ABSTRACT
In 2005 and 2013, the "Deutsche Gesellschaft für Neurowissenschaftliche Begutachtung" (German Society for Neuroscientific Evaluation) together with other societies developed and consented guidelines fort the legal evaluation of patients with closed head injuries and published them trough the National Working Group of Scientific Medical Societies and in this journal. Five years later, a revision was necessary, this was developed on the higher S2 k level of consent through a Delphi conference.
Subject(s)
Head Injuries, Closed/diagnosis , Legislation, Medical , Consensus , Delphi Technique , Guidelines as Topic , Head Injuries, Closed/classification , Humans , Terminology as TopicABSTRACT
Prolonged weaning of patients with neurological or neurosurgery disorders is associated with specific characteristics, which are taken into account by the German Society for Neurorehabilitation (DGNR) in its own guideline. The current S2k guideline of the German Society for Pneumology and Respiratory Medicine is referred to explicitly with regard to definitions (e.g., weaning and weaning failure), weaning categories, pathophysiology of weaning failure, and general weaning strategies. In early neurological and neurosurgery rehabilitation, patients with central of respiratory regulation disturbances (e.g., cerebral stem lesions), swallowing disturbances (neurogenic dysphagia), neuromuscular problems (e.g., critical illness polyneuropathy, Guillain-Barre syndrome, paraplegia, Myasthenia gravis) and/or cognitive disturbances (e.g., disturbed consciousness and vigilance disorders, severe communication disorders), whose care during the weaning of ventilation requires, in addition to intensive medical competence, neurological or neurosurgical and neurorehabilitation expertise. In Germany, this competence is present in centers of early neurological and neurosurgery rehabilitation, as a hospital treatment. The guideline is based on a systematic search of guideline databases and MEDLINE. Consensus was established by means of a nominal group process and Delphi procedure moderated by the Association of the Scientific Medical Societies in Germany (AWMF). In the present guideline of the DGNR, the special structural and substantive characteristics of early neurological and neurosurgery rehabilitation and existing studies on weaning in early rehabilitation facilities are examined.Addressees of the guideline are neurologists, neurosurgeons, anesthesiologists, palliative physicians, speech therapists, intensive care staff, ergotherapists, physiotherapists, and neuropsychologists. In addition, this guideline is intended to provide information to specialists for physical medicine and rehabilitation (PMR), pneumologists, internists, respiratory therapists, the German Medical Service of Health Insurance Funds (MDK) and the German Association of Health Insurance Funds (MDS). The main goal of this guideline is to convey the current knowledge on the subject of "Prolonged weaning in early neurological and neurosurgery rehabilitation".
Subject(s)
Nervous System Diseases/rehabilitation , Neurological Rehabilitation/standards , Neurosurgical Procedures/rehabilitation , Neurosurgical Procedures/standards , Practice Guidelines as Topic , Respiratory Insufficiency/prevention & control , Ventilator Weaning/standards , Germany/epidemiology , Humans , Nervous System Diseases/surgery , Ventilator Weaning/methodsABSTRACT
BACKGROUND: Colonization or infection with multi-drug resistant (MDR) bacteria is considered detrimental to the outcome of neurological and neurosurgical early rehabilitation patients. METHODS: In a German multi-center study, 754 neurological early rehabilitation patients were enrolled and and reviewed in respect to MDR status, length of stay (LOS) and the following outcome variables: Barthel Index (BI), Early Rehabilitation Index (ERI), Glasgow Outcome Score Extended (GOSE), Coma Remission Scale (CRS), Functional Ambulation Categories (FAC). RESULTS: The mean age of the study population was 68.0 ± 14.8 years. Upon admission, the following prevalence for MDRs was observed: MRSA (methicillin resistant staphylococcus aureus) 7.0% (53/754), ESBL- (extended spectrum beta-lactamase) producing bacteria strains 12.6% (95/754), VRE (vancomycin resistant enterococci) 2.8% (21/754). Patients colonized or infected with MDR bacteria (MDR+) were significantly more frequently diagnosed with a critical illness polyneuropathy - CIP - than non-colonized (MDR-) patients: 29.0% vs. 14.8%. In addition, they were more frequently mechanically ventilated (MDR+: 55/138, 39.9%; MDR- 137/616, 22.2%). MDR+ patients were referred to rehabilitation earlier, had a longer LOS in early rehabilitation, lower BI on admission and at discharge, lower ERI on admission and lower CRS at discharge than MDR- patients. There was a highly significant correlation of the BI upon admission with the BI at discharge (rs = 0.492, p < 0.001). GOSE at discharge differed significantly between both groups (χ 2-test, p < 0.01). Perhaps of greatest importance, mortality among MDR+ was higher in comparison to MDR- (18.1% vs. 7.6%). CONCLUSIONS: The outcome of neurological early rehabilitation patients colonized or infected with MDR bacteria including MRSA or ESBL producing strains is significantly poorer than by non-colonized patients. There is some evidence that the poor outcome could be related to the higher morbidity and lower functional status upon admission.
Subject(s)
Bacterial Infections/rehabilitation , Drug Resistance, Multiple, Bacterial , Early Medical Intervention/methods , Hospitalization/statistics & numerical data , Nervous System Diseases/rehabilitation , Neurological Rehabilitation/methods , Outcome Assessment, Health Care , Aged , Aged, 80 and over , Bacterial Infections/epidemiology , Comorbidity , Female , Germany/epidemiology , Humans , Male , Middle Aged , Nervous System Diseases/epidemiologyABSTRACT
BACKGROUND: Evaluation of functional status is difficult in neurological and neurosurgical early rehabilitation patients. The Early Rehabilitation Index (ERI) was introduced in Germany over 20 years ago, but since then validation studies are lacking. The ERI (range -325 to 0 points) includes highly relevant items including the necessity of intermittent mechanical ventilation or tracheostomy. METHODS: The present paper analyzed data from a German multi-center study, enrolling 754 neurological early rehabilitation patients. Together with ERI, Barthel Index (BI), Glasgow Coma Scale (GCS), Glasgow Outcome Score Extended, Coma Remission Scale (CRS), Functional Ambulation Categories and length of stay were obtained. RESULTS: ERI showed significant improvements from admission to discharge (p < 0.001). In addition, there were significant correlations of the ERI upon admission and at discharge with BI, CRS and GCS. CONCLUSIONS: Evaluation of our study data suggest that the ERI may be used as a valid assessment instrument for neurological and neurosurgical early rehabilitation patients.
Subject(s)
Brain Injuries/rehabilitation , Glasgow Coma Scale/statistics & numerical data , Intracranial Hemorrhages/rehabilitation , Peripheral Nerve Injuries/rehabilitation , Research Design , Activities of Daily Living , Aged , Aged, 80 and over , Brain Injuries/pathology , Brain Injuries/therapy , Female , Germany , Humans , Intracranial Hemorrhages/pathology , Intracranial Hemorrhages/therapy , Length of Stay , Male , Middle Aged , Peripheral Nerve Injuries/pathology , Peripheral Nerve Injuries/therapy , Prospective Studies , Rehabilitation Research , Stroke/pathology , Stroke/therapy , Trauma Severity Indices , Treatment OutcomeABSTRACT
In the context of neurological assessment, neuropsychological deficits, in particular of attention and memory functions, usually require additional neuropsychological evaluation. Clinical neuropsychology also has at its disposal an inventory of validated and standardized tests for assessing symptom validity. Procedure, test selection, quality criteria and limitations of neuropsychological expert medical evaluations are presented. Independent expert evaluations should be conducted by a qualified clinical neuropsychologist.
Subject(s)
Brain Diseases/diagnosis , Cognitive Dysfunction/diagnosis , Disability Evaluation , Expert Testimony/legislation & jurisprudence , Neuropsychological Tests/statistics & numerical data , Psychometrics/statistics & numerical data , Attention , Brain Damage, Chronic/diagnosis , Brain Damage, Chronic/psychology , Brain Diseases/psychology , Cognitive Dysfunction/psychology , Diagnosis, Differential , Executive Function , Humans , Malingering/diagnosis , Malingering/psychology , Memory Disorders/diagnosis , Memory Disorders/psychology , Neurocognitive Disorders/diagnosis , Neurocognitive Disorders/psychologyABSTRACT
BACKGROUND: In Germany, neurological-neurosurgical early rehabilitation is well established in the treatment of severe neurological diseases. To develop quality standards, knowledge of the current rehabilitation course is required. PATIENTS AND METHODS: A retrospective analysis was performed on the course of rehabilitation from patients in an early neurological/neurosurgical rehabilitation program in 16 centers from 10 German states. The odds for a good or poor outcome were investigated using a multivariate logistic regression model. RESULTS: Seven hundred and fifty-four patients were included in the study. The average age of the patients was 68 ± 15 years. Of the patients studied, 26â¯% were on mechanical ventilation commencing their neurological rehabilitation. The average duration of stay was 56 ± 51 days. Weaning rate from mechanical ventilation was 65â¯% and the rate of weaning from tracheal cannula was 54â¯%. Mean improvement in the Barthel Index of 17 points, significant reduction of dysphagia (from 62 to 30â¯%) and depended walking (from 99 to 82â¯%), and the achievement of phase C (the next stage of rehabilitation) in 38â¯% can still be counted as signs of successful rehabilitation. During their course of stay, near 10â¯% of the patients died. Of these, 67â¯% received solely palliative care. In the multivariate logistic models, the absence of the factor "necessity for mechanical ventilation on admission" (odds ratio 0.61; 95 % confidence interval (CI): 0.42 0.89) increased the chance for good outcome and the presence of this factor the risk of dying with an odds ratio of 8.07 (95 % CI: 4.54-14.34). DISCUSSION: In spite of the severity of neurological deficits, significant functional progress has been made. These results could be interpret as positive proof of the efficacy of neurological/neurosurgical early rehabilitation programs.
Subject(s)
Nervous System Diseases/rehabilitation , Neurological Rehabilitation/methods , Neurosurgical Procedures/rehabilitation , Aged , Aged, 80 and over , Disability Evaluation , Female , Germany , Humans , Length of Stay/statistics & numerical data , Male , Middle Aged , Multivariate Analysis , Nervous System Diseases/mortality , Neurosurgical Procedures/mortality , Retrospective Studies , Treatment Outcome , Ventilator WeaningSubject(s)
Community Participation/statistics & numerical data , Neurological Rehabilitation/statistics & numerical data , Patient Participation/statistics & numerical data , Stroke Rehabilitation/statistics & numerical data , Stroke/epidemiology , Stroke/therapy , Evidence-Based Medicine , Germany/epidemiology , Humans , Prevalence , Risk Factors , Treatment OutcomeABSTRACT
Under the German DRG-system, hospital-based rehabilitation of still critically ill patients becomes increasingly important. The code for early neurological rehabilitation in the DRG-system's (Diagnosis Related Groups) list of operations and procedures requires an average daily therapeutic intensity of 300 min, part of which is being contributed by therapeutic nursing. As therapeutic aspects are integrated in other nursing activities, it is difficult to separate its time consumption. This problem is pragmatically resolved by catalogues of therapeutic nursing activities which assign plausible amounts of therapeutic minutes to each activity. The 4 catalogues that are used most often are described and compared. Nursing science has not focused yet on therapeutic nursing.
Subject(s)
Catalogs as Topic , Nervous System Diseases/rehabilitation , Practice Patterns, Nurses'/classification , Rehabilitation Nursing/classification , Secondary Prevention/classification , Workload/classification , Germany , Humans , Rehabilitation Nursing/statistics & numerical data , Secondary Prevention/statistics & numerical data , Terminology as Topic , Workload/statistics & numerical dataABSTRACT
In 2005, the "Deutsche Gesellschaft für Neurowissenschaftliche Begutachtung" (German Society for Neuroscientific Legal Evaluation) together with other Societies published a guideline for the legal evaluation of patients with closed head injuries. Meanwhile, not only scientific progress in imaging techniques but also in other fields such as neuropsychology has necessitated a revision, which is presented here. In the mean time, the handling of guidelines has been systematised in Germany so that a registration with the Cooperation of German Medical Learned Societies is applied for and publication in the German Guideline Registry is expected.
Subject(s)
Head Injuries, Closed/psychology , Liability, Legal , Brain Injuries/diagnosis , Brain Injuries/psychology , Contusions/diagnosis , Contusions/psychology , Disability Evaluation , Electroencephalography , Forensic Psychiatry , Germany , Head Injuries, Closed/diagnosis , Humans , Legislation, Medical , Mental Processes , Neuroimaging , Neuropsychological TestsABSTRACT
It is being discussed how prioritization affects access to rehabilitation and rehabilitation practice. Multiprofessional in-patient rehabilitation is being challenged to produce proofs of its efficiency in comparison to out-patient oligo- and monoprofessional interventions. In clinical practice, prioritization among different interventions is determined by ICF orientation and available or affordable staffing resources.
Subject(s)
Delivery of Health Care/organization & administration , Health Care Rationing/methods , Health Care Rationing/organization & administration , Health Priorities/organization & administration , Hospital Administration , Models, Organizational , Rehabilitation/organization & administration , Germany , Organizational ObjectivesABSTRACT
The present state of medicolegal evaluation of persons with traumatic brain injury is discussed in this contribution. Both the ICD and German jurisdiction see a strict separation between structural and only functional brain damage that can be reliably evaluated through neurological, neuropsychological and neuroradiological means. However, there is evidence mainly from MRI investigations that there can be structural changes that presently cannot be detected in the single case, e.g. anisotropy. Furthermore, the neurological and neuropsychological differentiation of directly traumatic and psychogenic disorders can be difficult and requires expertise.