Service Specification for Rehabilitation in Major Trauma Network
Discussion document for South Central SHA
Section Page
Content
Executive summary
2
Introduction.
1
2
Sets the context
The challenges
2
3
Outlines some of the difficulties faced by commissioners. Particularly
considers classifications used by Specialist Services National Definition Set
Quality Rehabilitation – some principles.
3
6
Covers some of the important general principles underlying effective and
efficient rehabilitation
The proposal
4
8
Suggests a general model for commissioning rehabilitation, based around five
clinical groups
The specification – general principles
5
9
Outlines some general principle that apply across all groups and services
6
11 Terminology
Covers specific use of terms within this context, especially covering phases of
rehabilitation
7
13 Commissioning acute phase rehabilitation
Covers day 0 to day 5-42; always in the major trauma centre itself
8
14 Early-phase rehabilitation
Covers day 5 – 42; may often be in the major trauma centre and may
encompass acute phase
9
16 Middle-phase specialist rehabilitation
For those patients who need a specialist service input; covers day 14 for upto
many months. Usually in-patient at least in part.
10
19 Other specialist rehabilitation
Covers assistive technology and vocational rehabilitation
11
19 Long-term support
Outlines a potential role for NHS commissioners in facilitate movement along
the pathway through ensuring good long-term support services exist,
including but not restricted to NHS services
12
20 Other aspects of commissioning
Covers a variety of other matters, including what should not be commissioned
and the non-clinical aspects of services (e.g. training, communication).
13
21 Summary
Dr Derick Wade
Consultant in Neurological Rehabilitation,
Oxford Centre for Enablement, OX3 7LD
Tel: 01865-737306; Fax: 01865-737309; email: derick.wade@noc.nhs.uk
August 8th 2011
Service specification for rehabilitation after major trauma. August 8th 2011
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This document discusses some general aspects of rehabilitation after major trauma leading up
to detailed guidance on commissioning rehabilitation for patients who have been admitted with
major trauma of any type. It suggests that commissioning should consider immediate, acute
rehabilitation (0-5 days); early rehabilitation (2 days - 8 weeks); middle-phase specialist
rehabilitation for five groups of disability (in- and out-patients and out-reach); other specialist
rehabilitation unrelated to underlying damage; and long-term support. It also discusses the
role of non-specialist rehabilitation. In each section it considers the goals of the rehabilitation
commissioned, what processes might be specified, the standards to be achieved, and the data to
be returned to the commissioners. The main principles are that all rehabilitation should be
given by specialist multi-disciplinary teams and that all inpatient treatment after hyper-acute
treatment should be in rehabilitation wards with support from the trauma specialists while
needed. The teams must be specialist (i.e. staffed by people with appropriate expertise and
experience) and must include not only therapists but nurses, psychologists, social service care
managers and doctors and they must work within a single managerial, geographic and
budgetary unit. The commissioning must be integrated with all other rehabilitation
commissioning, and not done separately. The data to guide the quantity of services to be
commissioned are not available.
1.0
INTRODUCTION
The lack of effective rehabilitation after major trauma has been identified as one of the
major factors underlying the poor outcome seen after major trauma in the UK.
Consequently the Major Trauma Centre within the network of trauma units has been
given the responsibility of ensuring that all patients receive appropriate rehabilitation
in a timely manner.
1.1
Ultimately this will be monitored in two ways: monitoring service quality and outcome
by asking patients; and auditing adherence to rehabilitation prescriptions for individual
patients and provision of services to a quality and quantity that are consistent with
agreed national guidelines such as the National Service Framework for longterm
conditions and other national guidelines.
1.2
However it is generally accepted by national bodies such as NICE and especially the
Clinical Advisory Group on Major Trauma Services that rehabilitation services for
people after major trauma are grossly inadequate. The amount is variable, with many
places having none and only a few places having enough for a part of the rehabilitation
for proportion of all patients with major trauma. And the standard varies greatly, with
few being adequately specialised.
1.3
Improvement will require effective commissioning of rehabilitation. Unfortunately
commissioning of rehabilitation is already weak and underdeveloped, and
rehabilitation services in the UK are poorly developed. These problems arise because a
very low priority has been given to rehabilitation in contrast to the priority given to
acute surgical and medical services in hospital.
1.4
The majority of rehabilitation received by patients in the UK is probably delivered by
individual therapists working not as part of an overall team, but working within their
department or even on their own in the community. However there is strong evidence
Service specification for rehabilitation after major trauma. August 8th 2011
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that rehabilitation is most effective if delivered by a multidisciplinary team working
together, and there is reasonable evidence that therapy provided outside the context of
a multidisciplinary team is less effective.
1.5
Rehabilitation services in the UK are also rarely specialised. Yet there is good evidence
that specialised services are effective, and that non-specialised services are less
effective. At present only a minority of people with a complex pattern of disability after
an injury, or in any other circumstance receive rehabilitation from a specialist service.
Moreover there is evidence that it is the whole ‘rehabilitation environment’ that is
important, and that simply have a ‘mobile team’ does not deliver effective
rehabilitation.
1.6
Under these circumstances it is obvious that commissioners need to become active in
commissioning more services and services of an adequate quality. Currently few
commissioners have expertise in commissioning rehabilitation at all.
1.7
There are documents available concerning the commissioning of rehabilitation services.
The first, the Brain Injury part of the Specialist Services National Definition Set (SSNDS)
underlies much of the second, the East Midlands Rehabilitation Service Specification.
In as far as they are relevant they will be discussed briefly in this document. However
they are focused on head injury alone, or general neurological rehabilitation services
and do not focus on Rehabilitation after Trauma; they are perhaps also not very
practical as will be shown.
1.8
One of the problems that arises when considering rehabilitation is a lack of agreement
on the meaning of words and phrases. Usually there is no discussion, and consequently
the various parties are unaware of the differences. These only become apparent later on.
Consequently this document will start with a discussion of the meaning of the various
terms.
1.9
This document considers the problem of commissioning rehabilitation services for
patients with major trauma,. This has to be set in the context of overall commissioning
of rehabilitation services because it is unwise specifically to isolate services for people
who have had major trauma.
2.0
THE CHALLENGES
Commissioners face many challenges in relation to commissioning rehabilitation after
major trauma. Some of these challenges will be discussed.
2.1
What is rehabilitation?
One major challenge is to understand exactly what is being commissioned; what is
rehabilitation? It is best considered as being the services which focus on disability,
aiming to increase both independence in activities of importance to the patient and
active participation in a range social roles on a daily basis. These services are generally
focused on a person’s needs, not on their disease diagnosis. It must be stressed that in
the context of trauma, the need for this service is not simply restricted to the time
immediately following the trauma but also includes situations where there has been
some later change, either in the patient or in their circumstances.
Service specification for rehabilitation after major trauma. August 8th 2011
2.2
Page 4
Consequently commissioners may have difficulty in knowing how to draw up a service
specification. And it is likely that communication between commissioners and service
providers, and between many other parties both as organisations and as individuals
will be confused and open to misinterpretation.
2.3
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One solution is to use the phrase used by the Clinical Advisory Group, namely
“Recovery, Re-ablement, and Rehabilitation”. This indicates that the services will include
to a greater or lesser extent elements of:
convalescence and allowing safe recovery,
helping the person to adapt and adjust to their losses, and
relearning skills and functions.
2.4
Another way to define the services is that they relate to all aspects of a person’s illness
with the specific exception of the diagnosis and specific medical or surgical treatment
of any underlying disease or damage of organs within the body (i.e. the ‘medical
diagnosis’, the pathology).
2.5
The patients and their needs
There are four major characteristics about patients who have had major trauma and
their needs that create challenges.
2.6
First, the range of problems that are presented to the health care system are huge,
covering a wide range of types of problem and a wide range of severity of problems
and a wide range of mixtures of problems.
2.5
Second, the problems encompass a mixture of those that are specific to a particular
damaged organ and those that are general across all patients. For example some of the
problems seen after burns are specific to the nature of the damage (e.g. vulnerable skin,
skin contractures), but others are general (e.g. emotional disturbance, inability to write
if the right hand is badly burned) to many people with trauma regardless of type.
2.6
Third, it is not possible to predict from the nature of the trauma (e.g. pelvic fracture,
head injury) the actual nature or severity of the clinical problems that need attention.
There are some very loose general rules, but most patients will be exceptions.
2.7
Fourth, it is not possible to predict how long someone’s problems will last except to
state that for many patients there are permanent losses. More importantly, the rate of
recovery cannot be predicted and there is no clear-cut end to the process.
2.8
Consequently it is impractical to commission specific pathways of care for patients
based on initial diagnosis as there will be multiple pathways, many being shared by
patients with other diagnoses.
2.9
It is equally impractical to commission a single service given the wide range of
problems, many of which need very specific expertise.
2.10
Thirdly, it is impossible to commission a service with specific durations of care for any
group of patients; patients with spinal cord injury might be a relative exception to this
rule. Commissioning needs to recognise that the amount of rehabilitation needed by an
Service specification for rehabilitation after major trauma. August 8th 2011
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individual patient can only be determined at the time, and that a small continuing input
may be needed over many years.
2.11
This last point makes it difficult to determine when the NHS responsibility ends.
Indeed there may be some need for health services indefinitely. This causes problems
with categorical decisions concerning funding.
2.12
Existing services and pathways
The rehabilitation services that exist are historical accidents; they arose through some
chance and were rarely designed as part of some overall service. Consequently they
vary greatly. For example some services take a few highly selected patients as
inpatients only whereas other services accept almost any patient and services may see
patients at home, or as an out-patient, or as an inpatient or in a residential placement, or
in any combination of these possibilities.
2.13
This has two consequences. The minor consequence is that there is no readily available
model to use.
2.14
The major consequence is that often there are many patients who do not fit within the
criteria for acceptance of any available service, yet who need rehabilitation. It is worth
noting that there are no criteria based on evidence that can be used to select patients
into or out of rehabilitation. All criteria are arbitrary and are more likely to lead to
misallocation of patients than to appropriate allocation [paper available].
2.15
The other major fact is that there simply are not services available for most patients.
For example the NHS has no specialist musculo-skeletal rehabilitation services despite
an obvious need after major trauma.
2.16
Classification and categorisation
The Specialist Services National Definition Set for brain injury suggests that there are
four categories of need (for rehabilitation), and these have been used in the East
Midlands document. This categorisation has not been used or suggested here for
several reasons which primarily concern the practical difficulty in categorising
patients in a fair justifiable way, especially in the first few weeks after injury.
2.17
First, many of the characteristics considered in separating the categories are ‘defined by
using words such as ‘severe’ and ‘moderate’ which are not further defined. Indeed there
are overlaps: category A patients have “.. severe physical, cognitive …” and category B
patients have “.. moderate to severe physical, cognitive ..”.
2.18
Second, one distinguishing feature used is the length of time needed in rehabilitation.
This is not sensible because the duration cannot be predicted with any certainty until
after someone has been in rehabilitation for a while. Moreover, it is arguable that a
higher input may reduce length of rehabilitation which distorts the classification.
2.19
Next, the number of therapies needed is used to classify a patient’s need, but the need
for a therapy can (a) only be determined after that profession has seen the patient and
(b) may not become evident or necessary until later. A comatose patient may only need
nursing, but later may need all professions.
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2.20
Therefore I would conclude that commissioning by category of need is neither
logically nor clinically sound, and is not actually possible in that there is no agreed
way to categorise patients at the time prospectively.
2.21
The East Midlands document has also used the four levels of service outlined in the
National Definition Set. This has not been used here for two reasons:
it is not possible to categorise patients to match the four levels of service
it is also probably not possible or sensible to categorise services into levels and, more
importantly
o most services will and should encompass patients with a range of needs, and
o most patients will vary in their needs over time, and it would be very disruptive
to move frequently from service to service
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2.22
Over time and with effective rehabilitation, a patient’s needs will vary, and will over
time often reduce in both amount and complexity. Separating services into four
categories risks further fragmentation of a patient’s pathway. And if a patient is within
a service that can meet a range of needs (‘Category A through C” and covers all four
levels), it is difficult to see how the patient can be transferred.
2.23
Therefore I would conclude that commissioning should be undertaken in a way that
each patient’s needs are re-evaluated on a planned regular basis and that the funds
released are determined by the needs over the time period. For a larger centre, the
commissioners could commission a number of bed-days in different bands of need,
recognising that this may encompass some patients who travel quickly through bands
and others who stay in one band throughout.
3.0
QUALITY REHABILITATION – some principles
Some general principles that should underlie commissioning of any rehabilitation
services are given here. They are all based on evidence and/or national documents.
3.1
Multi-disciplinary teams
Any ‘proper’ rehabilitation needs to be delivered in the context of a multi-disciplinary
team, even if only one or two team members are actually active with a particular patient
at a particular time. There are always debates about the precise membership. A
practical definition is that the team should be able to manage from within its
membership at least 80% of all problems presented by patients.
3.2
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A reasonable minimum would be that the team should include staff with specialist
rehabilitation experience and knowledge appropriate to the patient group covering the
following professions:
nurses – for all inpatient services and some out-patient/out-reach services
doctors, usually a consultant in rehabilitation medicine but for small groups (e.g. burns)
then possible a doctor with specialist training/experience in rehabilitation of the
particular disorder
physiotherapists
occupational therapists
speech and language therapists, certainly if speech, communication, or swallowing are
affected in the patients seen
Service specification for rehabilitation after major trauma. August 8th 2011
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clinical psychology – in all services
social workers/care managers – in all inpatient services
barrier-free access to appropriate assistive technologies and the associated specialised
clinical professions (wheelchairs, orthoses, prostheses etc)
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3.3
Based on rehabilitation need, not disease diagnosis
Services should be defined by the expertise that they bring to bear upon clinical
rehabilitation problems, and not by diagnosis. For example, a service might be good at
assessing and managing people who are amnesic and confused after brain damage, and
they should be expected to consider people with any diagnosis – traumatic brain injury,
Korsakoff’s syndrome, hypoxic brain damage etc. But another patient with hypoxic
brain injury might be more appropriately be referred to a service expert in assessing
and managing people in the low awareness state, or with marked spasticity.
3.4
In reality services will manage people with a range of problems, and it is likely that a
service will see most people with damage to the particular organ system because many
patients will individually have a range of problems. Nonetheless the principle is
important.
3.5
In relation to the rehabilitation network, it would be inappropriate and very inefficient
(costly) to have services that were exclusive to trauma, either in general or in relation to
particular injuries.
3.6
Timely availability
It is generally agreed that rehabilitation should start as soon as possible, and that
waiting is inappropriate.
3.7
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3.8
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3.9
There are several arguments for making rehabilitation available as soon as it is needed,
including:
inappropriate use of other resources. While someone is waiting, they may well be
occupying space in another setting that is equally in demand. This is wasteful.
development of ‘complications’ while waiting. If a patient is waiting outside a
rehabilitation service, they may develop complications. These include not only the
immediate, obvious physical problems such as skin pressure ulcers, joint contracture etc
but also, more importantly, depression, unrealistic expectations, apathy, anger and even
challenging behaviour. These all require additional resources on arriving in
rehabilitation. Thus this is very wasteful of resources.
prolongation of time in health care.
There are additional arguments for ensuring that community-based rehabilitation is
made available as soon as it is needed, to reduce the negative long-term consequences
of residual disability in terms of:
failed attempts to return to work (reduced by specialist job retention interventions);
failed attempts for those unable to return to previous work to secure alternative
employment (reduced by suitable vocational rehabilitation programmes);
family breakdown (reduced by carer support / specialist family interventions);
avoidable residential care placement (reduced by ongoing availability of community
rehabilitation and support services, in combination with carer/family support);
avoidable distress and suicide risk (reduced by availability of psychological support);
avoidable social isolation (reduced by adequate funding for / support of voluntary
groups).
It is also possible, but not proven, that delays are associated with a less good final
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outcome.
3.10
Expertise
It is vital that patients are seen by teams with an appropriate level of expertise. This is
common to all guidelines.
3.11
There is some limited evidence to support the hypothesis that being seen in a nonexpert service is associated with a worse outcome and also often a longer length of stay
in hospital and a greater use of resources. The evidence comes primarily from stroke
rehabilitation.
4.0
THE PROPOSAL
The challenge is to balance the desire to have a single simple contract with the apparent
clinical imperative to have almost an infinite number of contracted pathways, or a caseby-case monitored contracts. This section makes a proposal (enlarged upon later) and
discusses briefly the difficulties that might arise from (a) patients who fall into two
groups, (b) patients whose problems are outside the five pathways and (c) lack of
capacity.
4.1
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The suggestion is that four major clinical groups exist, and that five general
specifications should suffice. The five clinical groups are:
neurological trauma, excepting spinal cord injury (certainly cervical, possibly also
thoracic)
cervical spinal cord injury and usually lower spinal cord injuries
musculo-skeletal and soft-tissue trauma
amputations
burns
4.2
Overlap
Although obviously some patients may have trauma in two or more groups, it seems
very likely that in the great majority it will be obvious which trauma is the most
significant and which pathway should be chosen. Any specification will have to have
enough flexibility to manage exceptions which should be less than 5% of all cases.
4.3
Other problems
Furthermore patients with exclusively cardio-respiratory problems (who will be rare)
will probably best be managed by existing cardiac and respiratory services.
4.4
Lack of capacity with health
The major problem to be faced is a lack of capacity within existing rehabilitation
resources to meet the needs of this population in a timely way. There will inevitably be
many patients who will experience one or more of:
waits to be transferred out of one setting when it is no longer meeting their needs
waits to be transferred into the setting that can best meet their needs
time in a setting that only partially meets their needs (if met at all)
failure to receive rehabilitation needed
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4.5
The challenges facing the system are:
Service specification for rehabilitation after major trauma. August 8th 2011
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to increase available resources – this will take time!
to optimise the use of available resources
4.6
I would argue that the most important component of any rehabilitation is to undertake
a full assessment early on, so that the problems are correctly indentified and analysed
and so that the needs and the prognosis are fully identified. In practice this may
sometimes avoid the use of resources through identifying what is not likely to benefit
the patient.
4.7
If this is accepted then specialist services will need to see and assess fully all patients as
soon as possible after referral, even if they cannot take on meeting their clinical needs
immediately. It also may mean transferring patients to a less specialist service who
may still not be fully able to meet all a patient’s needs sooner that is clinically indicated.
4.8
Commissioners and providers will need to meet and agree how to manage the clinical
risks and how to manage the inevitable upset of patients and families, and to agree on
principles governing early assessment, early transfer, and managing risk.
5.0
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THE SPECIFICATION – general principles
For each group the specification is likely to be similar in outline. It will follow the
rehabilitation process of:
initial processing of a referral
assessment and formulation, and setting goals
intervening, providing care and providing treatments
re-evaluation, and transfer on to another service
5.1
Responding to referrals
The service will need to publicise in simple clear terms what its area of expertise is so
that people can make appropriate referrals, and so that they can refer all appropriate
patients.
5.2
For some patients who are referred it will be very obvious that the patient will (or will
not) benefit. However this will often not be the case.
5.3
In this context it is vital to recognise that having specific criteria for acceptance or
refusal is extremely unwise as they are likely both to cause appropriate patients not to
receive the service they need, and to encourage inappropriate patients to think they
may gain benefit (paper available to explain this).
5.4
It is also important to recognise that simply basing acceptance on written referrals is
also invalid, or at least does not give a consistent answer because the answer depends
upon the person or people who look at the form. Training does not help (evidence
available).
5.5
Consequently, for a significant proportion of patients, a face-to-face clinical assessment
will be needed if appropriate decisions are to be made.
5.6
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The service specification should consider:
availability of information about service and how to refer and how to discuss
Service specification for rehabilitation after major trauma. August 8th 2011
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availability of senior staff for initial discussion (who, how)
modes of referral accepted
response time (maximum delay)
nature of the response (e.g. letter, email, etc and who to and additional advice)
5.7
Assessment and formulation, and goal setting
Once a patient has been accepted into a service, the key to successful rehabilitation is a
clear understanding of all of the problems, and all of the factors relevant to their
management. This depends upon collecting and analysing data (making a diagnosis,
formulating the case).
5.8
The resource needed for this process depends upon the situation. In the very early
stage there will be little time, and only relatively simple major decisions are needed to
cover the next few days. But if a person is potentially going to use many resources over
a long time, then a much more thorough assessment is needed.
5.9
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5.10
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5.11
5.12
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5.13
5.14
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The service specification should consider:
the goals of the assessment process (e.g. next stage in a pathway, prolonged inpatient
stay, determining level of awareness)
the output expected (e.g. rehabilitation prescription, set of goals, formal report)
the resource to be involved (e.g. one senior person visiting, whole team, time)
Care, and treatment
People with a disability may need two types of intervention:
care, the support needed to maintain safety and well being
treatment, any action that is intended to alter the natural history
In any inpatient setting, the service will naturally provide both. But for patients
elsewhere (e.g. at home, in a nursing home, in another specialist setting), the care will
often be provided by other organisations and people. However often the specialist
rehabilitation service may need to (a) define the care needed and (b) train the care staff.
The service specification will need to consider:
overall goal(s) of the treatment package(s) offered
what care is expected (i.e. the level, and the types of problems to be managed)
what treatment interventions are expected from the team
how other treatments are organised and paid for
frequency of reviews of progress
Re-evaluation, transfer of care and discharge
Throughout involvement with a rehabilitation service, the person or team should
consider whether the patient is benefitting from the input, and from time to time there
should be a more formal re-evaluation (re-assessment) to reconsider goals. Also at all
times the service should be working towards an ending of their active involvement
with a transfer to another setting and service.
Transfers of care may be to one or more of:
another specialised rehabilitation service
Service specification for rehabilitation after major trauma. August 8th 2011
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5.15
5.16
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primary care services/community-based rehabilitation services
patient responsibility – self-management
social services care management/other care management services
nursing home/residential care
It is probably also appropriate for services to be aiming for discharge, which refers to a
situation where the patient has no more planned contact with a service. They will of
course still be under the general care of their general practitioner. Some professionals
argue that the rehabilitation services should continue a monitoring follow-up role
indefinitely for at least some patients. This is debatable and for most patients in most
circumstances it is appropriate to ‘discharge’ (i.e. not to have any further planned
meetings) provided that the patient can easily re-refer themselves. There is evidence
that this reduces use of resources.
Non-clinical aspects
It must be recognised that commissioning should be concerned not simply with the
direct service to each individual patient but also with
serving the population, meeting all the rehabilitation needs of all patients over time.
This requires attention to factors such as
o requiring good communication between services
o ensuring a complete network of services is commissioned
maintaining and improving service quality. This requires attention to factors such as:
o supporting training, education, and research
o ensuring feedback between services
o ensuring that teams are robust and able to function if someone leaves
increasing collaboration with Social Services, Employment, Education and other
statutory services. This requires:
o inter-organisational agreements
o possibly shared budgets
encouraging engagement of non-statutory organisations with services to:
o support families and patients with information and emotional and practical help
o comment on ways that services could improve and change
6.0
TERMINOLOGY.
This section will outline the meaning attached to various terms within this document. It
is hoped that these definitions are reasonably obvious, and not controversial. The
terminology used in other documents will be discussed at the end of this section.
6.1
Acute-phase rehabilitation.
This refers to rehabilitation that is delivered starting at or as soon as possible after the
time of trauma. Consequently acute-phase rehabilitation will be delivered within the
acute wards in major trauma centre. It will include any interaction between the
rehabilitation service and the patient that occurs in the intensive care unit, all while the
patient is still receiving specialist trauma interventions. It covers the time from
admission to somewhere between day 2 and day 5 in most people.
6.2
Early-phase rehabilitation
Many patients will no longer need the very specialist trauma services within 24-48
Service specification for rehabilitation after major trauma. August 8th 2011
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hours, but will still need easy access to the trauma services (e.g. to monitor initial
treatment). Others may still have significant ‘medical’ needs such as ventilatory
support, or other physiological support and monitoring. These patients could move
from the immediate trauma service environment but need to be close and in an
environment that can meet both their rehabilitation needs and their medical needs.
This would be an ‘early-phase’ rehabilitation environment.
6.3
The early-phase rehabilitation covers the time from no longer needing specialist tertiary
trauma active treatments (operations etc) to being safe and appropriate to transfer away
from easy access to the trauma medical management expertise. It also covers the time
from being ready to transfer to the next place actually being available, because it is
inappropriate to transfer someone to a setting that cannot meet both the medical and
the rehabilitation needs to the patient.
6.4
Thus early-phase rehabilitation may start at 48 hours or sooner, and may extend to
eight weeks, but should aim to be over within six weeks or less in most cases.
6.5
Rehabilitation team.
This refers to the multidisciplinary team. This team must include at a minimum a
rehabilitation medicine physician, physiotherapists, occupational therapists, speech and
language therapists, specialist nurses, specialist social workers (care managers) and
clinical neuropsychology. It should also include other professions that are needed by
patients in the particular group on a regular basis, for example prosthetists for patients
who have suffered an amputation.
6.6
Middle-phase rehabilitation
This refers to the rehabilitation after the patient leaves the acute and early phase
rehabilitation, which will usually be based within the organisation housing the Major
Trauma Centre. It may start as soon as four days after admission, but usually will start
between 4 and 8 weeks after admission. It should always start with an assessment by a
specialist service, though it may not require their continuing direct input. It ends when
the patient no longer needs specialist rehabilitation, and may extend for up to twelve
months.
6.7
Specialist.
This adjective may be applied to a team, or to an individual professional. It means that
the individual or the team has recognised expertise in a particular problem or
condition. Evidence for this would include having worked with patients with that
problem over several years, the acquisition of specific postgraduate qualifications,
attending specialised courses and so on.
6.8
Rehabilitation prescription.
This has been defined and discussed elsewhere. It is a document that formulates the
case in terms of the underlying disease and damage, the goals of the patient, the
anticipated short medium and long-term goals, and the specific actions needed in order
to achieve these long-term goals.
6.9
Assessment.
This is the process of collecting data in order to understand the situation. Usually, in the
Service specification for rehabilitation after major trauma. August 8th 2011
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context of rehabilitation, this means collecting information concerning the “medical
diagnosis” (i.e. what organs have been damaged by the trauma), the underlying
impairments (i.e. what physiological and bodily functions have been disturbed), and
activities (i.e. how the patient is functioning in various goal directed behaviours and
actions such as walking). In addition it will usually require collecting information about
a patient’s context: their housing, their social contacts, their goals and wishes and
expectations, family expectations, past medical history, and their previous social role
functioning.
7.0
COMMISSIONING ACUTE-PHASE REHABILITATION.
All patients with major trauma should be admitted to a major trauma centre. This will
include patients with all types of trauma. Consequently the rehabilitation service
commissioned to see patients in the first few days and weeks needs to be able to
respond appropriately to patients with a wide variety of problems.
7.1
The commissioner should set the following goals for acute-phase rehabilitation within
a major trauma centre:
every patient admitted after major trauma to a major trauma centre should have a full
initial rehabilitation prescription within two full working days of being deemed ready
for transfer out of the high intensity, specialist tertiary trauma service.
The general practitioner, and all other relevant parties and organisations should be sent
both a copy of the rehabilitation prescription and a typed summary of the history,
current situation and long-term expectations (in as far as they can be given) within five
working days of admission
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7.2
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7.3
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The commissioner may wish to leave the detail to the provider, but they could
commission the following processes:
every patient will have their first contact with a senior member of the rehabilitation team
within 36 hours of admission
every patient will be seen and assessed by all members of the team deemed appropriate
by the initial assessor within two working days of the initial rehabilitation contact
at least one close family member or friend will be seen both to gain additional
information and to give information (as agreed by the patient if possible) about the
immediate rehabilitation plan and longer term outlook.
every patient able to receive rehabilitation interventions will receive these each day, this
including:
o preventative treatments (e.g. avoiding skin breakdown and joint contractures)
o provision of specialist rehabilitation equipment
o active mobilisation out of bed as soon as possible (evidence is available showing
benefit after stroke)
o support, both emotional support and informational
The commissioner should commission to the following standards:
all initial rehabilitation assessments should be by a senior professional with at least
three years specialist rehabilitation experience and should:
o identify all other immediate assessments needed (which professionals), and
organise these from within the team
o identify any immediate rehabilitation actions needed, and ensure that these occur
Service specification for rehabilitation after major trauma. August 8th 2011
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7.4
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7.5
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all rehabilitation teams must include specialists of all of the following professions:
o nurses
o doctors, including a consultant in rehabilitation medicine
o physiotherapists
o occupational therapists
o speech and language therapists,
o clinical psychologists, including neuro-psychologists
o social workers/care managers (absolutely essential)
the rehabilitation prescription should consider all of the following domains, recognising
that the level of detail at first will be limited in some domains:
o the ‘pathology’; all of the diseases and damage (whether still active or treated)
o the patient’s current level of impairment in all major domains (neurological,
musculo-skeletal, cardio-respiratory, etc)
o the patient’s current level of activity limitation in all major domains (personal
activities, mobility, dexterity, domestic and community activities, social
interaction and communication, vocational and academic activities, leisure)
o the patient’s social participation (roles etc), past and present
o The context:
 the social context (family, friends, work and other social networks)
 the physical context (housing especially)
 the personal context (expectations, wishes, goals etc)
 the temporal context, especially any landmarks in the illness, but also the
patient’s age and stage of life
o immediate care and support needs to preserve safety and well-being
o immediate treatment needs
o suggested prognosis in terms of activities and any particular complications
o rehabilitation goals, and suggested treatments needed in the medium term
o risks to be considered
o when the next systematic rehabilitation evaluation of progress against goals and
future needs should be undertaken
The commissioners should request the services to provide the following data:
numbers of patients:
o admitted to the trauma service
o discharged alive from the acute trauma treatment service
o receiving an initial rehabilitation assessment
o having a rehabilitation prescription at transfer out of the acute trauma wards
length of stay on acute trauma wards
state at discharge
o Barthel ADL index
o Discharge destination (classified as meeting rehabilitation need or not)
For re-imbursement (or measuring against an agreed planned annual work-load) the
commissioners should request data for each patient on:
care needs at day seven and each two weeks (measure to be agreed, but the Barthel ADL
index is a proven good measure of nursing time, and the Northwick Park Care
Dependency Scale is an alternative)
rehabilitation complexity at day seven and each two weeks (using at present the
Service specification for rehabilitation after major trauma. August 8th 2011
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Rehabilitation Complexity Scale). This is supported by the Department of Health but its
added value at this stage is still uncertain.
8.0
EARLY-PHASE REHABILITATION
This refers to the period starting when the patient has completed all immediate trauma
treatments and is sufficiently stable physiologically so that they can move out of the
tertiary trauma service area, until the patient’s continuing specialist medical, surgical
and rehabilitation needs can all be fully and safely met in a more local service or in a
more specialist rehabilitation service, which ever is identified as being needed.
8.1
This service will necessarily be provided within the same organisation and location as
the major trauma centre service.
8.2
The commissioner should commission services towards the following goals:
as rapid reduction in activity limitations as possible
o and especially early active mobilisation
as rapid transfer out as possible, to
o home with out-patient or other services actively involved immediately, or
o a local service fully able to meet their needs from the moment of transfer, or
o a specialist service able to meet their specific, on-going specialist needs
prevention of all avoidable adverse events and outcomes
providing a more detailed rehabilitation prescription and summary for the next service
and all other interested parties.
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8.3
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8.4
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The commissioner could commission the following processes:
attention from a full multi-disciplinary team with appropriate specialist skills:
o assessing needs and prognosis
o giving all required interventions to the patient, including emotional support and
all necessary equipment and aids
o providing information and support to family and friends
o monitoring progress and evaluating interventions
o preventing avoidable complications
nursing from a nursing team with specialist rehabilitation training and experience
actively working towards a transfer to the next more local or more specialist service:
o identifying needs and the services able to meet those needs
o contacting potential services to confirm their capability and discover their
capacity
o liaising weekly with the service chosen for transfer
The commissioner should commission the service to meet the following standards:
The rehabilitation team should include all the professions needed (listed above in 3.3)
All admitted patients should have an initial documented (written, recorded) full
assessment, formulation and set of goals within ten working days
Patients should receive attention from all involved professions from the specialist team
on at least five days a week
While patients are within the service there should be:
o documented weekly team reviews of progress and problems
o documented goal setting reviews every three weeks after the initial review, with
Service specification for rehabilitation after major trauma. August 8th 2011
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8.5
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8.6
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copies being sent to the general practitioner and all other interested parties
The rehabilitation prescription should be provided at the time of transfer, and should
cover the domains listed above in 3.3.
The commissioners should request the following data from the early-phase
rehabilitation service:
number of patients:
o referred and accepted as appropriate
o admitted
o discharged
o died
o having a full rehabilitation prescription at discharge
length of stay
clinical data:
o admission and discharge Barthel ADL index
o discharge destination (classified as meeting rehabilitation needs or not)
For re-imbursement (or measuring against an agreed planned annual work-load) the
commissioners should request data for each patient on:
care needs at day seven and each two weeks (measure to be agreed, but the Barthel ADL
index is a proven good measure of nursing time, and the Northwick Park Care
Dependency Scale is an alternative)
rehabilitation complexity at day seven and each two weeks (using at present the
Rehabilitation Complexity Scale). This is supported by the Department of Health but its
added value in this situation has yet to be proven.
9.0
MIDDLE-PHASE, SPECIALIST REHABILITATION
Some but not all patients will have problems after major trauma that are sufficiently
severe and complex and/or sufficiently long-lasting that they will need attention from a
more specialised service on an in-patient basis initially.
9.1
It is at least arguable that all patients who have suffered a major trauma (as defined)
should be seen by an appropriate specialist service, even if they do not require inpatient
rehabilitation, if only to check that there are not important remaining problems perhaps
not immediately obvious either to the patient or to non-expert services. Until this
contention has been researched further, it should be assumed that a large enough
proportion of all patients classified as having major trauma will have problems for a
few months to warrant at least one routine follow-up contact with a specialist service
regardless of apparent recovery.
9.2
Thus this section encompasses all contact with specialist services. The time extends
from the point of transfer out of the major trauma centre rehabilitation services to the
time when the patient no longer needs ongoing treatment from a specialist service. The
section will also consider later follow-up.
9.3

The main specialist services to be commissioned cover the following five groups of
problems and most patients should fall into one of these even if they have relatively
minor problems in others:
Neurological rehabilitation, which will encompass both central nervous system and
Service specification for rehabilitation after major trauma. August 8th 2011
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peripheral nervous system injuries. Some people with less complex spinal cord injuries
are likely to be managed in this service appropriately.
Spinal cord injury rehabilitation, which will encompass all people with spinal cord
injuries above the thoracic level, and most people with complete thoraco-lumbar spinal
cord injuries. It specifically includes patients who need respiratory support secondary to
very high spinal cord damage.
Musculo-skeletal rehabilitation, encompassing all patients with damage to bones, joints
and muscles. This will include some inpatients, but may mainly be provided on an outpatient basis.
Amputation rehabilitation, encompassing people with limb loss.
Burns rehabilitation, encompassing people with major burns
9.4
It seems likely that most people with major injuries will fall into one or other of these
groups. There may be a minority of patients who have unusual problems after major
trauma, such as severe loss of abdominal organs or thoracic organs. Their rehabilitation
should be started in the acute and early phase services and then a specific solution
found.
9.5
The commissioning recommendations below are all prefaced by the following, intended
to indicate that five separate commissioning discussions will be needed, one for each
group of patients:
This set of commissioning recommendations should be applied to “all patients who
have been admitted with major trauma and have survived to be discharged from or
transferred out from the major trauma centre to any other placement including both
home, and long-term care:”
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9.5
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9.6
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The commissioner should commission services towards the following goals:
the identification and treatment of all clinical problems that arise from the major trauma,
specifically including the psychological (emotional, cognitive etc) problems as well as
immediate, direct problems
ensuring that at the time of transfer or discharge all of the patient’s persisting, much
longer term problems are identified and the resulting needs for support and/or lowerlevel treatment are met
achieving the best outcomes possible in the domains of emotional state, activities and
social roles, and particularly considering vocational activities (work, paid or unpaid),
ongoing care needs, and family situation.
providing, if needed, a rehabilitation prescription for all services involved after transfer,
including health, social services and employment services
The commissioner could commission the following processes:
Every patient transferred out of a major trauma centre with problems arising from
[category] must be seen within two weeks of transfer by a senior person from the
specialist multi-disciplinary team, this contact being for an initial assessment of ongoing
problems and rehabilitation needs.
[NB this applies to all patients including those discharged home, to a nursing home or residential
home, and to a non-specialist ward awaiting admission to the specialist service.]
Every patient transferred out of a major trauma centre with problems arising from
[category] who is identified as needing it must have a full multi-disciplinary assessment
Service specification for rehabilitation after major trauma. August 8th 2011
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9.7
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9.8
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of their situation within four weeks of transfer from the major trauma centre.
[NB this applies to all patients including those discharged home, to a nursing home or residential
home, and to a non-specialist ward awaiting admission to the specialist service.]
Every patient transferred out of a major trauma centre with problems arising from
[category] must have a multi-disciplinary team meeting to write a full rehabilitation
prescription and set immediate and long-term goals within four weeks of transfer from
the trauma centre.
[NB this applies to all patients including those discharged home, to a nursing home or residential
home, and to a non-specialist ward awaiting admission to the specialist service.]
All patients prescribed specialist rehabilitation treatments by the major trauma centre
service should have those treatments provided by a specialist multi-disciplinary team
each working day within ten working days of transfer. This includes specialist nursing
input throughout the 24 hours, seven days a week where patients are still in hospital.
While patients are under the care of the service, and following the initial goal setting
review, there should be multi-disciplinary specialist team meetings held at intervals of
no longer than six weeks.
All formal team goal setting reviews should be documented, with copies going to the
general practitioner and all interested parties.
Planning for transfer to a less specialist setting (if an inpatient) and to less specialist
services and/or other relevant specialist services should be started at the time of transfer,
with active seeking of and liaison with other services to meet longer-term needs.
The commissioner could commission the service to the following standards:
The rehabilitation team should include all the professions needed (listed above)
All patients should have an initial documented (written, recorded) full assessment,
formulation and set of goals within twenty working days of transfer out of the trauma
centre
Patients should receive attention from all involved professions from the specialist team
on at least five days a week within ten working days of transfer
While patients are within the service there should be:
o documented weekly team reviews of progress and problems
o documented goal setting reviews every 4-6 weeks after the initial review, with
copies being sent to the general practitioner and all other interested parties
The rehabilitation prescription should be provided at the time of transfer, and should
cover the domains listed above
The commissioner should require services to provide the following data:
number of patients:
o referred and accepted as appropriate
o admitted
o discharged
o died
o having a full rehabilitation prescription at discharge
length of stay
clinical data:
o admission and discharge Barthel ADL index
o discharge destination (classified as meeting rehabilitation needs or not)
Service specification for rehabilitation after major trauma. August 8th 2011
9.9
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For re-imbursement (or measuring against an agreed planned annual work-load) the
commissioners should request data for each patient on:
care needs at day seven and each two weeks (measure to be agreed, but the Barthel ADL
index is a proven good measure of nursing time, and the Northwick Park Care
Dependency Scale is an alternative)
rehabilitation complexity at day seven and each two weeks (using at present the
Rehabilitation Complexity Scale). This is supported by the Department of Health, and its
added value in this situation is unproven but it is used to define the level of service.
10.0
OTHER SPECIALIST REHABILITATION SERVICE
There are some specialist rehabilitation services that are relevant to people with a wide
range of underlying disease or damage and/or to people at any stage of their illness.
For example specialist wheelchairs may be needed by people in any of the five groups
identified at any time, and vocation rehabilitation may be needed late after injury.
10.1
Thus commissioners should commission a range of other specialist rehabilitation
services for their populations (regardless of underlying diagnosis or age or stage in
illness) including:
assistive technology – this includes all equipment, aids, adaptations etc. The importance
of this, the (cost-)effectiveness of this, and the failure of health services to commission
adequately have all been highlighted in official reports
vocational rehabilitation – this is particularly important for people who have suffered
major trauma because many are working when injured and are necessarily off work for a
long time. Work also improves health.
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10.2
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The commissioners will need to commission from these services at an appropriate level:
initial assessment to determine the need of each patient
provision of the intervention:
o the equipment, including resources to educate the patient or others in its use and
to monitor its use, and to maintain it and replace it as needed
o the vocational rehabilitation, including resources for work-based assessments, job
shadowing and other work-place based activities and liaison with employers.
11.0
LONG-TERM SUPPORT
A significant proportion of patients will inevitably be left with long-term problems, and
will need support from many agencies. The (health) commissioners need to ensure that
there are adequate resources available to meet these needs, because any failure to do so
is not only harmful to patients and families, but also hinders transfer of patients from
more expensive services; delayed discharges are a continuing problem, and most are a
direct result of severe and complex disability for which there are inadequate long-term
community resources.
11.1
The long-term support will encompass a huge variety of needs from housing and
accommodation through personal care needs, needs for drugs and medical support,
supervision and control to maintain safety, prevention of avoidable complications and
harm, social support, emotional support and so on. It will often be expensive, and
involve close cooperation between many agencies.
11.2
The commissioners should commission directly, or should facilitate and encourage the
Service specification for rehabilitation after major trauma. August 8th 2011
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12.0
12.1
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12.2
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12.3
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commissioning by other agencies the following general resources:
residential and nursing home places suitable for and able to meet the needs of younger
people with high and specialist care needs, particularly those associated with brain
damage
supported community placements (e.g. group homes) suitable for and able to meet the
needs of younger people with high and specialist care needs, particularly those
associated with brain damage
community support and care services delivered into homes, suitable for and able to meet
the needs of younger people with high and specialist care needs, particularly those
associated with brain damage
ongoing specialist rehabilitation service support to patients over their lifetime to be
available to them wherever they reside, particularly for patients who have had brain
damage, spinal cord injuries, or amputations needing prostheses
OTHER ASPECTS OF COMMISSIONING
This section covers some general points relevant to commissioning.
Non-clinical aspects
It must be recognised that commissioning should be concerned not simply with the
direct service to each individual patient but also with
serving the population, meeting all the rehabilitation needs of all patients over time.
This requires attention to factors such as
o requiring good communication between services
o ensuring a complete network of services is commissioned
maintaining and improving service quality. This requires attention to factors such as:
o supporting training, education, and research
o ensuring feedback between services
o ensuring that teams are robust and able to function if someone leaves
increasing collaboration with Social Services, Employment, Education and other
statutory services. This requires:
o inter-organisational agreements
o possibly shared budgets
encouraging engagement of non-statutory organisations with services to:
o support families and patients with information and emotional and practical help
o comment on ways that services could improve and change
Avoid commissioning
Commissioners should not commission rehabilitation for patients after major trauma
from any service that cannot fulfil the following criteria:
is an integrated (i.e. employed and managed as a whole) specialist (i.e. team members
have expertise in the relevant areas) multi-disciplinary team with the full complement of
professions
has capacity to meet the assessment, treatment and care needs of the patient, maintaining
patient safety at all times without compromising or reducing the service to other (NHS)
patients needing their service
The evidence suggests that it is also inappropriate to commission, for patients after
major trauma:
Service specification for rehabilitation after major trauma. August 8th 2011
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12.4
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12.5
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generic services to provide rehabilitation to patients who have needs best met by
specialist services
services from individual professions, even if a panoply of professions are commissioned
to cover all relevant professions
services from teams that are incomplete
two or more separate services for a single clinical group
o especially to commission psychological and/or psychiatric services separately
from the organ-based specialist services
Miscellaneous
It would be appropriate to commission support from non-specialist services or from
individual clinicians (therapists, nurses, doctors etc) provided the following criteria are
met:
the problem being treated is outside the remit and expertise of the specialist service:
o this must be confirmed with the relevant specialist service as soon as possible,
whether the problem is new or long-standing
the specialist service has transferred responsibility to the clinician or service with:
o guidance both on treatment and on how to seek help if needed
o a plan to review progress
Patients needing rehabilitation should not be managed on a general ward. Therefore,
although specialist rehabilitation services are insufficient to meet the need,
commissioners should ensure that once patients no longer need the acute specialist
trauma service, they should be managed within a ward setting that at a minimum:
focuses on rehabilitation and
has specialist rehabilitation nurses working throughout each day and night
12.6
There is currently no information available that can indicate the amount of
rehabilitation needed. However commissioners will need to commission services at a
level that not only satisfies the need of patients who have experienced major trauma,
but also the needs of all other patients who require the same specialist rehabilitation
services (this is a requirement of the Clinical Advisory Group). The Clinical Advisory
Group also specifically noted that the commissioners will need to commission a great
increase in rehabilitation to meet the needs of all patients, which are currently not met.
13.0
SUMMARY
The commissioners needs to commission an appropriate range and quantity of
rehabilitation services for their whole population. This documents focuses on the
rehabilitation that needs to be commissioned to meet the needs of people who have
experienced major trauma, and to comply with National Guidance. However
rehabilitation cannot be commissioned specifically for this group in isolation. The
major themes are the need for specialist multi-disciplinary teams and the need for a
rehabilitation environment with specialist nursing for all inpatients from the outset.
Unfortunately there are no data to guide the quantity of rehabilitation services that
need to be commissioned.
Professor Derick Wade, Consultant in Neurological Rehabilitation
Director of Trauma Rehabilitation Thames Valley (Bucks, Berks, Oxon)
Oxford Centre for Enablement, Windmill Road, Oxford OX3 7HE
January 29th 2012
Service specification for rehabilitation after major trauma. August 8th 2011
Tel: 01865-73736 Fax: 01865-737309
email: derick.wade@ouh.nhs.uk derick.wade@ntlworld.com
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