(中德康复技术培训课件) 康复技术培训 神经康复

1、Neuroimaging MRI and CT 神经影像设备神经影像设备核磁及核磁及CTThe six-phase model of the Federal RehabilitationCouncil (BAR, 1994)联邦康复委员会六级模式（联邦康复学会，联邦康复委员会六级模式（联邦康复学会，1994）Six-phase model of the German Federal Rehabilitation Council 德意志联邦康复委员会六级模式德意志联邦康复委员会六级模式资方主体健康保险公司健康保险公司健康保险公司私人保险公司雇主及私保公司护理及健康保险公司联邦康复学会分段分段特点

2、急诊入院治疗早期康复巴塞尔量表得分六级模式由德国联邦康复委员会确立对早期康复影响较大的，急性期，需要密集治疗的，包括辅助呼吸病人康复分级仍处在需要高度护理及医疗处置期的康复分级处于大部分获得深度日常独立活动能力，剩余康复以后续治疗为主医疗专业康复达到2级，包括门诊随诊长期维持性看护，转相关专科XPhase B (Early Rehabilitation) B级级 早期康复早期康复-admission to neurological and neurosurgical early rehabilitation immediately after acute-care hospital stay神

3、内/外科早期入院，急诊处理后立即进入康复-patients suffer from disorders of consciousness 意识障碍病人-patients need mechanical ventilation and monitoring on ICU or IMC wards ICU 或IMC 病房需要机械通气及监护的病人-challenge: multiresistant germs挑战：多重耐药性细菌DRG-System: OPS 8-552 诊断相关分类系统Phase B Admission diagnoses B 级级 入院诊断入院诊断(Rollnik & J

4、anosch, 2010)早期康复病例的诊断相关分类，降序或频率诊断相关分类比例男/女平均年龄平均住院时间脑缺血颅脑外伤脑出血蛛网膜下腔出血缺氧性损害肿瘤形成感染,传染性疾病脊髓损伤，截瘫格林巴利综合症其他诊断总计Phase B Outcome B级级 结果结果(Rollnik und Janosch, 2010)排除类别，降序或频率排除类别转后续康复转院转其他护理机构常规转出死亡自动转出转临终关怀(Rollnik, 2013)Phase B Outcome B级级 结果结果年龄巴塞尔量表改变Phase B length of stay (LOS)(Rollnik und Janosch, 2

5、010)病例百分比住院时间（月）住院时间（病程）Phase B LOS 病程病程(Rollnik und Janosch, 2010)平均住院时间（天）早期康复巴塞尔量表得分区间Phase B Weaning from mechanical ventilation取下呼吸机取下呼吸机(Rollnik et al., 2010)-Mortality: 6.1% 死亡-Weaning was successful after a mean of 12.9 (12.0) days of neurological early rehabilitation 早期康复中，平均12.912.0天可以成功取下

6、呼吸机Phase B Mechanical ventilation机械通气机械通气(Rollnik et al., 2010)Outcome 结果结果n%1. Succesful weaning 成功取下呼吸机5668.32. Discharge to another hospital, still on ventilation 转院，仍使用呼吸辅助1619.53. Discharge to a long-term care facility, still on ventilation 转入长期看护，仍呼吸辅助56.14. Death 死亡56.1Sum82100-Results from a

7、 multicenter study (Oehmichen et al., 2012) 多中心研究结果-n=1486, 69.8% weaned successfully 1486例，69.8%成功取下呼吸机Phase B Mechanical ventilation机械通气机械通气Phase B Multiresistant germs多重耐药细菌多重耐药细菌-high prevalence of ESBL-producing gram-negative bacteria: 11.8% 大肠埃希菌高发病率，革兰氏阴性细菌11.8%-MRSA prevalence: 11.4% 抗药性金黄色葡

8、萄球菌发病率 11.4%SUM: One out of four early rehabilitation patients is colonized with multiresistant germs on admission!小结：四分之一的早期康复病人入院时遭遇多重耐药菌感染小结：四分之一的早期康复病人入院时遭遇多重耐药菌感染Phase B Multiresistant germs多重耐药细菌多重耐药细菌Phase B MRSA and outcome 抗药性金黄色葡萄球菌抗药性金黄色葡萄球菌 及结及结果果MRSA positiveMRSA negativep-value*Age yea

9、rs65.8 (15.1)67.0 (15.8)n.s.Length of stay (LOS) referring hospital days32.8 (42.9)34.4 (260.5)n.s.LOS neurological early rehabilitation days63.7 (37.1)25.8 (24.5) 0.001LOS entire neurological rehabilitation days75.0 (42.5)46.8 (47.1) 0.001Number of co-diagnoses n20.5 (5.1)13.3 (5.5) 0.001Barthel In

10、dex (BI) on admission 0 to 100 13.6 (9.9)25.6 (24.1) 0.001Barthel index on discharge 0 to 10025.5 (21.2)47.4 (31.0) 0.001Early Rehabilitation Index (ERI) on admission -325 to 0-80.1 (59.5)-47.9 (47.6) 0.001ERI on discharge -325 to 0-47.3 (51.4)-26.0 (35.4) 0.001Coma Remission Scale (CRS) 0 to 24昏迷量表

11、得分昏迷量表得分11.0 (6.2)14.0 (6.8)n.s.Glasgow Coma Scale (GCS) 3 to 15格拉斯哥昏迷量表格拉斯哥昏迷量表9.5 (3.2)12.0 (3.3) 0.001Early functional abilities (EFA) vegetative 4 to 208.6 (3.0)12.4 (7.0) 0.001EFA faciooral 4 to 209.2 (5.0)15.4 (5.3) 0.001EFA sensorymotor 7 to 35 14.4 (6.9)22.8 (8.2) 0.001EFA cognitive 5 to 251

12、3.3 (6.4)18.7 (5.2) 0.001Total main therapies min/day131.6 (16.6)140.2 (18.7) 0.001(Rollnik, 2014)Phase B MRSA and outcome 抗药性金黄色葡萄球菌抗药性金黄色葡萄球菌 及结及结果果抗药性金黄色葡萄球菌(+)抗药性金黄色葡萄球菌(-)年龄住院时间早期康复时间全部康复时间共同诊断数巴塞尔量表得分转出时巴塞尔量表得分入院时早期康复指数得分传出时早期康复指数得分早期功能评定营养早期功能评定面口早期功能评定感觉，运动早期功能评定认知Phase B ESBL and outcome 大肠

13、埃希菌大肠埃希菌 及结果及结果(Rollnik, 2015)Phase C C级级-patients are still dependent on nursing, but they dont need ICU or IMC 患者仍需支持护理，但不需要ICU或IMC-patients cooperate more and more actively 患者日趋活跃，并合作良好Phase C C级级Phase C diagnoses 诊断诊断(Rollnik, 2009)Phase C Outcome C级级 结果结果(Rollnik, 2009)Phase C Outcome C级级 结果结果(

14、Rollnik, 2009)Phase C LOS C级级 病程病程(Rollnik, 2009)MEmbeR-study on medical-occupational rehab 职业医疗康复的研究职业医疗康复的研究-Design of the MEmbeR-study: 研究设计Multicenter 多中心Multiple indications (neurological, psychiatric, orthopedics, internal medicine) 多学科参与 1.Prospective 预期MEmbeR: Centers 多中心分布多中心分布MEmbeR: Study

15、 sample 研究样本研究样本-mean age 34.1 (9.9) y, 113 m, 83 f 平均年龄34.19.9岁，男113，女83-LOS: 148.6 (SD=223) days (approx. 5 months), range 10 1080 病程：平均148.6天， 标准差223，（约5个月） 范围处于10-1080天r=-0.47 (p0.001)(Rollnik et al., 2014)MEmbeR: Unfit for work 无法适应工作无法适应工作Before: 69.9%, 24 months after rehab only 5.6%康复前：69.9%

16、，康复24个月后仅5.6%(Rollnik et al., 2014)MEmbeR: Jobless 失业失业Before: 19.9%, 24 months after rehab: 3.1% 康复前19.9%，24个月康复后3.1%(Rollnik et al., 2014)MEmbeR: Return to work(Rollnik et al., 2014)24 months after medical occupational rehabilitation, 153/196 (78.1%) returned to work!职业医疗康复职业医疗康复24个月后，个月后，78.1%病人病

17、人回归社会工作生活回归社会工作生活回归工作回归工作Summary-The Federal Rehabilitation Council has established a successful 6-phase model forneurological and neurosurgical patients. 联邦康复委员会为神内/外系统成功推出6级康复模式-The BDH-Clinic offers inpatient rehabilitation from phase A (acute-care hospital treatment) to E (medical-occupational r

18、ehab) 本中心提供A-E 共五级康复-Early rehabilitation allows rehabilitation of mechanically ventilated and critically illpatients. Weaning is succesful in approx. 70% of cases.早期康复接受机械通气及严重病患 70%可以成功转入下一级别-The burden of multiresistant germs (MRSA, ESBL) is challenging in neurological early rehabilitation (prevalence on admission: approx. 25%).对于早期神经系统康复，多重耐药菌（抗药性金黄色葡萄球菌、 ESBL 菌）的压力是一大挑战 （入院病人约25%）-Patients colonized with MRSA or ESBL-producing bacteria have a worse outcome(lower functional status on admission, higher morbidity).抗药性金黄色葡萄球菌、 ESBL 菌感染病人预后普遍较差，