Andréane Richard-Denis

Costs and Length of Stay for the Acute Care of Patients with Motor-complete Spinal Cord Injury Following Cervical Trauma: The Impact of Early Transfer to Specialized Acute Sci Center.

Objective Acute spinal cord injury (SCI) centers aim to optimize outcome following SCI. However, there is no timeframe to transfer patients from regional to SCI centers in order to promote cost-efficiency of acute care. Our objective was to compare costs and length of stay (LOS) following early and late transfer to the SCI center. Design A retrospective cohort study involving 116 individuals was conducted. Group 1 (n = 87) was managed in an SCI center promptly after the trauma, whereas group 2 (n = 29) was transferred to the SCI center only after surgery. Direct comparison and multivariate linear regression analyses were used to assess the relationship between costs, LOS, and timing to transfer to the SCI center. Results Length of stay was significantly longer for group 2 (median, 93.0 days) as compared with group 1 (median, 40.0 days; P < 10−3), and average costs were also higher (median, Canadian

Does the Acute Care Spinal Cord Injury Setting Predict the Occurrence of Pressure Ulcers at Arrival to Intensive Rehabilitation Centers

17,920.0 vs.

Effectiveness of a multi‐layer foam dressing in preventing sacral pressure ulcers for the early acute care of patients with a traumatic spinal cord injury: comparison with the use of a gel mattress

10,521.6; P = 0.004) for group 2, despite similar characteristics. Late transfer to the SCI center was the main predictive factor of longer LOS and increased costs. Conclusions Early admission to the SCI center was associated with shorter LOS and lower costs for patients sustaining tetraplegia. Early referral to an SCI center before surgery could lower the financial burden for the health care system. To Claim CME Credits Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME Objectives Upon completion of this article, the reader should be able to: (1) Determine the optimal timing for transfer of individuals with cervical traumatic spinal cord injury (SCI) in order to decrease acute care resource utilization; (2) Determine benefits of a complete perioperative management in a specialized SCI center; and (3) Identify factors that may influence resource utilization for acute care following motor-complete tetraplegia. Level Advanced Accreditation The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Association of Academic Physiatrists designates this activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

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

Objective The objective of this study was to evaluate the impact of acute care in specialized spinal cord injury (SCI) trauma centers on the prevalence of pressure ulcers (PU) upon arrival at a functional rehabilitation center after a traumatic SCI. Design This is a retrospective cohort study among 123 patients with traumatic SCI referred to intensive functional rehabilitation between January 1, 2009, and December 31, 2011. Group 1 (n = 90) was referred from a level 1 specialized SCI trauma center and group 2 (n = 33) was referred from seven trauma centers not specialized in SCI. Results The total prevalence of patients with PU at admission to functional rehabilitation was 33.3% (26.7% in group 1 and 51.5% in group 2, P = 0.017). There were also more patients with multiple PU in group 2 (24.2% vs. 2.2%, P = 0.0001). A binary logistic regression showed a significant relationship between the occurrence of PU and the type of acute care facility as well as the ASIA (American Spinal Injury Association) Impairment Scale grade. Receiving acute care at the specialized SCI trauma center was associated with a decrease in the number of patients developing one and multiple PU. Conclusions These results highlight the importance of specialized SCI trauma centers in acute care of patients with traumatic SCI in reducing PU at their admission to functional rehabilitation settings.

The use of regression tree analysis for predicting the functional outcome following traumatic spinal cord injury

Individuals with spinal cord injury are at risk of sacral pressure ulcers due to, among other reasons, prolonged immobilisation. The effectiveness of a multi‐layer foam dressing installed pre‐operatively in reducing sacral pressure ulcer occurrence in spinal cord injured patients was compared to that of using a gel mattress, and stratified analyses were performed on patients with complete tetraplegia and paraplegia. Socio‐demographic and clinical data were collected from 315 patients admitted in a level‐I trauma centre following a spinal cord injury between April 2010 and March 2016. Upon arrival to the emergency room and until surgery, patients were transferred on a foam stretcher pad with a viscoelastic polymer gel mattress (before 1 October 2014) or received a multi‐layer foam dressing applied to their sacral‐coccygeal area (after 1 October 2014). The occurrence of sacral pressure ulcer during acute hospitalisation was similar irrespective of whether patients received the dressing or the gel mattress. It was found that 82% of patients with complete tetraplegia receiving the preventive dressing developed sacral ulcers as compared to only 36% of patients using the gel mattress. Although multi‐layer dressings were suggested to improve skin protection and decrease pressure ulcer occurrence in critically ill patients, such preventive dressings are not superior to gel mattresses in spinal cord injured patients and should be used with precaution, especially in complete tetraplegia.

Quality of life in the subacute period following a cervical traumatic spinal cord injury based on the initial severity of the injury: a prospective cohort study

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.

The use of classification tree analysis to assess the influence of surgical timing on neurological recovery following severe cervical traumatic spinal cord injury

Predicting the long-term functional outcome following traumatic spinal cord injury is needed to adapt medical strategies and to plan an optimized rehabilitation. This study investigates the use of regression tree for the development of predictive models based on acute clinical and demographic predictors. This prospective study was performed on 172 patients hospitalized following traumatic spinal cord injury. Functional outcome was quantified using the Spinal Cord Independence Measure collected within the first-year post injury. Age, delay prior to surgery and Injury Severity Score were considered as continuous predictors while energy of injury, trauma mechanisms, neurological level of injury, injury severity, occurrence of early spasticity, urinary tract infection, pressure ulcer and pneumonia were coded as categorical inputs. A simplified model was built using only injury severity, neurological level, energy and age as predictor and was compared to a more complex model considering all 11 predictors mentioned above The models built using 4 and 11 predictors were found to explain 51.4% and 62.3% of the variance of the Spinal Cord Independence Measure total score after validation, respectively. The severity of the neurological deficit at admission was found to be the most important predictor. Other important predictors were the Injury Severity Score, age, neurological level and delay prior to surgery. Regression trees offer promising performances for predicting the functional outcome after a traumatic spinal cord injury. It could help to determine the number and type of predictors leading to a prediction model of the functional outcome that can be used clinically in the future.

The impact of a specialized spinal cord injury center as compared with non-specialized centers on the acute respiratory management of patients with complete tetraplegia: an observational study

Study designProspective cohort study.ObjectivesTo evaluate the relationship between quality of life (QOL) after a traumatic spinal cord injury (TSCI) and acute predictors, with a particular emphasis on the initial severity of the neurological injury. Secondarily, to compare the QOL after a TSCI with the general population.SettingA single Level-1 SCI-trauma centre.MethodsA cohort of 119 individuals admitted after a cervical TSCI between April 2010 and September 2016 was studied. QOL was assessed using the SF-36v2 questionnaire 6–12 months following the injury, and compared to the general population. The relationship between the initial severity of the neurological injury and the SF-36 summary scores was assessed using linear multivariable regression analyses.ResultsIndividuals sustaining less severe neurological injury (grade D) exhibited higher PCS than individuals with grades A, B or C injury. Individuals with initial grade A injury showed increased MCS than individuals with incomplete grade B, C or D injury, with 42.9% scoring higher than the general population. The initial grade was significantly associated with chronic PCS and MCS.ConclusionsThe initial severity of the neurological injury after a cervical TSCI may be used to estimate QOL in the subacute period following the injury. Individuals with complete tetraplegia may report good mental QOL despite severe physical impairment. Our findings could help clinicians to determine realistic expectations for patients in terms of QOL, and optimize the rehabilitation plan based on the initial evaluation after a TSCI.

Determining priorities in functional rehabilitation related to quality of life one-year following a traumatic spinal cord injury

Study designPost hoc analysis of prospectively collected data.ObjectivesAssess the influence of surgical timing on neurological recovery using classification tree analysis in patients sustaining cervical traumatic spinal cord injury.SettingHôpital du Sacré-Coeur de MontrealMethods42 patients sustaining cervical SCI were followed for at least 6 months post injury. Neurological status was assessed from the American Spinal Injury Association impairment scale (AIS) and neurological level of injury (NLI) at admission and at follow-up. Age, surgical timing, AIS grade at admission and energy of injury were the four input parameters. Neurological recovery was quantified by the occurrence of improvement by at least one AIS grade, at least 2 AIS grades and at least 2 NLI.ResultsProportion of patients that improved at least one ASIA grade was higher in the group that received early surgery (75 vs. 41 %). The proportion of patients that improved two AIS grades was also higher in the group that received early surgery (67 vs. 38 %). Finally, 30 % of the patients that received early decompression improved two NLI as compared with 0% in the other group. Early surgery was also associated with a non-statistically significant improvement in functional recovery.ConclusionsNeurological recovery of patients sustaining cervical traumatic spinal cord injury can be improved by early decompression surgery performed within 19u2009h post trauma.SponsorshipU.S. Army Medical Research and Material Command, Rick Hansen Institute.

Early Predictors of Global Functional Outcome after Traumatic Spinal Cord Injury: A Systematic Review

Study DesignRetrospective cohort study.ObjectivesTo compare the proportion of tracheostomy placement and duration of mechanical ventilation (MV) in patients with a complete cervical spinal cord injury (SCI) that were managed early or lately in a specialized acute SCI-center. The second objective was to determine the impact of the timing of admission to the SCI-center on the MV support duration.SettingA single Level-1 trauma center specialized in SCI care in Quebec (Canada).MethodsA cohort of 81 individuals with complete tetraplegia over a 6-years period was included. Group 1 (Nu2009=u200957- early group-) was admitted before surgical management in one specialized acute SCI-center, whereas Group 2 (Nu2009=u200924 -late group-) was surgically managed in a non-specialized center and transferred to the SCI-center for post-operative management only. The proportion of tracheostomy placement and MV duration were compared. Multivariate regression analysis was used to assess the impact of the timing of admission to the SCI-center on the MV duration during the SCI-center stay.ResultsPatients in Group 2 had a higher proportion of tracheostomy (70.8 vs. 35.1%, pu2009=u20090.004) and a higher mean duration of MV support (68.0u2009±u200964.2 days vs. 21.8u2009±u200929.7 days, pu2009=u20090.006) despite similar age, trauma severity (ISS), neurological level of injury and proportion of pneumonia. Later transfer to the specialized acute SCI-center was the main predictive factor of longer MV duration, with a strong impact factor (su2009=u2009946.7, pu2009<u20090.001).ConclusionsEarly admission to a specialized acute SCI-center for surgical and peri-operative management after a complete tetraplegia is associated with lower occurrence of tracheostomy and shorter mechanical ventilation duration support.SponsorshipMENTOR Program of the Canadian Institute of Health Research and US Department of Defense Spinal Cord Injury Research Program.