Rehabilitationsverlauf von Patienten in der neurologisch-neurochirurgischen Frührehabilitation

[Certification by the German Society for Neurorehabiliation, DGNR : Performance and quality of the "Centers for weaning from a ventilator in early neurological and neurosurgical rehabilitation"]

BACKGROUND

Certification of centers for weaning from a ventilator in neurological neurosurgical early rehabilitation (NNER) by the German Society for Neurorehabilitation (DGNR) is possible since 1 October 2021.

OBJECTIVE

The results of certification of facilities in the first year after starting the procedure are presented.

MATERIAL AND METHODS

As part of the certification process 28 criteria are assessed including a set of mandatory characteristics of the facility. The criteria are divided into structural criteria (i = 7), diagnostic criteria (i = 6), personnel criteria (i = 3), internal organization criteria (i = 7), and quality management criteria (i = 5).

RESULTS

A total of 13 centers were certified in the first year, with a combined total of 283 beds for weaning from a ventilator in the NNER and served 2278 persons to be weaned from a ventilator in the year before certification, with a median of 134 per facility (range 44-414). Only rarely was weaning unsuccessful, requiring conversion to home mechanical ventilation before discharge (invasive home mechanical ventilation median per facility 10 persons, range 2-25; non-invasive home mechanical ventilation median 0 persons, range 0-57). A high level of process and structural quality was documented for the certified centers: across all areas of assessment, the individual certification criteria were met in the vast majority of cases (median degree of complete fulfilment 86%) or met with improvement potentials documented by the auditors (median 11%).

CONCLUSION

Successful weaning in NNER and a high level of process and structural quality can be demonstrated by the certification results of centers that follow this integrative approach to weaning from a ventilator in a NNER setting.

The Neurological Rehabilitation of Adults With Coma and Disorders of Consciousness

BACKGROUND

Severe quantitative disorders of consciousness (DoC) due to acute brain injury affect up to 47% of patients upon admission to intensive care and early rehabilitation units. Nevertheless, the rehabilitation of this vulnerable group of patients has not yet been addressed in any German-language guidelines and has only been studied in a small number of randomized clinical trials.

METHODS

In an S3 clinical practice guideline project, a systematic literature search was carried out for interventions that could improve consciousness in patients with coma, unresponsive wakefulness syndrome, or minimally conscious state after acute brain injury, and an evidence-based evaluation of these interventions was performed. Recommendations concerning diagnostic methods and medical ethics were issued by consensus.

RESULTS

Misdiagnoses are common in patients with DoC, with minimal consciousness often going unrecognized. Patients with DoC should, therefore, be repeatedly assessed with standardized instruments, particularly the Coma Recovery Scale-Revised. The literature search yielded 54 clinical trials, mostly of low quality; there were two randomized controlled clinical trials providing level 1 evidence. The best available evidence for the improvement of impaired consciousness is for the administration of amantadine (4 studies) and for anodal transcranial direct-current stimulation of the left dorsolateral prefrontal cortex in patients in the minimal conscious state (8 studies, 2 systematic reviews). Further important components of rehabilitation include positioning methods and sensory stimulation techniques such as music therapy.

CONCLUSION

For the first time, evidence-based German-language clinical practice guidelines have now become available for the neurological rehabilitation of patients with DoC.

Optimizing home-based long-term intensive care for neurological patients with neurorehabilitation outreach teams - protocol of a multicenter, parallel-group randomized controlled trial (OptiNIV-Study)

Background

Even with high standards of acute care and neurological early rehabilitation (NER) a substantial number of patients with neurological conditions still need mechanical ventilation and/or airway protection by tracheal cannulas when discharged and hence home-based specialised intensive care nursing (HSICN). It may be possible to improve the home care situation with structured specialized long-term neurorehabilitation support and following up patients with neurorehabilitation teams. Consequently, more people might recover over an extended period to a degree that they were no longer dependent on HSICN.

Methods

This healthcare project and clinical trial implements a new specialised neurorehabilitation outreach service for people being discharged from NER with the need for HSICN. The multicentre, open, parallel-group RCT compares the effects of one year post-discharge specialized outpatient follow-up to usual care in people receiving HSICN. Participants will randomly be assigned to receive the new form of healthcare (intervention) or the standard healthcare (control) on a 2:1 basis. Primary outcome is the rate of weaning from mechanical ventilation and/or decannulation (primary outcome) after one year, secondary outcomes include both clinical and economic measures. 173 participants are required to corroborate a difference of 30 vs. 10% weaning success rate statistically with 80% power at a 5% significance level allowing for 15% attrition.

Discussion

The OptiNIV-Study will implement a new specialised neurorehabilitation outreach service and will determine its weaning success rates, other clinical outcomes, and cost-effectiveness compared to usual care for people in need for mechanical ventilation and/or tracheal cannula and hence HSICN after discharge from NER.

Trial registration

The trial OptiNIV has been registered in the German Clinical Trials Register (DRKS) since 18.01.2022 with the ID DRKS00027326.

One-year outcome of brain injured patients undergoing early neurological rehabilitation: a prospective observational study

Background

The present study intended to analyze the outcome of patients with severe brain injury one-year after discharge from early rehabilitation.

Methods

Early neurological rehabilitation patients admitted to intensive or intermediate care units and discharged between June 2018 and May 2020 were screened for eligibility. The level of consciousness was evaluated using the Coma Recovery Scale-Revised (CRS-R) upon admission and at discharge. At one-year follow-up, the outcome was assessed with the Glasgow Outcome Scale-extended (GOSE). Demographical and clinical data collected during inpatient rehabilitation were used to predict the outcome 1 year after discharge.

Results

Two hundred sixty-four patients (174 males, 90 females) with a median age of 62 years (IQR = 51–75) and a median duration of their disease of 18 days (IQR = 12–28) were included in the study. At follow-up, the mortality rate was 27% (n = 71). Age and discharge CRS-R total score were independent predictors in a Cox proportional hazards model with death (yes/no) as the dependent variable. According to the GOSE interviews, most patients were either dead (n = 71; 27%), in a vegetative state (n = 28; 11%) or had a severe disability (n = 124; 47%), whereas only a few patients showed a moderate disability (n = 18; 7%) or a good recovery (n = 23; 9%) 1 year after discharge. Age, non-traumatic etiology, discharge CRS-R total score and length of stay independently predicted whether the outcome was good or poor at follow-up.

Conclusion

Age was an important predictor for outcome at one-year follow-up, which might be due to altered brain plasticity and more comorbidities in elderly subjects. In addition, the present study demonstrated that the CRS-R total score at discharge might be more important for the prediction of one-year outcome than the initial assessment upon admission.

[The certification of centers for weaning from mechanical ventilation in neurological and neurosurgical early rehabilitation by the German Society for Neurorehabilitation]

Die Zertifizierung von Zentren für Beatmungsentwöhnung in der neurologisch-neurochirurgischen Frührehabilitation durch die Deutsche Gesellschaft für Neurorehabilitation (DGNR) ist ab dem 01.10.2021 möglich. Die Zertifizierungskriterien beschreiben ein Anforderungsprofil, das für eine fachgerechte und qualitätsgesicherte Versorgung von Beatmungspatienten in der neurologisch-neurochirurgischen Frührehabilitation (NNFR) steht. Das Zertifikat berücksichtigt die strukturellen Unterschiede der in der NNFR tätigen Einrichtungen und kann sowohl durch Facheinrichtungen als auch durch Frührehabilitationsabteilungen an Akutkrankenhäusern erworben werden. Die Durchführung der Zertifizierung erfolgt analog zur Zertifizierung von Stroke-Units der Deutschen Schlaganfall-Gesellschaft in Zusammenarbeit mit dem TÜV Rheinland. Zunächst sendet die Einrichtung den Erhebungsbogen an den TÜV Rheinland. Anschließend erfolgt die Begehung durch einen vom TÜV Rheinland gestellten leitenden Auditor und einen Fachauditor der DGNR. Deren Bericht wird dem Zertifizierungsausschuss der DGNR vorgelegt zur Erteilung einer Empfehlung oder Ablehnung der Zertifizierung. Die Zertifizierung schafft objektive Kriterien, die die Rolle der Neurologie in der Beatmungsmedizin in Deutschland beschreiben. So erleichtert sie den Dialog mit anderen beatmungsmedizinischen Disziplinen und ebnet den Weg für die Diskussion mit Politikern, Kostenträgern und nicht zuletzt Betroffenenverbänden über Behandlungsinhalte und -kapazitäten.

[Relevance of the Clinical Ethics Committee (CEC) for Clinical Staff of a Specialized Neurological Clinic]

BACKGROUND

Clinical ethics committees (CECs) have been implemented in German clinics since the 1990s. Besides problems with the integration into clinical routines, CECs result in an enrichment and relief for employees and relatives. Investigating the current status of CECs in specialized neurological clinics is crucial because changes in therapy goals towards palliative care are often requested and the treatment team is sometimes overwhelmed with clarifying the presumed patient's wishes. So far, however, there have been no studies that have examined the work of the CEC and its importance for clinical staff in specialized neurological clinics.

METHOD

In a single-center, prospective observational study, 161 clinic employees with contact to the patients and 10 members of the CEC were asked about their previous experiences and impressions with and in the CEC. At the same time, 31 patients were retrospectively identified for whom an ethical case consultation was carried out by the CEC in 2019. A qualitative evaluation was carried out for the protocols of the ethical case counseling.

RESULTS

56% of the clinic employees and 90% of the CEC members considered the CEC as enrichment for the clinic. Although more than a third of the clinic employees evaluated the CEC as a relief during difficult ethical decisions, the presence of the CEC in particular for relatives and employees is described as insufficient. In the majority, a reduction in the hierarchy by the CEC was confirmed by the members of the CEC (70%), whereas the majority of the clinic employees increasingly denied this (55%). The CEC recommendation was implemented in 94% of the cases.

CONCLUSION

A central problem in working with and within a CEC is maybe the lack of presence and information for employees. Due to this lack of presence, the CEC is not sufficiently visible in everyday clinical practice.

Prolonged Weaning: S2k Guideline Published by the German Respiratory Society

Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by respiratory muscle insufficiency and/or lung parenchymal disease; that is, when other treatments such as medication, oxygen administration, secretion management, continuous positive airway pressure (CPAP), or nasal high-flow therapy have failed. MV is required for maintaining gas exchange and allows more time to curatively treat the underlying cause of respiratory failure. In the majority of ventilated patients, liberation or "weaning" from MV is routine, without the occurrence of any major problems. However, approximately 20% of patients require ongoing MV, despite amelioration of the conditions that precipitated the need for it in the first place. Approximately 40-50% of the time spent on MV is required to liberate the patient from the ventilator, a process called "weaning". In addition to acute respiratory failure, numerous factors can influence the duration and success rate of the weaning process; these include age, comorbidities, and conditions and complications acquired during the ICU stay. According to international consensus, "prolonged weaning" is defined as the weaning process in patients who have failed at least 3 weaning attempts, or require more than 7 days of weaning after the first spontaneous breathing trial (SBT). Given that prolonged weaning is a complex process, an interdisciplinary approach is essential for it to be successful. In specialised weaning centres, approximately 50% of patients with initial weaning failure can be liberated from MV after prolonged weaning. However, the heterogeneity of patients undergoing prolonged weaning precludes the direct comparison of individual centres. Patients with persistent weaning failure either die during the weaning process, or are discharged back to their home or to a long-term care facility with ongoing MV. Urged by the growing importance of prolonged weaning, this Sk2 Guideline was first published in 2014 as an initiative of the German Respiratory Society (DGP), in conjunction with other scientific societies involved in prolonged weaning. The emergence of new research, clinical study findings and registry data, as well as the accumulation of experience in daily practice, have made the revision of this guideline necessary. The following topics are dealt with in the present guideline: Definitions, epidemiology, weaning categories, underlying pathophysiology, prevention of prolonged weaning, treatment strategies in prolonged weaning, the weaning unit, discharge from hospital on MV, and recommendations for end-of-life decisions. Special emphasis was placed on the following themes: (1) A new classification of patient sub-groups in prolonged weaning. (2) Important aspects of pulmonary rehabilitation and neurorehabilitation in prolonged weaning. (3) Infrastructure and process organisation in the care of patients in prolonged weaning based on a continuous treatment concept. (4) Changes in therapeutic goals and communication with relatives. Aspects of paediatric weaning are addressed separately within individual chapters. The main aim of the revised guideline was to summarize both current evidence and expert-based knowledge on the topic of "prolonged weaning", and to use this information as a foundation for formulating recommendations related to "prolonged weaning", not only in acute medicine but also in the field of chronic intensive care medicine. The following professionals served as important addressees for this guideline: intensivists, pulmonary medicine specialists, anaesthesiologists, internists, cardiologists, surgeons, neurologists, paediatricians, geriatricians, palliative care clinicians, rehabilitation physicians, intensive/chronic care nurses, physiotherapists, respiratory therapists, speech therapists, medical service of health insurance, and associated ventilator manufacturers.

[Out-of-hospital ventilation after prolonged weaning]

An increasing number of patients require prolonged weaning from mechanical ventilation as a result of advanced age, patient comorbidities, technical progress in surgery and intensive care medicine. The data of the WeanNet register show that more than half (64%) of patients transferred from the intensive care unit (ICU) to a specialized weaning center could definitely be weaned from the respirator. Weaning failure was associated with prolonged ventilation prior to transfer to a weaning center, low body mass index, pre-existing neuromuscular diseases and advanced age. The number of patients with out of hospital ventilation who had to be re-hospitalized because of ventilation control or as part of emergency management quadrupled in Germany between 2006 and 2016. Invasive out-of-hospital ventilation and long-term noninvasive ventilation are associated with a significant loss of autonomy and with low quality of life. Therefore, the initiation must be carefully reviewed and regularly re-evaluated in the context of patient comorbidities and, if necessary, decisions should be made with respect to changing treatment targets. Specialized weaning centers have been established for patients in whom weaning on the ICU was unsuccessful. In cases of persisting weaning failure the adequate transition to out-of-hospital ventilation should be managed by a weaning unit. Weaning centers are responsible for outpatient invasive or noninvasive ventilation strategies and control of treatment quality. Depending on the infrastructure and networking of the respective weaning center, it is basically also possible to provide outpatient care for clinically stable patients in a cooperation model together with pulmonologists in private practice experienced in respiratory medicine.

Influence of systemic infection and comorbidities on rehabilitation outcomes in severe acquired brain injury

BACKGROUND

Severe infectious complications are a frequent problem in patients with disability due to a severe acquired brain injury. Previous studies reported that the rehabilitation outcome is significantly lower in patients colonized or infected. However, these results could be influenced by comorbidities of those patients admitted in rehabilitation hospital with a lower functional status.

AIM

To explore the influence of systemic infection, in particular concerning multidrug resistant bacteria and analyze the role of comorbidities, as a risk factor for the development of systemic infection, on rehabilitation outcomes in patients with severe brain injury.

DESIGN

This research is a cohort, prospective-observational study, comparing patients with and without systemic infections, in terms of rehabilitation outcomes.

SETTING

An Italian Intensive Care Rehabilitation Department.

POPULATION

A group of 221 patients (mean age: 59 years, range: 16-93 years, 127 males, 94 females) with severe acquired brain injury admitted to rehabilitation hospital.

METHODS

We compared the rehabilitation outcomes between patients with and without a systemic infection (at least a positive blood culture) during the rehabilitation period. A secondary analysis was performed on 70 patients with infection versus 70 patients without infection, matched for functional status at admission. The used clinical scores were: Cumulative Illness Rating Scale for Geriatrics (CIRS-G), Coma Recovery Scale Revised (CRS-R), Glasgow Coma Scale (GCS), Functional Independence Measure (FIM), Glasgow Outcome Scale (GOS), Disability Rating Scale (DRS), Levels of Cognitive Functioning (LCF) administered at admission and discharge. Length of hospitalization and the role of comorbidities were also considered.

RESULTS

The group of patients with systemic infection (in particular due to Gram-negative bacteria) had a significantly lower outcome for 5 out 6 clinical scales and with a more than doubled length of hospitalization (P<0.001). However, these patients with, at least, a positive blood culture resulted having lower functional status at admission. In the secondary analysis, worst outcome was found in patients with positive blood culture in terms of FIM (P=0.033), GOS (P=0.048), and CRS-R (P=0.001).

CONCLUSIONS

Systemic infections during rehabilitation increased the length of hospitalization and reduce the rehabilitative outcomes, even when the analysis was performed on groups matched for the functional status at admission. Moreover, the cardiological and endocrine metabolic comorbidities seem to influence the outcome, without representing a further risk factor for systemic infection.

CLINICAL REHABILITATION IMPACT

The impact of infections during rehabilitation inpatient should be more taken into account, with specific procedures and suitable environments to avoid the diffusions of infections.

German hospital capacities for prolonged mechanical ventilator weaning in neurorehabilitation - results of a representative survey

A brief survey among members of the German Neurorehabilitation Society aimed to document the hospital capacities (“beds”) for prolonged weaning from a mechanical ventilator for patients with neuro-disabilities that require simultaneous multi-professional neurorehabilitation treatment. Sixty-eight institutions declared to have capacities with a broad distribution across Germany and its federal states. Overall, 1094 “beds” for prolonged weaning (and neurorehabilitation) were reported, 871 together with further information regarding their identification and hence regional location. These units had on average 16.1 beds for prolonged weaning (95% confidence interval 12.6 to 19.6) with a range from 2 to 68 beds per organization. The data indicate substantial capacities for the combined prolonged weaning and neurorehabilitation treatment in Germany. For most “beds” included in this analysis a basic validation was possible. While a reasonable coverage of these specialized service capacities by the survey is likely, the number reported could still be biased by underreporting by non-response. Both the broad variation of number of “beds” for prolonged weaning per unit and their unequal geographical distribution across federal states (per capita rate) warrant a more refined follow-up survey that will provide insights into reasons for the observed pattern of variation for these specialized hospital capacities.

Management of patients with multidrug-resistant organisms in rehabilitation facilities. Results of a survey in the Rhine-Main region, Germany, 2019

Introduction: Multidrug-resistant organisms (MDRO) are a problem in medical facilities, including rehabilitation facilities in Germany. The national recommendations of the Commission for Hospital Hygiene and Infection Prevention (KRINKO) for prevention of and dealing with patients affected by MDRO are obligatory in rehabilitation facilities. A survey on the management of patients with MDRO in rehabilitation facilities in the Rhine-Main area is presented below. Materials and methods: The questions from a recently published survey in 45 rehabilitation facilities in 26 European countries (Doherty et al., 2019) were largely adopted unchanged: the type, size, and organization of the facility, availability of guidelines on MDRO, screening and (estimated) prevalence of MDRO, as well as special hygiene measures or restrictions for patients with MDRO. Results: 22 of the 43 institutions contacted participated (58%). All facilities had specific recommendations on how to deal with MDRO and more than 95% had adequate hygiene staff. The facilities encompassed 4,369 beds, with 3,909 (89%) of them in single-bed rooms, and only a few offered 3-bed rooms. About 20% of patients in general rehabilitation and 100% in early neurological rehabilitation are screened on admission. Six (27%) facilities refused to accept patients with MDRO. 40% of the facilities treated these patients in their own room and/or in a separate area. 27% of the facilities prohibited eating in the dining room and participating in hydrotherapy. Only 6 (27%) of the rehabilitation centers indicated that patients with MDRO are allowed to participate in full rehabilitation programs. Discussion: In accordance with the results of Doherty et al. (2019), there were many restrictions for rehabilitation patients with MDRO, indicating considerable need for improvement. Necessary hygiene recommendations to avoid the transmission of MDRO must not lead to rejection of inpatient rehabilitation or to less intensive rehabilitation.

Influence of paroxysmal sympathetic hyperactivity (PSH) on the functional outcome of neurological early rehabilitation patients: a case control study

Background

Paroxysmal Sympathetic Hyperactivity (PSH) is a frequently observed condition among critically ill patients on intensive care units. According to different studies, PSH is associated with worse recovery and increased mortality in acute-care facilities. In this monocentric, retrospective case-control study, we investigated whether this association also applies to post-acute neurological early rehabilitation.

Methods

The study included n = 387 patients, admitted to an intensive care or intermediate care unit within 1 year (2016). Among these, 97 patients showed clinical signs of PSH. For each patient with PSH, a patient without PSH was identified, controlling for age, gender, functional and respiratory status upon admission. However, for 25 patients with PSH, there was no suitable control patient fulfilling all defined matching criteria. Primary outcome was type of discharge, dichotomized into favorable (follow-up rehabilitation) and unfavorable outcome (all others). Secondary outcome measures were functional and respiratory status, number of secondary diagnoses, duration of treatment interruptions and length of stay at discharge.

Results

About 25% of neurological early rehabilitation patients showed clinical signs of PSH. A young age (OR = 0.94; CI = 0.91–0.97) and less severe PSH symptoms (OR = 0.79; CI = 0.69–0.90) were independent predictors of a favorable outcome. In addition, severity of PSH symptoms was associated with weaning duration, while the occurrence of PSH symptoms alone had no influence on most secondary outcome variables. The treatment on intermediate care units proved to be longer for patients with PSH symptoms, only.

Conclusions

Patients with PSH represent a large group of neurological early rehabilitation patients. Overall, we did not find PSH-related differences in most of the examined outcome measures. However, severe PSH symptoms seem to be associated with poorer outcome and longer treatment on intermediate care units, in order to prevent possible complications.

Standardized nutritional supply versus individual nutritional assessment: Impact on weight changes, complications and functional outcome from neurological early rehabilitation

BACKGROUND & AIMS

Approximately 55% of neurological and neurosurgical early rehabilitation (NNER) patients are in need of enteral nutrition, but long-term nutritional assessment of these critically ill patients is suboptimal. Therefore, this study analyzed the effect of an individual nutritional assessment on weight changes during rehabilitation and impact on complications and functional outcome.

METHODS

170 NNER patients on enteral nutrition were enrolled in the study. According to the initial ward, patients were assigned to receive standardized enteral nutrition (n = 107, control group) or an individual nutritional assessment (n = 63, intervention group). Weight changes, complications, assessment of the functional outcome (Early Rehabilitation Index, Barthel Index, Early Rehabilitation Barthel Index) and the length of stay were recorded and compared between groups using non-parametric tests for non-paired samples (Mann-Whitney U test for metric data or the χ² test for categorical data) or paired samples (Wilcoxon test). In addition, daily energy requirement was calculated and compared with daily intake. Correlation analysis by Spearman was performed to investigate linear relationship between weight changes and the difference of administered and calculated calories in both study groups.

RESULTS

A weight loss was observed in the control group, whereas the weight of the intervention group remained stable over time. The difference between calculated and administered calories correlated with weight changes in the control group. Regarding complications during rehabilitation, control patients showed more frequently impaired diuresis. In addition, control patients were suffering longer from diarrhea than patients of the intervention group. Both groups improved in functional status to a comparable degree. Relationships between these improvements and weight changes or administered calories could not be found.

CONCLUSIONS

Individual nutritional assessment had not an additional affect for the improvement of functional outcome or the prevention of complications. However, weight turned out to be more stable and signs of nutritional incompatibilities are less frequent among patients being treated with an individualized nutritional assessment.

Clinical neurophysiology of neurologic rehabilitation

Clinical neurophysiologic testing provides valuable support in predicting outcome in the setting of disorders of consciousness (DOC), including coma and traumatic brain injury (TBI). Electroencephalography (EEG) and evoked potentials (EP) are simple to apply, inexpensive, safe, and available in most rehabilitation facilities. This chapter reviews the use of EEG and EP in postanoxic coma and TBI. Bilateral absence of cortical somatosensory evoked potentials (SSEP) may be regarded as a predictor of poor outcome in hypoxic brain damage. Flash VEP may be useful to differentiate between good and poor outcome. In addition, low EEG frequencies, burst suppression, and isoelectric EEG patterns prognosticate poor outcomes in hypoxic brain damage. While a loss of cortical SSEP is generally regarded as a negative prognostic sign in the acute phase of hypoxic brain damage, absence of cortical SSEP responses is not necessarily associated with poor outcome in TBI. Event-related potentials (ERPs) can provide support in outcome prediction. In particular, the N100, mismatch negativity, P300, and N400 may improve accuracy of outcome prediction DOC of different etiologies. Some evidence suggests that ERPs may be superior to SSEP in predicting functional and DOC outcomes (Lew et al., 2003). ERPs are measured brain responses resulting from specific cognitive tasks, sensory stimulation, or planned motor activity.

[Predictors of cognitive outcome in ventilated early rehabilitation patients]

BACKGROUND

After weaning failure, patients who are transferred from intensive care units to early rehabilitation centers (ERC) not only suffer from motor deficits but also from cognitive deficits. It is still uncertain which patient factors have an impact on cognitive outcome at the end of early rehabilitation.

OBJECTIVE

Investigation of predictors of cognitive performance for initially ventilated early rehabilitation patients.

METHODS

A total of 301 patients (mean age 68.3 ± 11.4 years, 67% male) were consecutively enrolled in an ERC for a prospective observational study between January 2014 and December 2015. To investigate influencing factors on cognitive outcome operationalized by the neuromental index (NMI), we collected sociodemographic data, parameters about the critical illness, comorbidities, weaning and decannulation as well as different functional scores at admission and discharge and carried out multivariate analyses by ANCOVA.

RESULTS

Of the patients 248 (82%) were successfully weaned, 155 (52%) decannulated and 75 patients (25%) died of whom 39 (13%) were under palliative treatment. For the survivors (n = 226) we could identify independent predictors of the NMI at discharge from the ERC in the final sex and age-adjusted statistical model: alertness and decannulation were positively associated with the NMI whereas hypoxia, cerebral infarction and traumatic brain injury had a negative impact on cognitive ability. The model justifies 57% of the variance of the NMI (R² = 0.568) and therefore has a high quality of explanation.

CONCLUSION

Because of increased risk of cognitive deficits at discharge of ERC, all patients who suffered from hypoxia, cerebral infarction or traumatic brain injury should be intensively treated by neuropsychologists. Since decannulation is also associated with positive cognitive outcome, a rapid decannulation procedure should also be an important therapeutic target, especially in alert patients.

Factors influencing weaning from mechanical ventilation in neurological and neurosurgical early rehabilitation patients

BACKGROUND

Studies analyzing risk factors of weaning failure in neurological and neurosurgical early rehabilitation (NNER) patients are rare.

AIM

The aim of this study was to identify clinical factors influencing the weaning of NNER patients.

DESIGN

An observational, retrospective data analysis of a German multicenter study was performed.

SETTING

German neurological early rehabilitation centers.

POPULATION

Inpatient ventilated NNER patients (N.=192) were enrolled in the study.

METHODS

Demographical data, main diagnosis, medical devices, special medical care and assessment instruments of functional abilities, consciousness and independence in activities of daily living were accrued and compared between patients with and without successful weaning. The prognostic power of factors associated with weaning success/failure was analyzed using binary logistic regression.

RESULTS

In total, 75% of the patients were successfully weaned. Colonization with multi-drug resistant bacteria and the need for dialysis were independent predictors of weaning failure. Successfully weaned patients had a shorter length of stay, better functional outcome, and lower mortality than non-successfully weaned patients.

CONCLUSIONS

Successfully weaned patients differ from patients with weaning failure in several clinical variables. All these variables are associated with the morbidity of the patient, indicating that the weaning process is strongly influenced by disease burden.

CLINICAL REHABILITATION IMPACT

Functional abilities, level of consciousness, independence in activities of daily living, colonization with multi-drug resistant bacteria, need for dialysis and disease duration might help to predict the weaning process of NNER.

Decannulation of tracheotomized patients after long-term mechanical ventilation - results of a prospective multicentric study in German neurological early rehabilitation hospitals

Background

In the course of neurological early rehabilitation, decannulation is attempted in tracheotomized patients after weaning due to its considerable prognostic significance. We aimed to identify predictors of a successful tracheostomy decannulation.

Methods

From 09/2014 to 03/2016, 831 tracheotomized and weaned patients (65.4 ± 12.9 years, 68% male) were included consecutively in a prospective multicentric observation study. At admission, sociodemographic and clinical data (e.g. relevant neurological and internistic diseases, duration of mechanical ventilation, tracheotomy technique, and nutrition) as well as functional assessments (Coma Recovery Scale-Revised (CRS-R), Early Rehabilitation Barthel Index, Bogenhausener Dysphagia Score) were collected. Complications and the success of the decannulation procedure were documented at discharge.

Results

Four hundred seventy patients (57%) were decannulated. The probability of decannulation was significantly negatively associated with increasing age (OR 0.68 per SD = 12.9 years, p < 0.001), prolonged duration of mechanical ventilation (OR 0.57 per 33.2 days, p < 0.001) and complications. An oral diet (OR 3.80; p < 0.001) and a higher alertness at admission (OR 3.07 per 7.18 CRS-R points; p < 0.001) were positively associated.

Conclusions

This study identified practically measurable predictors of decannulation, which in the future can be used for a decannulation prognosis and supply optimization at admission in the neurological early rehabilitation clinic.

[Prolonged weaning during early neurological and neurosurgical rehabilitation : S2k guideline published by the Weaning Committee of the German Neurorehabilitation Society (DGNR)]

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".

[Costs associated with multiresistant bacteria in neurorehabilitation]

BACKGROUND AND OBJECTIVES

The number of patients with multiresistant bacteria (MRB) in rehabilitation facilities is increasing. The increasing costs of hygienic isolation measures reduce resources available for core rehabilitation services. In addition to the existing lack of care, patients with MRB are at further risk of being given lower priority for admission to rehabilitation facilities. Therefore, the Hygiene Commission of the German Society for Neurorehabilitation (DGNR) attempted to quantify the overall risk for deterioration of rehabilitation care due to the financial burden of MRB.

MATERIALS AND METHODS

To analyze the added costs associated with the rehabilitation of patients with MBR, the DGNR Hygiene Commission identified criteria for a cost assessment. Direct (consumables, personnel and miscellaneous costs) and indirect costs of loss of opportunity were evaluated in seven neurorehabilitation centers in different states across Germany.

RESULTS

On average, hygienic isolation measures amounted to direct costs of 144 € per day (47 € consumables, 92 € personnel, 5 € for other costs such as extra transportation expenditure) and indirect costs of 274 €, totaling 418 € per patient with MRB per day. Given that approximately 10% of patients had MRB, the added costs of hygienic isolation measures equaled about one tenth of the overall budget of a rehabilitation center and can be expected to rise with the increasing numbers of patients with MRB.

CONCLUSIONS

Admission of patients carrying MRB to neurorehabilitation centers triggers added costs that critically diminish the overall capacity for centers to provide their core rehabilitation services.

Outcome of neurological early rehabilitation patients carrying multi-drug resistant bacteria: results from a German multi-center study

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.

[Efficacy of early neurological and neurosurgical rehabilitation : Evidence-based treatment, outcome and prognostic factors]

BACKGROUND

Early neurological and neurosurgical rehabilitation (ENNR) as a complex post-acute form of treatment for patients with severe neurological diseases and continued need for intensive care is well established in Germany.

OBJECTIVE

To assess the efficacy of ENNR from the perspective of evidence-based medicine as well as to present data on the outcome of ENNR patients including the analysis of prognostic factors.

MATERIAL AND METHODS

A search was carried out in PubMed databases to identify early rehabilitation treatment forms evaluated by randomized controlled trials and with respect to large multicenter surveys of outcome and prognostic factors.

RESULTS

For ENNR as a complex treatment concept, effectiveness not has been shown with regard to evidence-based medicine but it includes individually effective treatment forms. In two large multicenter evaluations the average duration of treatment was between 51 and 57 days and mortality was between 6 % and 10 %, increasing with the proportion of mechanically ventilated patients. Lower need for nursing support on admission indicated better outcome, whereas mechanical ventilation was more likely to be associated with poor outcome. Long-term outcome was negatively influenced by mechanical ventilation as well as severe neurogenic dysphagia with and without the need for a tracheal cannula and/or percutaneous endoscopic gastrostomy (PEG) and also by severely impaired communication at the end of ENNR.

DISCUSSION

These prognostic factors indicate the primary aims of ENNR, which are to reduce the need for nursing support and to establish the capability for rehabilitation. If these aims are achieved, favorable functional and long-term outcome can be expected for ENNR patients. The presented studies verify the sustained efficacy of ENNR as an essential part of the overall treatment concept for severely neurologically impaired patients.

Criterion validity and sensitivity to change of the Early Rehabilitation Index (ERI): results from a German multi-center study

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.