Development of Minimal Clinical Pathway for TBI Rehabilitation program in Saudi Arabia.

Sultan Bin Abdulaziz Humanitarian City is a new, unique and dynamically developing Rehabilitation Hospital in Saudi Arabia with JCIA and CARF accreditations, aspiring to be a Centre of excellence and a model for other facilities in the Middle East. It has 450 beds inpatient and outpatient services including Brain Injury, Stroke, Spinal Cord Injury, Pediatric, Surgical, Amputee and General Rehabilitation programs utilizing all rehabilitation related professions.

1 500 Employees 27 Nationalities

Czech RepublicIndiaPhilippines KSA Jordan South Africa

Kenya

Malaysia

PakistanPalestine Sudan CanadaEgypt USA

Eritrea KoreaAustralia New Zealand Algeria China

LebanonYemenUKSyria NetherlandsBangladesh Russia

Our therapy team members are coming to work here from many countries and are communicating in different versions of English in Arabic speaking environment.

Facing some communication challenges related to different cultural and educational backgrounds of employees, we made an attempt to develop a Clinical Pathway for TBI rehabilitation program adjusted to this special situation. Main goal is to facilitate precise mutual understanding and standardization of evaluation and therapy.

• Clinical pathway by definition is a Multidisciplinary management tool based on evidence-based practice for a specific group of patients with a predictable clinical course, in which the interventions by the professionals involved in the patient care are defined, optimized and sequenced. Outcomes are tied to specific interventions.

• Clinical pathways might be a useful tool for coordination and standardization of therapeutic efforts across multidisciplinary team.

• Clinical Pathways for TBI Rehabilitation are not yet widely documented and available for clinical practice and difficult to find in literature and on the web.

OBJECTIVES:• We are aspiring to present our approach to the development of

Minimal TBI Rehabilitation pathway adjusted to special conditions of growing rehabilitation infrastructure and multinational therapy team.

CHALLENGES - FINDING A RIGHT WAY FOR THE PATHWAY• Clinical pathway is supposed to work with homogenous group of

patients with same or similar clinical problems and predictable clinical course and outcome.

• Our TBI rehabilitation program is unique in the region. Case mix of our TBI patients is largely heterogeneous regarding functional impairment and time passed from the injury.

• Clinical course of TBI rehabilitation in time is predictable only in general and with large inter individual variations regarding progress of functional recovery

• PROPOSED METHODS TOWARDS RESOLVING OF CHALLENGES:

• Main goal of our team was to achieve SIMPLICITY in description of even such a complex task as rehabilitation of patients after Traumatic brain injury.

• The Minimal Pathway in our understanding generally should:

• 1. Identify and describe patient problems related to every therapist profession in standardized terminology understandable to all team members - Evaluation

• 2. Identify a way if available, to improve patient condition or situation - Therapy planning

• 3. Evaluate if it works - Monitoring and feedback, and define when and how to progress to the next step once a particular goal is achieved

• 4. Coordinate therapy with other team members by sharing information through Hospital information system - Recording

• 5. And finally make a final evaluation of achieved results and discharge the patient - Discharge planning, with continuous outpatient or home therapy program and readmissions.

• PROPOSED SOLUTIONS ARE ADJUSTED TO SPECIFIC CONDITIONS:• Available treatment possibilities in Sultan Bin Abdulaziz Humanitarian City

considering also current economic, environmental and cultural conditions in Saudi Arabia in AH 1435. (2014 Gregorian) with:

• Unique natural conditions with extreme climate• Long distances between urbanized areas• Society focused on spiritual development beside technological advance• Specific stratification of the community in Saudi Arabia• Good ability of families and extended families to provide long term care and

support for the impaired family members and carry on home based therapy program

• Limited accessibility of outpatient, community based and home health care services

• Limited network of professional, vocational and community reentry services• Limited capacity of available inpatient rehabilitation services• Case mix of our patient with predominantly severe functional impairment and

limited mobility.

To overcome a problem of case to case variability we are proposing Case mix groups related to the time passed from the injury in months correlated with severity of impairment based on FIM score.To overcome a problem of large variability in type and severity of impairment and limited predictability of outcomes we are proposing detailed Individual problem oriented evaluation method with continuous feedback, recording changes during therapy interventions and Individual rehabilitation therapy plan with assignment of therapeutic resources appropriate to changing situation.Based on experiences and available resources we are proposing Common General long term rehabilitation plan.

TBI Case mix groups Based on empirical experience with 850 TBI cases from 2006-2013

• 1. INITIAL STAGE with time from the injury between 3-12 months.• a/ Severe impairment initial FIM on first admission 18-54• b/ Moderate impairment initial FIM on first admission 55-90• c/ Light impairment initial FIM on first admission 91-126

• 2. SUBACUTE STAGE with time from the injury 12-24 months.• a/ Severe impairment initial FIM on first admission 18-54 • b/ Moderate impairment initial FIM on first admission 55-90• c/ Light impairment initial FIM on first admission 91-126

• 3. CHRONIC STAGE with time from the injury over 24 months.• a/ Severe impairment initial FIM on first admission 18-54• b/ Moderate impairment initial FIM on first admission 55-90• c/ Light impairment initial FIM on first admission 91-126

Problem oriented evaluation of individual Patient impairments

Proposed Evaluation form is generating following Numerical data for comparison and statistical evaluation and is giving basic guidance in assignment of therapeutic interventions• Age• Sex (code)• Length of stay• Number of previous admissions• Region where he is coming from (code)• Time from beginning of the disease/impairment• ICD (code)• Modified Rankin Scale• FIM cognitive• FIM motoric• FIM total• Distance Walked • Distance traveled in Wheelchair• Mini Mental Status score• Clinical Outcome Variables Scale• 2 Minute Walk Test• Berg Balance Scale• Brief ICF Core Set for Traumatic Brain Injury score

Individual rehabilitation plan with assignment of therapeutic resources appropriate to particular situation with continuous feedback in 7 steps

• 1. Evaluate the patient using the Evaluation form

• 2. Assign appropriate therapeutic intervention to every impairment from the list of Therapeutic interventions units

• 3. Re-evaluate the patient after every two weeks using the Evaluation form

• 4. If improvement is found by your measurements, continue with the same therapy

• 5. If possibility to train new function is gained by this improvement, assign new more demanding therapy intervention from the list of Therapeutic interventions units

• 6. If no more improvement is found by your measurements, stop the therapy

• 7. Continue with adjustment strategies on the impairment, prescription of appropriate equipment and social adjustment on the handicap

Common general long term rehabilitation plan based on TBI case mix groupsINITIAL STAGE with time from the injury between 3-12 months.

Severe impairment initial FIM on first admission 18-54First admission 12 weeks – intensive home or ODP program

for three months– First readmission for 4 weeks three months from the first discharge – intensive home or OPD program for three months – Second readmission for 4 weeks three months from the second discharge – intensive home or OPD program for three months –

Third readmission for 4 weeks three months from the second discharge – home or 2x weekly OPD program for six months – Fourth readmission six months from the third discharge - home or OPD program for six months – Fifth readmission six months from the fourth discharge - home or OPD program for six months – sixth readmission six months from the fifth discharge.

Moderate impairment initial FIM on first admission 55-90First admission 8-12 weeks – intensive home or OPD

program 3 x weekly 3 hours PT,OT, SLP (or intensive home program) for three months - First readmission for 4 weeks three months from the first discharge - intensive home or OPD program 2 x weekly 3 hours PT,OT, SLP for three months – Second readmission for 4 weeks three months from the second discharge - intensive home or OPD program 2 x weekly 3 hours PT,OT, SLP for six months – Third readmission for 2 weeks after six months.

Light impairment initial FIM on first admission 91-126First admission 4-12 weeks – intensive home or OPD

program 3 x weekly 3 hours PT,OT, SLP for three months - First readmission for 4 weeks three months from the first discharge.

SUBACUTE STAGE with time from the injury 12-24 months.

Severe impairment initial FIM on first admission 18-54First admission - 12 weeks – intensive home or OPD

program for three months – First readmission for 4 weeks three months from the first discharge – intensive home program for six months – Second readmission for 4 weeks six months from the second discharge – intensive home program for six months – Third readmission for 4 weeks six months from the second discharge – home and community program for six months – Fourth readmission six months from the third discharge - home and community program for six

months – Fifth readmission six months from the fourth discharge.

Moderate impairment initial FIM on first admission 55-90First admission 8-12 weeks – OPD program 2 x weekly 3

hours PT,OT, SLP (or intensive home program) for six months - First readmission for 4 weeks six months from the first discharge - OPD program 2 x weekly 3 hours PT,OT, SLP (or intensive home program) for six months – Second readmission for 2 weeks six months from the second discharge.

Light impairment initial FIM on first admission 91-126First admission 4 weeks – OPD or home program 2 x weekly

3 hours PT, OT, SLP for six months - First readmission for 2 weeks six months from the first discharge.

Severe impairment initial FIM on first admission 18-54• First admission 12 weeks – intensive home or OPD program for three

months – First readmission for 4 weeks three months from the first discharge – intensive home program for six months – Second readmission for 4 weeks six months from the second discharge – intensive home program for six months – Third readmission for 4 weeks six months from the second discharge – home and community program for six months – Fourth readmission six months from the third discharge - home and community program for six months – Fifth readmission six months from the fourth discharge.

CHRONIC STAGE with time from the injury over 24 months.

Severe impairment initial FIM on first admission 18-54First admission 4-8 weeks – home program for six months -

First readmission if indicated for 4 weeks six months from the first discharge – home program for six months – Second readmission for 4 weeks six months from the second discharge – home program for six months – Third readmission for 4 weeks six months from the second discharge – home and community program for 12 months.

Moderate impairment initial FIM on first admission 55-90First admission 4-8 weeks – OPD program if needed 2 x

weekly 2 hours PT, OT (or intensive home program) for six months - First readmission if indicated for 4 weeks six months from the first discharge - intensive home program for six months.

Light impairment initial FIM on first admission 91-126First admission 4 weeks – OPD or home program 2 x weekly

2 hours PT, OT, for three months

Thank you for your attention in the name of all contributors

• Jiri Pazdirek• Sadia Misbach• Abdulaziz Al Hraibat• Mona Bakhet• Martin Muriuki• Daniel Ruhiu• Rozliza Mudarshah• Sze Ling Chai• M.Tahar Si Larbi

With best wishes from the country of breathtaking contrasts…