• We are sorry, but NCBI web applications do not support your browser and may not function properly. More information
Logo of neuMary Ann Liebert, Inc.Mary Ann Liebert, Inc.JournalsSearchAlerts
Journal of Neurotrauma
J Neurotrauma. Aug 2011; 28(8): 1363–1370.
PMCID: PMC3143414

The Impact of Specialized Centers of Care for Spinal Cord Injury on Length of Stay, Complications, and Mortality: A Systematic Review of the Literature

Abstract

Specialized centers of care for spinal cord injury (SCI) were first established in 1944 in England. The objective of these centers is to improve care and neurological recovery of patients suffering from a spinal cord injury. An interdisciplinary group of experts composed of medical and surgical specialists treating patients with SCI formulated the following questions: (1) Is there any evidence to suggest that specialized centers of care in SCI decrease the length of patient stay? and (2) Is there evidence that specialized centers of care for SCI reduce mortality and secondary complications? A systematic review of the current evidence was performed using multiple databases to answer these two specific questions. Two independent reviewers graded each paper using the Black and Downs method. Recommendations were then formulated based on the evidence available and were reviewed by a panel of experts using a modified Delphi approach. Two recommendations were formulated and both received complete agreement from a panel of experts. The first recommendation is “Early transfer of a patient with traumatic SCI to a specialized center of care should be done promptly to decrease overall length of stay.” The second recommendation is “Early transfer of patients with traumatic SCI to an integrated multidisciplinary specialized center of care decreases overall mortality, and the number and severity of complications.”

Key words: hospitalization, spinal cord injury, systematic review

Introduction

Spinal cord injury (SCI) tertiary care designated centers have been developed to help improve clinical outcome and neurological recovery in patients suffering from acute spinal cord injury (ASCI), with an estimated incidence of 15–40 cases per million population (Sekhon and Fehlings, 2001). The total SCI care system hospital charges per patient were over $250,000 in 2003, and have likely risen since then. The first spinal cord injury centers were established in the U.K. under the supervision of Sir Ludwig Guttman in 1944 in Aylesbury, England. Guttman's philosophy was that rehabilitation following SCI should not be dissociated from the acute treatment period. Several SCI centers have since appeared, mostly in developed countries, with the objective of improving the care and neurological recovery of patients with SCI.

This systematic review of the literature was undertaken to evaluate the benefits of centers of excellence in the treatment of SCI, and to review the evidence regarding improvements in outcome for patients treated in SCI centers vs. community hospitals. A Cochrane review of the existing literature found no randomized clinical trials surrounding SCI centers. The authors thus concluded that the current evidence is insufficient to “comment on the benefits of early referral to SICs in patients with traumatic SCI” (Jones and Bagnall, 2004). The limitation of the Cochrane approach is that it is limited to randomized controlled trials and controlled trials.

The current review was done to evaluate the following two questions: (1) Is there any evidence to suggest that centers of expertise in SCI decrease the length of patient stay? and (2) Is there evidence that centers of expertise in SCI reduce mortality and secondary complications?

Methods

A systematic review of the literature in three online databases (EMBASE, Medline, and the Cochrane database) was performed for articles matching the search criteria published before June 2009. The following search strategy was used: (“Spinal Cord Injury” OR “Paraplegia” OR “Quadriplegia”) AND (“Hospitalization” OR “Length of Stay” OR “transfer” OR “Referral and Consultation”), all mapped to subject heading, including all subheadings, and searched as keywords. This returned a total of 761 abstracts. The search was then limited to English language abstracts and human-subject studies. Case reports of fewer than 10 patients were excluded. The abstracts were then read by title and relevant abstracts were reviewed. Full-length articles of interest were then obtained. All articles were then reviewed according to the method of Downs and Black (Downs and Black, 1998) by two independent reviewers.

A total of 15 articles were kept at the end of this process and reviewed. An evidentiary table was prepared (Table 1).

Table 1.
Study Design, Population, Treatment or Therapeutic Measures, Outcome Measures, Study Purposes, and Key Results of the Studies

Data compilation

The following data were then compiled in the evidentiary table: study design, population, treatment or therapeutic measure, outcome measure, study purpose, and key results. The evidentiary table was then used to answer the two study questions.

Results

Is there any evidence to suggest that specialized centers of care in SCI decrease the length of patient stay?

A total of 10 retrospective studies including three case-control studies and seven retrospective cohort studies were identified to answer this question.

In a study evaluating the benefits of early admission to an organized Spinal Cord Injury Care System, DeVivo and associates (DeVivo et al., 1990) reviewed all admissions at one center over a 13-year period (1973–1985). They reviewed the medical records of 794 SCI patients, of which 284 had been admitted within 1 day of injury. They compared this group to 377 patients that were admitted later, mainly for rehabilitation. Four groups were formed based on neurological involvement (paraplegia incomplete, paraplegia complete, quadriplegia incomplete, and quadriplegia complete). For all but complete quadriplegics, the acute care LOS was considerably shorter for the early-admission group. Total LOS was also significantly shorter for both the paraplegia complete (LOS 81.7 vs. 95.5 days) and quadriplegia incomplete (LOS 79.2 vs. 108.0 days) groups.

In another study comparing rehabilitation times following SCI between 185 patients treated in a specialized short-term care unit and 153 patients in general hospitals,(Heinemann, 1989), total time at the rehabilitation center was no different. The duration from time of injury to transfer to the rehabilitation center was almost twice as long for non-center patients. Center patients also had greater daily gains during rehabilitation, although their level of injury did not differ from the non-center patients.

A study evaluating the effect of the implementation of specialized acute spinal cord injury units (ASCIU) in the province of Ontario compared 351 pre-ASCIU patients (1947–1973) with 201 ASCIU patients (1974–1981) (Tator et al., 1995). Although the management of patients over the two periods was probably not equivalent, LOS was decreased by nearly 50% (86.9 vs. 48.2 days). In another retrospective study of the same ASCIU cohort, the authors found that LOS was directly related to injury severity, complications, and time delay to admission, with patients admitted after 48 h having a significantly longer LOS than those admitted before 48 h (Tator et al., 1993).

Oakes and colleagues (Oakes et al., 1990) evaluated the effect of early admission to a comprehensive trauma center for patients with spinal cord injury. They compared early and late transfer for both paraplegics and quadriplegics, and their effect on LOS and medical complications. The acute and overall LOS for the early-admission group with quadriplegia was significantly decreased (3 vs. 75 days and 131 vs. 197 days, respectively), with both groups spending equivalent amounts of time in the rehabilitation phase. This was also the case for the paraplegia group, with the acute and overall LOS being significantly lower for the early-admission group (6 vs. 59 days and 93 vs. 126 days, respectively). The late-admission group also experienced 45% more complications than the early-admission group.

Review of larger databases (Becker and DeLisa, 1999; Chen et al., 1999) has shown that LOS has steadily decreased over the past 20–25 years. In the Model system, total LOS was 144 days when the system began collecting data, and this had decreased to approximately 69 days by 1999. Acute LOS has decreased by approximately 50%, and rehabilitation LOS has decreased by 60%. The reasons for this are probably multifactorial, but these changes are certainly related in part to the Model system.

Finally, a retrospective cohort study of all patients admitted to a spinal injury center between 1985 and 1988 (Aung and el Masry, 1997) demonstrated a significant difference between three subgroups of patients, both paraplegics and quadriplegics. The three groups were composed of patients admitted within 1 week of injury (group 1), between 1 week and 2 months (group 2), and more than 2 months after injury (group 3). The total hospitalization time was shown to be significantly different between the three groups, with groups 1 and 3 showing a significant difference, as well as groups 2 and 3 for the paraplegia group, and groups 1 and 3 for quadriplegic patients.

Is there evidence that specialized centers of care in SCI reduce mortality and secondary complications?

A total of eight retrospective studies were identified, including two retrospective case-control studies.

The study by DeVivo and colleagues (1990) found no major difference in the incidence of most medical complications, except for pressure ulcers that developed during acute care. All delayed-admission patients except for the neurologically-incomplete paraplegics had a higher likelihood of developing pressure ulcers. Early-admission patients saw a decrease in the rate of pressure ulcers over time, but this was not the case for the late-admission group. Also of note, early-admission patients with incomplete lesions were less likely to develop pulmonary emboli (0.7% vs. 5.4%, p=0.05), and complete quadriplegics were more likely to develop pneumonia (37.1% vs. 19.1%, p=0.02).

In the study comparing pre-ASCIU and ASCIU periods (Tator et al., 1995), mortality was found to be significantly affected, both for complete and incomplete neurological injuries. In the pre-ASCIU group, 49 patients died (14%) compared to 15 patients (7.5%) in the ASCIU group (p=0.022). The most important decline was in the complete group, which saw a decrease from 22.1% to 12.1% in the ASCIU group. The decline was not as substantial in the incomplete group, which decreased from 10.1% in the pre-ASCIU group to 7.8% in the ASCIU group. The complications in the same ASCIU population were associated with a longer LOS and an increase in the total cost of care (Tator et al., 1995).

The benefits of early admission on complications was also shown in a study by Oakes and associates (Oakes et al., 1990) Again, in this series the late-admission group had more complications in the quadriplegic group, who experienced 45% more complications than the early-admission group. This trend was not seen in the paraplegic group.

In the study by Aung and el Masry (1997), the occurrence of pressure sores was reduced in the early-admission group (less than 1 week), compared to the group admitted between 1 week and 2 months, and the group admitted more than 2 months after injury.

In the only study examining medical complications specifically in the rehabilitation period, the authors reported a frequency of 23.7% for pressure ulcers. The authors noted that this may be due to the decreasing LOS in the acute centers, making it more common for medical complications to occur in the rehabilitation setting. (Chen et al., 1999).

Discussion

The Model system in the United States has 14 centers collecting data on patients and three centers responsible for patient follow-up. The Model system has a multidisciplinary approach to the patient with an acute SCI. There are other centers in the United States that treat patients with SCI, but a complete list of these was not available for this review. There are 15 active sites in Canada that are part of the Rick Hansen Registry for SCI, representing 35 facilities including acute SCI centers and rehabilitation units. These specialized centers of care represent nearly all acute and rehabilitation centers treating patients with acute SCI in Canada.

There are no clear requirements or guidelines to determine what a specialized center of care should have available in the U.S. or in Canada. The authors of this review, however, feel that the following features should be taken into consideration when determining what represents a specialized center of care. First, these centers should be located inside or within close proximity of a Level 1 trauma center. A dedicated spinal surgery team with 24-hour on-call coverage should be mandatory. Rapid 24-hour access to an MRI and operating room is also a prerequisite. A “spinal unit” would not only represent a physical space, but would also encompass a wide range of specialists (e.g., physiotherapist, occupational therapist, physiatrist, spine surgeon, nurse coordinator, social worker, and psychologist). Easy referral to a long-term SCI rehabilitation center would also be a logical part of a specialized center of care. The number of SCI patients treated each year should be closely monitored, as expertise in treating these injuries is probably closely related to seeing a certain volume of cases per year. Although the exact number of cases per year needed to maintain a given level of expertise is unknown (Macias et al., 2009), studies have clearly shown a reduction in the number of paralysis in Level 1 and 2 trauma centers, especially those with higher surgical volumes (odds ratio 0.67). These higher surgical volumes are in contrast with non-trauma centers, where higher caseloads are associated with worse outcomes. This is probably due to the less-than-optimal structure for caring for patients with a traumatic SCI.

Specialized centers of care have radically changed the way patients with SCI are treated. The current systematic review of the literature identified several cohort studies and a few case-control studies, looking at both LOS and complications following transfer to a center of expertise, as well as neurological recovery following admission to a specialized center of care. Length of stay is consistently decreased with early admission to an organized SCI care system. Acute care hospitalization is reduced by almost 50% when patients are treated in a specialized short-term care center. There is also good evidence that delaying transfer of a patient past 48 h significantly increases the overall length of stay. These findings must be taken in context, as it is possible that patients with more severe injuries or more comorbidities may not be transferred as early as other patients, making these findings not as significant. Although the evidence reviewed is weak, it all points in the same direction, namely that specialized centers of care consistently reduce LOS and complications, and improve neurological recovery.

The following recommendations were therefore formulated and presented to a panel of experts:

Recommendation #1: Early transfer of a patient with traumatic SCI to a specialized center of care should be done promptly to decrease overall length of stay.

Recommendation #2: Early transfer of patients with traumatic SCI to an integrated multidisciplinary specialized center of care decreases overall mortality, as well as the number and severity of complications.

Both recommendations were greeted with complete agreement. Although the evidence presented was weak, the strength of the recommendations in both cases was strong, as each received complete agreement from a panel of medical and surgical experts through a modified Delphi approach.

Summary

This systematic review of the literature has shown a reduction in length of stay and decreased overall mortality following early transfer to specialized centers of care for SCI patients. The proposed guidelines both reflect that early transfer of patients with SCI to specialized centers is strongly recommended.

Author Disclosure Statement

No competing financial interests exist.

References

  • Aung T.S. el Masry W.S. Audit of a British Centre for spinal injury. Spinal Cord. 1997;35:147–150. [PubMed]
  • Becker B.E. DeLisa J.A. Model Spinal Cord Injury System trends, and implications for the future. Arch. Phys. Med. Rehabil. 1999;80:1514–1521. [PubMed]
  • Celani M.G. Spizzichino L. Ricci S. Zampolini M. Franceschini M. Spinal cord injury in Italy: A multicenter retrospective study. Arch. Phys. Med. and Rehab. 2001;82:589–596. SCI RSGo. [PubMed]
  • Chen D. Apple D.F. Hudson L.M. Bode R. Medical complications during acute rehabilitation following spinal cord injury—current experience of the Model Systems. Arch. Phys. Med. Rehabil. 1999;80:1397–1401. [PubMed]
  • Demetriades D. Martin M. Salim A. Rhee P. Brown C. Chan L. The effect of trauma center designation and trauma volume on outcome in specific severe injuries. Ann. Surg. 2005;242:512–519. [PMC free article] [PubMed]
  • DeVivo M.J. Kartus P.L. Stover S.L. Fine P.R. Benefits of early admission to an organised spinal cord injury care system. Paraplegia. 1990;28:545–555. [PubMed]
  • Downs S.H. Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J. Epidemiol. Community Health. 1998;52:377–384. [PMC free article] [PubMed]
  • Heinemann A.W. Yarkony G.M. Roth E.J. Lovell L. Hamilton B. Ginsburg K. Brown J.T. Meyer P.R. Functional outcome following spinal cord injury. A comparison of specialized spinal cord injury center vs. general hospital short-term care. Arch. Neurol. 1989;46:1098–1102. [PubMed]
  • Jones L. Bagnall A. Spinal injuries centres (SICs) for acute traumatic spinal cord injury. Cochrane Database Syst. Rev. 2004 (online), CD004442. [PubMed]
  • Macias C.A. Rosengart M.R. Puyana J.-C. Linde-Zwirble W.T. Smith W. Peitzman A.B. Angus D.C. The effects of trauma center care, admission volume, and surgical volume on paralysis after traumatic spinal cord injury. Ann. Surg. 2009;249:10–17. [PMC free article] [PubMed]
  • Oakes D.D. Wilmot C.B. Hall K.M. Sherck J.P. Benefits of early admission to a comprehensive trauma center for patients with spinal cord injury. Arch. Phys. Med. Rehabil. 1990;71:637–643. [PubMed]
  • Pickett W. Simpson K. Walker I. Brison R.I. Traumatic spinal cord injury in Ontario, Canada. J. Trauma. 2003;55:1070–1076. [PubMed]
  • Sekhon L.H. Fehlings M.G. Epidemiology, demographics, and pathophysiology of acute spinal cord injury. Spine. 2001;26:S2–S12. [PubMed]
  • Sipski M.I. Jackson A.B. Gómez-Marín O. Estores I. Stein A. Effects of gender on neurologic and functional recovery after spinal cord injury. Arch. Phys. Med. and Rehab. 2004;85:1826–1836. [PubMed]
  • Stover S.L. DeVivo M.I. Go B.K. History, implementation, and current status of the National Spinal Cord Injury Database. Arch. Phys. Med. and Rehab. 1999;80:1365–1371. [PubMed]
  • Tator C.H. Duncan E.G. Edmonds V.E. Lapczak L.I. Andrews D.F. Complications and costs of management of acute spinal cord injury. Paraplegia. 1993;31:700–714. [PubMed]
  • Tator C.H. Duncan E.G. Edmonds V.E. Lapczak L.I. Andrews D.F. Neurological recovery, mortality and length of stay after acute spinal cord injury associated with changes in management. Paraplegia. 1995;33:254–262. [PubMed]
  • Tator C.H. Rowed D.W. Schwartz M.L. Gertzbein S.D. Bharatwal N. Barkin M. Edmonds V.E. Management of acute spinal cord injuries. Canadian J. Surg. 1984;27:289–293. , 296. [PubMed]
  • Yarkony G.M. Roth E.I. Meyer P.R. Lovell L. Heinemann A.W. Betts H.B. Spinal cord injury care system: fifteen-year experience at the Rehabilitation Institute of Chicago. Paraplegia. 1990;28:321–329. [PubMed]

Articles from Journal of Neurotrauma are provided here courtesy of Mary Ann Liebert, Inc.
PubReader format: click here to try

Formats:

Related citations in PubMed

See reviews...See all...

Cited by other articles in PMC

See all...

Links

  • MedGen
    MedGen
    Related information in MedGen
  • PubMed
    PubMed
    PubMed citations for these articles

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...