Dr. Christos Georgopoulos, MD, PhD, CCST-NS (UK)
President of “ANAPLASI” Rehabilitation Center
Director of Neurosurgery “Henry Dunant” Hospital.
Stroke (cerebrovascular accident, CVA) and traumatic brain injury are the leading causes of disability both in Greece and internationally.
Since the inauguration of Anaplasi (this year celebrating its 18th year, we have “come of age”) we have attempted a thorough analysis of the clinical and epidemiological characteristics in these serious disease categories, and put into practice innovative ideas to deal with them most effectively. During the process we made two important observations:
1) The management of many stroke patients is incomplete, fragmented and uncoordinated.
2) Effective management necessitates a complete, integrated and inclusive approach to diagnosis and therapeutic intervention.
Every year in ANAPLASI an average 270 new patients with stroke are evaluated after their acute needs have been dealt with. The large number of patients available for study gives added weight to our conclusions.
Initially we observed and then confirmed by statistical analysis that four out of ten patients who presented to us were categorized as having moderate functional impairment (as measured on the Barthel scale) while two in ten were classified as having severe disability. However of the patients presenting acutely only 10% meet the international criteria for inpatient rehabilitation. Thus the vast majority of stroke patients can be treated as outpatients, after acute problems have been treated at the admitting general hospital.
A proportion of patients, in the order of 10-15%, the prognosis for functional recovery are extremely poor. These patients are better with supportive home care or admission to long-term care institutions under medical supervision after consultation with the family.
The rehabilitation therapy of stroke patients begins – or should begin – during the acute phase of hospitalization at the general hospital; that is as soon as the diagnosis is made and urgent medical problems attended to.
Bearing in mind that recovery from stroke is a natural process, the role of rehabilitation therapy is to provide a complete, comprehensive and coordinated service by the rehabilitation team, to identify the patients’ needs and set objective targets for recovery. This can be summarized as follows:
1. Prevent complications.
2. Take all necessary measures to prevent recurrence of stroke and related potentially fatal conditions such as coronary heart disease, pulmonary embolism, etc.
3. Strengthening remaining functions.
4. Teach new skills in order to counteract functional deficits, maximize independence in performing daily life activity and improve quality of life for the patient and his family, including vocational and social rehabilitation of the patient.
35% of patients referred to us for rehabilitation treatment, with equal proportions of men and women are in the range of 40 to 60 years old and thus of working age. The speed and extent of neurological and functional recovery in these patients has direct bearing on their ability to start or return to work to financially support themselves or their dependents.
The rest of the patients are at a pensionable age. In this group good progress will minimize the burden for their families or carers. It can be seen that the degree of satisfaction of patients (and relatives) is inextricably linked to the degree of functional independence in the final outcome, hence as a result of successful
A) Treatment of stroke in the acute phase and
B) Rehabilitation therapy in:
- Post – acute and
- Chronic phase.
The total financial cost of the above this is great and sometimes impossible to meet:
Personal cost – cost of living
Cost to the family – as a dependent
Social cost – lengthy and expensive treatments, particularly for “failure” of A and B.
In the period 2009-2011 Anaplasi treated 179 inpatients with stroke. Of these the 91 men and 79 were women, with a mean age of 61years. The following data will refer to that specific population of patients hospitalized in Anaplasi.
These w ere patients selected for admission on as having good prospects and good prognosis for a worth wile outcome of the rehabilitation treatment at our center and, therefore, satisfied the inclusion criteria of Anaplasi (neurological, functional ).
The average length of inpatient hospital stay was 74 days with a range from one to – in exceptional cases – eight months.
A program of therapies is prescribed by the rehabilitation team, according to the needs of patients, on admission and a re-evaluated at regular intervals with daily follow-up by a team member.
Therapies take place daily, seven days a week – morning and afternoon – and the program lasts as long as team deems the patient is receiving an objective benefit.
Regarding the severity of disability in our patients, it is worth noting that we are the only rehabilitation center in the prefecture of Attica, to accept patients with tracheostomy / gastrostomy and specialize in the treatment of pressure ulcers , urinary problems (Department urodynamic for patients with neurogenic bladder), dysphagia (Department dysphagia) and pain syndromes (pain clinic).
Patients taking advantage of the geographical position of the new ANAPLASI (Nea Ionia – opened 17th November 2008) and its easy access, come from all parts of Attica.
A small number of patients come from other, chiefly neighboring, counties. Occasionally we treat patients from Cyprus, Italy, Germany and UK.
Data analysis of patient records, and personal communication with physicians in general hospitals where patients were treated with stroke during the acute phase, showed two striking, and unexpected findings:
Firstly, in the majority of these patients, from General Hospitals, Public and Private, despite unfavorable to tragic conditions in many hospitals due to the economic crisis, pertinent investigations and appropriate treatment was instigated with remarkable speed. It was noted that, in both General Medical and in Neurological departments, internationally recognized scales for initial evaluation of patients with stroke are used to assess the severity of the episode, the initial risk of mortality, and the long-term outcome.
Secondly, during the first year of the new ANAPLASI, the average length of hospital stay during the acute phase in the receiving hospital, was 17 days.
Over the years the degree of confidence in ANAPLASI has increased by leaps and bounds. Proving that ANAPLASI enjoys the confidence of the medical community the fact that, two years later, in 2011, the average length of hospital stay in stroke patients at the General Hospital, before coming to our center, dropped dramatically to just five (!) days .
Through informal discussions, we found that, initially, main factors affecting positively and quickly ANAPLASI perspective was both the quality of the staff (well-known members of the medical and therapeutic community covering all specialties), as well as the advanced electronic equipment, the robotic beds and the unique therapy pool in the center.
Soon the excellent clinical outcomes supported and strengthened the initial impressions.
From our series of 170 patients, only 7 required urgent transfer to a general hospital for serious or life-threatening, complications; after dealing with these situations all returned to our care.
90% (153) of hospitalized patients at admission were within range Barthel (BI) in the group of ‘complete’ dependence (0-20/100).
The remaining 10% of patients recorded as ‘seriously’ dependent (BI 21-60/100).
The patients showed, on average, a statistically significant improvement of 46 “whole” steps on the Barthel index, measured on discharge.
We emphasize that patients objectively graded with an index greater than 40 in BI (patients with a good degree of independence), were encouraged to continue their treatment as outpatients.
In ANAPLASI the staff body recognizes, regardless of specialty or seniority (as clearly embodied in the concept of the Rehabilitation Team) that our primary task in the context of the patient-oriented system of organization and operation is the preservation, protection and promotion of the HEALTH, SECURITY AND DIGNITY OF ALL PATIENTS.
Compliance with this task (given the excellent infrastructure and advanced technological equipment) at the outset ensured the emergence of a dynamic relationship between two factors:
A) Firstly, personnel with proven knowledge and experience in their area of specialization responsible personally and collectively – toward patients and their colleagues;
B) Secondly, the existence of patient-oriented total quality management systems relating to the design, development, organization, and provision of top quality healthcare and rehabilitation.
Anaplasi has been a pioneer and in this important catalytic domain:
“Holistic Approach – Total Care – Total Quality”
Venturing into unknown, unexplored, turbulent seas during the second half of the 1990s, in a climate of ignorance and hostility towards Rehabilitation Services in Greece, Anaplasi found a safe harbor in Quality Assurance System for Hospitals and Health Rehabilitation, jointly developed by DQS and IQNet, which with its wide international acceptance and impact, which officially recognized us as a leader in our field and ANAPLASI as synonymous Rehabilitation Science.
It is assumed that Anaplasi is the last stage of a long and arduous journey the patient commences at the onset of the disease and continues with the acute medical and nursing treatment in the acute phase.
Crossing the threshold of ANAPLASI, the patient, may be fearful, frustrated and pessimistic about the evolution of the situation, or the opposite, have exaggerated expectations for recovery from (a possibly permanent) disability; angry perhaps by the hospitalization conditions he has encountered, or by the bureaucracy; drained of money and mental strength; surrounded by relatives or carers fed up the usual necessity of acting as nursing staff; and weakened by the struggle to extract their (entitled) benefits from insurance funds.
During the first moments of their stay in the Anaplasi, the element of surprise is initially replaced by suspicion…….. “Everywhere must be the same even if it doesn’t appear so.”
With time (because the hospital stay in a rehabilitation center is long) they recognize, understand and appreciate the values and principles that govern and characterize us:
We are honest, responsible and accountable to our patients and their relatives,
We go beyond the minimum acceptable to do as much as possible
Help the patient – disabled citizen to formulate the problem and his needs
We believe that our duty extends beyond the walls of Anaplasi, towards all health professionals, and the wider society.
In this sense Anaplasi has a wide scientific and social role beyond contributions to the scientific community through participation in scientific conferences and events (an inherent and intrinsic feature of Anaplasi).
Additionally we provide information through articles and publications both to the general public and to the state, and support and assist any inquiries from scientific, government or non-governmental bodies, where we are regarded as experts in Neuroscience and Rehabilitation.
These interventions, are sometimes targeted and sometimes general, clinical or sociopolitical, but always with a scientific basis, aim at:
- Protection of patients’ rights regarding the maintenance, improvement and restoration of health.
- Better organization of health services.
- Establishing and maintaining the trust of patients and society in healthcare professionals not only as individuals but also as organized groups.
- Audit of data perform and instigation of preventive and corrective interventions where necessary, within a certified total quality management system.
- Configuring Infrastructure (facilities and equipment) to ensure it is fit for purpose, both quantitative and qualitative, and ensuring excellence through continuous reappraisal, appropriate development and application of the most advanced technology.
- Integration of human resources in a transdisciplinary team, where health professionals, administrative and support staff communicate, cooperate, coordinate and provide services in the context of promoting a single health policy. The latter is ensured by dynamic appraisal of the Total Quality System, where the management of risks of adverse events is performed through preventive and corrective actions.
Historically there are two dominant models of organization and functioning of human groups and collectives:
– the hierarchical model
– the egalitarian model
The transdisciplinary rehabilitation team was created ANAPLASI, as an evolution of the Interdisciplinary Rehabilitation Team. The criteria for selecting its members was, not only the required traditional skills (literacy, knowledge, experience), but also personal skills (integrity, emotional maturity, empathy – empathy). We support and encourage the team with a program of continuing education. Finally, under the supervision of team leaders who are respected by their co-workers, these qualities are combined with the collective attributes of the functioning group (respect, openness, solidarity).
In the transdisciplinary rehabilitation team members are equal and its operation is governed by transparency, honesty, and sound judgment.
18 years ago we promised that we would introduce Rehabilitation to our country. Now we are telling the story of the future for those who wish to hear us.
We have engendered unparalleled trust, making Anaplasi synonymous with Rehabilitation.
We have told the truth. We have kept our promises. We show that we have fulfilled what we promised.
We hope that our ideas and our opinions are not copied superficially but in keeping with our underlying principles.
Today and every day we proclaim our belief that patients with stroke are entitled to and deserve the most effective rehabilitation, so we never stop exploring innovative services and each time find new value to our work and our vision.
We distance ourselves (against the spirit of our age) from a shallow, conceited, or narcissistic viewpoint. Instead, we analyze with great seriousness and a sense of responsibility, as our position as an internationally acclaimed hospital befits, the reports of the quality of our services without from exception ALL of our patients and their relatives.
Our aspirations, and our goals, are transformed (certainly not without potential for further improvement and progress) into recognizable – and thus acquired – special features of the large family of ANAPLASI.
Patients receive unconditional compassion, kindness, understanding, empathy, and care from the Team; which is spontaneously and automatically appreciated judging from the “compliments” received by the members of our Team during the hospitalization of the patient and their integration within the great family of ANAPLASI.
For us, these compliments are titles of honor and the greatest academic distinctions.
This article was published on 3 December 2012, on the website of medical journal (www.iatrikostypos.com), as a contribution by ANAPLASI on the occasion of the International Day of People with Disabilities.