St John's Hospital, Livingston
Hospital A&E Information
Since September 2004 there has been an 8 bed observation ward at St John where head injured patients may be kept under the care of the A & E consultant (there are no general surgical beds at St John Hospital). The vast majority stay for less than 12 hours and the aim is to limit stay to 48 hours. Occasional cases remain beyond this time and some problems arise particularly with elderly patients with co-morbidity or social problems.
Those discharged are provided with written information and the GP informed. In addition there is a Head Injury Review Clinic and West Lothian patients are referred to the community rehabilitation service (Community Rehabilitation & Brain Injury Service (CRABIS)).
Hospital Post A&E Information
After 6 hours in the CA unit in RIE, head injured patients come under the care of one of the 11 general surgeons who is on call. After 24 hours they are taken to one of two general surgical wards (106/107). There is limited access to allied health professional (AHP) input in the general surgical wards. If stay is prolonged the patient is referred to the Scottish Brain Injury Rehabilitation Service (SBIRS) at the Astley Ainslie Hospital. There is AHP available seven days a week in the CA unit who are particularly useful for elderly patients to facilitate early discharge.
Post-neurosurgical patients are not referred back to the general surgeons but go to SBIRS.
If an individual in the surgical ward had made a good physical recovery but had some persisting cognitive issues (scenario A) advice would be obtained from neurosurgery and some are referred to rehabilitation. Similarly those fitting scenario B would be referred to rehabilitation.
If an individual was acutely behaviourally disturbed (scenario C) help may be sought from liaison psychiatry but if present in CA and suspected as relating to drug or alcohol abuse they may be directed to the toxicology bay. This is not however the case of behaviour that is felt to be solely caused by the head injury. In the event of more chronic challenging behaviour (scenario D) referral would be made to the liaison psychiatry who in turn might refer on to the Scottish Neurobehavioural Rehabilitation Service (SNBRS).
There have been no cases of younger people fitting the vegetative or minimally conscious state (scenario E) in recent years but some elderly individuals who have fitted this classification have remained in the ward for some time.
The orthopaedic surgeons do encounter TBI cases but only in those with concomitant fractures. Individual infrequent cases with persisting challenging behaviour (scenario D) and minimally conscious state (scenario E) have occurred over the years and have had prolonged lengths of stay.
Reviews, Plans and StrateigiesNHS Lothian and the four local authorities recently agreed the Lothian Joint Physical & Complex Disability Strategy 2008 which refers to acquired brain injury.
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