Accredited in September 2011
Authors:
Dr Klemen GRABLJEVEC, MD., MSc
Head of Unit
Department for Traumatic Brain Injury Rehabilitation
University Rehabilitation Institute
Linhartova 51
SI-1000 Ljubljana
SLOVENIA
klemen.grabljevec@ir-rs.si
SUMMARY
Traumatic brain injury represents one of greatest national health problems in Slovenia, since it is closely related to low traffic safety (1) and high alcohol consuming ratio (2) in the country. Approximately two out of three patients with brain injury were injured in any kind of traffic accident. The current incidence of traumatic brain injuries in the country is 200/100.000 (population of 2 million), from which 90 % of them representing mild brain injury (3). There are approximately 350 moderate and severe brain injuries a year, with 30 – 50 % mortality in first week and 15 % mortality in first month after severe brain injury, giving the number of 150 – 200 patients surviving long term after injury.
This programme for Rehabilitation after traumatic brain injury takes place at the Department for rehabilitation of patients with brain injury, multiple sclerosis and neuro-muscular diseases, which is part of University Rehabilitation Institute Ljubljana. Department serves as a national referral centre for people after severe and moderate traumatic as well as hypoxic-anoxic brain injury. By the mean time, the same Department runs three other programmes – for rehabilitation of patients with Multiple Sclerosis, patients with Parkinson Disease and patients with Neuro-Muscular diseases.
There are 20 beds available (out of 38 in the department) for inpatient rehabilitation and there is a day-hospital accommodation available. The programme is run in a comprehensive and interdisciplinary way, with a rehabilitation team consisting of one PRM specialist, 1 neuro-psychologist, 1 Speech and Language therapist and 1 registered nurse. Those staff members are dedicated to the programme of traumatic brain injury rehabilitation only. Other staffs are shared with other programmes. Rehab-nursing care is provided by 14 nurses and two nurse-assistants, but they are also responsible for all patients in the department (38 patients). A social worker is available for patients with brain injury together with the programme for spinal cord injury rehabilitation. There are 5 physiotherapists in the department, performing the therapy for the patients of other rehabilitation programmes as well (for together 38 patients) and 4 occupational therapists also performing the therapy for the patients of other rehabilitation programmes as well (for together 38 patients).
Acute surgical and intensive treatment of people with moderate to severe brain injury is performed at one of the three neurosurgery clinical departments in the country (Ljubljana, Maribor, Celje) or at the Level I Trauma Centres. If further prolonged intensive care is needed, patients are later transferred from neurosurgical department to local acute hospitals, nearest to the region where they live.
Patients are admitted to the Rehabilitation Institute directly from acute hospitals as soon as their vital signs are stable and when they do not need intensive care interventions any more. In rare situations, patients in suitable conditions are discharged from acute hospitals to home care and are admitted to Rehabilitation Institute later. Generally it is favourable that patients regain their full consciousness, before they are included in the Rehabilitation programme, but there is also a special programme for early neurostimulation therapy available. Patients in Minimal Conscious State (MCS) are admitted for a three to six week period of “observation – therapy – observation” programme, but currently only one such patient at a time. It has been decided that patients in Permanent Vegetative State (PVS) were not suitable for the existing rehabilitation programme and so they are transferred for permanent and long term care to dedicated institutions or nursing homes.
Patients are admitted into the rehabilitation programme after being presented to a department specialist with a standardized referral letter where his/her clinical/functional status has been described by the PRM specialist of the acute hospital. If there is no PRM specialist in the acute hospital, the patient is invited to come to an outpatient evaluation, performed by the PRM specialist at the Rehabilitation Institute. In some cases, the department specialist performs a consulting visit in the acute hospital. After outpatient evaluation, patients suitable for the programme are informed about the waiting period for admission, and those patients not suitable for the programme are informed about the reasons for that and provided with written information and suggestions for further treatment.