中德康復(fù)技術(shù)培訓(xùn)課件)24.06康復(fù)技術(shù)培訓(xùn) 神經(jīng)康復(fù)

1、BDH-Clinic Hessisch Oldendorf,,Prof. Dr. Jens D. RollnikMedical DirectorInstitute for Neurorehabilitation Research (InFo),歡迎,Schedule,,9:30 Welcome-meeting (Prof. Rollnik) 歡迎見面會(huì)9:35Lecture on neurological rehabilit

2、ation in Germany(Prof. Rollnik) 講座---神經(jīng)康復(fù)在德國(guó)10:15Tour of the BDH-Clinic Hessisch Oldendorf (Dr. Lenz and co-workers) 參觀BDH-Clinic Hessisch Oldendorf 11:30Question time (Dr. Lenz) 提問環(huán)節(jié)12:00Lunchtime snack 午餐

3、時(shí)間,,,,,,BDH-Clinic Hess. Oldendorf,,-non-profit organisation非營(yíng)利性組織-Teaching Hospital of Hannover Medical School漢諾威醫(yī)學(xué)院教學(xué)醫(yī)院-Institute for Neurorehabilitation Research (InFo), Medical School Hannover漢諾威醫(yī)學(xué)院神經(jīng)康復(fù)研究所-KTQ-c

4、ertified, certified Stroke Unit優(yōu)質(zhì)-透明-醫(yī)療服務(wù)合作培訓(xùn)中心， 中風(fēng)單元培訓(xùn)中心-113 hospital beds (incl. 25 ICU- and 39 IMC-beds) and 140 rehabilitation beds113 張臨床床位（包括ICU 25張，IMC 39張）康復(fù)床位140張-400 employees 400名員工,New ICU,Investment:10.

5、000.000 €資產(chǎn)投入：一千萬歐元ICU-beds:25 ICU床位： 25,New ICU 全新的ICU病區(qū),New ICU 全新的ICU病區(qū),Neuroimaging – MRI and CT 神經(jīng)影像設(shè)備—核磁及CT,,,,,The six-phase model of the Federal RehabilitationCouncil (BAR, 1994)聯(lián)邦康復(fù)委員會(huì)六級(jí)模式（聯(lián)邦康復(fù)學(xué)會(huì)，1994）,

6、,,,,,Six-phase model of the German Federal Rehabilitation Council 德意志聯(lián)邦康復(fù)委員會(huì)六級(jí)模式,資方主體,健康保險(xiǎn)公司,健康保險(xiǎn)公司,健康保險(xiǎn)公司,私人保險(xiǎn)公司,雇主及私保公司,護(hù)理及健康保險(xiǎn)公司,聯(lián)邦康復(fù)學(xué)會(huì)分段,分段特點(diǎn),急診入院治療,早期康復(fù)巴塞爾量表得分,六級(jí)模式由德國(guó)聯(lián)邦康復(fù)委員會(huì)確立,對(duì)早期康復(fù)影響較大的，急性期，需要密集治療的，包括輔助呼吸病人,康復(fù)分

7、級(jí)仍處在需要高度護(hù)理及醫(yī)療處置期的,康復(fù)分級(jí)處于大部分獲得深度日常獨(dú)立活動(dòng)能力，剩余康復(fù)以后續(xù)治療為主,醫(yī)療專業(yè)康復(fù)達(dá)到2級(jí)，包括門診隨診,長(zhǎng)期維持性看護(hù)，轉(zhuǎn)相關(guān)?？?X,,,,,Phase B (Early Rehabilitation) B級(jí) 早期康復(fù)-admission to neurological and neurosurgical early rehabilitation immediately after acute-

8、care hospital stay神內(nèi)/外科早期入院，急診處理后立即進(jìn)入康復(fù)-patients suffer from disorders of consciousness 意識(shí)障礙病人-patients need mechanical ventilation and monitoring on ICU or IMC wards ICU 或IMC 病房需要機(jī)械通氣及監(jiān)護(hù)的病人-challenge: multiresistant

9、 germs挑戰(zhàn)：多重耐藥性細(xì)菌,,,,,DRG-System: OPS 8-552 診斷相關(guān)分類系統(tǒng),,,,,Phase B – Admission diagnoses B 級(jí) 入院診斷,(Rollnik & Janosch, 2010),早期康復(fù)病例的診斷相關(guān)分類，降序或頻率,診斷相關(guān)分類,比例,男/女,平均年齡,平均住院時(shí)間,腦缺血,顱腦外傷,腦出血,蛛網(wǎng)膜下腔出血,缺氧性損害,腫瘤形成,感染,傳染性疾病,脊髓損傷

10、，截癱,格林巴利綜合癥,其他診斷,總計(jì),,,,,Phase B – Outcome B級(jí) 結(jié)果,(Rollnik und Janosch, 2010),排除類別，降序或頻率,排除類別,轉(zhuǎn)后續(xù)康復(fù),轉(zhuǎn)院,轉(zhuǎn)其他護(hù)理機(jī)構(gòu),常規(guī)轉(zhuǎn)出,死亡,自動(dòng)轉(zhuǎn)出,轉(zhuǎn)臨終關(guān)懷,,,,,(Rollnik, 2013),Phase B – Outcome B級(jí) 結(jié)果,年齡,巴塞爾量表改變,,,,,Phase B – length of st

11、ay (LOS),(Rollnik und Janosch, 2010),病例百分比,住院時(shí)間（月）,住院時(shí)間（病程）,,,,,Phase B – LOS 病程,(Rollnik und Janosch, 2010),平均住院時(shí)間（天）,早期康復(fù)巴塞爾量表得分區(qū)間,,,,,Phase B – Weaning from mechanical ventilation取下呼吸機(jī),(Rollnik et al., 2010),-Mortal

12、ity: 6.1% 死亡-Weaning was successful after a mean of 12.9 (12.0) days of neurological early rehabilitation 早期康復(fù)中，平均12.9±12.0天可以成功取下呼吸機(jī),,,,,Phase B – Mechanical ventilation機(jī)械通氣,(Rollnik et al., 2010),,,,,-Results fr

13、om a multicenter study (Oehmichen et al., 2012) 多中心研究結(jié)果-n=1486, 69.8% weaned successfully 1486例，69.8%成功取下呼吸機(jī),Phase B – Mechanical ventilation機(jī)械通氣,,,,,Phase B – Multiresistant germs多重耐藥細(xì)菌,,,,,-high prevalence of ESBL

14、-producing gram-negative bacteria: 11.8% 大腸埃希菌高發(fā)病率，革蘭氏陰性細(xì)菌11.8%-MRSA prevalence: 11.4% 抗藥性金黃色葡萄球菌發(fā)病率 11.4%SUM: One out of four early rehabilitation patients is colonized with multiresistant germs on admission!

15、小結(jié)：四分之一的早期康復(fù)病人入院時(shí)遭遇多重耐藥菌感染,Phase B – Multiresistant germs多重耐藥細(xì)菌,,,,,Phase B – MRSA and outcome 抗藥性金黃色葡萄球菌 及結(jié)果,,,,,(Rollnik, 2014),Phase B – MRSA and outcome 抗藥性金黃色葡萄球菌 及結(jié)果,抗藥性金黃色葡萄球菌(+),抗藥性金黃色葡萄球菌(-),年齡,住院時(shí)間,早期康復(fù)時(shí)間,全部康

16、復(fù)時(shí)間,共同診斷數(shù),巴塞爾量表得分,轉(zhuǎn)出時(shí)巴塞爾量表得分,入院時(shí)早期康復(fù)指數(shù)得分,傳出時(shí)早期康復(fù)指數(shù)得分,早期功能評(píng)定—營(yíng)養(yǎng),早期功能評(píng)定—面口,早期功能評(píng)定—感覺，運(yùn)動(dòng),早期功能評(píng)定—認(rèn)知,,,,,Phase B – ESBL and outcome 大腸埃希菌 及結(jié)果,(Rollnik, 2015),,,,,Phase C C級(jí)-patients are still dependent on nursing, but the

17、y don`t need ICU or IMC 患者仍需支持護(hù)理，但不需要ICU或IMC-patients cooperate more and more actively 患者日趨活躍，并合作良好,,,,,Phase C C級(jí),,,,,Phase C – diagnoses 診斷,(Rollnik, 2009),,,,,Phase C – Outcome C級(jí) 結(jié)果,(Rollnik, 2009),,,,,Phase C

18、 – Outcome C級(jí) 結(jié)果,(Rollnik, 2009),,,,,Phase C – LOS C級(jí) 病程,(Rollnik, 2009),,MEmbeR-study on medical-occupational rehab 職業(yè)醫(yī)療康復(fù)的研究,-Design of the MEmbeR-study: 研究設(shè)計(jì)Multicenter 多中心Multiple indications

19、(neurological, psychiatric, orthopedics, internal medicine) 多學(xué)科參與 Prospective 預(yù)期,,MEmbeR: Centers 多中心分布,,MEmbeR: Study sample 研究樣本-mean age 34.1 (9.9) y, 113 m, 83 f 平均年齡34.1±9.9歲，男113，女83-LOS: 148.6 (SD=223

20、) days (approx. 5 months), range 10 – 1080 病程：平均148.6天， 標(biāo)準(zhǔn)差223，（約5個(gè)月） 范圍處于10-1080天r=-0.47 (p<0.001),(Rollnik et al., 2014),,MEmbeR: Unfit for work 無法適應(yīng)工作Before: 69.9%, 24 months after rehab only 5

21、.6%康復(fù)前：69.9%，康復(fù)24個(gè)月后僅5.6%,,(Rollnik et al., 2014),,MEmbeR: Jobless 失業(yè)Before: 19.9%, 24 months after rehab: 3.1% 康復(fù)前19.9%，24個(gè)月康復(fù)后3.1%,,,(Rollnik et al., 2014),MEmbeR: Return to work,(Rollnik et al., 2014),24 months af

22、ter medical occupational rehabilitation, 153/196 (78.1%) returned to work!,職業(yè)醫(yī)療康復(fù)24個(gè)月后，78.1%病人回歸社會(huì)工作生活,回歸工作,,Summary-The Federal Rehabilitation Council has established a successful 6-phase model forneurological and

23、neurosurgical patients. 聯(lián)邦康復(fù)委員會(huì)為神內(nèi)/外系統(tǒng)成功推出6級(jí)康復(fù)模式-The BDH-Clinic offers inpatient rehabilitation from phase A (acute-care hospital treatment) to E (medical-occupational rehab) 本中心提供A-E 共五級(jí)康復(fù)-Early rehabilitation allows

24、 rehabilitation of mechanically ventilated and critically illpatients. Weaning is succesful in approx. 70% of cases.早期康復(fù)接受機(jī)械通氣及嚴(yán)重病患 70%可以成功轉(zhuǎn)入下一級(jí)別-The burden of multiresistant germs (MRSA, ESBL) is challenging in neurol

25、ogical early rehabilitation (prevalence on admission: approx. 25%).對(duì)于早期神經(jīng)系統(tǒng)康復(fù)，多重耐藥菌（抗藥性金黃色葡萄球菌、 ESBL 菌）的壓力是一大挑戰(zhàn) （入院病人約25%）-Patients colonized with MRSA or ESBL-producing bacteria have a worse outcome(lower functional

26、status on admission, higher morbidity).抗藥性金黃色葡萄球菌、 ESBL 菌感染病人預(yù)后普遍較差，（入院時(shí)功能狀態(tài)較差，高發(fā)病率）-Medical-occupational rehabilitation helps patients to return to work (two years afterrehab approx. 80% return to work)!職業(yè)醫(yī)療康復(fù)有效幫助患者回歸