Incidence of medical complications in spinal cord injury: patients in specialised, compared with non-specialised centres

The experiences of individuals with cervical spinal cord injury and their family during post-injury care in non-specialised and specialised units in UK

BACKGROUND

Individuals with acute cervical spinal cord injury require specialised interventions to ensure optimal clinical outcomes especially for respiratory, swallowing and communication impairments. This study explores the experiences of post-injury care for individuals with cervical spinal cord injury and their family members during admissions in specialised and non-specialised units in the United Kingdom.

METHODS

Semi-structured interviews were undertaken with individuals with a cervical spinal cord injury and their family member, focussing on the experience of care across units. Eight people with spinal cord injury levels from C2 to C6, were interviewed in their current care settings. Six participants had family members present to support them. Interviews were audio-recorded and transcribed with data inputted into NVivo for thematic analysis.

RESULTS

The study identified six themes from the participant interviews that highlighted different experiences of care in non-specialised and specialised settings. A number of these were related to challenges with the system, whilst others were about the personal journey of recovery. The themes were titled as: adjustment, transitions, "the golden opportunity", "when you can't eat", communication, and "in the hands of the nurses and doctors".

CONCLUSIONS

Whilst participants reported being well cared for in non-specialised units, they felt that they did not receive specialist care and this delayed their rehabilitation. Participants were dependent on healthcare professionals for information and care and at times lost hope for recovery. Staff in non-specialised units require training and guidance to help provide support for those with dysphagia and communication difficulties, as well as reassurance to patients and families whilst they wait for transfer to specialised units.

The impact of acute management on the occurrence of medical complications during the specialized spinal cord injury acute hospitalization following motor-complete cervical spinal cord injury

CONTEXT/OBJECTIVE

Determine the impact of early admission and complete perioperative management in a specialized spinal cord injury (SCI) trauma center (SCI-center) on the occurrence of medical complications following tetraplegia.

DESIGN

A retrospective comparative cohort study of prospectively collected data involving 116 individuals was conducted. Group 1 (N=87) was early managed in a SCI-center promptly after the trauma, whereas Group 2 (N=29) was surgically and preoperatively managed in a non-specialized (NS) center before being transferred to the SCI-center. Bivariate comparisons and multivariate logistic regression analyses were used to assess the relationship between the type of acute care facility and the occurrence of medical complications. Length of stay (LOS) in acute care was also compared.

SETTING

Single Level-1 trauma center.

PARTICIPANTS

Individuals with acute traumatic motor-complete cervical SCI.

INTERVENTIONS

Not applicable Outcome measures: The occurrence of complications during the SCI-center stay.

RESULTS

There was a similar rate of complications between the two groups. However, the LOS was greater in Group 2 (p=0.04). High cervical injuries (C1-C4) showed an important tendency to increase the likelihood of developing a complication, while high cervical injuries and increased trauma severity increased the odds of developing respiratory complications.

CONCLUSION

Although complication rates were similar in non-specialized and specialized centers, peri-operative management in a non-specialized center required a longer length of stay. Prompt transfer to a SCI-center may optimize the care trajectory by favoring earlier transfer to rehabilitation.

Spinal Cord Injuries and Helicopter Emergency Medical Services, 6,929 Patients: A Multicenter Analysis

OBJECTIVE

Traumatic spinal cord injury (SCI) impacts quality of life for patients and caregivers, generating lifetime costs in the millions. Previous studies show delayed treatment of SCI patients at specialized centers is linked to complicated outcomes and extended hospitalizations. This study characterizes helicopter emergency medical service (HEMS) use in SCI and develops a methodology to study large volumes of HEMS electronic medical record data from multiple providers.

METHODS

This descriptive study used deidentified data of HEMS providers that use Golden Hour Data Systems, Inc (San Diego, CA) software service from 34 states in the United States from 2004 to 2011. Demographic and logistical data underwent a deidentification protocol developed specifically for this study before analysis.

RESULTS

Six thousand nine hundred twenty-nine SCI patients were transported. HEMS use increased but decreased relative to total transports from 2004 to 2011. The average patient was 39 ± 21 years old, male, and had a 63-minute total transport time. The largest age bracket was 15 to 25 years.

CONCLUSION

HEMS improved access for SCI patients to all localities and generally took under 2 hours. SCI patients are mostly young adult males, thus supporting the loss of years of productivity and also supporting the high lifetime cost for care for SCI. This study created a methodology for future multicenter aggregate data studies.

Right care, right time, right place: improving outcomes for people with spinal cord injury through early access to intervention and improved access to specialised care: study protocol

Background

Traumatic spinal cord injury is a devastating condition impacting adversely on the health and wellbeing, functioning and independence, social participation and quality of life of the injured person. In Australia, there are approximately 15 new cases per million population per year; economic burden estimates suggest 2 billion dollars annually. For optimal patient outcomes expert consensus recommends expeditious transfer (“<24 hours of injury”) to a specialist Spinal Cord Injury Unit, where there is an interdisciplinary team equipped to provide comprehensive care for the many and complex issues associated with traumatic spinal cord injury. No study of this patient population has been undertaken, that assessed the extent to which care received reflected clinical guidelines, or examined the patient journey and outcomes in relation to this. The aims of this study are to describe the nature and timing of events occurring before commencement of specialist care, and to quantify the association between these events and patient outcomes.

Methods and design

The proposed observational study will recruit a prospective cohort over two years, identified at participating sites across two Australian states; Victoria and New South Wales. Included participants will be aged 16 years and older and diagnosed with a traumatic spinal cord injury. Detailed data will be collected from the point of injury through acute care and subacute rehabilitation, discharge from hospital and community reintegration. Items will include date, time, location and external cause of injury; ambulance response, assessments and management; all episodes of hospital care including assessments, vital signs, diagnoses and treatment, inter-hospital transfers, surgical interventions and their timing, lengths of stay and complications. Telephone follow-up of survivors will be conducted at 6, 12 and 24 months.

Discussion

There is limited population level data on the effect of delayed commencement of specialist care (>24 hours) in a Spinal Cord Injury Unit. Examining current health service and clinical intervention pathways in this Australian population-based sample, in relation to their outcomes, will provide an understanding of factors associated with patient flow, resource utilisation and cost, and patient and family quality of life. Barriers to streamlined effective early-care pathways and facilitators of optimal treatment for these patients will be identified.

Spinal cord injured persons’ conceptions of hospital care, rehabilitation, and a new life situation

BACKGROUND

The basic aim of spinal cord injury (SCI) rehabilitation is to help patients return to a life worth living. It is therefore important that the staff at spinal units and rehabilitation centres understand how the patients experience their rehabilitation and their adjustment process to the new situation.

AIM

To describe SCI persons' experiences of their rehabilitation process.

METHOD

Nineteen SCI persons were interviewed. Data from the tape-recorded interviews were analysed according to a modified descriptive version of the phenomenographic analysis process.

RESULTS

Six categories that describe the informants' conceptions of their rehabilitation process emerged: access to information, participation in planning rehabilitation, emotional support, feelings of vulnerability, adjustment to a new life situation, and emotional consequences of the injury.

CONCLUSION

Straightforward information, participation in the planning of the rehabilitation programme and emotional support were important factors influencing the rehabilitation process after the SCI. Professionals working with SCI rehabilitation should make use of patients' experiences in order to develop better rehabilitation programmes that focus on the individual needs of the patient. People are individuals and failure to take this into account can impact negatively on quality of life and the effectiveness of the rehabilitation.

Challenge of percutaneous nephrolithotomy in patients with spinal neuropathy

OBJECTIVE

To assess the technical difficulties, associated complications and stone clearance rates in patients with spinal neuropathy undergoing percutaneous nephrolithotomy.

METHODS

Twenty-nine patients with spinal neuropathy underwent percutaneous nephrolithotomy in the two centers studied between October 1995 and January 2002. They were nine patients with traumatic spinal cord injury, 10 patients with spina bifida and 10 with other heterogeneous causes for their spinal neuropathy. The group included 12 men and 17 women, with an average age of 44 years (14-80). Patients' medical records were reviewed retrospectively for data relating to their renal lithiasis.

RESULTS

A total of 39 percutaneous nephrolithotomy procedures were undertaken on 32 kidneys. Thirteen procedures were for staghorn calculi. Preoperatively, eight kidneys required nephrostomy and 5 J stent decompression. The average American Society of Anesthesiologists (ASA) score was 3, and one patient had percutaneous nephrolithotomy performed under local anaesthetic as the risk of general anaesthetic was felt to be too high. The associated morbidity and mortality in this group is significant. There were two postoperative deaths. Major complications were associated with three procedures, and consisted of seizures, aspiration pneumonia and pressure necrosis. Nine patients experienced minor complications including fever, hypotension and nephrostomy site leakage. Nine patients required intensive therapy unit care postoperatively and the average hospital stay for the group was 13.32 days. Only 18 (62%) patients were rendered stone-free from their initial percutaneous nephrolithotomy. Seven patients required a further procedure for stone clearance: four underwent extracorporeal shock-wave lithotripsy, two ureteroscopy and one nephrectomy.

CONCLUSIONS

Patients with spinal neuropathy and renal lithiasis pose a significant operative challenge. Technical difficulties and potential complications should be considered carefully before undertaking percutaneous nephrolithotomy in these patients.

Rehabilitation unit staff attitudes toward substance abuse: changes and similarities between 1985 and 20011,21No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or any organization with which the authors are associated.2Reprints are not available

OBJECTIVES

(1) To assess the attitudes of the members of an inpatient rehabilitation unit team toward their unit's substance abuse and tobacco use policies, and (2) to compare the findings with those of a survey 16 years earlier.

DESIGN

An anonymous repeated assessment of staff attitudes and behaviors.

SETTING

A 47-bed inpatient rehabilitation unit.

PARTICIPANTS

Rehabilitation unit nurses, occupational and physical therapists, psychologists, physicians, social workers, and speech pathologists.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Change in response with time.

RESULTS

Seventy percent (89/128) of the staff members completed the survey. Seventy-two percent believed that they were "familiar or very familiar" with the unit's substance abuse policy and 51% were "concerned" or "very concerned" about their patients' alcohol and drug use. Nineteen percent reported complaints about the policy from their patients and 8% reported complaints from family members. Support for a uniform substance abuse policy remained high: 96% supported a uniform policy in both 1985 and 2001. However, only 15% believed that staff drug abuse education was adequate and only 45% believed that the current policy was "adequate" or "very adequate." (Corresponding responses in 1985 were 20% and 50%, respectively.) All but 1 respondent considered tobacco use an addiction, but only 48% believed that their patients were routinely assessed for its use.

CONCLUSION

Support for a uniform substance abuse policy remains strong. Although most team members support the policy, they believe that their education about substance abuse is inadequate. Staff members almost unanimously accept tobacco use as an addiction, but they believe that assessment and intervention efforts are poor.

Respiratory complications in patients with traumatic cervical spine injuries: case report and review of the literature

Spinal cord injuries continue to be a devastating medical problem. By impairing voluntary and involuntary nervous system function, virtually every body system function is affected. However, pulmonary function alteration and respiratory complications continue to be the major causes of morbidity and mortality in patients with spinal cord injuries. The current understanding of respiratory problems faced by patients with loss of innervation from cervical spinal cord injuries are reviewed.

Mobilization of patients after spinal surgery for acute spinal cord injury

STUDY DESIGN

A retrospective review was conducted covering records of patients who underwent spinal surgery after acute spinal cord injury.

OBJECTIVE

To study the relation between time of operation and mobilization of patients.

SUMMARY OF BACKGROUND DATA

No such report has existed in the literature.

METHODS

Reviews were conducted for the medical records of 102 consecutive patients with acute spinal cord injury admitted to the National Spinal Injuries Center whose spines had been stabilized surgically. The surgeries had been performed either in the National Spinal Injuries Center or in hospitals of the United Kingdom or Continental Europe not specialized in comprehensive care of spinal cord injury. For the patients in three groups, the date of operation and the date of mobilization were compared. The causes for delay in mobilization were identified.

RESULTS

A trend of negative correlation was found between the mean number of days from injury to operation and the mean number of days from injury to mobilization. Conversely, a trend of positive correlation was found between the mean number of days from injury to admission or transfer to the National Spinal Injuries Center and the mean number of days from injury to mobilization. Long stay in bed was associated with complications. None of the patients in Group A stayed in bed longer than 77 days, whereas 13 patients in Groups B and C combined had a longer stay. The difference was statistically significant (P = 0.02, chi2). Eight of these patients had pressure sores.

CONCLUSION

To ensure early mobilization, early spinal surgery must be supported by specialized comprehensive care.

Neurologic outcome in conservatively treated patients with incomplete closed traumatic cervical spinal cord injuries

STUDY DESIGN

The neurologic outcomes in patients with conservatively managed incomplete closed traumatic cervical spinal cord injuries was evaluated using the motor scoring system and the Frankel classification.

OBJECTIVES

To show that the motor scoring of recovery system combined with functional Frankel grading will make the documentation of final neurologic outcome more accurate for future comparisons of various methods of treatment.

SUMMARY OF BACKGROUND DATA

The influence of surgical and pharmacologic methods of treatment on recovery remains debatable.

METHODS

Sixty-three consecutive patients with incomplete cervical injuries who were admitted to the hospital within 2 days after injury were included. All patients were treated conservatively with 6 weeks of bedrest and 6 weeks of mobilization with neck support.

RESULTS

Five patients had neurologic deterioration, and all but one patient recovered without surgery. The evaluation of 44 patients who were observed for more than 12 months showed that the preservation of sharp sensation below the level of injury was an indicator of a good prognosis in patients whose injuries were classified as Frankel B, and the degree of recovery of these patients according to the motor score system was comparable with that of patients who were classified as Frankel C. All patients classified as Frankel C who did not deteriorate recovered in Frankel grade. All but one of the patients in the Frankel D group recovered full motor power. The degrees of motor deficit and recovery did not correlate with the mechanism or the degree of the injury of the spinal axis.

CONCLUSION

Conservative treatment remains a good option for patients with incomplete cervical cord injuries. It is hoped the current study will be a good basis for comparison of the neurologic outcomes of different treatment modalities.

Percutaneous nephrolithotomy: spinal cord injury vs. ambulatory patients

One hundred patients, 35 with spinal cord injury (SCI) and 65 who were ambulatory, underwent percutaneous nephrolithotomy (PNL). Success of complete stone excision, operative morbidity and mortality were compared in the two patient populations. Stone size and complexity were evaluated by X-ray and a single-stage PNL was done using general anesthesia, bi-planar C-arm fluoroscopy, Amplatz renofascial dilators, and two guide wires. Eleven percent of the patients had previously-placed percutaneous nephrostomy tubes for hydronephrosis and/or pyonephrosis. In the ambulatory group, 98.5% (64/65) were stone-free after the procedure as compared to 85.7% (31/35) in the SCI group. The success rate in those patients who followed postoperative instructions exceeded 96% in both groups of patients. One operative mortality, related to infectious complications, occurred in the SCI group. Major morbidity in the SCI population consisted of three perirenal abscesses, a hydrothorax, an aspiration pneumonia, a respiratory arrest and a nephro-colonic fistula for a rate of 20% (7/35), or 7% of all patients. One major complication, a nephroduodenal fistula, occurred in the ambulatory population. Four patients, three of whom were SCI, required open surgery related to infectious complications. Other significant complications consisted of hemorrhage requiring transfusion, and fever (101.5 degrees F). Minor complications included dislodged nephrostomy tubes, retained stones, and ureteral edema causing obstruction. These complications were three times more common in the SCI population. Percutaneous nephrolithotomy is an effective surgical means for stone removal for SCI and ambulatory patients. The SCI patient has a high incidence of infectious complications causing increased morbidity and mortality.

Percutaneous nephrolithotomy in the spinal cord injury population

We evaluated 23 male spinal cord injury patients who underwent percutaneous nephrolithotomy for the success rate of stone removal and the incidence of operative complications. There were 18 quadriplegic and 5 paraplegic patients, and 5 had bilateral procedures. Of the kidneys 7 had staghorn calculi, 8 had pelvic and caliceal combinations, 6 had large multiple caliceal stones, 4 had large (more than 2.5 cm.) pelvic stones and 3 had pelvic stones less than 2.5 cm. Placement of a nephrostomy tube and stone extraction were performed as a single procedure with the use of general anesthesia in all but 4 patients. Our results showed that 19 of 21 compliant patients (90.4 per cent) were free of stone, with an average of 2.04 procedures per patient. A total of 47 procedures was performed, with an average operative time of 1 hour 45 minutes. Major complications were associated with 4 of the 47 procedures (8.5 per cent), and consisted of a respiratory arrest, 2 perirenal abscesses and a hydrothorax. Minor complications included fever (more than 101.5F) in 64.3 per cent and retained stones in 14.3 per cent of the kidneys operated upon, dislodged nephrostomy tubes in 12.6 per cent of the procedures (21.4 per cent of the kidneys operated upon), and anemia requiring transfusion in 17.0 per cent (8 of 47) of the procedures (27.8 per cent of the kidneys operated upon). The presence of infected stones, prior operative procedures and medical complexity of these patients make complications more frequent. Nevertheless, percutaneous nephrolithotomy is a safe and effective procedure for the spinal cord injury population.

New trends in urologic management of spinal cord injured patients

We have attempted to address some of the current issues and new trends in the urologic management of SCI patients. Although tremendous progress has been made with these patients, resulting in a significant lowering of renal morbidity and mortality, there is still room for improvement. Newer methods of bladder management and refinements of older techniques are being sought. Progress in treating urinary infections should occur through development of new antibacterials and through improved understanding of host-bacterial interactions. Research into these problems and the general management of the neurologic dysfunction in SCI offers the hope of an even brighter future for these severely disabled patients.