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Useful information about working in Rehabilitation Medicine

For all rehabilitation services

Information needed when calling the Rehabilitation Registrar / Rehabilitation Medicine Specialist

  • Patient’s ID information

  • Underlying diagnosis/pathology, investigations, previous findings

  • Current and prior medical/physical/cognitive/behavioural/functional status

  • Interdisciplinary team assessment updates

  • Current medications

  • Patient’s rehab goals and realistic goals to be achieved during inpatient setting

Call for advice regarding

  • Spinal patient pathway/protocols (bowel and bladder management, pressure wound prevention and management, prevention of contractures, management of spasticity, DVT prophylaxis, therapy interventions, management of hypotension, education and management of Autonomic Dysreflexia). Please contact ASRU.

  • Amputee management to prevent complications like joint contractures, stump care, pain management (both phantom and nociceptive stump pains) etc. If there are any concerns regarding optimal surgical level pre-operatively, this can be discussed with a rehab specialist. Pre- and post-surgery patient counselling and education can be very useful and is advisable and this can be discussed with Peke Waihanga Artificial Limb Service.

  • Acute management of acquired brain injury (ABI) related cognition and behavioural concerns. Please contact Liaison Psychiatry for advice (ABI will have role in rehabilitation and can give advice).

  • Rehabilitation strategies to help prevent short-term and long-term complications (especially poststroke) e.g. spasticity management, pressure sores, joint contractures, positioning, UTIs, faecal retention, renal/bladder complications, upper/lower limb resting splints, etc.

  • Suitability for inpatient vs. outpatient rehabilitation. Rehabilitation can assist with safe transition to home. Early involvement of the Allied Health team (physiotherapist, occupational therapist, speech and language therapist and social worker) is imperative to assist with discharge planning.

  • There is a significant psychological impact on patients (and their families) with a newly acquired disability. Careful attention should be paid not only to physical, but also to psychological/counselling support for the patient and the family.

Admission Criteria

Eligibility for Adult Rehabilitation (Ward 51)

  • Adults aged 16-64 residing in ADHB and WDHB catchment areas that would benefit from a comprehensive rehabilitation programme following accident, illness or injury resulting in complex cognitive and/or physical deficits.

  • Medical/psychological stability, stable discharge destination, patient motivation and consent from patient /families are important pre-requisites for consideration of inpatient rehabilitation.

  • Appropriateness for inpatient rehabilitation is determined by the triage team led by the Rehabilitation Medicine Physician.

Referral management

Outpatient clinic referrals can be made via electronic referral.

Eligibility for Auckland Spinal Rehabilitation Unit (ASRU)

Persons 15 years of age and older who have an acquired spinal cord impairment through either an accident or medical condition. Individuals must be medically able to participate in comprehensive and interdisciplinary spinal rehabilitation. This is a regional service from Taupo to Gisborne and all areas north.

Referral management

For all referral queries, contact Admissions Coordinator or Consultant.

Eligibility for ABI Rehabilitation Service

Any person aged 16 and over with a moderate to severe brain injury as the primary diagnosis. This includes TBI, hypoxic brain injury or stroke. ABI Auckland covers the Waikato, Auckland region and Northland DHBs. Persons with mild to moderate traumatic brain injury (concussion) who are to be discharged may be referred to the Concussion Clinic for outpatient community assessment and therapies.

Clinical stability for transfer to ABI

These patients should be medically stable enough to be managed in a step-down rehabilitation environment i.e. no active infection or bleeding, not on a ventilator, stabilised fractures, little likelihood of neurosurgical or other specialist surgical intervention.

However, note ABI routinely look after persons with lowered levels of consciousness and agitation as well as those with tracheostomies and PEGs.

Referral management

Phone the Brain Injury Nurse Specialists. Useful information to have available is age of client, nature of injury, current hospital and likely funder (ACC, Health, Private, Other).

Or contact Registrar or Consultant.

Eligibility for Adult/Neuro Rehabilitation Unit, Ward 23, Middlemore Hospital

https://www.healthpoint.co.nz/public/neurology/counties-manukau-health-adult-general-rehabilitation/

Persons aged 16-64 who have experienced neurological, cognitive and/or physical deficits following accident, illness or injury. Individuals must be medically able to participate in comprehensive and interdisciplinary rehabilitation.

Referral management

All internal inpatient referrals for inpatient rehab are through Task Manager on Clinical portal.

E-referral portal is available for GPs and other DHBs. These may change in accordance with Health NZ policies & protocols in future.

Who to contact

Management tips for common rehabilitation issues

Acquired Brain Injury

  • ABI patients (traumatic, non-traumatic or hypoxic) have special environmental needs (dark, quiet single room, minimal stimulation, orientation cues, etc).

  • Avoidance of both physical and mental over-activity (fatigue management) is paramount as this can lead to more cognitive, behavioural and physical deterioration.

  • Patient and families/friends need proper education.

  • Avoid sedatives (unless clearly indicated). Sodium valproate (200 mg bd to tds) can be useful for agitation/restlessness and behavioural difficulties and has less undesirable side effects than medications like haloperidol and benzodiazepines.

Amputees

  • Rigid Removable Dressing (RRD) applied immediately post-operatively is preferable to stump bandaging for amputees as it controls oedema more effectively, promotes early healing and offers protection for the stump (consult with the surgeon in charge first for wound appropriateness for RRD use).

  • Manage stump pain adequately with analgesia (including opiates/tramadol for severe pain).

  • Phantom pain responds well to amitriptyline, starting at 10 mg nocte (caution: may cause sedation and increase risk of falling). Add/change to gabapentin / pregabalin if amitriptyline is not able to control pain.

  • Beware of risk of falls while transferring in the early post-operative period.

Stroke patients

  • Taiao Ora / Ward 51 at Auckland Hospital and Adult Neuro Rehabilitation Unit at Middlemore Hospital follow the same guidelines for management and prevention strategies as the acute Stroke Units at Auckland City Hospital and Middlemore Hospital.

  • Special attention to preventive strategies. Liaise with Physiotherapists/Occupational Therapists regarding splints (elbow/wrist/ankle) to prevent joint deformity and tendon shortening, elbow support (e.g. with a pillow) at all times to prevent shoulder pain/subluxation and regular stretching of the affected joints to avoid contractures. Nursing skin cares to prevent pressure sores (especially sacrum and heels); consult with Occupational Therapists regarding best mattress/cushion to aid with management/prevention of pressure sores.

  • DVT prophylaxis – Early mobilisation and maintenance of hydration can help prevent DVT post stroke. Use of graduated compression stockings is not recommended. Low-molecular-weight heparin can be considered if cleared by Neurology, Neurosurgery or the Stroke Service. • Avoid constipation/impaction – this is often overlooked. Maintain daily bowel regimen with medication as needed.

Spinal Cord Injury (SCI) patients

Bladder

  • Monitor renal/bladder function by keeping a urine flow chart, check urine concentration, check bladder scan for post-void residual volumes; overall ability to pass urine.

  • Encourage adequate hydration (generally 2+ litres/24h).

  • Catheterise if urinary retention (volume >100 mL).

  • If unable to pass urine, catheterise by intermittent catheterisation.

  • "Uri-tip" (external catheter) for males with urinary incontinence and with residual bladder volume less than 100 mL.

  • Place indwelling catheter only as a last resort as persons with indwelling catheters have the highest rate of urinary tract infections.

  • For clarification regarding bladder issues, contact ASRU Admissions Coordinator via ASRU reception.

Bowel

  • Bowel to be managed with flaccid regime (lower motor neurone lesion/all cases spinal shock) or reflexic regime (upper motor neurone lesion) as per spinal protocol.

  • For clarification regarding bowel issues, contact ASRU Admissions Coordinator via ASRU reception.

Skin / decubitus / pressure ulcer prevention

  • Regular turning q2h initially then if tolerated, q3-4h taking necessary SPINAL PRECAUTIONS and with close skin observation.

  • Positioning with close skin observation.

  • Maintain dry skin, avoid urinary and faecal contact.

  • Heel protection (position heels off ALL surfaces or use heel protection/ankle positioning boots/splints which maintain heel off surface).

  • Patient and family education.

DVT prophylaxis

  • Subcutaneous Low Molecular Weight Heparin (enoxaparin).

  • Pneumatic compression.

  • TEDS.

  • Those with spinal fractures should be managed as per spinal surgeon’s advice, keeping in mind the basic rehabilitation principles of dealing with SCI as listed above.