Benefits of local brain injury services
Case histories from South Wales
Dr David Abankwa
Consultant in Rehabilitation Medicine
13th November 2013
John
• 38 year old male
• TBI following assault
• Initially managed conservatively, but readmitted
for evacuation of bilateral chronic SDH via burr
holes, transferred to local DGH and discharged
home
• History of excessive use of alcohol
• Post TBI epilepsy, on Phenytoin
• Parents in England, was living with partner in
West Wales
John
• Seen in clinic after six months(? reason for
delay)
• C/o headaches, confusion, poor memory,
tremor of hand
• Carer (friend) reported “change in
personality” – less outgoing than
previously
• Housebound due to fear of having more
seizures
John
• Outcome of consultation:
– Brain injury advice/ information given
– Advise re pain medication containing codeine
– Review of anti-epileptic medication
– Offer of inpatient review but patient not keen
to come in,
– Enquiries about brain injury teams where
parents live
John
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Admitted to local DGH with “epileptic fits”
Transferred to surgical ward
Referral to NRU and reviewed by me
Significant behaviour component to
reported seizures (pseudo-seizures)
• Referral sent to Neurologists
• Significant conflict with nurses while on
ward (lack of understanding of brain injury)
John
• Eventually discharged to girlfriend’s house
but not allowed to have contact with her
children
• Neuropsychological assessment showed
deterioration in attention and verbal
fluency as well as executive functioning
• Recommended referral to residential brain
injury unit and Neuropsychiatry unit in
Whitchurch
John
• Currently
– Occupational Therapist identified locally,
willing to accept referral and identify
appropriate person to see
– No community brain injury team in his locality
– Living with parents in England, community
brain injury team identified
– Referral to Neuropsychiatry unit
Dave
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42 year old male
TBI when fell off trailer in England
GCS 14/15 but agitated, sedated
CT scan multiple pockets of air in brain,
Managed conservatively
Returned home with no follow up arranged
Previously extremely hardworking but after TBI
struggled to maintain successful business which
eventually failed
Dave
• Problems in marital relationship eventually
leading to separation
• Depression with three attempts at suicide/
self harm
• Under care of local Mental Health services
• “Emergency” admission to specialist brain
injury unit in England but able to afford
only two weeks, found input beneficial
Dave
• Had case manager through compensation
claim, eventually referred to Rookwood
and then to us and Neuropsychiatry
• Keen to go back to brain injury unit but
issue with funding
• Currently under care of OT via Mental
Health services in West Wales
Issues
• Coordination of services – transfers out of
N/surgical unit do not always come to our
attention
• Lack of services for all patients with ABI
• Awareness of our services especially in
West Wales
• Willingness of patients to travel for
residential placements
• Accessibility due to funding constraints
How can a local BIRT unit help us?
• Geographical accessibility
• Organisation with national/ international
reputation
• Evidence base for interventions including
economic benefit
• Long term follow up for clients discharged
from their units
Barriers to access
• Funding
– Application usually done via IPFR route which
requires the demonstration of “exceptionality”
– Eligibility of patients for CHC funding can be
hard to demonstrate using “decision support
tool”
– Need to demonstrate cost benefit
– Arguments regarding whether responsibility is
health or social
Thoughts ….
• Provision of non residential services, possibly in
a location closer to areas of greatest need
(Ceredigion, Pembs)
• Joint projects with NHS and voluntary sector
organisations eg Headway
• Considerations about equity of access
• Helping to make a case to Commissioners re
benefits of unit
– In due course local “good news” stories can help
Questions?