Pioneering aftercare for trauma patients

Patients treated at a major trauma centre in Bristol are the first in the country to receive digital eRehabilitation Prescriptions following discharge from hospital.

Digital Rehabilitation Prescriptions for Major Trauma Patients – Severn Major Trauma Network and Patients Know Best from Mohammad Al-Ubaydli on Vimeo.

From 1st April, NHS England requires that all major trauma centres provide patients a copy of their rehabilitation prescription following serious injury as part of new national guidelines which have come into force. Although many trauma centres now offer paper rehabilitation prescriptions, North Bristol NHS Trust is the first to provide digital patient-held eRehabilitation Prescriptions and care plans. This is using a system by Patients Know Best that is uniquely used as a live record, following the patient wherever they go.

With holidaymakers visiting nearby tourist spots like Western-super-Mare, the trust also cares for patients who come from outside Bristol and the wider region. These patients will have experienced serious injury or trauma, and will often have little or no memory of the incident itself. This can make it difficult to manage and navigate their own care without the direct healthcare intervention they have become accustomed to during their lengthy stay in hospital. For patients like this, continuity of care is paramount to ensure that recovery continues when they are back home.

Victoria Legrys, Severn Major Trauma Network Manager, said: “Our feedback told us that patients, and sometimes their families or carers, felt like they’d been ‘forgotten’ once they left the hospital and there really was no sort of care plan in place to help with that.”

The eRehabilitation Prescription is part of a 3-step discharge process, helping trauma patients leaving Southmead Hospital to better manage their aftercare. It includes:  

  1. eRehabilitation Prescription – a tailored care plan informing patients about what has happened to them and signposting support services to give advice about commonly confronted problems.
  2. Discharge consultation – a detailed consultation conducted in collaboration with patients and their specialist healthcare professional (i.e. trauma practitioner and pharmacist) before leaving hospital.
  3. Two-week follow-up phone call / ongoing access and online consultation via Patients Know Best – to reinforce the contents of the eRehabilitation Prescription and move forward using online consultations and remote monitoring.

The eRehabilitation Prescription is an important part of the patient’s own digital health record. It is theirs for life and can be updated, shared digitally or even printed by healthcare teams, including the patient’s own local GP.  With the lines of communication between patients and healthcare teams more open and access to information across geographic boundaries more easily available, evidence suggests that patient engagement and self-management has increased while unscheduled GP visits within the first 30 days of discharge have decreased by 28%.

Victoria added: “Other specialities outside of major trauma are now contacting us to ask how we are doing this. Particularly because the systems of care are changing now with more networked models of care. That means that patients might travel a long way from home to get the specialist care they need. And so, we needed a system that was going to support that, with the data following the patient beyond local providers, and major trauma is now a perfect example of that.”

Charlie Howard, Major Trauma Practitioner, added: “If you have a patient that comes in with a head injury and they have short-term memory loss, they can’t always retain the information they’re being told. By using Patients Know Best, it means that when going home or to a local hospital, the information is there and can be reiterated and utilised when needed.”

Amelia Jones, Physiotherapist in the Outpatients Department at Southmead Hospital, often sees patients much later in their recovery when a lot may have happened since. She says: “Patients aren’t always the best historians. So it allows us to access a database which provides lots and lots of really important information which perhaps a patient might not inform us fully about at the time, or not realise how important it is. It gives us detailed information such as how many injuries they have which are generally quite complex with lots of different management plans. It breaks it down really nicely for us to understand each injury and care plan individually.”

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