中德康復(fù)技術(shù)培訓(xùn)2406康復(fù)技術(shù)培訓(xùn)神經(jīng)康復(fù)課件

BDH-ClinicHessischOldendorfProf.Dr.JensD.RollnikMedicalDirectorInstituteforNeurorehabilitationResearch(InFo)歡迎BDH-ClinicHessischOldendorfP1Schedule9:30 Welcome-meeting(Prof.Rollnik)歡迎見面會9:35 LectureonneurologicalrehabilitationinGermany (Prof.Rollnik)講座---神經(jīng)康復(fù)在德國10:15 TouroftheBDH-ClinicHessischOldendorf(Dr.Lenzand co-workers)參觀BDH-ClinicHessischOldendorf11:30 Questiontime(Dr.Lenz)提問環(huán)節(jié)12:00 Lunchtimesnack午餐時間Schedule9:30 Welcome-meeting2BDH-ClinicHess.Oldendorf-non-profitorganisation非營利性組織-TeachingHospitalofHannoverMedicalSchool漢諾威醫(yī)學(xué)院教學(xué)醫(yī)院-InstituteforNeurorehabilitationResearch(InFo),MedicalSchoolHannover漢諾威醫(yī)學(xué)院神經(jīng)康復(fù)研究所-KTQ-certified,certifiedStrokeUnit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-113hospitalbeds(incl.25ICU-and39IMC-beds)and140rehabilitationbeds113張臨床床位（包括ICU25張，IMC39張）康復(fù)床位140張-400employees400名員工BDH-ClinicHess.Oldendorf-non3NewICUInvestment: 10.000.000€資產(chǎn)投入：一千萬歐元ICU-beds: 25ICU床位：25NewICUInvestment: 10.000.0004NewICU全新的ICU病區(qū)NewICU全新的ICU病區(qū)5NewICU全新的ICU病區(qū)NewICU全新的ICU病區(qū)6Neuroimaging–MRIandCT神經(jīng)影像設(shè)備—核磁及CTNeuroimaging–MRIandCT神經(jīng)影像7Thesix-phasemodeloftheFederalRehabilitationCouncil(BAR,1994)聯(lián)邦康復(fù)委員會六級模式（聯(lián)邦康復(fù)學(xué)會，1994）Thesix-phasemodeloftheFed8Six-phasemodeloftheGermanFederalRehabilitationCouncil德意志聯(lián)邦康復(fù)委員會六級模式資方主體健康保險公司健康保險公司健康保險公司私人保險公司雇主及私保公司護理及健康保險公司聯(lián)邦康復(fù)學(xué)會分段分段特點急診入院治療早期康復(fù)巴塞爾量表得分六級模式由德國聯(lián)邦康復(fù)委員會確立對早期康復(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)分級仍處在需要高度護理及醫(yī)療處置期的康復(fù)分級處于大部分獲得深度日常獨立活動能力，剩余康復(fù)以后續(xù)治療為主醫(yī)療專業(yè)康復(fù)達到2級，包括門診隨診長期維持性看護，轉(zhuǎn)相關(guān)?？芐ix-phasemodeloftheGerman9XX10PhaseB(EarlyRehabilitation)B級早期康復(fù)-admissiontoneurologicalandneurosurgicalearlyrehabilitationimmediatelyafteracute-carehospitalstay神內(nèi)/外科早期入院，急診處理后立即進入康復(fù)-patientssufferfromdisordersofconsciousness意識障礙病人-patientsneedmechanicalventilationandmonitoringonICUorIMCwardsICU或IMC病房需要機械通氣及監(jiān)護的病人-challenge:multiresistantgerms挑戰(zhàn)：多重耐藥性細(xì)菌PhaseB(EarlyRehabilitation)11DRG-System:OPS8-552診斷相關(guān)分類系統(tǒng)DRG-System:OPS8-552診斷相關(guān)分類12PhaseB–AdmissiondiagnosesB級入院診斷(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，截癱格林巴利綜合癥其他診斷總計PhaseB–Admissiondiagnoses13PhaseB–OutcomeB級結(jié)果(RollnikundJanosch,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)其他護理機構(gòu)常規(guī)轉(zhuǎn)出死亡自動轉(zhuǎn)出轉(zhuǎn)臨終關(guān)懷PhaseB–OutcomeB級結(jié)果(R14(Rollnik,2013)PhaseB–OutcomeB級結(jié)果年齡巴塞爾量表改變(Rollnik,2013)PhaseB–Outco15PhaseB–lengthofstay(LOS)(RollnikundJanosch,2010)病例百分比住院時間（月）住院時間（病程）PhaseB–lengthofstay(LOS)16PhaseB–LOS病程(RollnikundJanosch,2010)平均住院時間（天）早期康復(fù)巴塞爾量表得分區(qū)間PhaseB–LOS病程(Rollnikund17PhaseB–Weaningfrommechanicalventilation取下呼吸機(Rollniketal.,2010)-Mortality:6.1%死亡-Weaningwassuccessfulafterameanof12.9(12.0)daysofneurologicalearlyrehabilitation早期康復(fù)中，平均12.9±12.0天可以成功取下呼吸機PhaseB–Weaningfrommechani18PhaseB–Mechanicalventilation機械通氣(Rollniketal.,2010)Outcome結(jié)果n%1.Succesfulweaning成功取下呼吸機5668.32.Dischargetoanotherhospital,stillonventilation轉(zhuǎn)院，仍使用呼吸輔助1619.53.Dischargetoalong-termcarefacility,stillonventilation轉(zhuǎn)入長期看護，仍呼吸輔助56.14.Death死亡56.1Sum82100PhaseB–Mechanicalventilati19-Resultsfromamulticenterstudy(Oehmichenetal.,2012)多中心研究結(jié)果-n=1486,69.8%weanedsuccessfully1486例，69.8%成功取下呼吸機PhaseB–Mechanicalventilation機械通氣-Resultsfromamulticenterst20PhaseB–Multiresistantgerms多重耐藥細(xì)菌PhaseB–Multiresistantgerms21-highprevalenceofESBL-producinggram-negativebacteria:11.8%大腸埃希菌高發(fā)病率，革蘭氏陰性細(xì)菌11.8%-MRSAprevalence:11.4%抗藥性金黃色葡萄球菌發(fā)病率11.4%SUM:Oneoutoffourearlyrehabilitationpatientsiscolonizedwithmultiresistantgermsonadmission!小結(jié)：四分之一的早期康復(fù)病人入院時遭遇多重耐藥菌感染PhaseB–Multiresistantgerms多重耐藥細(xì)菌-highprevalenceofESBL-produ22PhaseB–MRSAandoutcome抗藥性金黃色葡萄球菌及結(jié)果PhaseB–MRSAandoutcome抗藥23MRSApositiveMRSAnegativep-value*Age[years]65.8(15.1)67.0(15.8)n.s.Lengthofstay(LOS)–referringhospital[days]32.8(42.9)34.4(260.5)n.s.LOS–neurologicalearlyrehabilitation[days]63.7(37.1)25.8(24.5)<0.001LOS–entireneurologicalrehabilitation[days]75.0(42.5)46.8(47.1)<0.001Numberofco-diagnoses[n]20.5(5.1)13.3(5.5)<0.001BarthelIndex(BI)onadmission[0to100]13.6(9.9)25.6(24.1)<0.001Barthelindexondischarge[0to100]25.5(21.2)47.4(31.0)<0.001EarlyRehabilitationIndex(ERI)onadmission[-325to0]-80.1(59.5)-47.9(47.6)<0.001ERIondischarge[-325to0]-47.3(51.4)-26.0(35.4)<0.001ComaRemissionScale(CRS)[0to24]昏迷量表得分11.0(6.2)14.0(6.8)n.s.GlasgowComaScale(GCS)[3to15]格拉斯哥昏迷量表9.5(3.2)12.0(3.3)<0.001Earlyfunctionalabilities(EFA)–vegetative[4to20]8.6(3.0)12.4(7.0)<0.001EFA–faciooral[4to20]9.2(5.0)15.4(5.3)<0.001EFA–sensorymotor[7to35]14.4(6.9)22.8(8.2)<0.001EFA–cognitive[5to25]13.3(6.4)18.7(5.2)<0.001Totalmaintherapies[min/day]131.6(16.6)140.2(18.7)<0.001(Rollnik,2014)PhaseB–MRSAandoutcome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(-)年齡住院時間早期康復(fù)時間全部康復(fù)時間共同診斷數(shù)巴塞爾量表得分轉(zhuǎn)出時巴塞爾量表得分入院時早期康復(fù)指數(shù)得分傳出時早期康復(fù)指數(shù)得分早期功能評定—營養(yǎng)早期功能評定—面口早期功能評定—感覺，運動早期功能評定—認(rèn)知MRSApositiveMRSAnegativep-va24PhaseB–ESBLandoutcome大腸埃希菌及結(jié)果(Rollnik,2015)PhaseB–ESBLandoutcome大腸埃25PhaseCC級-patientsarestilldependentonnursing,buttheydon`tneedICUorIMC患者仍需支持護理，但不需要ICU或IMC-patientscooperatemoreandmoreactively患者日趨活躍，并合作良好PhaseCC級26PhaseCC級PhaseCC級27PhaseC–diagnoses診斷(Rollnik,2009)PhaseC–diagnoses診斷(Rollni28PhaseC–OutcomeC級結(jié)果(Rollnik,2009)PhaseC–OutcomeC級結(jié)果(Roll29PhaseC–OutcomeC級結(jié)果(Rollnik,2009)PhaseC–OutcomeC級結(jié)果(Rolln30PhaseC–LOSC級病程(Rollnik,2009)PhaseC–LOSC級病程(Rollnik,31MEmbeR-studyonmedical-occupationalrehab

職業(yè)醫(yī)療康復(fù)的研究-DesignoftheMEmbeR-study:研究設(shè)計Multicenter多中心Multipleindications(neurological,psychiatric,orthopedics,internalmedicine)多學(xué)科參與

Prospective預(yù)期MEmbeR-studyonmedical-occupa32MEmbeR:Centers多中心分布MEmbeR:Centers多中心分布33MEmbeR:Studysample研究樣本-meanage34.1(9.9)y,113m,83f平均年齡34.1±9.9歲，男113，女83-LOS:148.6(SD=223)days(approx.5months),range10–1080

病程：平均148.6天，標(biāo)準(zhǔn)差223，（約5個月）范圍處于10-1080天

r=-0.47(p<0.001)

(Rollniketal.,2014)MEmbeR:Studysample研究樣本(Rol34MEmbeR:Unfitforwork無法適應(yīng)工作Before:69.9%,24monthsafterrehabonly5.6%康復(fù)前：69.9%，康復(fù)24個月后僅5.6%(Rollniketal.,2014)MEmbeR:Unfitforwork無法適應(yīng)工作35MEmbeR:Jobless失業(yè)Before:19.9%,24monthsafterrehab:3.1%康復(fù)前19.9%，24個月康復(fù)后3.1%(Rollniketal.,2014)MEmbeR:Jobless失業(yè)(Rollniket36MEmbeR:Returntowork(Rollniketal.,2014)24monthsaftermedicaloccupationalrehabilitation,153/196(78.1%)returnedtowork!職業(yè)醫(yī)療康復(fù)24個月后，78.1%病人回歸社會工作生活回歸工作MEmbeR:Returntowork(Rollnik37Summary-TheFederalRehabilitationCouncilhasestablishedasuccessful6-phasemodelforneurologicalandneurosurgicalpatients.聯(lián)邦康復(fù)委員會為神內(nèi)/外系統(tǒng)成功推出6級康復(fù)模式-TheBDH-ClinicoffersinpatientrehabilitationfromphaseA(acute-carehospitaltreatment)toE(medical-occupationalrehab)本中心提供A-E共五級康復(fù)-Earlyrehabilitationallowsrehabilitationofmechanicallyventilatedand