please note: the following text is not a complete translation but a gist translation of the original german article „Phaseneinteilung neurologischer Krankheitsprozesse“
PHASES OF NEUROLOGICAL ILLNESS
1. General Introduction:
• Neurological illnesses are seen as processes during which diverse neurorehabilitative activities are necessary. Thus a split into phases is useful for adjusting neurorehabilitation to the changing needs of the patient (see also Part 2 of this proposal). Further, the requirements (quality criteria) for institutions dedicated to neurological rehabilitation are to be defined.
• The following notes are based on the WHO model of functioning, disability and health.
• Each neurological illness must be seen as an individual process specific to a person and all interventions have to focus on the wellbeing of the individual.
• The split of neurological processes into individual phases is random but should serve to help with the planning and equipping of care centres like hospitals, stroke units, rehabilitation clinics and centres for out-patient rehabilitation. The change from one phase into the next is normally fluid. A patient does not always have to go through each phase and switching between phases is also possible within a process of illness.
• The criteria used for each phase are as clear and comprehensible as possible. The functional state, the ability to cooperate, the requirements to maintain vital function, additional illnesses as well as individual problems have to be taken into account.
• In each phase of the illness process their could be a need for “acute neurological“ or “neurorehabilitative“ treatment. Different weighting is partly predictable. During the entire illness process a strict division between diagnostics and therapy is not necessary but the extent of diagnostic procedures will be particularly big at the beginning of the illness process.
• The timing of the individual phases of neurological illness can in most cases not be predicted as there is such an amount of different neurological illnesses.
• Care has to be delivered by an interdisciplinary team. This team has to focus on problems and change the focus of treatment accordingly in the course of the illness process.
• In which institution the most appropriate care can be delivered depends on the quality of their staff and equipment. In any case the institutions have to fulfil structural quality criteria which are still to be defined, if they intend to take on the care of patients in particular phases of the illness process.
• Specific disorders, in particular accompanying illnesses, but also individual resources of patients can be as decisive as psychosocial factors and regional circumstances to take an unusual course of treatment (which is not in the typical sense of care according to the phases)
• An Austrian „phase model“ should be comparable with other European models, in particular with the neighbouring German speaking countries, so as to promote comparability and to enable scientific evaluation of treatment results.
2. Phase model of neurological illness processes:
• Phase A: Each acute neurological illness or acute deterioration of chronic illness is classified as Phase A during the first treatment days, as it requires a specific extent of diagnostic or acute therapeutic measures, possibly intensive care treatment. There are often grave accompanying illnesses, head trauma occurs frequently as part of a polytrauma. Therefore the complete infrastructure of acute care hospitals or specialised hospitals is very often necessary to treat the patient adequately during phase A.
• Phase B: The patient intermittently has a reduced level of consciousness, the ability to cooperate is not given or is severely impaired. Regarding the activities of daily living the patient is dependent on care. She does not need constant respiratory treatment, complications are frequent, as is the possibility for the condition to worsen from time to time so that intensive care incl. of respiration can be necessary.
• Phase C: The patient is conscious, at least partly oriented, and can participate in therapy for a minimum of three hours per day. The patient is at least independent in some ADLs. Normally there is no danger of aspiration, the patient depends however to a significant extend on professional nursing care. Accompanying illnesses and injuries must not interfere with the necessary therapeutic measures. The patient must not be danger to himself or others.
• Phase D: The patient is largely independent in the activities of daily living, s/he possibly needs some technical aid. The patient is able to participate in therapy physically and mentally for several hours a day. S/he is cooperative and is able to be without professional supervision for several hours during the day.
• Phase E: The patient is able to plan, organise and conduct everyday life and leisure activities for several days without help. Neurorehabilitative measures are however necessary in order to achieve the following goals: extending and stabilising or maintaining achievements in therapy, returning to work, acquiring a variety of social competences.
3. Notes on special circumstances:
In each phase stagnation or a chronification of the illness process can occur.
This means in phase A the patient remains in continuous need of respiration.
In phase B it means that the patient remains in the state of a reduced level of consciousness, that complications (e.g. aspiration) can occur constantly and that therefore therapeutic success cannot be attained, that severe neurological deficits prevent that even basic activities of daily living can be conducted by the patient, or that even basic mental functions do not improve.
Regarding phase C it should be added that the patient might possibly be a danger to him-/herself or others, therefore a closed psychiatric ward may be necessary.
Recommendations of the OeGNR for staff in departments for neurological rehabilitation
The following staff resources should be standard for departments of neurorehabilitation:
Staff requirement per bedPhase B0,2 (2)s.u. (3)1,50,50,050,0250,05 medical doctors (1)neuro-psychologistsnurses (4)therapists (total number) (5)medical technical assistants (6)social workersdepartmental secretaries (7)Phase C0,10,050,70,510,050,0250,05Phase D0,0750,0670,330,50,020,050,05Die Berufsbezeichnungen gelten jeweils für beide Geschlechter
1 At least 50% have to be medical doctors specialised in neurology; the head of department is not included but has to be a senior neurologist in any case.
2 During Phase B a medical doctor specialised in neurology has to be available for 24h a day.
3 During Phase B neuropsychological diagnostics and psychological care (also for the relatives) has to be sufficiently available.
4 At least 75% of nursing staff have to be qualified nurses.
5 „Therapists“ are understood to be exclusively members of the higher level paramedical professions, such as: physiotherapists, occupational therapists, speech and language therapists, orthoptists, special education professionals or comparable professions.
6 Medical-technical assistants conducting general and specific diagnostics.
7 Staff for medical, nursing and therapeutic documentation. Personal assistants are not included.
Österreichische Gesellschaft für Neurorehabilitation | Hermanngasse 18/1/4, 1070 Wien