Principles of Care for Complex Injuries and Multi-System Conditions

Original Editor - User Name

Top Contributors - Wanda van Niekerk and Jess Bell  

Introduction

Introduction

Definition of complex injuries and conditions

Complex injuries – situations where patients have multiple, often interrelated, health issues that require a comprehensive and coordinated approach to rehabilitation

Types of complex injuries and conditions

Multiple trauma or Polytrauma - Iyengar KP, Venkatesan AS, Jain VK, Shashidhara MK, Elbana H, Botchu R. Risks in the Management of Polytrauma Patients: Clinical Insights. Orthopedic research and reviews. 2023 Dec 31:27-38.

-         The presence of 2 or more injuries to physical regions or organ systems, one of which may be life threatening, resulting in physical, psychological or psychosocial impairments or disability. Al Hanna R, Amatya B, Lizama LE, Galea MP, Khan F. Multidisciplinary rehabilitation in persons with multiple trauma: a systematic review. Journal of Rehabilitation Medicine. 2020 Oct 2;52(10):1-9.

-         Berlin definition - Polytrauma is defined as patients with an Abbreviated Injury Scale (AIS) ≥3 for two or more different body regions with one or more additional features from five physiologic parameters of age, consciousness,

-         hypotension, coagulopathy, and acidosis. - Iyengar KP, Venkatesan AS, Jain VK, Shashidhara MK, Elbana H, Botchu R. Risks in the Management of Polytrauma Patients: Clinical Insights. Orthopedic research and reviews. 2023 Dec 31:27-38.

Limb loss

Complex pain conditions, such as fibromyalgia and complex regional pain syndrome Taylor SS, Noor N, Urits I, Paladini A, Sadhu MS, Gibb C, Carlson T, Myrcik D, Varrassi G, Viswanath O. Complex regional pain syndrome: a comprehensive review. Pain and Therapy. 2021 Dec;10(2):875-92.

Multi-system challenges – patients with multiple medical issues such diabetes, heart disease, hypertension

Chronic illness, cancer, communicable diseases - Kudre D, Chen Z, Richard A, Cabaset S, Dehler A, Schmid M, Rohrmann S. Multidisciplinary outpatient Cancer rehabilitation can improve Cancer patients’ physical and psychosocial status—a systematic review. Current oncology reports. 2020 Dec;22:1-7.

Neurological injuries – traumatic brain injuries, stroke Wagner AK, Franzese K, Weppner JL, Kwasnica C, Galang GN, Edinger J, Linsenmeyer M. Traumatic brain injury. InBraddom's Physical Medicine and Rehabilitation 2021 Jan 1 (pp. 916-953). Elsevier.

Cognitive and psychological challenges – depression, anxiety, post-traumatic stress disorder

Other relevant conditions, genetic disorders, autoimmune diseases, age-related decline

Prevalence of complex injuries and conditions

Causes of complex injuries and conditions

Trauma – road traffic accidents, falls, sports, acts of violence

Chronic conditions – diabetes, heart diseases, autoimmune disorders.

Aging

Genetic factors – muscular dystrophy Iftikhar M, Frey J, Shohan MJ, Malek S, Mousa SA. Current and emerging therapies for Duchenne muscular dystrophy and spinal muscular atrophy. Pharmacology & Therapeutics. 2021 Apr 1;220:107719.

Environmental factors – air pollution or exposure to environmental hazards Meghji J, Mortimer K, Agusti A, Allwood BW, Asher I, Bateman ED, Bissell K, Bolton CE, Bush A, Celli B, Chiang CY. Improving lung health in low-income and middle-income countries: from challenges to solutions. The Lancet. 2021 Mar 6;397(10277):928-40.

Lifestyle choices Mintzer J, Donovan KA, Kindy AZ, Lock SL, Chura LR, Barracca N. Lifestyle choices and brain health. Frontiers in medicine. 2019 Oct 4;6:204.  – poor diet, physical inactivity Katzmarzyk PT, Friedenreich C, Shiroma EJ, Lee IM. Physical inactivity and non-communicable disease burden in low-income, middle-income and high-income countries. British journal of sports medicine. 2022 Jan 1;56(2):101-6., substance use - Shearer RD, Howell BA, Bart G, Winkelman TN. Substance use patterns and health profiles among US adults who use opioids, methamphetamine, or both, 2015-2018. Drug and alcohol dependence. 2020 Sep 1;214:108162.

Socioeconomic impact of complex injuries and conditions

Healthcare costs – for the individual and the healthcare system Khan F, Amatya B, Hoffman K. Systematic review of multidisciplinary rehabilitation in patients with multiple trauma. Journal of British Surgery. 2012 Jan;99(Supplement_1):88-96.

Loss of productivity and income -  Haas B, Jeon SH, Rotermann M, Stepner M, Fransoo R, Sanmartin C, Wunsch H, Scales DC, Iwashyna TJ, Garland A. Association of severe trauma with work and earnings in a national cohort in Canada. JAMA surgery. 2021 Jan 1;156(1):51-9.

Social stigma and isolation - Ross E, Crijns TJ, Ring D, Coopwood B. Social factors and injury characteristics associated with the development of perceived injury stigma among burn survivors. Burns. 2021 May 1;47(3):692-7.

Educational and vocational challenges Soberg HL, Roise O, Bautz-Holter E, Finset A. Returning to work after severe multiple injuries: multidimensional functioning and the trajectory from injury to work at 5 years. Journal of Trauma and Acute Care Surgery. 2011 Aug 1;71(2):425-34.

Family and caregiver burden Kjeldgaard A, Soendergaard PL, Wolffbrandt MM, Norup A. Predictors of caregiver burden in caregivers of individuals with traumatic or non-traumatic brain injury: A scoping review. NeuroRehabilitation. 2023 Jan 6(Preprint):1-20. Perfetti AR, Jacoby SF, Buddai S, Kaplan LJ, Lane-Fall M. Improving post-injury care: key family caregiver perspectives of critical illness after injury. Critical care explorations. 2022 May;4(5).

Quality of life - Angerpointner K, Ernstberger A, Bosch K, Zeman F, Koller M, Kerschbaum M. Quality of life after multiple trauma: results from a patient cohort treated in a certified trauma network. European journal of trauma and emergency surgery. 2021 Feb;47:121-7.

Principles of Care

Person-centred approach

Person-centred care means that the patient is treated as an individual and as an equal partner in their healing, rehabilitation and recovery. It is a personalised, coordinated and enabling approach. Coulter A, Oldham J. Person-centred care: what is it and how do we get there?. Future hospital journal. 2016 Jun;3(2):114.

Build a therapeutic alliance with the patient

Establishing meaningful connections between the patient and rehab professional results in all parties being seen, heard and appreciated. Ways that rehab professionals can establish these connections are: Hutting N, Caneiro JP, Ong'wen OM, Miciak M, Roberts L. Patient-centered care in musculoskeletal practice: Key elements to support clinicians to focus on the person. Musculoskeletal Science and Practice. 2022 Feb 1;57:102434.

Acknowledge the individual

Rehabilitation professionals meet the patient as an equal, validate their experience and individualise treatment

For example, sit at the patient’s level, affirm the patients expression of emotion, adapt the rehabilitation programme through consideration of the patient’s unique circumstances.

Use the body as a pivot point

The rehabilitation professional can explain the patient’s physical problems and explain the treatment plan or solution. They are in a position to facilitate the patient’s connection to their body/

For example, providing the patient with clear explanations of the assessment findings, carefully handling the patients affected body regions

Giving of self

This is the extra mile that rehabilitation professionals goes to help their patients when its needed, this can be inside or outside of the clinical interaction.

For example, the rehab professional shares a part of their life or experiences if and when appropriate and consults with the patient’s other healthcare providers.

Understand the patient’s goals and values

Empowerment of patients to participate in their care

Rehab professionals can support patients in self-management of their condition through goal setting, shared-decision making, action planning and forming partnerships

Challenges to person-centered care in low- and middle-income countries may include:

Inadequate human resources

Inadequate budget and finances

Poor leadership and management

Implementation of person centred care in clinical practice

Incorporate the patient’s perspectives as part of the rehabilitation process

Pay attention to what you communicate and how you communicate

Encourage patient involvement during the examination and management creating a personalised plan that is considerate of the patient’s context

Rehab professionals are encouraged to reflect on their own beliefs and practice through peer review or self-reflective questions such as Is my communication effective with patients, Is my consult long enough to implement a person-centered approach? https://www.sciencedirect.com/science/article/pii/S2468781221001181#sec3

Read more: Therapeutic Alliance  (PP link)

Interdisciplinary team approach

Within an interdisciplinary team approach rehabilitation professionals from different disciplines work together and there is overlap in their practice (instead of each person working individually) with shared goals coordinated into a unified management plan. Team members in an interdisciplinary team build on each other’s expertise to achieve common, shared goals. Mukpradab S, Mitchell M, Marshall AP. An Interprofessional Team Approach to Early Mobilisation of Critically Ill Adults: An Integrative Review. International Journal of Nursing Studies. 2022 Feb 18:104210. Patient progress is communicated through written documentation and regular team meetings focused on the common overall patient goals. Interdisciplinary care plans are generally developed through consideration of these questions: Ferguson, M. Multidisciplinary vs. Interdisciplinary Teamwork: Becoming a More Effective Practitioner. 2014 Available from: http://www.socialworkhelper.com/2014/01/14/multidisciplinary-vs-interdisciplinary-teamwork-becoming-effective-practitioner/ (Accessed 2 October 2018).

What are the issues?

Who will be involved?

What will the interventions be?

What are the goals of the intervention?

When will re-evaluation occur?

Interdisciplinary teams are common in inpatient rehabilitation centres and involve:

Professionals involved in joint problem solving

Overlapping, patient-focused treatment goals

Collaboration with other disciplines

Regular communication between team members

Active involvement of the patient

Balancing urgent treatment with comprehensive care

Read more: Rehabilitation Teams; Characteristics of Successful teams; Barriers to effective teams

Collaborative goal setting

Setting realistic and achievable goals with the patient

Developing a plan to achieve these goals

Person-centered and collaborative goal setting leads to improved outcomes and patient satisfaction. Goal setting provides a way to incorporate the patient’s perspectives and desires. Brown J, Ackley K, Knollman-Porter K. Collaborative goal setting: A clinical approach for adults with mild traumatic brain injury. American Journal of Speech-Language Pathology. 2021 Nov 4;30(6):2394-413.

Read more: Goal Setting in Rehabilitation

Continuity of care and communication

Coordinating care across different settings

Providing clear and timely communication to the patient and their family

https://apps.who.int/iris/bitstream/handle/10665/274628/9789241514033-eng.pdf?ua=1

Ljungolm et al suggests a care continuity model with six interconnected concepts to achieve continuity of care in patients with complex care needs and their families/ carers.  Ljungholm L, Klinga C, Edin‐Liljegren A, Ekstedt M. What matters in care continuity on the chronic care trajectory for patients and family carers?—A conceptual model. Journal of Clinical Nursing. 2022 May;31(9-10):1327-38.

These concepts are:

Time and space

Tailored information

Mutual understanding

Clarity in responsibilities and roles

Interprofessional collaboration

Trusting relationships

Patients and families feel that time is crucial in the continuity of care. It takes time to create and strengthen relationships with different members of the interdisciplinary team and access to tailored information is key for mutual understanding to develop. For this to happen, clarity in responsibilities and roles, interprofessional collaboration and cultivating a trusting relationship between all of these are required. Ljungholm L, Klinga C, Edin‐Liljegren A, Ekstedt M. What matters in care continuity on the chronic care trajectory for patients and family carers?—A conceptual model. Journal of Clinical Nursing. 2022 May;31(9-10):1327-38.

Function-focused care

Function focused care analyses the patient’s underlying capabilities for function and physical activity and helping the patient to optimise and maintain these functional abilities. It is often used to develop the highest possible level of self-care and independence in patients. Kim MS, Lee SJ, Park MS, Jeong EH, Chang SO. Toward a conceptual framework for the interdisciplinary function‐focused care in nursing homes. Japan Journal of Nursing Science. 2020 Jul;17(3):e12330. A function-focused approach involves:

Emphasising functional outcomes and quality of life

Addressing physical, cognitive and psychosocial aspects of rehabilitation

Considering the impact on participation (quality of life, community and social engagement, self-care, work/employment)

Monitor progress and adjust the care plan as needed

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