Neurosurgical Early Rehabilitation Research Articles

Certification by the German Society for Neurorehabiliation, DGNR : Performance and quality of the "Centers for weaning from aventilator in early neurological and neurosurgical rehabilitation"

Certification of centers for weaning from aventilator in neurological neurosurgical early rehabilitation (NNER) by the German Society for Neurorehabilitation (DGNR) is possible since 1 October 2021. The results of certification of facilities in the first year after starting the procedure are presented. As part of the certification process 28criteria are assessed including aset of mandatory characteristics of the facility. The criteria are divided into structural criteria (i = 7), diagnostic criteria (i = 6), personnel criteria (i = 3), internal organization criteria (i = 7), and quality management criteria (i = 5). A total of 13 centers were certified in the first year, with acombined total of 283 beds for weaning from aventilator in the NNER and served 2278 persons to be weaned from aventilator in the year before certification, with amedian of 134 per facility (range 44-414). Only rarely was weaning unsuccessful, requiring conversion to home mechanical ventilation before discharge (invasive home mechanical ventilation median per facility 10persons, range 2-25; non-invasive home mechanical ventilation median 0persons, range 0-57). Ahigh level of process and structural quality was documented for the certified centers: across all areas of assessment, the individual certification criteria were met in the vast majority of cases (median degree of complete fulfilment 86%) or met with improvement potentials documented by the auditors (median 11%). Successful weaning in NNER and ahigh level of process and structural quality can be demonstrated by the certification results of centers that follow this integrative approach to weaning from aventilator in aNNER setting.

The Respiratory Therapist in Neurology An Evolving Specialization in Germany

In Germany, nurses, physiotherapists and speech and language therapists follow a qualifying training for about 1,5 years to become respiratory therapists (RTs). With respect to neurological illness, RTs diagnose and treat disorders of respiration, cough and swallowing as well as a retention of tracheobronchial secretions. There is an increasing demand for RTs in neurology, in neurointensive care and in neurological and neurosurgical early rehabilitation. The certification of specialized centers for weaning in neurological and neurosurgical early rehabilitation was introduced by the German Society for Neurorehabilitation (DGNR) in 2021. As a certification criterion it includes the employment of a respiratory therapists. In neurological organizations treating critically and severely ill patients, RTs work at an important interdisciplinary intersection of physicians, nurses and therapists. RTs are qualified to train teams, patients and family caregivers and to establish care structures for critically and severely ill neurological patients. Due to the complexity of neurological illnesses RTs working in neurological institutions need specific qualification. Specific training for RTs in neurology and neurorehabilitation might improve care for critically and severely ill neurological patients. Further professionalization of RT in Germany requires standardizing curricula, a professional society for RTs and, finally, academization.

The certification of centers for weaning from mechanical ventilation in neurological and neurosurgical early rehabilitation by the German Society for Neurorehabilitation

Die Zertifizierung von Zentren für Beatmungsentwöhnung in der neurologisch-neurochirurgischen Frührehabilitation durch die Deutsche Gesellschaft für Neurorehabilitation (DGNR) ist ab dem 01.10.2021 möglich. Die Zertifizierungskriterien beschreiben ein Anforderungsprofil, das für eine fachgerechte und qualitätsgesicherte Versorgung von Beatmungspatienten in der neurologisch-neurochirurgischen Frührehabilitation (NNFR) steht. Das Zertifikat berücksichtigt die strukturellen Unterschiede der in der NNFR tätigen Einrichtungen und kann sowohl durch Facheinrichtungen als auch durch Frührehabilitationsabteilungen an Akutkrankenhäusern erworben werden. Die Durchführung der Zertifizierung erfolgt analog zur Zertifizierung von Stroke-Units der Deutschen Schlaganfall-Gesellschaft in Zusammenarbeit mit dem TÜV Rheinland. Zunächst sendet die Einrichtung den Erhebungsbogen an den TÜV Rheinland. Anschließend erfolgt die Begehung durch einen vom TÜV Rheinland gestellten leitenden Auditor und einen Fachauditor der DGNR. Deren Bericht wird dem Zertifizierungsausschuss der DGNR vorgelegt zur Erteilung einer Empfehlung oder Ablehnung der Zertifizierung. Die Zertifizierung schafft objektive Kriterien, die die Rolle der Neurologie in der Beatmungsmedizin in Deutschland beschreiben. So erleichtert sie den Dialog mit anderen beatmungsmedizinischen Disziplinen und ebnet den Weg für die Diskussion mit Politikern, Kostenträgern und nicht zuletzt Betroffenenverbänden über Behandlungsinhalte und -kapazitäten.

Weaning in neurological and neurosurgical early rehabilitation-Results from the "WennFrüh" study of the German Society for Neurorehabilitation

Neurologisch-neurochirurgische Frührehabilitanden sind klinisch oft so schwer betroffen, dass sie neben der frührehabilitativen Behandlung auch von der mechanischen Beatmung entwöhnt werden müssen. In einer Umfrage der Deutschen Gesellschaft für Neurorehabilitation (DGNR) wurden neurologische Weaningzentren gebeten, Informationen zu Strukturmerkmalen ihrer Einrichtung, ihrer personellen und apparativen Ausstattung sowie basierend auf anonymen Daten zu Fallzahl und Behandlungsergebnis zur Verfügung zu stellen. Es nahmen 36 Weaningeinheiten aus 11 Bundesländern mit insgesamt 496 Betten teil. Von 2516 erfassten Weaningfällen im Jahr 2019 wurden 2097 (83,3 %) primär erfolgreich entwöhnt und nur 120 (4,8 %) mussten mit Heimbeatmung entlassen werden. Die Mortalität in dieser Stichprobe lag bei 11,0 % (n = 276). Die Erhebung zeigt, dass das prolongierte Weaning in der neurologisch-neurochirurgischen Frührehabilitation ein wichtiger und erfolgreicher Bestandteil der Versorgung schwerstkranker Patienten darstellt.

Standardized nutritional supply versus individual nutritional assessment: Impact on weight changes, complications and functional outcome from neurological early rehabilitation

Approximately 55% of neurological and neurosurgical early rehabilitation (NNER) patients are in need of enteral nutrition, but long-term nutritional assessment of these critically ill patients is suboptimal. Therefore, this study analyzed the effect of an individual nutritional assessment on weight changes during rehabilitation and impact on complications and functional outcome. 170 NNER patients on enteral nutrition were enrolled in the study. According to the initial ward, patients were assigned to receive standardized enteral nutrition (n=107, control group) or an individual nutritional assessment (n=63, intervention group). Weight changes, complications, assessment of the functional outcome (Early Rehabilitation Index, Barthel Index, Early Rehabilitation Barthel Index) and the length of stay were recorded and compared between groups using non-parametric tests for non-paired samples (Mann-Whitney U test for metric data or the χ2 test for categorical data) or paired samples (Wilcoxon test). In addition, daily energy requirement was calculated and compared with daily intake. Correlation analysis by Spearman was performed to investigate linear relationship between weight changes and the difference of administered and calculated calories in both study groups. A weight loss was observed in the control group, whereas the weight of the intervention group remained stable over time. The difference between calculated and administered calories correlated with weight changes in the control group. Regarding complications during rehabilitation, control patients showed more frequently impaired diuresis. In addition, control patients were suffering longer from diarrhea than patients of the intervention group. Both groups improved in functional status to a comparable degree. Relationships between these improvements and weight changes or administered calories could not be found. Individual nutritional assessment had not an additional affect for the improvement of functional outcome or the prevention of complications. However, weight turned out to be more stable and signs of nutritional incompatibilities are less frequent among patients being treated with an individualized nutritional assessment.

Mechanical ventilation in neurological organizational units in Germany

Mechanical ventilation is provided for neurological patients in the following settings: in neurointensive care units, in centers providing weaning and early rehabilitation and in home mechanical ventilation. In the last decade there has been asharp rise in treatment and bed capacities for mechanically ventilated neurological patients in specialized centers in Germany in the areas of weaning and neurological neurosurgical early rehabilitation of ventilated patients. Neither the number of beds nor details about structures in these centers with respect to bed capacity, personnel and qualifications, equipment, treatment methods and concepts are known. The aim of this survey was to generate detailed numbers regarding structural criteria of specialized centers for mechanically ventilated neurology patients, regarding hospital beds, technical infrastructure, personnel and qualifications as well as treatment methods and concepts. An online survey with 48questions on the type and size of the institution, structural criteria, equipment and personnel was developed and supported by the German Society for Neurology (DGN), the German Interdisciplinary Society of Out-of-Hospital Ventilation (DIGAB) and the German Society of Neurorehabilitation (DGNR). A total of 63centers took part in the survey and reported a total of 687 beds for mechanically ventilated neurological patients. Furthermore, they reported complex structures regarding personnel and qualifications, medical devices, methods and concepts but neurophysiological electrophysiology was the only technical method provided in all centers. Of the institutions 49% (n = 27/55) provided the initiation of home mechanical ventilation, 18% (n = 18/55) provided inpatient control of home mechanical ventilation, 9% (n = 5/55) had an outpatient department for home mechanical ventilation and 18% (n = 10/55) extracted data from home ventilators. Mechanical ventilation in neurological units offers vast and complex treatment and bed capacities for severely ill patients in Germany. The structures are inhomogeneous and a consensus on specific criteria should be established. This is especially true for the treatment of patients needing out-of-hospital mechanical ventilation, also with respect to a possible weaning in the long-term duration of the disease.

Neurological and neurosurgical early rehabilitation in Lower Saxony and Bremen

We analyzed the delivery of healthcare services among patients in neurological and neurosurgical early rehabilitation programmes in the German states of Lower Saxony and Bremen. Patients´applications and admissions for neurological and neurosurgical early rehabilitation in Lower Saxony and Bremen were recorded during a period of two weeks both in November 2015 as well as 2016. The proportion of patients admitted to early rehabilitation within a six-week-period after disease onset was calculated. In addition, factors influencing the probability of admission were investigated. Only 45 % of all patients transferred from a primary neurological / neurosurgical unit to an early rehabilitation facility in Lower Saxony / Bremen were successfully admitted. The probability of admission fell when patients were colonized with multi-drug resistant bacteria (21 % in comparison), in particular Methicillin-resistant Staphylococcus aureus (MRSA) with an admission rate of only 13 %. Deleterious effects were also observed in patients dependent on hemodialysis (20 %), or those with a primary diagnosis of polyneuropathy / Guillain-Barré-Syndrome (33 %) or hypoxic brain damage (37 %), as well as patients on mechanical ventilation (37 %). Patients had a higher probability of being admitted with the primary diagnoses of subarachnoid hemorrhage (52 %) or stroke (51 %). Age, Early Rehabilitation Index (ERI), monitoring, presence of tracheostomy, dysphagia, orientation or behavioral disturbances had no influence on the probability of admission, as well as other primary diagnoses or the number of admissions in one or more rehabilitation centers. Over one-half of the patients applying for admission to neurological / neurosurgical early rehabilitation facilities in Lower Saxony and Bremen were not admitted. Apparently, the capacity of early rehabilitation treatment in these two German states is not optimal.

Nutritional situation of enterally fed patients in neurological early rehabilitation and impact of nutritional status on functional outcome

Studies focusing on the nutritional status of neurological and neurosurgical early rehabilitation (NNER) patients are limited. The aim of the current study was to determine the nutritional status of NNER patients upon admission, to observe weight changes and to investigate the influence of nutritional status on complications and outcome. 109 enterally fed NNER patients were included in this prospective observational study. Weight changes, complications, neurological outcome scores (Early Rehabilitation Index [ERI], Barthel-Index [BI]) and the length of stay (LOS) were recorded. In addition, daily energy requirement was calculated and compared with daily intake to identify under-/optimally- and oversupplied patients. A general weight loss was observed in the study group. Weight changes during rehabilitation differed between men and women as well as between under- and oversupplied patients. Nutritional supply during rehabilitation had no influence on the LOS and the change of neurological outcome scores, but significant differences in the frequency of nosocomial infections was observed between under-/optimally- and oversupplied patients. The nutritional status (weight group on admission) had a crucial impact on neurological outcome scores, indicated by lower BI at discharge in normal-compared to underweight patients. In addition, underweight+undersupplied patients showed a significantly lower improvement of the BI than underweight+oversupplied patients. To the contrary, underweight+oversupplied patients had a higher BI improvement than underweight+optimally supplied patients. The nutritional status upon admission in combination with the nutritional supply during rehabilitation appears to have an impact on changes of neurological outcome scores.

Nutritional status of enterally nourished patients in neurological early rehabilitation

Rationale: Currently, the nutritional status of enterally nourished neurological and neurosurgical early rehabilitation (NNER) patients and its impact on rehabilitation outcome are poorly described. Therefore, the study aimed to investigate if the nutritional status on admission as well as weight changes during treatment is associated with the number and duration of complications during treatment and the clinical outcome.

Effects of Respiratory Muscle Training on the Incidence of Pneumonia in Neurological and Neurosurgical Early Rehabilitation: Results from a Matched-Pair Analysis

Most disorders in neurological and neurosurgical early rehabilitation (NNER) are associated with an increased pneumonia risk. Respiratory therapy aims to prevent respiratory complications. However, there are no studies showing an effect of respiratory muscle training on the incidence of pneumonia in NNER. The study included 81 phase-B-patients receiving respiratory muscle training and 81 control patients. Routine data such as age, sex, diagnoses, and comorbidities, length of stay, information on ventilation and incidence of pneumonia were analyzed retrospectively. The development of pneumonia was associated with a longer duration of treatment, a higher number of ventilation hours, the presence of a tracheal canula, and a tendency to lower Early Rehabilitation Barthel-Index on admission. The incidence rate of nosocomial pneumonia was 20% in both study groups. The groups differed significantly in disease severity on admission, duration of treatment, number of dysphagia patients, and in therapy intensities of physio and speech therapy. A direct correlation between the respiratory muscle training and the incidence of pneumonia in the NNER could not be conclusively demonstrated due to the insufficient comparability of both study groups. Besides the duration of ventilation, the intensity of dysphagia therapy was the strongest factor influencing the pneumonia incidence.

Factors influencing weaning from mechanical ventilation in neurological and neurosurgical early rehabilitation patients.

Studies analyzing risk factors of weaning failure in neurological and neurosurgical early rehabilitation (NNER) patients are rare. The aim of this study was to identify clinical factors influencing the weaning of NNER patients. An observational, retrospective data analysis of a German multicenter study was performed. German neurological early rehabilitation centers. Inpatient ventilated NNER patients (N.=192) were enrolled in the study. Demographical data, main diagnosis, medical devices, special medical care and assessment instruments of functional abilities, consciousness and independence in activities of daily living were accrued and compared between patients with and without successful weaning. The prognostic power of factors associated with weaning success/failure was analyzed using binary logistic regression. In total, 75% of the patients were successfully weaned. Colonization with multi-drug resistant bacteria and the need for dialysis were independent predictors of weaning failure. Successfully weaned patients had a shorter length of stay, better functional outcome, and lower mortality than non-successfully weaned patients. Successfully weaned patients differ from patients with weaning failure in several clinical variables. All these variables are associated with the morbidity of the patient, indicating that the weaning process is strongly influenced by disease burden. Functional abilities, level of consciousness, independence in activities of daily living, colonization with multi-drug resistant bacteria, need for dialysis and disease duration might help to predict the weaning process of NNER.

Weaning of neurological early rehabilitation patients from mechanical ventilation: a retrospective observational study.

There is little known about the factors influencing the weaning process of long-term mechanically ventilated patients in the neurological early rehabilitation. The aim of this study was to identify salient clinical and neurophysiological variables with impact upon weaning from mechanical ventilation during neurological and neurosurgical early rehabilitation. Observational, retrospective data analysis. The BDH-Clinic Hessisch Oldendorf in Northern Germany. A sample of 65 mechanically ventilated neurological and neurosurgical early rehabilitation patients. Most patients were suffering from brain disorders (stroke, brain hemorrhage, hypoxic brain damage). Clinical (ventilation hours, duration of daily therapy, Barthel Index [BI]) and neurophysiological data (evoked potentials) were analyzed retrospectively. The data was collected from the medical records of patients treated in our weaning facility. Weaning was successful in 92.3% (60/65) of all cases after a mean of 341.1 (±423.9) hours of ventilation; 2 patients (3.1%) died during the course of weaning and 3 (4.6%) were discharged on home ventilation. There was no significant correlation between ventilation hours and the amount of daily physio-, occupational or speech therapy, but there was a tendency towards a negative correlation of cognitive therapy with ventilation hours (rs=-0.234, P=0.088). Longer periods of ventilation correlated with poorer outcomes as measured by improvements in the BI (rs=-0.259, P<0.05). The more secondary diagnoses - a surrogate indicator of the total burden of morbidity - the more ventilation hours were necessary to wean the patient (rs=0.268, P<0.05). Patients isolated due to colonization with multi-drug resistant bacteria tended to require longer periods of ventilation than non-isolated persons (413.2 [±463.7] vs. 158.8 [±221.6], P=0.068). Data of evoked potentials did not correlate with ventilation hours. Most patients could be weaned from mechanical ventilation during early rehabilitation within approximately two weeks. Results from this study suggest that patients' morbidity (as indicated by the total number of secondary diagnoses) and isolation due to colonization with multi-drug resistant bacteria may be deleterious to the weaning process. In evaluation of the weaning prognosis of critically ill neurological and neurosurgical early rehabilitation patients, concomitant morbidity and colonization with multi-drug resistant bacteria should be taken into account.

Outcome of neurological early rehabilitation patients carrying multi-drug resistant bacteria: results from a German multi-center study

BackgroundColonization or infection with multi-drug resistant (MDR) bacteria is considered detrimental to the outcome of neurological and neurosurgical early rehabilitation patients.MethodsIn a German multi-center study, 754 neurological early rehabilitation patients were enrolled and and reviewed in respect to MDR status, length of stay (LOS) and the following outcome variables: Barthel Index (BI), Early Rehabilitation Index (ERI), Glasgow Outcome Score Extended (GOSE), Coma Remission Scale (CRS), Functional Ambulation Categories (FAC).ResultsThe mean age of the study population was 68.0 ± 14.8 years. Upon admission, the following prevalence for MDRs was observed: MRSA (methicillin resistant staphylococcus aureus) 7.0% (53/754), ESBL- (extended spectrum beta-lactamase) producing bacteria strains 12.6% (95/754), VRE (vancomycin resistant enterococci) 2.8% (21/754). Patients colonized or infected with MDR bacteria (MDR+) were significantly more frequently diagnosed with a critical illness polyneuropathy – CIP – than non-colonized (MDR-) patients: 29.0% vs. 14.8%. In addition, they were more frequently mechanically ventilated (MDR+: 55/138, 39.9%; MDR- 137/616, 22.2%). MDR+ patients were referred to rehabilitation earlier, had a longer LOS in early rehabilitation, lower BI on admission and at discharge, lower ERI on admission and lower CRS at discharge than MDR- patients. There was a highly significant correlation of the BI upon admission with the BI at discharge (rs = 0.492, p < 0.001). GOSE at discharge differed significantly between both groups (χ2-test, p < 0.01). Perhaps of greatest importance, mortality among MDR+ was higher in comparison to MDR- (18.1% vs. 7.6%).ConclusionsThe outcome of neurological early rehabilitation patients colonized or infected with MDR bacteria including MRSA or ESBL producing strains is significantly poorer than by non-colonized patients. There is some evidence that the poor outcome could be related to the higher morbidity and lower functional status upon admission.

Impact of Thyroid Hormone Levels on Functional Outcome in Neurological and Neurosurgical Early Rehabilitation Patients.

Background Neurological and neurosurgical early rehabilitation (NNER) is a specialized treatment option for patients with severe neurological disorders. The present study investigated whether thyroid hormone levels on admission have an impact on the outcome of NNER patients. Method The study included 500 NNER patients who were admitted to the BDH-Clinic Hessisch Oldendorf between 2009 and 2010. Data such as age, sex, diagnoses, comorbidities, Glasgow Coma Scale score, length of stay, and thyroid hormone levels (obtained as part of clinical routine care) were analyzed retrospectively. Improvement in the Early Rehabilitation Barthel Index (ERBI) at the end of the NNER treatment was defined as outcome parameter. Results Most patients made functional progress during treatment, as reflected in significant enhancements of the ERBI. Approximately half of the patients were transferred to further rehabilitation treatment. Young age, early onset of NNER treatment, low functional impairment on admission, and, in particular, low total T3 levels were independently associated with a good outcome. Conclusion Age, severity of disease, and time between injury and admission are known to predict outcome. The present study confirms the influence of these general factors. In addition, an association between thyroid hormones and functional outcome was demonstrated for NNER patients.

Criterion validity and sensitivity to change of the Early Rehabilitation Index (ERI): results from a German multi-center study.

BackgroundEvaluation of functional status is difficult in neurological and neurosurgical early rehabilitation patients. The Early Rehabilitation Index (ERI) was introduced in Germany over 20 years ago, but since then validation studies are lacking. The ERI (range −325 to 0 points) includes highly relevant items including the necessity of intermittent mechanical ventilation or tracheostomy.MethodsThe present paper analyzed data from a German multi-center study, enrolling 754 neurological early rehabilitation patients. Together with ERI, Barthel Index (BI), Glasgow Coma Scale (GCS), Glasgow Outcome Score Extended, Coma Remission Scale (CRS), Functional Ambulation Categories and length of stay were obtained.ResultsERI showed significant improvements from admission to discharge (p < 0.001). In addition, there were significant correlations of the ERI upon admission and at discharge with BI, CRS and GCS.ConclusionsEvaluation of our study data suggest that the ERI may be used as a valid assessment instrument for neurological and neurosurgical early rehabilitation patients.

May clinical neurophysiology help to predict the recovery of neurological early rehabilitation patients?

BackgroundSo far, the role of clinical neurophysiology in the prediction of outcome from neurological and neurosurgical early rehabilitation is unclear.MethodsClinical and neurophysiological data of a large sample of 803 early rehabilitation cases of the BDH-Clinic Hessisch Oldendorf in Northern Germany have been carefully reviewed. Most patients (43.5 %) were transferred to rehabilitation after stroke, mean age was 66.6 (15.5) years. Median somatosensory (SEP), auditory (AEP) and visual evoked potentials (VEP) along with EEG recordings took place within the first two weeks after admission. Length of stay (LOS) in early rehabilitation was 38.3 (37.2) days.ResultsAbsence of SEP on one or both sides was associated with poor outcome, χ2 = 12.98 (p = 0.005); only 12.5 % had a good outcome (defined as Barthel index, BI ≥50) when SEP were missing on both sides. In AEP, significantly longer bilateral latencies III were observed in the poor outcome group (p < 0.05). Flash VEP showed that patients in the poor outcome group had a significantly longer latency III on both sides (p < 0.05). The longer latency III, the smaller BI changes (BI discharge minus admission) were observed (latency III right r = −0.145, p < 0.01; left r = −0.206, p < 0.001). While about half of the patients with alpha EEG activity belonged to the good outcome group (80/159, 50.3 %), only 39/125 (31.2 %) with theta and 5/41 (12.2 %) with delta rhythm had a favourable outcome, χ2 = 24.2, p < 0.001.ConclusionsResults from this study suggest that loss of median SEP, prolongation of wave III in AEP and flash-VEP as well as theta or delta rhythms in EEG are associated with poor outcome from neurological early rehabilitation. Further studies on this topic are strongly encouraged.

The Early Functional Abilities (EFA) scale to assess neurological and neurosurgical early rehabilitation patients.

BackgroundIt is difficult to assess neurological and neurosurgical early rehabilitation patients comprehensively. Available scales focus on activities of daily living (Barthel (BI) and Early Rehabilitation Barthel Index (ERBI)) or wakefulness (Glasgow Coma Scale (GCS), Coma Remission Scale (CRS)) while cognitive items are missing.MethodsThe Early Functional Abilities (EFA) scale comprises 20 items referring to activities of daily living (ADL), wakefulness and cognitive abilities. To evaluate its validity, n = 623 early neurological and neurosurgical rehabilitation patients (most of them after ischemic stroke or cerebral bleeding) were assessed on admission using the EFA, ERBI, GCS, CRS and measures of morbidity (co-diagnoses).ResultsThe more co-diagnoses the lower EFA sum scores were obtained (Spearman-Rho rs = -0.509, p < 0.001). EFA predicted length of stay (LOS, rs = -0.565, p < 0.001) and BI at discharge (rs = 0.571, p < 0.001).ConclusionsThe results suggest that EFA is a valid instrument to assess critically ill neurological and neurosurgical early rehabilitation patients. It may be used as a measure of morbidity and a predictor of LOS and outcome. Further studies are strongly encouraged.

Multidrug-resistant germs in neurological early rehabilitation (2004-2013)

Multidrug-resistant germs are an increasing problem in neurological and neurosurgical early rehabilitation but reliable data is missing. The present study examined the prevalence of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and multidrug-resistant gram negative germs (MRGN) in a German neurological early rehabilitation facility (BDH Clinic Hessisch Oldendorf). Observation period was 2004-2013 (10 years). MRSA prevalence on admission was 11.4%, MRGN prevalence during rehabilitation 11.8%. A combination of different multidrug-resistant germs (MRSA plus MRGN) was observed in 3.8% of all cases. VRE were first detected in 2009, prevalence was as low as 0.1%. High prevalence of MRSA and MRGN raises major financial, medical, and ethical problems in early rehabilitation facilities. The authors encourage further multi-center studies and suggest a better recompense for this group of patients in the German DRG-system (Diagnosis Related Groups).

Current Trends in the Length of Stay in Neurological Early Rehabilitation

Neurological early rehabilitation (phase B) is an integral component of the phase model of the German Federal Rehabilitation Council (Bundesarbeitsgemeinschaft für Rehabilitation, BAR). We studied the current trend in patients' length of stay. This study included 2060 cases of the BDH-Klinik Hessisch Oldendorf (a neurological rehabilitation clinic) from 2005 to 2008 that fulfilled the structural characteristics of item 8-552 of the German coding system for operations and procedures (Operationen- und Prozedurenschlüssel, OPS), which codes for neurological and neurosurgical early rehabilitation. We studied the parameters age, sex, length of stay, type of discharge, diagnoses, and morbidity. 75.7% of the collective carried a diagnosis of cerebral ischemia, traumatic brain injury, or intracerebral hemorrhage. The mean length of stay over the entire period of the study was 44.6 days. A successive reduction of the mean length of stay from 2005 to 2008 was evident, from 46.8 days in 2005 to 37.5 in 2008 (p<0.001). The morbidity, too, declined over the period of the study. 76.4% of the cases analyzed stayed in hospital for at least the minimum of 8 weeks proposed by the BAR. 39.5% of the patients improved to such an extent in phase B that they were able to be transferred to a further rehabilitation facility, while about one patient in five was transferred from early rehabilitation to a nursing facility. The mortality was 0.9%. Although the early rehabilitation procedure was correctly coded, a total of 60 different diagnosis-related groups (DRGs) were applied. These data support the BAR's recommendation for a minimum length of stay of 8 weeks in phase B. The observed shortening of the length of stay was found to be primarily the result of a reduction in morbidity during early rehabilitation. This, in turn, may well be due to a selection effect of the early rehabilitation procedure code 8-552.

Neurorehabilitation Following Craniocerebral Trauma

To review the quality management of functional neurorehabilitation in patients after craniocerebral trauma with an emphasis on factors that may explain variability of early and late outcomes after 1 year and how this might be influenced to improve health-related quality of life after traumatic brain injury (TBI). First ever prospective controlled, population- based, multicenter study on epidemiology of acute craniocerebral injuries (CCI) in Germany and analysis of acute medical care and functional rehabilitation with early and 1-year outcome. Catchment areas Hanover and Muenster (sum of inhabitants 2.114 million). The definition of acute CCI was according to the ICD-10: S-02, S-04, S-06, S-07, S-09 in combination with dizziness or vomiting, retrograde or anterograde amnesia, impaired consciousness, skull fracture, and/or focal neurologic impairment. 6,783 CCI patients (58% male) were admitted for emergency hospital treatment. 28% patients were 65 years of age. Completed questionnaires of 63.5% of the patients were analyzed. 1-year follow-up of two thirds of acute CCI. Incidence was 321/100,000. Initial CCI severity (Glasgow Coma Scale [GCS]) of 55% of patients showed 90.9% mild, 3.9% moderate, and 5.2% severe TBI. 5,221 patients (77%) were hospitalized, 1.4% of them died. Follow-up of 63.5%. Only 258 patients (3.8%) received neurologic-neurosurgical rehabilitation (73% male), 68% within 1 month after injury, 5% were 65 years of age. Early rehabilitation of 100 patients (39%), one fifth referred within first week. Outcome end of early rehabilitation phase “B”: Glasgow Outcome Scale (GOS) 1 = 4%; GOS 2 = 2.7%, GOS 3 = 37.3%, GOS 4 = 26.7%, GOS 5 = 29.3%, and end of rehabilitation “B–E”: GOS 1 = 1.2%, GOS 2 = 1.7%, GOS 3 = 21.8%, GOS 4 = 36.2%, and GOS 5 = 39.1%. Data on the epidemiology and quality management of early functional rehabilitation met the criteria set in 1992. Management of frequent multiple organ lesions and complications (57%) without referring the patient to another hospital and early functional outcome confirm the author’s concept of neurosurgical early rehabilitation.