In 2008, the National Rehabilitation Hospital announced a €200 million development plan for the hospital that promised a HSE-funded expansion to almost double the provision of national medical rehabilitation services. The 44,000sq m purpose-built rehabilitation facility, due for completion in 2012 (with planning approval), was to provide almost 235 beds (there are currently 110 beds) and be the largest in Europe, providing a full range of neurological and prosthetic rehabilitation services.
As with other large infrastructural projects at that time, it never happened. This month, the National Rehabilitation Hospital received planning permission for a more modest redevelopment, of which the first phase is due for completion in 2017. Sheila Bonham, the project manager, says: “This will be for patient accommodation: 120 en-suite bedrooms with integrated treatment spaces.”
The project is a partnership between the National Rehabilitation Hospital Foundation and the HSE, and involved the hospital selling a portion of land to fund the building. The second phase of the project, which hasn’t yet been designed, will house the different therapies, catering departments, administration, pharmacy, radiology and outpatient clinics. The entire project will follow universal design principles with larger lifts for wheelchair users, wide corridors, access to courtyards, and so on. “We are following evidence-based design around all our requirements for patients and staff. We are striving to become the most accessible building in the country,” says Bonham.
The National Rehabilitation Hospital started as Our Lady of Lourdes hospital for people with tuberculosis, set up by the Sisters of Mercy. In the 1950s, demand for beds for tuberculosis declined and it was converted to the National Rehabilitation Hospital to deal with medical spinal injuries, amputee patients, head injuries and stroke patients.
The National Brain Injury Rehabilitative Unit
Dr Jacinta McElligot is the medical director of the National Brain Injury Rehabilitative programme and the overall medical director of the National Rehabilitation Hospital. “We are the only acute rehabilitation hospital in Ireland so we give priority to the most complex cases and see patients with the most severe impairments caused by disease or injury.
“Traumatic brain injuries [from road traffic crashes] and stroke are main causes of brain injuries, but some patients may also have multiple sclerosis or a tumour. They require specialised interdisciplinary work from doctors, occupational therapists, physiotherapists and speech therapists,” says McElligot. “Some patients require the whole gamut of services. Others require a core part and others will require lifelong management.”
She is keen to emphasise that the approach is interdisciplinary rather than multidisciplinary. The difference is that the health professionals work together on the interdisciplinary assessment and design of the rehabilitation programme. “The new hospital is designed so that each unit will have a treatment gym or therapeutic space to discuss patients’ goals and each therapy’s goals. Having this space in the unit allows nurses to give feedback into the care plan to make it more dynamic. At the moment, we meet only once a week as a team, whereas the ideal is to meet every morning.” A case co-ordinator is assigned to each patient to check that they are happy with the programme and their progress.
The brain injury patients account for 56 of the 102 beds at the hospital. “We are consistently challenged with our waiting lists, but last year we released 10 beds for an early-access rehabilitative unit for patients with an acute traumatic brain injury or a stroke. This allows early discharge of patients from an intensive care unit to the hospital so that their rehabilitation programme can be carried out in a timely manner. It’s a huge help to a subset of our patients for whom a six-month wait would be too late,” says McElligott.
She is keen to point out that a rehabilitation hospital is unlike an acute hospital. “It’s a place for recovery, to help people move back into their normal life.”
For that reason, patients wear their own clothes and spend the day partaking in different therapies, returning to their bedrooms only at night or for periods of rest. The current eight-bedded wards will all be replaced by private bedrooms with ensuites in the new hospital. “It’s a question of dignity, privacy and infection control,” says McElligott.
The therapeutic spaces will double up as community hubs for families, friends and other groups to use at different times of the day. “We are very short on these kinds of spaces at the moment,” she says. “We view life here as a 24-hour rehabilitation day, because when they go home, patients will have to function in their own environments.”
The National Spinal Injury Rehabilitation Unit
Contrary to what its name might suggest, the National Spinal Injury Rehabilitation Unit does not deal with spinal injuries of the vertebrae or spinal discs. Instead, the team, led by spinal rehabilitative consultant Dr Eimear Smith, deals with spinal cord injuries. “We deal with neurological problems as opposed to musculoskeletal ones,” says Smith.
The spinal cord is an extension of the brain. It houses all the nerve cells that transmit messages between the brain and the other parts of the body to signal pain, sensation, movement or balance.
Spinal cord injuries are much rarer than spinal injuries. They can be caused by inflammation of the spinal cord, triggered by a virus, a haemorrhage, or a benign or malignant tumour.
“Falls among middle-aged and older people are the biggest cause of spinal cord injuries. The early management of the injury takes place in an acute hospital and then the patient comes here for rehabilitation,” says Smith.
More advanced treatment for cancer that has developed in the spine also means that such cancer patients are living longer and require rehabilitation following surgery. “The problem for us is that we still have the same number of beds to deal with spinal cord injuries, and [an increasing number of] oncology patients,” says Smith.
The average time a patient stays in the National Spinal Injury Rehabilitation Unit is 12 to 13 weeks. “Another problem we face is that these patients may need adaptations to their homes and care packages before they can go home, and there are delays in funding for both,” says Smith.
“People recovering from spinal cord injuries need support when back in their communities, and encouragement when back at work. Otherwise, they will face mental health problems farther down the line.”
Between four and six out of 10 patients will recover fully from spinal cord injuries. The outpatients’ clinic at the unit helps patients deal with the long-term care needs associated with these conditions. The unit also treats a small number of children who have spinal cord injuries.
The National Prosthetic, Orthotic and Limb Absence Rehabilitation Unit Dr Nicola Ryall is the medical director of the National Prosthetic, Orthotic and Limb Absence Rehabilitation Unit. “We deal with everyone from young children to very elderly patients. We have some patients who have stayed with us for decades,” explains
Ryall. The paediatric programme is for children up to the age of 18, with a school in the hospital for those on inpatient programmes.
The majority of patients have lost their leg or, in some cases, both legs. Arm amputees are a small percentage of those seen. “Two-thirds of our patients have either diabetes or peripheral vascular disease. We are seeing more and more diabetes patients as obesity becomes a bigger problem. We are also seeing older patients who have other medical conditions, which makes rehabilitation more difficult.”
Being physically and mentally able for rehabilitation makes a big difference to how patients progress. “Patients need to learn new ways of doing things. It takes a lot of cognitive strength to get through a rehabilitation programme. If there are memory problems, it takes longer,” says Ryall.
The average age of patients at the unit is 65, and most are men. “We have 10 inpatient beds and seven day cases for people who can remain safely in their homes. We have an outpatients clinic at the Mercy University Hospital in Cork and we are trying to establish one at the Merlin Park University Hospital in Galway.”
One of the biggest challenges faced by the service is HSE-funding delays for patients who require prosthetic limbs. “There are private providers of prosthetic limbs . . . but there is no regulation for these private operations and no proper clinical governance through the consultant system. I see this as an area of clinical risk,” says Ryall.
Before patients come to the unit’s outpatients clinic, they are assessed by the rehabilitative consultant, physiotherapist, occupational therapist and prosthetic/orthotic specialist, psychologist and dietitian.
“The patients will have undergone surgery in an acute hospital, and the amputation is paid for by the acute hospital, but then, there are huge variations in funding allocations for the prosthetic limbs,” says Ryall. “Everything is free here except the prosthetic and when there are delays in approving payment for it, the patient can become weaker and stiffer. Occasionally, they can lose so much movement that they can’t be rehabilitated at all.”
The rehabilitative programme takes six to eight weeks for a patient who has lost their leg below the knee and 10 to 12 weeks for a patient who has lost their leg above the knee. They are followed up at an outpatients clinic six weeks, 12 weeks and 24 weeks later. Generally speaking, the prosthetic will last for about five years.
Young People’s Rehabilitation Services
There are eight beds at the National Rehabilitation Hospital for children with traumatic brain injury, cerebral palsy or infectious conditions that result in brain or spinal cord injury. “We run a five-day programme for these children. They go home at the weekends or back to the acute hospital, which is tough on families and patients,” says McElligott.
Dr Susan Finn, a paediatric rehabilitation consultant who also works in Our Lady’s Children’s Hospital, Crumlin, deals with these cases. The National Rehabilitation Hospital would require another paediatric rehabilitation consultant on its staff before children could stay at weekends.
The Rehabilitative Training Unit at the hospital is a residential space for young people who are trying to get back into work or training. “It allows people to restore a sense of independence in their lives. They might have been living with friends before the injury and then moved back in with their parents so they need to relearn ways to maximise their independence,” says McElligott.
