupational therapy, speech & language therapy, dietician, neuropsychology staff and generic assistants. They offer both clinic based and domiciliary input. These services have a mix of patients, principally those with neurological disorder and it is estimated that about 10% are people with TBI.
There is also the Community Treatment Centre for Brain Injury (CTCBI) which is based at Commercial Road, Gorbals. This is a specialist service within the Disability Services of NHS Greater Glasgow & Clyde. Opened in 2002, it is aimed at those with non-progressive brain injury. TBI is the commonest diagnostic group but all forms of ABI are considered including those with non- progressive brain tumours. The principal aim is to address the cognitive and emotional consequences of brain injury. The multidisciplinary team comprises psychology, occupational therapy, speech & language therapy staff complemented by rehabilitation and psychology assistants. The service is not accessible to those with major concomitant physical disabilities whose needs are met by the CPDTs.
Referrals are accepted from a wide range of sources including self referral. They also offer a post-concussion service so that individuals fitting Scenario A are offered assessment by letter after discharge from A&E. This service has been used by Glasgow Royal Infirmary but not by other A&E departments. The centre also liaises with other relevant services such as those for addictions, mental health and alcohol-related brain damage.
Clyde
Royal Alexandra Hospital, Paisley
A & E There are 10 consultants* in Emergency Medicine who provide input to the A & E department at both the Royal Alexandra and Inverclyde Royal Hospitals. Patients requiring admission at RAH are admitted to 8 orthopaedic beds (it is possible to expand this number) under the care of the Emergency Medicine consultants (previously the general surgeons provided this care).The vast majority of admissions are for less than 48 hours but occasionally extend to as long as 2-3 weeks. The main problem of extended stay cases is with elderly patients.
Patients fitting scenarios A & B would be referred to the Rehabilitation Medicine (RM) consultants. Acutely behaviourally disturbed cases (scenario C) are managed with existing
32 resources and occasionally referred to the RM consultant. The informant had no experience of scenario D & E. Those returning from neurosurgery are referred to the Larkfield Unit.
Inverclyde Royal Hospital The same consultants as the Royal Alexandra Hospital. At IRH patents requiring admission are taken to the general surgery wards under the care of the general surgeon on call. Those returning from neurosurgery are admitted to the general surgeons or to the PDRU at Southern General Hospital.
* These consultants also work in the West Coast Retrieval Service, stabilising patients before transfer to the Southern General Hospital.
Rehabilitation A single handed consultant in rehabilitation medicine has had access to two rehabilitation medicine wards – one the Larkfield Unit (8 beds) at Inverclyde Royals Hospital and the other the Islay Cottage Ward, Merchiston Hospital, Johnston, Renfrewshire. The latter unit which has a mixed population of rehabilitation and continuing care patients is in the process of closing with patients to be transferred to the PDRU and YDU, Southern General Hospital respectively. Thus patients previously from the Royal Alexandra Hospital and Renfrewshire will go to the Southern General Hospital, while those from the Greenock area and Inverclyde Royal Hospital will be managed in the Larkfield Unit.
The Larkfield Unit accepts patients from general surgery, orthopaedic surgery neurosurgery and A & E with occasional admissions from general practice. Hospital referrals are usually seen within 3 working days and admitted within 1-3 weeks. Traumatic brain injury make up an estimated 20-30% of the 140 admissions per year. Average length of stay is 4-6 weeks.
The rehabilitation medicine consultant holds out-patient clinics and sees patients fitting scenario A. The psychiatrist from Ravenscraig Hospital will provide advice on patients fitting scenario C. Transfer to mental health is rare. Extra nursing can be provided but not RMN trained. Those with chronic challenging behaviour (scenario D) have been rare. Although our informant could only recall one patient referred but not transferred to SNBRS, there have been Clyde residents treated by SNBRS in recent years. Those in a vegetative/minimally conscious state (scenario E) might be taken for assessment but rarely and would be directed to nursing home care.
In addition to out-patient services at the Larkfield Unit, the rehabilitation medicine consultant does outreach clinics within the lower Argyll & Clyde area.
Neuropsychology A consultant neuropsychologist based at Ravenscraig Hospital provides input to in- patients in Inverclyde Royal Hospital and sees patients within their own homes after discharge or on the basis of GP referral.
Patients are seen within about 6 weeks and contact is maintained for periods up to 8 weeks.
Community Services in Greater Glasgow & Clyde Headway Glasgow has the Renfield Centre at 260 Bath Street, Glasgow which offers a drop in service for people with acquired brain injury, including TBI. They see a spectrum of
33 people after TBI including some with ostensibly mild injury but with on going problems. They provide a support and social contact facility for people but also signpost people to other services such as the CTCBI who accept referrals and Momentum for vocational advice.
In addition there is a small Headway support group in Inverclyde.
Momentum based in the Savoy Tower, Renfrew Street, Glasgow provides vocational advice and assistance and a befriending service.
West Dunbartonshire Council Acquired Brain Injury Service Based at Social Work offices, Bridge Street, Dumbarton this is an integrated health and social care service with a remit for assessment, case management and social rehabilitation in the community. The team consists of a service co-ordinator, care manager, part time consultant neuropsychologist, support worker, assistant psychologist, and part time administrator.
In addition, the service provides a range of training to a wide range of statutory and voluntary sector providers, carers, family members including brain injury awareness training, dealing with stress, challenging behaviour and epilepsy. Team members co-train with people with brain injury and their carers.
The team also commission services for a range of providers including Momentum, the Richmond Fellowship and the Mungo Foundation as well as signposting to support organisations such as Headway.
Renfrewshire Council Head Injury Service This service, provided by Quarriers, was located at the Disability Resource Centre at Love Street, Paisley and has recently transferred to the Mile End Centre. Staff consists of a project manager and a development worker. They see over 100 ABI cases aged 16-65 annually receiving referrals form GP s and directly from A & E discharges but many are self referrals. They provide carer support, support for independent living and help people apply for appropriate benefits. They signpost people to other services (e.g. Momentum and do outreach work as well as seeing patients at Love St/ Mile End Centre.
Interviewees Jean Alexander Clinical Services Manager for Disability Mr Ian Anderson Consultant in Emergency Medicine, Victoria Infirmary Dr Jacob Benjamin Consultant in Rehabilitation Medicine, Inverclyde Royal Hospital Vivienne Cochrane Project Worker Renfrewshire Head Injury Service Lorraine Crowther Occupational Therapist, Community Treatment Centre Dr Keith Dawson Neuropsychologist, Ravenscraig Hospital, Greenock Mr Laurence Dunn Consultant Neurosurgeon, Southern General Hospital Simon Glen Project Co-ordinator, Headway Glasgow Mr Malcolm Gordon Consultant in Emergency Medicine, Southern General Hospital Mr Pat Grant Consultant in Emergency Medicine, Western Infirmary Anne Harkness NHS GG&C Director of Rehabilitation & Assessment Wendy Jack West Dunbartonshire Brain Injury Service Denyse Kersel Manager, Community Treatment Centre for Brain Injury Lynda Mason Lead Therapist, PDRU, Southern General Hospital
34 Dr Christine McAlpine Clinical Director, Stroke & Disability Clare McDade Project Manager, Renfrewshire Head Injury Service Professor Tom McMillan Professor of Clinical Neuropsychology Fiona Munro Community Rehabilitation Team Clare O Brien Specialist Head Injury Nurse, Glasgow Royal Infirmary Angela Sprott West Dunbartonshire Brain Injury Service Dr David Stoddart Consultant in Emergency Medicine, Inverclyde Royal Hospital Mr Ian Swann Consultant in Emergency Medicine, Glasgow Royal Infirmary Sharon Watt Manager Renfrewshire Head Injury Service Dr Alasdair Weir Consultant in Rehabilitation Medicine, PDRU, Southern General Hospital Jan Whyte NHS GG&C Planning Manager
Reviews, plans and strategies
Joint strategies have been agreed between NHS Greater Glasgow & Clyde and the following local authorities Glasgow City - Glasgow City acquired brain injury strategic framework 2005 – 2014 http://library.nhsggc.org.uk/mediaAssets/library/nhsggc_strategic_framework_gcabi_2005- 2014.pdf
West Dunbartonshire – Acquired Brain Injury Strategy 2006 - 2009 http://www.wdcweb.info/social-care-and-health/supporting-people/acquired-brain- injury/strategy-information
35 36 NHS Highland
Land Area: 32,568 km²
Population: 308,790
Population Density: 9 per km²
Local Authorities: Highland: 217,440 Argyll & Bute: 91,350
Principal Hospitals: Belford Hospital, Fort William Caithness General Hospital, Wick Raigmore Hospital, Inverness
Raigmore Hospital, Inverness
A & E There are 3 A & E consultants. There is no observation ward and occasionally TBI cases lead to a breach of the 4 hour limit. CT scans are transmitted to the neurosurgeons in Aberdeen for advice and the majority of cases requiring neurosurgery go to Aberdeen. Some are transferred to Glasgow and it is now possible to transmit CT scans to Glasgow.
Those patients not requiring neurosurgery are transferred to a surgical ward under the care of general surgeons.
People discharged from A & E are provided with a head injury advice sheet and a letter is sent to GP within 24 hours. The informant was unaware of any support for head injury patients and routine follow up is not provided.
Post A & E TBI cases are admitted to ITU or one of 3 surgical wards under the care of one of 8 general surgeons. The surgical wards have a HDU. This includes occasional patients transferred from Caithness General Hospital, Wick or Belford Hospital, Fort William or referred by GP because of problems post injury (e.g. vomiting). They also receive patients from throughout the Highland area (excluding Argyll and Bute) after neurosurgical admission.
Length of stay is usually of the order of one or two days for most admissions but varies.
Those able to be discharged but with persisting impairment (Scenario A) would be referred to the rehabilitation medicine consultant. Alcohol advice is offered to appropriate cases.
Those requiring rehabilitation (Scenario B) are referred to the rehabilitation service within
37 the hospital. Acute behaviourally disturbed patients (Scenario C) are referred to liaison psychiatry and occasionally transferred to their care. It is possible to get increased nursing staff, including RMN, on occasion. Persisting challenging behaviour (Scenario D) is uncommon and the informant recalls only one case being referred to the Scottish Neurobehavioural Rehabilitation Service (SNBRS) in the last six years.
Similarly vegetative/minimally conscious state cases (Scenario E) are uncommon but might remain in surgical care for prolonged periods prior to nursing home placement.
Rehabilitation There is a single handed rehabilitation medicine consultant with an 8 bedded unit within the hospital. Advice is provided for TBI patients in surgical wards prior to discharge and many are offered outpatient review appointments. Referrals are accepted and patients admitted from surgical wards at Raigmore; from other acute hospitals (e.g. Belford Hospital, Fort William and Caithness General Hospital, Wick); from neurosurgical units; after periods at Scottish Brain Injury Rehabilitation Service (SBIRS) and from general practice. All patients resident in the Highland area discharged from the rehabilitation unit are offered outpatient review at their nearest location which may be at a peripheral hospital.
Time from referral to admission varies between 3 – 4 weeks when a bed is not available. In the latter cases allied health professionals will provide input in the referring ward.
Length of stay in rehabilitation varies between 2 weeks and 18 months.
Acutely behaviourally disturbed patients (scenario C) are seen by the liaison psychiatrist but they are no longer accepted to their in-patient facility. Sometimes extra nurses including RMN trained will be provided to assist. Approximately one patient per year will be referred to the Scottish Neurobehavioural Rehabilitation Service (SNBRS). These individuals are difficult to discharge to nursing homes etc. Vegetative and minimally conscious state patients (Scenario E) are rare but would be transferred to a cottage hospital, nursing home or cared for at home with support.
The neuropsychologist (0.7 wte) maintains a number of patients for prolonged periods and occasional new patients from their GP or by self referral. She covers all of the Highlands. A part-time clinical psychologist deals with stroke.
Other Hospitals A & E services at Belford Hospital, Fort William and Caithness General Hospital, Wick are provided by general surgeons. At the Dr MacKinnon Memorial Hospital/Broadford Hospital, Skye, a surgeon provides the service with a team of general practitioners. A CT scanner is available in Fort William but not in Wick or Skye. Belford and Caithness General Hospitals have small rehabilitation units mainly run by physicians and predominantly for elderly patients.
Community After rehabilitation as an inpatient there are few resources in the community; limited Headway provision and no vocational rehabilitation service. Support is very limited for those living outside Inverness. Most of those requiring on going AHP input need to rely on generic services provided by generalist staff.
38 Interviewees Dr Louise Blackmore Consultant Neuropsychologist Brian Clingan Headway Highland Regional Co-ordinator Dr Lorna Fisher Consultant in Rehabilitation Medicine Mr John Logie Consultant Surgeon Dr Andrew Rolands Consultant in Emergency Medicine, Raigmore Dr Cameron Stark Consultant in Public Health Medicine
Reviews, plans and strategies Report of the working group on Services for people with brain injury 2002 is a review of services following the SNAP report and was compiled by a group chaired by Dr Cameron Stark. It estimates the number of people with a brain injury in Highland, their needs, what services are available and what changes they would recommend. However, there are currently no specific plans for services for people with ABI.
39 40 NHS Lanarkshire
Land Area: 2,181 km²
Population: 560,042
Population Density: 257 per km²
Local Authorities: North Lanarkshire: 324,680 South Lanarkshire: 309,500
Principal Hospitals: Hairmyres Hospital, East Kilbride Monklands Hospital, Airdrie Wishaw General Hospital, Wishaw
Monklands Hospital, Airdrie
A & E There are 4 A & E consultants (until very recently 3) who take responsibility for TBI patients. They have an observation ward, the Emergency Recovery Unit ( ERU) of 30 beds of which about 6 are used for TBI (although not ring fenced for the purpose).
Those patients not requiring neurosurgery or ITU admission remain in the ERU. Average stay is 2-3 days but may be as long as 2 – 3 weeks. Occasionally ‘overflow’ TBI cases will be transferred to an orthopaedic ward but remain the responsibility of the A & E consultants.
Neurosurgery is provided by the Southern General Hospital, Glasgow.
Patients returning after neurosurgery are admitted to the orthopaedic wards, principally one ward (ward 10) of three possible under the care of the orthopaedic surgeon.
In the event of a patient being discharged from A & E with any persisting cognitive or other impairment (scenario A) they are given an appointment for the Head Injury Clinic which is held fortnightly. They are given appointments within 4 weeks depending on need. Head injury warning forms are regularly given and Headway leaflets are available.
Patients requiring in-patient rehabilitation (scenario B) are referred to the Central Scotland Brain Injury Rehabilitation Centre (CSBIRC) and are generally seen and accepted quickly.
Acutely behaviourally disturbed patients (scenario C) are not usually seen by the liaison psychiatrist but by a psychiatry liaison nurse. It is possible to get increased nurse staffing (including Registered Mental Nurse trained staff although this is uncommon). Psychology input is very limited with long waiting lists.
41 Longer term challenging behaviour cases (scenario D) are usually discharged home with a care package. Our informant was unaware of the Scottish Neurobehavioural Rehabilitation Service (SNBRS).
Vegetative & minimally conscious state patients (scenario E) are rarely encountered and do not prove a problem.
An additional resource is a family and carer support worker who sees all families to provide advice and direct families to organisations such as Citizen s Advice Bureau, Headway and the Princes Royal Trust.
Post A & E As indicated above the A & E consultants provide this in the ERU. The exceptions are those returning from neurosurgery who are under the care of orthopaedic surgeons.
Wishaw General Hospital
A&E Thereare3A&Econsultants.Atthetimeofthevisitthereweresomeunresolvedissues. Until recently TBI cases were admitted to the surgical receiving ward and looked after by thegeneralsurgeonsbutthishasbeenrelocated.ThenumberofA&Econsultantshad increased and TBI cases now remain in the acute receiving unit under the care of the A & E consultants only those with an extracranial injury requiring surgery being admitted to the surgical unit.
Post A & E Patients returning from neurosurgery in Glasgow are admitted to general surgical wards under the care of one of 8 general surgeons.
Length of stay can be 2 – 3 months. Those discharged are not routinely reviewed but may be referred to neurologist or occupational therapist.
Those requiring rehabilitation (scenario B) may be referred to CSBIRC but the waiting time may be long. Some input is provided by generic therapists on the surgical ward.
Additional nursing (non RMN) may be provided in the care of acutely behaviourally disturbed patients (scenario C) but no input from psychiatry. The informant was unaware of the Scottish Neurobehavioural Rehabilitation Service (SNBRS) for those with persistent challenging behaviour (scenario D). Although uncommon these patients disrupt other patients care and it is difficult to get psychiatric input to assist with management.
Vegetative and minimally conscious state cases (scenario E) would be referred to CSBIRC.
Hairmyres Hospital
A & E and post A&E There is no observation facility in the A & E department and patients requiring admission are taken to the surgical ward under the care of one of the six general surgeons after CT scanning. Similarly patients returning from the Southern General Hospital after neurosurgery are admitted under the care of the general surgeons.
42 Patients discharged directly from A & E are given written information and contact details for Headway.
Older patients may be admitted to medical rather than surgical wards especially if co- morbidities are present.
Tertiary Referrals Patients referred from the three above hospitals to the CSBIRC or the SNBRS are discussed at health board level prior to transfer. This applied to some from South Lanarkshire (Rutherglen and Cambuslang) referrals to the Community Treatment Centre for Brain Injury in Glasgow, however this arrangement is no longer in place.
Community Services North Lanarkshire Council has the Alexander Resource Centre in Coatbridge for people with physical disability including those with TBI. They commissioned an independent agency, the Disability and Rehabilitation Education (DARE) Foundation to undertake a user led analysis of the needs of people with brain injuries in North Lanarkshire in 2004. A project aimed at redesigning ABI services in North Lanarkshire began in December 2007.
South Lanarkshire Council has had a specific sole worker with responsibility for people with TBI age 16-65 years since 2004, based at Larkhall social work department. She receives referrals from multiple sources including A & E departments, psychiatry, psychology, general surgery, orthopaedic surgery, neurosurgery, rehabilitation units in Lanark and Edinburgh, GP s and social workers. The only restriction is that the individual has a South Lanarkshire address. People are seen in their own home and although there is no team as such the worker directs them to the Physical Disability Team, Headway, psychiatrists and psychologists, substance abuse services etc.
Interviewees Dr Ian Anderson Consultant in Emergency Medicine, Monklands Mr Hakim Ben Younis Consultant Surgeon, Wishaw Dr Donogh McGuire Consultant in Emergency Medicine, Wishaw Gina Muir Carer Support, Monklands Dr Trish O onnor Consultant in Emergency Medicine, Hairmyres Dr Brian O Suilleabhain Consultant in Public Health Gail Somerville Specialist TBI Occupational Therapist, South Lanarkshire Social Work Department Mr Martin Watt Consultant in Emergency Medicine, Monklands
Reviews, plans and strategies
There are no specific plans for services for people with ABI. However, both local authorities have carried scoping work on ABI. North Lanarkshire council commissioned a review of brain injury services. http://www.northlan.gov.uk/your+council/policies+strategies+and+plans/social+care/dare+r eport+physical+disability.html South Lanarkshire Council undertook a Traumatic Brain Injury Service Development Project which review current services and identified gaps.
43 44 The Central Scotland Brain Injury Rehabilitation Centre (CSBIRC)
The CSBIRC is a private hospital operated by the Huntercombe Group and is located at Murdostoun Castle, Bonkle, Newmains, Lanarkshire. One of the three units comprising the national brain injury rehabilitation service since 1991, it originally had 30 beds but now has 21. The majority of patients are funded by the NHS.
The centre offers multidisciplinary rehabilitation with nursing, occupational therapy, physiotherapy, speech & language therapy, neuropsychology and dietician staff supplemented by rehabilitation assistants. There are sessional commitments from a consultant in rehabilitation medicine and general practice and access to psychiatry.
Approximately 60 patients are admitted annually about three quarters of whom have had a TBI. Referrals are principally from NHS Greater Glasgow & Clyde and NHS Lanarkshire with occasional patients from Ayrshire & Arran and NHS Western Isles.
Referrals are seen by the centre’s manager or occasionally the consultant in rehabilitation medicine prior to admission. The average length of stay is about 4-5 months.
Most referrals have combined physical and psychological problems with the latter being most prominent. Thus they may have cognitive and behavioural issues. Patients are accepted with agitated behaviour but not individuals under section. In the event of a patient developing chronic challenging behaviour (scenario D) referral would be made to the Scottish Neurobehavioural Rehabilitation Service (SNBRS) via their own health board.
The centre offers a “minimally conscious programme” for those in a vegetative/minimally conscious state (scenario E) for a period of up to 9 months. Discharge of such cases is usually to a nursing home rather than return to the referring unit.
The centre sometimes encounters difficulties engaging local social work departments in discharge planning.
At the time of the visit to the unit (April 2008) the centre was initiating an outpatient service.
Interviewees Ann Hunter Manager Central Scotland Brain Injury Rehabilitation Centre Dr Brian O’Neill Clinical Neuropsychologist
45 46 NHS Lothian
Land Area: 1,760 km²
Population: 809,764
Population Density: 460 per km²
Local Authorities: City of Edinburgh: 468,070 East Lothian: 94,440 Midlothian: 79,510 West Lothian: 167,770
Principal Hospitals: Royal Infirmary of Edinburgh St John s Hospital, Livingston Western General Hospital, Edinburgh Astley Ainslie Hospital Royal Edinburgh Hospital
Royal Infirmary of Edinburgh
A&E Head injured patients requiring observation are taken to the Combined Assessment (CA) unit under the care of the A & E consultant, for up to 6 hours. [This is not classed as an admission]. Combined Assessment nurses are trained in neurological observation and manage patients according to a protocol including arranging discharge. They arrange CT scans and contact the A & E doctor if issues ariseorneurologicaladviceisrequired. Those at higher risk (e.g. elderly, those on warfarin) are observed for longer periods of up to 24 hours in the CA unit under the auspices of the general surgeon on call, who determines their future management and placement after 24 hours.
Those discharged directly from CA are provided with written information and a letter is sent to the GP. There is no routine follow-up and onward referral to rehabilitation is rare.
St John s Hospital, Livingston SinceSeptember2004therehasbeenan8bedobservationwardatStJohns where head injured patients may be kept under the care of the A & E consultant. (There are no general surgical beds at St John Hospital). The vast majority stay for less than 12 hours and the aim is to limit stay to 48 hours. Occasional cases remain beyond this time and some problems arise particularly with elderly patients with co-morbidity or social problems.
Those discharged are provided with written information and the GP informed. In addition there is a Head Injury Review Clinic and West Lothian patients are referred to the community rehabilitation service (Community Rehabilitation & Brain Injury Service (CRABIS)).
47 Post A & E After 6 hours in the CA unit in RIE, head injured patients come under the care of one of the 11 general surgeons who is on call. After 24 hours they are taken to one of two general surgical wards (106/107). There is limited access to allied health professional (AHP) input in the general surgical wards. If stay is prolonged the patient is referred to the Scottish Brain Injury Rehabilitation Service (SBIRS) at the Astley Ainslie Hospital. There is AHP available seven days a week in the CA unit who are particularly useful for elderly patients to facilitate early discharge.
Post-neurosurgical patients are not referred back to the general surgeons but go to SBIRS.
If an individual in the surgical ward had made a good physical recovery but had some persisting cognitive issues (scenario A) advice would be obtained from neurosurgery and some are referred to rehabilitation. Similarly those fitting scenario B would be referred to rehabilitation.
If an individual was acutely behaviourally disturbed (scenario C) help may be sought from liaison psychiatry but if present in CA and suspected as relating to drug or alcohol abuse they may be directed to the toxicology bay. This is not however the case of behaviour that is felt to be solely caused by the head injury. In the event of more chronic challenging behaviour (scenario D) referral would be made to the liaison psychiatry who in turn might refer on to the Scottish Neurobehavioural Rehabilitation Service (SNBRS).
There have been no cases of younger people fitting the vegetative or minimally conscious state (scenario E) in recent years but some elderly individuals who have fitted this classification have remained in the ward for some time.
The orthopaedic surgeons do encounter TBI cases but only in those with concomitant fractures. Individual infrequent cases with persisting challenging behaviour (scenario D) and minimally conscious state (scenario E) have occurred over the years and have had prolonged lengths of stay.
Neurosurgery, Western General Hospital The neurosurgical service serves NHS Lothian, Borders, Fife, Forth Valley and Dumfries & Galloway (approximately 1.5 million). There are seven neurosurgeons (six wte) and six neuroanaesthetists, the latter having charge of an integral Intensive Care Unit. Most admissions fulfil the criteria of severe TBI, usually requiring intubation and ventilation and most neurosurgical intervention.
The average length of stay is of the order of two weeks. Individuals with mixed physical and cognitive problems (scenario B) are referred to the Astley Ainslie Hospital or the local rehabilitation unit in Fife, Forth Valley or Dumfries & Galloway. [Those who have made a good physical recovery but have some persisting cognitive impairment would be seen by the neuropsychologist on the unit and referred as necessary to rehabilitation.]
There are some who remain on the unit for prolonged periods. This may relate to combined brain and spinal injury or lack of availability of beds in the referring health board area especially in those in a vegetative or minimally conscious state (scenario E).
Acutely behaviourally disturbed individuals (scenario C) are seen by the Neuropsychiatrist
48 and advice may be sought from the SNBRS. Similarly those fitting scenario D are referred to SNBRS but there may be a delay of several weeks before transfer is possible.
Rehabilitation
Astley Ainslie Hospital There are two consultants concerned with Acquired Brain Injury rehabilitation in charge of 36 beds in two wards in the Charles Bell Pavilion. 20 of the 36 beds are the base for the Scottish Brain Injury Rehabilitation Service (SBIRS). NHS Lothian has access to 12 beds, other health boards to the other 8. The service is predominantly targeted at the 16-65 year age group but exceptions are made.
Referrals come from neurosurgeons, general surgeons, orthopaedic surgeons and occasionally general practitioners in Lothianandfromotherhealthboards–usually general or orthopaedic surgeons. One consultant does a weekly session assessing patients at the neurosurgical unit. Other patients are usually seen within 3 days of referral with occasional patients from a distance out of area waiting up to 2 weeks. Median length of stay is 6 weeks. About 8% of ABI cases remain in the unit for more than 6 months.
Acutely behaviourally disturbed patients (scenario C) are seen by the liaison Neuropsychiatrist based at the SNBRS. It is possible to employ extra nursing staff but not RMN s. Very occasionally a patient may be transferred to the local psychiatric hospital or SNBRS (the latter s capacity is limited by having only 3 Lothian beds).
The SNBRS would be approached about people with persisting challenging behaviour (scenario D) but often would wait for a bed.
Patients in a vegetative or minimally conscious state (scenario E) are admitted for periods of 4 – 6 weeks for assessment on the understanding that they return to the referring unit. This usually works with non NHS Lothian patients but can prove problematic with Lothian patients who can be difficult to place. NHS Lothian had a policy of one persistent vegetative state patient in the unit at one time – there is always one but sometimes more.
The unit provides outpatient rehabilitation programmes for those discharged and for some referred to the consultant clinic and an outreach nurse follows all discharge TBI cases. The outpatient resource is very limited in terms of staffing. On discharge some patients are given therapy input at home from the generic community rehabilitation teams.
West Lothian has a Community Rehabilitation and Acquired Brain Injury Service (CRABIS) which will provide outpatient programmes for people from West Lothian discharged from the unit. CRABIS also provides a service to those fitting scenario A discharged from A & E at St John s Hospital.
Scottish Neurobehavioural Rehabilitation Service, Royal Edinburgh Hospital This service is based in the 19 bed Robert Fergusson Unit. Principally aimed at people with challenging behaviour after ABI, it occasionally accepts people with progressive neurological problems (e.g. Huntington s disease) associated with behavioural difficulties. Referrals are accepted from throughout Scotland. Only 3 beds are for NHS Lothian and occasionally an additional case is accepted. Occupancy approaches 100%. Patients are seen by the Associate Specialist in Psychiatry within a week or two of referral. However patients may have to wait about 2 months before admission (exceptionally as long as 6 months).
49 On average the unit discharges 12 patients per year. The length of stay is at least 3 months with an exceptional case being as long as 4½ years. Discharge arrangements are often difficult and protracted as many patients still require institutional care after their time in rehabilitation.
In addition to admitting patients the team is often asked to advise on patient management within their current setting.
Community Service There are 2 Social Work day centres in the city of Edinburgh that provide services to people with TBI: Firhill and Craighall for the south and north of the city respectively.
In West Lothian the CRABIS service is based in the Social Work Ability Centre at Carmondean. East Lothian patients can be referred to Presponpans day centre. There is no specific Social Work provision in Midlothian.
Edinburgh Headway has premises within the grounds of Astley Ainslie Hospital providing a range of services including art and music therapy, exercise classes, complementary therapies and a befriending service and is accessible to all people in Lothian. There is also support for local patients by Headway East Lothian.
A vocational rehabilitation, Into Work, is specifically directed at the needs of brain injured people and those with autistic disorders. The Brain Injury Action group for Edinburgh and the Lothians (BIAGEL) holds regular meetings to review the services for individuals with brain injury. Membership includes representatives from neurosurgery, rehabilitation, CRABIS, social work, Into Work, Headway, VOCAL, and NHS Lothian.
Leonard Cheshire Disability run the Pinewood acquired brain injury unit in Livingston which offers transitional, residential rehabilitation for people with brain injuries.
Interviewees Ms Tracey Gilles Consultant Surgeon, RIE Mr Colin Howie Consultant Orthopaedic Surgeon, RIE Lorna Langrell Associate Specialist Psychiatrist, REH Dr Martin McKechnie Consultant in Emergency Medicine, RIE& St John s Hospital Dr Brian Pentland Consultant Neurologist, AAH Dr Stephen Smith Consultant in Rehabilitation Medicine, AAH Mr Patrick Statham Consultant Neurosurgeon, WGH
Reviews, plans and strategies NHS Lothian and the four local authorities recently agreed the Lothian Joint Physical & Complex disability strategy 2008 which refers to acquired brain injury. http://www.nhslothian.scot.nhs.uk/pcds/
50 NHS Orkney
Land Area: 990 km²
Population: 19,860
Population Density: 20 per km²
Local Authorities: Orkney Islands: 19,860
Principal Hospitals: Balfour Hospital, Kirkwall
NHS Orkney is the smallest health board in Scotland serving a population of 19,860. There is one hospital, Balfour Hospital, Kirkwall which has 6 wards (male, female, maternity, Piper (Rehabilitation), St Ninians, MacMillan Unit) and a Casualty & Outpatients Department.
Emergency Care Trauma cases are seen in the Casualty and Outpatient Department in the Outpatient Treatment Room. However, as there is no CT scanner on Orkney all moderate or severe head injuries requiring CT scan are airlifted to Aberdeen Royal Infirmary (ARI). Those not requiring transfer are seen by one of the two general surgeons and admitted if necessary. Those with milder injuries are referred to occupational therapy and can be reviewed by the surgeon.
Post-acute Care Patients returning from neurosurgery may be admitted to either a surgical ward or the Piper rehabilitation ward if unable to go directly home. Those who do not require neurosurgical intervention are returned to Orkney as soon as possible principally to return to their families. There is variation in the notice given to the Balfour Hospital of those returning.
Occasionally patients with severe disabilities may be transferred for rehabilitation to the Maidencraig Unit, Woodend Hospital, Aberdeen from ARI before returning to Orkney. While in ARI only the minority of patients will be seen by the neuropsychologist.
Individuals with mild or moderate injury with no significant physical problem but some cognitive impairment (Scenario A) might be identified in the Casualty and Outpatient Department at Balfour Hospital and be referred to the occupational therapists. Others would have to rely on GP to identify problems and refer them on. Those requiring rehabilitation for combined physical & psychological issues (Scenario B)
51 would receive in-patient input in Piper ward or might be picked up by the NHS rapid response/early supported discharge service. This service is usually available for two weeks post-discharge but occasionally extends to about six weeks. A small number may go from ARI to the Maidencraig Unit, Aberdeen before returning to Balfour Hospital or home in Orkney. Very occasionally individuals with complex problems at a later stage may be referred and admitted to the Maidencraig Unit (estimated two or three over last seven years). One recent case has been sent to a private rehabilitation facility in Leeds.
People with acute challenging behaviour (Scenario C) are managed locally and no cases of chronic/severe challenging behaviour (Scenario D) have been referred to the Scottish Neurobehavioural Rehabilitation Service, Edinburgh. Both types of case are a common reason for seeking telephone or e mail advice from the neuropsychology consultant based in Aberdeen.
There is no specific resource for managing those in a vegetative/minimally conscious state (ScenarioE)andtheywouldremaininhospital.
The consultant neuropsychologist based in Aberdeen visits Orkney for 3 days four times each year. At these visits in-patients and out-patients are seen, with occasional home visits, and educational sessions delivered. All forms of neurological disorder are dealt with in these visits although an estimated 75% of the work relates to Acquired Brain Injury (the majority of which is TBI). The frequency of these visits has been reduced from 4 to 2 times annually. A proposal has been made to enable videoconferencing facilities so that the neuropsychologist can advise the local team from Aberdeen between visits. There is a clinical psychologist locally who is given NHS contracted services to provide cognitive behavioural therapy but, to the best of our knowledge, this has not been used for head injured cases.
Community Service Apart from the rapid/response/early supported discharge team which links with Social Work services there are regular liaison planning meetings between the occupational therapists in the Balfour with the local authority and Social Workers.
There is a Day Centre for younger people in Kirkwall which operates three days per week. A recent service offering supported employment and job coaches has been established with Employability. Links have also been made with Momentum in Aberdeen who can offer a service, subject to funding.
Interviewees Sylvia Campbell Charge Nurse, Piper Ward, Balfour Hospital Dr Bob Hazlehurst General Practitioner & Clinical Lead for Stroke MCN, Balfour Hospital Pam Marwick Senior Occupational Therapist Orkney Council Nicky Milne MCN manager, Balfour Hospital Dr Fiona Summers Visiting Consultant Neuropsychologist Additional information from Mr Ameir Al-Mukhtar Consultant General surgeon Occupational Therapy Dept Balfour Hospital
52 Reviews, plans and strategies Orkney community care plan 2006-9 describes current services and areas for improvement http://www.orkney.gov.uk/media/v3/service/Social%20care%20and%20health/community Care/Community_Care_Plan_2006-2009.pdf
53 54 NHS Shetland
Land Area: 1,466 km²
Population: 21,950
Population Density: 15 per km²
Local Authorities: Shetland Islands: 21,950
Principal Hospitals: Gilbert Bain Hospital, Lerwick
Shetland NHS Board is responsible for health care for a population of 21,950. Local Hospital and Community Services are provided from the Gilbert Bain and Montfield Hospitals, Lerwick. In addition, visiting consultants from NHS Grampianprovideout-patient clinics as well as in-patient and day-case surgerytosupplementtheserviceprovidedby the locally-based Consultants in General Medicine, General Surgery, Anaesthetics and Psychiatry.
Gilbert Bain Hospital has 26 acute surgical & 20 acute medical beds; 8 rehabilitation beds and an Accident & Emergency department.
MontfieldHospitalhastwo20bedwards(Ronas&Vaila).Vailawardhas4ofitsbeds allocated to young physically disabled
A&E Trauma cases are seen in the A &E Department by the surgeon and anaesthetist on call who are usually forewarned of the patient’s arrival by the ambulance or air rescue. After stabilisation and CT scanning there is liaison with the neurosurgeons in Aberdeen Royal Infirmary (ARI) and transfer is made by air ambulance with the anaesthetist accompanying the patient. Occasionally if a bed is unavailable in Aberdeen one of the other three neurosurgical centres will be used. [The CT scan facility has only been established for less thanayearandisnotavailable24hoursperday].
Many moderate or severe head injuries are airlifted directly from the scene of the accident to ARI. Those not requiring transfer are seen by the general surgeon on call and admitted if necessary. They are seen by the physician with responsibility for rehabilitation who decides if they should be managed at home, be admitted for rehabilitation or referred on to other specialists. Most severe injuries, including those not requiring neurosurgical intervention, go to ARI
55 Post A&E Individuals with mild or moderate injury with no significant physical problem but some cognitive impairment (Scenario A) are likely to be identified in Gilbert Bain Hospital and referred to the rehabilitation team. Others can be referred by their GP to the team.
Those requiring rehabilitation for combined physical & psychological issues (Scenario B) would receive in-patient input in the surgical ward by the rehabilitation team. Patients returning from neurosurgery may be admitted to the surgical ward if unable to go directly home. Shetland patients with severe disabilities are considered for transfer for rehabilitation to the Maidencraig Unit, Woodend Hospital but rarely do as when medically stable prefer to return to Shetland. While in ARI the minority of patients will be seen by the neuropsychologist.
People with acute challenging behaviour (Scenario C) are managed locally and no cases of chronic/severe challenging behaviour (Scenario D) have been referred to the Scottish Neurobehavioural Rehabilitation Service, Edinburgh. Both types of case are a common reason for seeking telephone or e mail advice from the neuropsychology consultant based in Aberdeen.
Those in a vegetative/minimally conscious state (Scenario E) might be placed in the younger physically disabled beds at Ronas Ward, Montfield Hospital or be referred for local authority placement.
There is an NHS Shetland liaison nurse based in Aberdeen to support patients and their families while in ARI and some patients are seen by the ARI consultant neuropsychologist before being transferred back to Gilbert Bain Hospital on Shetland. Most returning patients would be seen by the medical consultant who has an interest in brain injury. The neuropsychologist is available 4 times per year, for 3 days at each visit dealing with all neurological disorders. Approximately 40% of the patients seen by this service are brain injured. As in Orkney, it is proposed that the frequency of neuropsychology visits will be reduced to twice yearly. Video conferencing services are available and may be used in the future when the number of visits to the island are reduced.
A neuropsychology trainee, employed by NHS Shetland (funded by NHS Education Scotland) is currently receiving neuropsychology training at ARI and will be on a neuropsychology placement in Shetland from November 08 to April 09.Itisnotknownif there will be a position on Shetland at the end of their degree course. Brain injured patients who suffer a set back can return to Aberdeen for further treatment, although this has been a very infrequent occurrence in recent years.
There have been cases where families of brain injured patients have used compensation monies they have received, to pay for private services, where no NHS alternative is available or forthcoming. Additionally, there is one consultant paediatric clinical psychologist on Shetland who has an interest in brain injury, but provides no services for adults.
Interviewees Dr Jim Unsworth Consultant Physician, Gilbert Bain Hospital Dr Maggie Whyte Visiting Consultant Neuropsychologist
56 Reviews, plans and strategies The Shetland Disability Strategy refers to developing a protocol for the multi-agency assessment and provision of services for people with head injury . http://www.shb.scot.nhs.uk/documents/others/DisabilityStrategy.pdf In the Health & Community Care Plan 2008 there is reference to developing a regional approach to aspects of brain injury service; http://www.shb.scot.nhs.uk/healthcare/shetlandwide/publichealth/documents/HealthComm unityCarePlan2005-08.pdf
57 58 NHS Tayside
Land Area: 7,508 km²
Population: 394,134
Population Density: 52 per km²
Local Authorities: Perth & Kinross: 140,140 Dundee City: 142,150 Angus: 109,870
Principal Hospitals: Ninewells Hospital, Dundee Perth Royal Infirmary, Perth Royal Victoria Hospital, Dundee
A & E Six consultants share responsibility for A & E departments in Ninewells Hospital, Dundee and Perth Royal Infirmary (PRI).
Ninewells Hospital Consultants provide care until midnight each day on a rota of 1 in 4 to 1 in 5. A second on call consultant is available to cover call outs by the Tayside Trauma Team.
There is an 8 bed short stay unit where patients can be observed. The majority stay for less than 24 hours with exceptional stays of up to 5 days. Having the neurosurgical unit on site means that those requiring neurosurgical care are readily transferred there. Others not requiring neurosurgery but needing admission may be transferred to the acute medical admissions unit (ward 15) under the care of physicians although some with cognitive problems may be admitted to neurosurgery even if surgical intervention is not required.
Leaflets are provided to those not requiring admission. For agitated patients in short stay ward there is access to CPN’s seven days per week. There are also good links with Tayside Alcohol Problems Service (TAPS).
Perth Royal Infirmary A specialist registrar or consultant provides input to the A & E unit at PRI on a 9 – 5 basis on weekdays. A bypass protocol operates so that patients requiring intubation/ventilation or neurosurgery are transferred directly to Ninewells. Others requiring observation are admitted under the care of the general surgeons to the acute receiving unit (Ward 4). The average length of stay is less than 24 hours with maximum stay of about 4 to 5 days. Those requiring longer stay would be transferred to general surgery (Ward 1) and are often referred to the neurorehabilitation service.
Patients discharged with some on-going problems are referred to the GP with the advice to arrange follow-up with the neurorehabilitation service. Acute behavioural problems can
59 usually be managed by existing staff and there is a liaison psychiatry service available but rarely used.
Neurosurgery There are three consultant neurosurgeons and the unit serves Tayside and north Fife. Any serious head injuries and those requiring more than 24 hours observation in A & E are usually admitted to the neurosurgical ward.
The average length of stay varies according to the nature of the TBI. Individuals with focal injuries such as contusions and haematomas are often in for about a week or two while some with diffuse injuries stay for prolonged periods.
Those with mixed physical and cognitive problems (scenario B) would be referred to the rehabilitation service at the Royal Victoria Hospital. The rehabilitation consultant attends once a week to discuss patients. Some patients from Perth and Kinross may be transferred back to Perth Royal Infirmary.
Acutely behaviourally disturbed patients (scenario C) are usually managed on the unit with advice from liaison psychiatry. Additional nursing staff may be employed, sometimes including RMN s. Very occasionally patients are transferred to Carseview mental health facility. Chronic challenging behaviour (scenario D) is a problem and liaison psychiatry advice would be sought. Placement of such patients is a problem.
Individuals in a vegetative/minimally conscious state (scenario E) may remain on the unit for prolonged periods. They may be transferred to the Seven Arches Nursing Home. Occasional cases have been referred to the Neurorehabilitation Service in Putney.
Rehabilitation A single handed consultant is responsible for the 16 bed neurorehabilitation unit (Royal Victoria Hospital) for patients aged 16-65 (with some flexibility at the older age). TBI accounts for almost 30% of admissions the great majority of whom come from the neurosurgical unit. A small number of patients are from north Fife or lower Grampian.
Referrals are seen within a week and usually admitted within a week of acceptance. Average length of stay is 4-5 months with occasional cases being in for around a month or over a year.
The rehabilitation team includes 3 physiotherapists, 2.7 occupational therapists, 2 speech & language therapists, 1 neuropsychologist, 1 clinical artist, 3 technical instructors. 0.5 dieticians, an junior doctor and nursing staff. After a period of rehabilitation some patients are discharged to Seven Arches Nursing Home (part of south Grange nursing home) where ongoing physiotherapy and a form of slow stream rehabilitation is available. Others are discharged home, often with planned support packages.
Acutely behaviourally disturbed patients (scenario C) would not be admitted. If a new pattern of this nature arises liaison psychiatry support is available and transfer to a psychiatric unit is possible. Persisting challenging behaviour (scenario D) is rare but referral to the Scottish Neurobehavioural Rehabilitation Service (SNBRS) would be made.
People in a vegetative or minimally conscious state (scenario E) are not taken into the unit but the consultant will advise in the neurosurgical unit.
60 The service also provides medical, neuropsychology and social work follow up clinics for those discharged from the unit and new referrals from primary care.
Community Services
Angus Local Authority s Physical Disabilities Team provides an Acquired Brain Injury service. The team are based Lunan Park Resource Centre, Guthrie Street,Friockheim The type of support provided is based on individual need and priority is given to people who have sustained their injuries within the last two years. Service provision might include assessment, information and advice, counselling and support, written information, rehabilitation activities, care management, training and support for carers.
There are Headways in Perth and Dundee both of which concentrate on social support for people with brain injury and their carers.
Interviewees Mr Douglas Gentleman Consultant in Brain Injury Rehabilitation Dr Jo Gouick Neuropsychologist Mr David Mowle Consultant Neurosurgeon Mr Bob Murdoch Consultant General Surgeon Mr Neil Nichol Consultant in Emergency Medicine
Reviews, plans and strategies Work on the redesign of the brain injury rehabilitation service is underway in Tayside
61 62 NHS Western Isles
Land Area: 3,071 km²
Population: 26,300
Population Density: 9 per km² Local Authorities: Eilean Siar: 26,300
Principal Hospitals: Western Isles Hospital, Stornoway
A & E The Western Isles Hospital A&E department mainly serves the north islands and GPs provide emergency care in the south Islands
The A & E department is nurse led and protocol – based with the ability to call on appropriate consultants as required. There is a resuscitation room and a CT scanner.
Patients who have no loss of consciousness and have a responsible adult at home are provided with advice and an information leaflet before discharge. When drink or drugs are involved then a doctor sees the patient before discharge. When loss of consciousness has occurred patients are admitted to the surgical ward for observation.
In the case of more serious injuries the Ambulance Service alerts the A & E department who inform surgeons, orthopaedic surgeons and x-ray departments. CT scans images are transmitted to the Southern General Hospital, Glasgow. Those requiring neurosurgery are airlifted to Glasgow while non-surgical cases are admitted to the High Dependency Unit. Occasionally, especially younger patients, who have no obvious need for neurosurgery, are transferred to Glasgow for observation.
Some serious cases from the Southern Islands are airlifted directly to Glasgow without admission to the Western Isles Hospital.
Post A & E Three general surgeons share the on-call rota and admit head injured patients to the male or female surgical ward or to the HDU. The majority of younger patients are in for 24 hours or less with elderly patients often in for several weeks, often for social rather than medical/surgical reasons. A recent innovation is a rehabilitation ward (Erisort Ward) principally for stroke and geriatrics which may be used for head injured patients. At present cases returning from neurosurgery are admitted to the surgical wards but may be routed to
63 Erisort Ward. Patients, particularly those from the southern-most isles, transferred to the Southern General Hospital (SGH) may have some or all of their rehabilitation in the Physical Disability Rehabilitation Unit (PDRU) at SGH before returning to the Western Isles. Stornoway Hospital has a neurological trained occupational therapist and physiotherapist but no clinical or neuropsychologist. Transfer to the community has to be customised for each person and there are very good links with the local authority Occupational Therapy service
Those discharged from observation are provided with a leaflet and told to consult their GP if needed. Acutely behaviourally disturbed patients are managed with existing resources with little if any capacity to increase nurse staffing and when increased nurses used not RMN’s. Those requiring rehabilitation as in-patients may in future go to Erisort Ward but at present depend on generic therapeutic input on the surgical ward.
Interviewees Janet Gordon Occupational Therapist (Community) Maggie Graham Neuro-physiotherapist Dr Brian Michie GP and Medical Director Sonja Smit Neuro-Occupational Therapist Ms Betty Smith Deputy Manager, A & E and Nurse Practitioner Prof. Andrew Sim Consultant Surgeon
Reviews, plans and strategies A ‘Review of current health and social service provision for the young disabled population of Lewis and Harris’ was carried out in 2005 This document records the current services being provided throughout Lewis and Harris for the young disabled adult population. It identifies a number of issues regarding service delivery, whilst making recommendations as to potential courses of action and additional activity. There are no specific plans for services for people with ABI.
64 4. Summary of Findings & Discussion
The mapping exercise investigated the journey from Accident & Emergency (A&E) as this is the principal initial contact of people with significant head injuries with the health services. It is accepted that some individuals with head injury do not attend hospital but may present to their general practitioner who may subsequently refer the patient on to neurological or other relevant services. This was partially addressed by asking services if they received referrals from primary care but it is accepted that there may be some cases missed by this approach.
It is recognised that interviews were held with only a proportion of service providers in each NHS Board. On occasion different informants in the same area gave slightly different views of the patient journey and account has been taken of this. It was apparent that no individual necessarily had an accurate overview of all services in their area. In addition, some individuals present to health or other services long after injury, having clearly been discharged at some stage of the patient journey without their difficulties having been detected and addressed. Thus, even when services appear to be available people can “slip through the net”, suggesting that some individuals may never have the consequences of head injury dealt with.
Changes to the services to TBI patients were underway or planned in some NHS Boards and inevitably this report provides a summary of the nature of the services at the time of the mapping exercise (July 2007 – August 2008).
While there are many examples of effective delivery of parts of the NHS provision for this population in various parts of the country, no NHS Boards offers a fully comprehensive service. There remains a patchy and poorly organised provision for this vulnerable and complex population of patients and their families in Scotland.
4.1 Initial stages of patient journey
The great majority of patient journeys begin in A & E departments and all informants stated that they follow procedures based on SIGN Guideline 46 (11). After initial resuscitation and CT scanning, cases of severe injury are discussed with the regional neurosurgical service. Although generally satisfied with the service provided several A & E respondents commented that delays occurred in these communications and sometimes they were discussing the patient with a relatively junior and inexperienced member of the neurosurgical staff. Some also commented that it would be valuable to have training or clearer instructions from the regional neurosurgical centre as to their criteria for admission. In this regard for instance a number commented on the issue of age of the patient, stating that elderly patients were less likely to be considered appropriate for transfer to the neurosurgical service.
Cases of severe injury not accepted for neurosurgical transfer are, where appropriate, admitted to the local Intensive Care Unit.
“All big centres need units of doctors trained to deal with head injuries, both slight and severe. In this way only is it possible to avoid the ill-effects of scattering these patients in general wards under the care of surgeons who have neither the knowledge nor the interest needful”
65 This quotation is not of recent origin but from the eminent neurologist, Dr (Lord) W Russell Brain in 1941 (12). Its sentiment was echoed by the Royal College of Surgeons of England in working party reports in 1986 and 1999 (13,14). The latter of these, often referred to after its chairman as the Galasko Report, includes surveys of the opinions of general and orthopaedic surgeons and A& E medicine specialists and stimulated further reports (15- 19).
The majority of A & E consultants interviewed in this survey commented that they would be in favour of being responsible for the initial care of head injured patients provided they had access to properly resourced observation areas. This corresponds with a follow up report by the College of Emergency Medicine (19). This cannot, of course, be taken as a consensus view of all consultants in Emergency Medicine but it would seem worthwhile to perform an updated survey of Scottish members of the British Association of Accident & Emergency Medicine similar to that done by Swann and Walker (17).
Many general surgeons expressed discontent at having to take responsibility for head injured patients. In support of this view they also referred to the Galasko report (14). Several explained that they did not feel they had the appropriate training and skills to manage such patients. Others commented on the unsuitability of the general surgical ward environment for managing head injured patients effectively. Although a few expressed resentment at the fact that they had to deal with these patients the majority of those interviewed accepted the situation but felt it was not ideal. A number felt it unsatisfactory that post neurosurgery many patients would be returned to their care often at short notice and in many instances they had not seen the patient initially.
Similar reactions were given by most of the albeit small number of orthopaedic surgeons interviewed. They accepted the necessity to care for some individuals with significant fractures in addition to head injury but disputed the appropriateness of caring for people with head injury but no accompanying fracture.
4.2 Rehabilitation
The Galasko report advised rapid transfer of patients to rehabilitation units. In a survey of general surgeons, Fellows of the Association of Surgeons of Great Britain and Ireland (16,18) 64% did not have easy access to neuro-rehabilitation facilities and, when available, 63% described delays of over a month from referral to transfer to neuro-rehabilitation.
In Scotland rehabilitation medicine resources remain patchy with 3 of the 11 mainland NHS boards having no in-patient facility (Ayrshire & Arran, Borders, Lanarkshire). Where facilities do exist, surgeons commented on delays before transfer and problems with placement of profoundly dependent patients who require slow stream rehabilitation or continuing care.
The British Society of Rehabilitation and Royal College of Physicians recommend that every patient with a brain injury should have access to specialist neurological rehabilitation services (20) so endorsing the advice of the Royal College of Surgeons in the Galasko report.
It would appear imperative that each NHS Board make provision for the management of individuals with mixed physical and psychological problems requiring multidisciplinary rehabilitation i.e. those fitting the description of scenario B. In the absence of a specific rehabilitation medicine service they should ensure the education and training of the
66 medical, nursing and AHP staff responsible for their care. All mainland NHS Boards should establish a rehabilitation medicine service.
4.3 Challenging Behaviour In the mapping exercise informants we asked about the management of the acutely behaviourally disturbed individual (scenario C) and those with more persisting challenging behaviour (scenario D). Most described rather ad hoc arrangements recruiting extra nursing staff whenever possible with limited or no access to Registered Mental Nursing staff and/or to liaison psychiatry. Brain injured patients because of their cognitive and behavioural impairments can be a risk to themselves, other patients and staff caring for them. The fact the head injured population is comprised largely of young otherwise fit adult males magnifies risk. Specialist advice and support should be available to manage them safely and effectively.
Although severe challenging behaviour of a persistent nature is relatively uncommon a number of consultants responsible for TBI patients unaware of the existence of the Scottish Neurobehavioural Rehabilitation Service (SNBRS). Those who were aware of it valued the advice provided as well as the ability to transfer patients.
4.4 Vegetative and Minimally Conscious states
Patients in a vegetative or minimally conscious state (Scenario E) represent a small number in total but make considerable demands on services. They require access to expert assessment and reassessment on a multidisciplinary basis and careful planning for their continuing care. This involves joint planning and resourcing by both NHS Boards and local authorities (21).
67 68 5. Recommendations
In view of the varying geography and size of NHS Boards in Scotland it is clear that a one size fits all approach is both inappropriate and impractical but the following statements are relevant.
1. There is a need to review which specialties should be responsible for the delivery of care to patients with head injury in the first 48 hours. The views of consultants in Emergency Medicine and the practicality of establishing resourced observation facilities should be explored.
2. If general or orthopaedic surgeons in Scotland are to continue to provide care for head injured patients after admission and/or beyond 48 hours they and their staff should be provided with specific training.
3. Details of the number of people admitted to hospital after head injury and their subsequent journey should be kept by NHS Boards. This information should be used both locally and nationally to plan service provision.
4. Each NHS board should establish a policy for the provision of in-patient rehabilitation of head injured patients.
5. Discharges from NHS care should be planned taking account of any persisting difficulties. This should include provision of community based rehabilitation.
6. Each NHS board should have defined policies for the management of TBI patients with acute and persisting challenging behaviour
7. Each NHS Board should establish a policy for the provision of continuing care of those with severe disabilities following head injury, including hose in minimally conscious or persisting vegetative state.
8. Patients and their families/carers should have access to high quality information
The companion report to this entitled Standards for Traumatic Brain Injury in Adults – Standards addresses most of these issues on an evidence base. It is the intention of the NMCN to encourage the adoption of these standards and to offer assistance to implement them.
69 70 REFERENCES
1. Jefferson G. Discussion on rehabilitation after injuries to the central nervous system. Proceedings from the Royal Society of Medicine 1941; 35:295-9 2. London PS. Some observations on the course of events after severe injury of the head. Annals of the Royal College of Surgeons England 1967; 41: 460-79 3. Pentland B, Boake C, McKinlay WW. Scottish Head injury rehabilitation: an historical account. Scottish Medical Journal 1989; 34: 411-2 4. Medical Officer of Health, City and Royal Burgh of Edinburgh. Annual Report on the Health of the City during 1945, p 65 5. Scottish Home and Health Department. Medical rehabilitation: the pattern for the future. Edinburgh: HMSO 1972 6. Brooks DN, Campsie LM, Beattie A, Bryden JS, Symington C. Head injury and the rehabilitation professions in the west of Scotland. Health Bulletin 1986; 44: 110 7. Scottish Needs Assessment Programme. Huntington’s Disease, Acquired Brain Injury, and Early Onset Dementia. Glasgow: Office for Public Health in Scotland, 2000 8. NHS Circular HDL (2002)69. Promoting the Development of Managed Clinical Networks in NHS Scotland 9. Jennett B. Epidemiology of head injury. Journal of Neurology, Neurosurgery and Psychiatry 1996; : 362-69 10. Thurmon DJ, Coronado V, Selassic A. The epidemiology of TBI: implications for public health. In Zasler HD, Katz DI, Zafonte RD ( eds) Brain Injury Medicine New York Demos 2007 pp 45-55 11. Scottish Intercollegiate Guidelines Network. Early Management of Patients with a Head Injury. Edinburgh: SIGN; 46 12. Brain WR. Discussion on rehabilitation after injuries to the central nervous system. Proceedings of the Royal Society of Medicine 1941; 35:302-5 13. Royal College of Surgeons of England. Report of the Working Party on Head Injuries. London: RCS, 1986 14. Royal College of Surgeons of England. Report of the Working Party on the Management of Patients with Head Injuries. London: RCS, 1999 15. Collins REC, Cashin PA. General surgeons and the management of head injuries. Annals of the Royal College of Surgeons England 1999; 81:151-3 16. Seeley HM, Maimaris C, Carroll G et al. Implementing the Galasko Report on the management of head injuries: the Eastern Region approach. Emergency Medicine Journal 2001; 18: 358-65 17. Swann IJ, Walker A. Who cares for the patient with head injury now? Emergency Medicine Journal 2001; 18: 352-7 18. Chaudhry MA, Santarius T, Wilson L et al. Head injuries: a prospective observational study evaluating the potential impact of the Galasko report on Accident and Emergency departments. Injury 2003; 34: 853-6 19. College of Emergency Medicine – Clinical Effectiveness Committee. Implementing the Galasko Report on Head Injury Care., 2005 www.Collemergencymed.ac.uk 20. British Society of Rehabilitation Medicine. Rehabilitation following acquired brain injury: national clinical guidelines. London: Royal college of Physicians. 2003 21. Royal college of Physicians. The Vegetative State: guidelines on diagnosis and management London: Royal college of Physicians. 2003
71 Appendix 1: Steering Group and Mapping Group# membership
Dr Brian Pentland # Consultant Neurologist/ ABI NMCN Clinical Lead Scottish Brain Injury Rehabilitation Service NHS Lothian Ms. Christine Flannery # ABI NMCN Manager
Mr. Bob Anderson Non- executive Health Board Representative NHS Lothian
Dr. Dallas Brodie Representative Royal College of Psychiatrists
Mr. William Bryden Carer, Edinburgh Headway
Dr Alan Carson Consultant Neuro psychiatrist Scottish Neurobehavioural Rehabilitation Service NHS Lothian
Ms. Myra Duncan Director of Regional Planning, South East & Tayside SEAT
Mr. Laurence Dunn# Consultant Neurosurgeon NHS Greater Southern General Hospital Glasgow & Clyde
Ms. Shona Forsyth Neuropaediatric Outreach Nurse NHS Glasgow Southern General Hospital Glasgow & Clyde Mr Douglas Gentleman Consultant in Brain Injury Rehabilitation Royal Victoria Hospital NHS Tayside
Dr. Jacques Kerr Consultant in A&E NHS Borders Borders General Hospital
Ms Bette Locke Service Manager & Occupational Therapist Ms Shiona Hogg Community Rehabilitation Service NHS Forth Valley (From July 2008)
Ms. Kitty Mason Association of Directors of Social Work Edinburgh (Feb 2007 – June 2008) Ms Wendy Jack Association of Directors of Social Work W. Dunbarton (From June 2008 ) Local Authority
Mrs. Ailsa McMillan Lecturer in Nursing Studies, Edinburgh Queen Margaret University
Prof. Tom McMillan # Professor of Clinical Neuropsychology NHS Glasgow University of Glasgow Glasgow & Clyde
Dr Phil Mackie Specialist in Public Health Medicine NHS Lothian (Feb 2007 – May 2008) Mr Ken Rutherford Patient Representative Edinburgh (May 2007 – June 2008) Ms. Helen Moran Patient Representative Glasgow (From July 2008) Dr Lance Sloan Consultant in Rehabilitation Medicine Cameron Hospital NHS Fife
Dr. Cameron Stark# Consultant in Public Health Medicine NHS Highland
72
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