A Comprehensive Spinal Cord Injury Treatment Protocol Improves Outcomes and Decreases Complications

Abstract

Background:

Spinal cord injury (SCI) is a devastating event with a complicated recovery. Through the use of an interdisciplinary team a comprehensive care plan was developed, utilizing all available best practices, to prevent secondary complications. Previous work has shown the benefit of single system protocols or interventions. This study aimed to assess changes in outcomes after implementation of a comprehensive protocol.

Material and Methods:

This was a retrospective cohort study performed at an ACS Level I trauma center. It was based on data abstract from the institutions trauma registry over a 10 year period. Patients with quadriplegia after a traumatic injury were included. Data on hospital outcomes and complications was collected and compared before and after the use of the Spinal cord injury protocol.

Results:

58 patients were evaluated. Overall, there was a reduction in complications after the implementation, with significant reductions in pneumonia (47% vs 16%; P = .02) and decubitus ulcers (47% to 11%; P = .005). ICU length of stay decreased by 7 days and hospital length of stay decreased 13 days. There was no difference in mortality. Hospital costs also decreased a mean of $42,000.

Conclusions:

A comprehensive SCI protocol can reduce secondary complications in quadriplegic patients. This study found significant decreases in pneumonia and decubitus ulcer rates after implementation of the protocol. Lengths of stay and cost were also significantly reduced. Future research using comprehensive SCI protocols is needed to further assess its effects on outcomes for this specific patient population. Similar centers should consider adoption of comprehensive SCI protocols.

Introduction

Spinal cord injury (SCI) is a devastating injury that occurs throughout the world, with an annual incidence of 15 to 40 cases per million.¹ In the United States, over 1 million patients live with a SCI, and more than 12 000 new cases occur every year.² Traffic accidents remain the primary cause of SCI. Unfortunately, SCIs are more common among young adults, with two-thirds of new SCI injuries occurring in individuals less than 30 years of age. Despite advances in trauma and critical care, mortality after SCI remains high—an estimated one-third of individuals die before reaching the hospital, and upwards of 10% die during their hospital stay because of predictable complications from these injuries.¹

Patients with an acute SCI experience physiological changes affecting nearly all organ systems. Respiratory complications are the most common cause of morbidity and mortality in acute SCI, and can be predicted based on the level of neurologic impairment, associated injuries, and preinjury medical conditions.³ Gastrointestinal complications, such as neurogenic bowel dysfunction, are also a major source of morbidity and are commonly rated among the top priorities for patients with SCI.⁴ Other important bodily systems significantly affected after an acute SCI can include cardiovascular, neurologic, genitourinary, integumentary, and hematologic.⁵

Since the first 72 hours post-injury are the most critical, it is important to identify these physiological changes as soon as possible. After initial life-saving interventions and spinal stabilization are complete, the care of the spinal cord injured individual focuses on preventing secondary complications.⁶ A reactionary strategy, one that treats these complications after they occur, leads to increased morbidity and in-hospital mortalities. Because many of the complications are predictable, early preventive measures are crucial during the patient’s time on the intensive care unit (ICU).⁷ Through the use of an interdisciplinary care team, a comprehensive care plan can be followed to prevent these secondary complications. Our facility developed a comprehensive SCI protocol based on available data and best practices. This study aimed to assess outcomes before and after utilization of the SCI protocol in traumatic quadriplegic SCI. The authors hypothesized that by proactively addressing each organ system, and potential complications, a significant decrease in morbidity would be demonstrated.

Methods

SCI Protocol Development and Implementation

A multidisciplinary workgroup of providers and nurses were selected to develop the SCI protocol in 2015. Once the protocol was established, an educational program was implemented for the care team. Providers utilizing the protocol including nursing, physical and occupational therapy, nutritionists, respiratory therapists, and physicians were educated on the new protocol by our trauma nurse clinician (Figure 1 and Supplementary Digital Content). To ensure continuity during hospitalization, providers in both the intensive care unit and surgical step down and floor were educated. Education was provided both at the bedside, through inter-departmental meetings, and in larger group lecturers by the physician and nursing champions. Paper and electronic copies of the protocol were available to all providers. Order sets in the electronic medical record were developed and implemented in order to promote adherence to the protocol, thus aiming to decrease variation in provider practice. The protocol was implemented into standard practice in January 2016. A trauma nurse clinician was also assigned to track performance improvement data on the protocol’s deployment.

Figure 1.

Spinal Cord Injury (SCI) management.

Data and Analysis

In this retrospective cohort study, data were extracted from our institution’s Trauma Registry from January 1, 2010 until December 31, 2019 assessing both pre- and post-implementation of the SCI protocol. Patients admitted after January 1, 2016 were considered in the post-period. The Trauma Registry collects data in our academic, ACS verified, Level 1 Trauma Center, which is a regional referral center for adult trauma patients. There are 6 Trauma Registrars that are dedicated to the Trauma Program. Data is abstracted according to the National Trauma Data Bank data rules and Trauma Quality Improvement Program process measures. Data is entered on a daily basis from patient identification for the entire admission to discharge, both concurrently and retrospectively.

Patients with documented quadriplegia secondary to a blunt or penetrating traumatic mechanism and on the adult trauma service were identified. Information regarding patients’ age, sex, mechanism of injury, level of spinal cord injury, ICU length of stay, hospital length of stay, and mortality (during index admission, 3-month, 6-month) rates were assessed. Additional data points collected included pneumonia and urinary tract infection (UTI) rates, frequency of return to the ICU, time to tracheostomy, frequency of physical therapy (PT) and occupational therapy (OT) consultation, frequency of nurse-directed out of bed (OOB) activity, pressure ulcer frequency, and injury severity scores (ISS). Patients were excluded from data collection and analysis if they were less than 17 years old, pregnant, incarcerated, or had a documented epidural abscess, central cord syndrome, or iatrogenic spinal cord injury.

Statistical analysis was conducted with the Chi Square Test, and Fisher’s Exact Test used to analyze categorical variables with smaller sample sizes, while Student’s T-test was utilized for continuous data. Due to the poor ISS matching between groups, regression analysis was utilized to assess the impact of ISS on outcomes. This study was reviewed and approved by our university’s institutional review board.

Results

From 2010 to 2019 a total of 57 patients with quadriplegia and admitted to the trauma service were identified through the Trauma Registry. In both cohorts (pre- and post-implementation), most patients were male (74%) and involved in a motor vehicle crash (MVC; 53% vs 47%, P = .8). The mean age of patient presentation prior to implementation of the protocol was 44 (IQR 20) years old, this was increased to 54 (IQR 33) old post-implementation (P = .04). There was however a significant decrease in mean ISS across the study, from 40 to 27 (P < .001). Cervical SCI levels were similar across the study period. (Table 1)

Table 1.

Demographics, Level, and Mechanisms of Injury.

Demographics	Pre (n = 19)	Post (n = 38)	P
Age (mean)	44	54	.04
Male	14 (74%)	28 (74%)	1
ISS (mean)	40	27	<.001
Smoker	4 (21%)	12 (31%)	0.4
Diabetes mellitus	1 (5%)	8 (21%)	.12
Injury level
C1-3	5 (26%)	5 (13%)	.22
C4-T1	14 (74%)	33 (87%)
Mechanism of injury
MVC	10 (53%)	18 (47%)	.56
Fall	6 (32%)	12 (32%)
Diving accident	1 (5%)	0 (0%)
BCC	1 (5%)	1 (3%)
ATV	0 (0%)	3 (8%)
Assault	1 (5%)	2 (5%)
GSW	0 (0%)	2 (5%)

ISS, injury severity score; MVC, motor vehicle collision; BCC, bicycle crash; ATV, all-terrain vehicle; GSW, gunshot wound.

Overall, there was a reduction in complications and a significant reduction in patients experiencing any complication (Table 2). The largest impact was seen with a significant decrease in pneumonia rates (47% vs 16%; P = .02) and decubitus ulcers (47% to 11%; P = .005). UTIs, PE/DVTs, cardiac arrests, and unplanned ICU visits also decreased across the study period. Unplanned intubation rates saw a non-significant increase, from 21% to 26% (P = .75). Mean ICU LOS of stay decreased by 7 days and hospital LOS decreased by 13 days. Mean duration to tracheostomy was 7 days in both groups. Regression analysis found no correlation between ISS difference and ICU LOS (P = .28), HLOS (P = .58), pneumonia rate (P = .23), or decubitus ulcers (P = .11).

Table 2.

Complications and Hospital Outcomes.

	Pre (n = 19)	Post (n = 38)	P
Pneumonia	9 (47%)	6 (16%)	.02
Urinary tract infection	6 (32%)	6 (16%)	.19
Deep vein thrombosis	4 (21%)	5 (13%)	.46
Pulmonary embolism	2 (11%)	0 (0%)	0.1
Unplanned ICU admission	4 (21%)	3 (8%)	0.2
Unplanned intubation	4 (21%)	10 (26%)	.75
Cardiac arrest	6 (32%)	9 (24%)	.54
Decubitus ulcer	9 (47%)	4 (11%)	.005
Any complication	17 (89%)	20 (52%)	.006
ICU LOS (mean days)	21	14	0.1
HLOS (mean days)	37	24	.08
Tracheostomy	14 (73%)	19 (50%)	.09

ICU LOS, intensive care unit length of stay; HLOS, hospital length of stay.

Physical therapy significantly improved post-implementation. Patients received on average daily PT post protocol, compared to every 2.5 days pre protocol. Nurse initiated daily out of bed activity increased from 68% to 95% of patients. Patients were also out of bed twice as many times daily in the post protocol analysis (Table 3).

Table 3.

Physical Therapy and Time Out of Bed.

	Pre (n = 19)	Post (n = 38)
Hospital day of first PT	2	2
PT frequency (mean days)	2.5	1
Nurse initiated daily OOB	13 (68%)	36 (95%)
Frequency OOB (mean #/day)	2	4

PT, physical therapy; OOB, out of bed.

The majority of patients were discharged to a rehabilitation facility in both groups (58% vs 45%, respectively). However, there was an increase in patients being discharged to a long-term acute care hospital (LTACH; 11% to 21%) and skilled nursing facilities (SNF; 11% to 13%). In-hospital mortality increased from 5% to 16% of patients, while 90-day and 6-month mortality rates both decreased (5% to 3%; 11% to 5%). Mortality and discharge disposition were not statistically different between groups. Total hospital costs were over $42,000 less on average in the post-protocol group ($380,784 vs $338,067, P = .53) (Table 4).

Table 4.

Discharge Disposition and Morality.

	Pre (n = 19)	Post (n = 38)	P
Discharge disposition
Home	2 (11%)	2 (5%)	0.6
SNF	2 (11%)	5 (13%)
Rehab	11 (58%)	17 (45%)
LTACH	2 (11%)	8 (21%)
Mortality
In hospital	1 (5%)	6 (16%)	0.6
90 day	1 (5%)	1 (3%)
6 month	2 (11%)	2 (5%)

SNF, skilled nursing facility; LTACH, long term acute care hospital.

Discussion

This study demonstrated a significant improvement in complications and activity related outcomes among patients with quadriplegia with a comprehensive SCI protocol. While other studies have assessed individual aspects of these patients’ care, the present study assessed an all-inclusive protocol designed to prevent secondary complications. There were a number of beneficial outcomes, including notable decreases in pneumonia and decubitus ulcer rates—outcomes of two organ systems that are high risk for complication and can lead to significant morbidity.⁸

Respiratory complications are a major cause of morbidity and mortality in patients with acute SCI.^8,9 Pulmonary complications seen after acute quadriplegia progressively increase over the first 5 days, with respiratory failure most commonly occurring 3 to 5 days after injury.³ Aggressive management of secretions is of utmost importance in caring for a patient with SCI to prevent mucous plugs, atelectasis, and pneumonia.^10,11 Eighty percent of deaths in patients hospitalized with cervical SCI are secondary to pulmonary dysfunction, with pneumonia the cause in 50% of the cases.³ Pneumonia development has also been shown to be correlated with long term need for respiratory support.¹² In our study, pneumonia rates significantly decreased from 47% to 16% among patients, which is a notably lower rate than seen in prior literature. This reduction in pneumonia rate may account for the large reduction in hospital and ICU length of stay. Attention to pulmonary toilet and daily forced vital capacity (FVC) measurement are critical portions of this SCI protocol. FVC has been shown to decrease after spinal cord injury.^13,14 Extrapolating from chest trauma data, FVC measurement provides objective data on which decisions on pulmonary care can be made, and high risk patients can be identified.¹⁵

Decubitus ulcers are also a common integumentary complication after SCI that can lead to significant morbidity/mortality, as well as prolonged hospitalization.^2,16 A recent analysis of these injuries identified a high rate (43%) of post-operative complications.¹⁷ This study saw a significant decrease in decubitus ulcers across the study period, from 47% prior to implementation of the SCI protocol to 11% post-implementation. This decrease in preventable complication may have contributed to reduction in total cost.

This study demonstrated a significant improvement in physical therapy and nurse initiated out of bed activities. With a multidisciplinary approach, patients were out of bed 4 times daily, and had daily PT sessions. The number of times a patient was out of bed doubled with increased nursing driven activity session. Multiple authors have demonstrated the importance for long term outcomes of increased PT interventions and time out of bed during inpatient admission.^18–20

This study has all of the usual limitation of a retrospective review. Furthermore, data was collected from a single site, meaning results may not be generalizable to other settings. Our study is also limited in its size and power, however do avoid larger differences in practice patterns we did not collect data earlier than 2010. Lastly, our study did not follow long-term outcomes of these patients after hospital discharge beyond 6-month mortality; thus, we were unable to determine any longer term benefits of implementing the SCI protocol.

Conclusion

A comprehensive SCI protocol can reduce secondary complications in quadriplegic patients. This study found significant decreases in pneumonia and decubitus ulcer rates after implementation of the protocol. Hospital and ICU LOS were also reduced by 13 days and 7 days, respectively. Future research using comprehensive SCI protocols is needed to further assess its effects on outcomes for this specific patient population. Similar centers should consider adoption of comprehensive SCI protocols.