Original Title: État des pratiques - Continuum de soins et services pour les personnes ayant une blessure médullaire traumatique au Québec

Authors' objectives: Spinal cord injuries (SCI) cause severe disorders of the nervous system. These disorders are characterized by the impaired transmission of nerve impulses, the development of sensory and motor dysfunctions, and impaired autonomic functions. Spinal cord injuries can progress rapidly into paraplegia or tetraplegia. Fast and effective multidisciplinary management is therefore necessary to limit neurological and functional damage. Centres of Expertise for Spinal Cord Injuries in Eastern and Western Québec have been designated within the Québec trauma care network to provide care and services to individuals with traumatic spinal cord injuries across the province's geographic territory. The Institut national d'excellence en santé et en services sociaux (INESSS) was mandated by the Ministère de la Santé et des Services sociaux (MSSS) to provide an overview of the care of adults with a traumatic spinal cord injury in Québec, with an emphasis on clinical pathways used and their impact on the quality of care and services offered.

Authors' results and conclusions: RESULTS: (#1 CLINICAL AND SOCIAL-DEMOGRAPHIC PROFILE OF SCIS IN QUÉBEC): In Québec, there is an average of 258 new patients with SCI annually, which represents a total of 1 807 individuals between 2014 and 2020, of which nearly three quarters (73%) are men. • Injury etiologies vary by age: motor vehicle accidents cause half of all SCIs in 16 to 25 years old individuals and decrease progressively with age, whereas samelevel falls follow the opposite trend. • Cervical injuries, which represent approximately 62% of SCIs in our cohort, also increase in proportion with age. • The overall injury severity score has had little change since 2014. However, the proportion of less severe SCIs (maximum Abbreviated injury scale – AIS – score of 3) has gradually decreased, from 42.0% of all cases in 2014 to 28.1% in 2020. On the other hand, SCIs with partial sensory and motor function (maximum AIS score of 4) has increased from 39.8% to 55.4%. The proportion of AIS 4 injuries increases with patient age, accounting for nearly 60% of SCI cases in individuals aged 66 to 85 years old, and in those aged 86 years and older. Furthermore, it particularly predominates (64.9%) in patients with cervical injuries. • The year 2020, characterized by the COVID-19 pandemic, witnessed the highest proportion of fall injuries (including falling from heights and same-level falls) and the lowest proportion of motor vehicle accidents. The median age of men with a SCI that same year was also higher: 63 years old, as opposed to 55 to 59 years old in previous years. (#2 SPINAL CORD INJURY PATIENTS BY ACUTE CARE FACILITY TYPE): Most patients with a SCI (66.2%, n = 1196) were treated in SCI centers. A relatively constant proportion of SCIs are treated outside of SCI centers every year, including 28.1% (n = 508 between 2014 and 2020) in TCFn and 5.7% (n = 103) in TCF. • The demographic profile and mechanisms of SCIs were comparable between patients treated in SCI centers and in TCFn. However, SCI centers treated more severely injured patients (New Injury Severity Score, NISS ≥ 25, 41.1% of cases in SCI centers) and more severe spine injuries (maximum AIS score ≥ 4, 79.8%) than TCFn (34.1% and 40.4% of cases, respectively). TCFn, however, treated a higher proportion of individuals with a concomitant injury that was more severe than the SCI (20.1% compared with 10.5% in SCICE). • SCI patients treated in TCF include more individuals aged 66 years and older (62.1% of TCF cases), women (41.8%), injuries caused by same-level falls (40.8%), and less severe injuries (72.8% having a SCI with a maximum AIS score = 3). (#3 CONTINUUM OF CARE AT THE DEFINITIVE CARE HOSPITAL): • Between 2014 and 2020, most patients treated in a SCI center came from another acute care facility (62.5%). More than a third (36.4%) of patients treated in TCFn and 11.7% of TCF cases also came from inter-hospital transfers, especially from the Montreal and the Montérégie regions. • Median time to emergency department arrival and median transfer time were similar between SCI centers and TCFn, but emergency department length of stay was shorter in SCI centers. For the most severe cases (NISS ≥ 25), the median length of stay in the emergency department was shorter and similar across centers: 4 h 25 (IQR: 2 h 50-6 h 44) in SCICEs, 4 h 05 (IQR: 1 h 35-7 h 20) in TCFn, and 3 h 08 (IQR: 2 h 14-5 h 08) in TCF. • Almost all patients with a SCI who underwent at least one spinal procedure in Québec had surgical decompression. These were more frequent for patients treated in a SCI center (80.1%) than in a TCFn (66.9%). Six patients (5.8%) had surgical decompression in a primary or secondary level trauma care facility. • For more than half of the patients, throughout all centers, the median time from injury to surgical decompression exceeded the 24-hour time frame recommended by expert consensus to improve the chances of neurological recovery. • In SCI centers, the median time from injury to surgery did not appear to depend on the type of admission (transfer versus direct admission). Median time to surgery was also similar for direct admissions in TCFn, but was about 10 hours longer for patients admitted to a TCRn from an interhospital transfer. (#4 ACUTE CARE CLINICAL OUTCOMES): Patients treated in SCI centers had a longer hospital length of stay than those treated in other centers – median of 17.0 days, versus 13.0 days in TCFn and 9.5 days in TCF. The median length of stay for patients discharged to a rehabilitation care center, however, was similar in SCI centers, TCFn, and TCF (21, 22, and 23 days, respectively), and was about twice as long as for patients who were discharged elsewhere. • Most patients had at least one complication during their acute care stay, with a higher proportion occurring in SCI centers. The most frequent complications, affecting 13.3% to 15.1% of patients in SCI centers, were delirium, as well as dysphagia, pneumonia, urinary tract infections and pressure ulcers, which are often reported with such an injury. Some rarer complications were reported more frequently in TCFn, notably shock (5.7% versus 4.1% in SCI centers), urinary retention (4.7% versus 2.0% in SCI centers) and hemorrhage (3.7% versus 1.3% in SCI centers). • The proportion of in-hospital deaths between 2014 and 2020 (9.4%, all centers combined) is comparable to the proportion observed across Canada. There were no significant differences between centers in the proportion of deaths or unplanned rehospitalizations within 30 days after acute care discharge, after adjusting for patient characteristics. • Between 2014 and 2019, the proportion of patients discharged home without service or to a general and specialized care hospital (GSCH) decreased from 7.2% to 2.8%, and from 18.6% to 9.6%, respectively. Meanwhile, rehabilitation resource use increased, both in rehabilitation care centers (from 40.9% to 48.6%) and in outpatient rehabilitation (from 2.7% to 6.8%). The year 2020, characterized by the COVID-19 pandemic, saw a higher proportion of deaths (13.8%) and of patients discharged to a GSCH (15.4%), and a lower proportion of patients discharged to a rehabilitation care center (39.6%). • SCI center patients were more likely to be referred to a rehabilitation center upon discharge from acute care - 54.2% of patients, compared with 26.8% in TCFn and 4.8% in TCF. Conversely, twice as many patients in TCFn (39.4%) and in TCF (40.8%) returned home, with or without service or outpatient follow-up, compared with patients in SCI centers (20.0%). Finally, a greater proportion of TCF patients were discharged home without service (21.4%) or to a long-term care facility (10.7%) compared with patients in TCFn (6.9% and 1.6%) and in SCI center (4.8% and 1.2%). Several limitations should be considered when interpreting these clinical results: the indication bias created by the systematic referral of the most severe spinal cord injury cases to centers of expertise; organizational differences that may affect the length of acute care stay and barriers to discharge; a lack of standardization in the definition of complications; and the small number of deaths, which makes odds ratio estimates very imprecise. Finally, this report is an overall picture of the continuum of care and does not allow for detailed case analysis. (#5 CONTINUUM OF CARE AT THE REHABILITATION CARE CENTER): • As the number of patients discharged from a primary or secondary trauma care facility (TCF) to a rehabilitation care center was low, they were grouped with patients discharged from a trauma facility offering neurosurgical services (TCFn). These individuals, treated in any acute care facilities other than a SCI center (referred here as “Other” facility), represent from 8.9% to 17.1% of the SCI clientele admitted to a rehabilitation care center annually in Québec - 76 individuals between 2014 and 2020, compared with 519 individuals admitted from a SCI center. • Injury severity for patients coming from an "Other" facility, as determined by the ASIA severity scale, is similar to patients from a SCI center. • The duration of inpatient rehabilitation varied according to injury severity: the length of stay was twice as long for patients when they were severely injured (ASIA levels A-B-C). Their rehabilitation lasted, respectively, 98 days versus 47 days for patients with ASIA levels D or E from a SCI center, and 81 days versus 48 days for patients with ASIA levels D or E from an "Other" facility. Upon admission to the rehabilitation center, a greater proportion of patients from an "Other" facility had at least one pressure ulcer (22.9% versus 12.8%). The median length of stay for this cohort was nevertheless similar to or shorter than that of patients from SCI centers. • The vast majority of patients were discharged home from the rehabilitation care facility. However, this percentage was higher for patients coming from a SCI center (81.1%) than for patients from an "Other" facility (72.4%). Conversely, more patients from an "Other" facility were discharged to a long-term care facility (10.5% versus 6.2% for patients from a SCI center), likely due to the higher proportion of patients aged 75 years and older. • Most patients maintained the same ASIA level from their arrival to their discharge from the rehabilitation care facility. The neurological level of a minority of patients deteriorated, while approximately 15% of patients improved by one or, more rarely, two ASIA grades during their inpatient rehabilitation stay. • The median SCIM (spinal cord independence measure) score doubled between admission and discharge from the rehabilitation care facility for all patients, regardless of their level of neurological impairment. • Among those who were less severely injured (ASIA grades D or E), patients coming from a SCI center may have greater potential for neurological (ASIA grade) and functional (motor score and mobility) improvement than patients coming from an "Other" facility. These observations should be viewed with caution given the small patient volumes and the high percentages of missing data. (#6 FUTURE PERSPECTIVES): In light of the results stemming from this analysis, supported by data from the literature and consultations with patients and stakeholders, a few key points deserve more careful thought and particular emphasis, as part of a continuous improvement outlook on the care of people with spinal cord injuries in Quebec. These involve: • designated clinical pathways and transfer agreements; • optimal care of older patients; • care of non-traumatic SCI; • heterogeneous documentation of complications and interventions; • barriers to fluidity of care; and • long-term follow-up of patients and availability of post-discharge resources. CONCLUSION: This report on the care of spinal cord injuries in Quebec shows that the various trends characterizing this clientele have generally been stable between 2014 and 2020 and are supported by the data available in the literature. The comparison of care pathways for patients with spinal cord injury highlighted some differences with regards to access to specialized care, to the continuity and efficiency of care, and to clinical outcomes - complications, and functional and neurological outcome - for patients. This report does not allow us to formulate a conclusion or recommendations on the organizational modalities for patient care, but it does raise several points to consider in a perspective of continuous improvement for the care of individuals having a spinal cord injury.

Authors' methods: Data analysis was conducted on two clinical registries. Information on the acute care of adults who experienced a traumatic spinal cord injury between 2014 and 2020 was extracted from the Système d'information du registre des traumatismes du Québec (SIRTQ). Information on rehabilitation care was extracted from the canadian Rick Hansen Spinal Cord Injury Registry (RHSCIR). For the analysis of clinical pathways, individuals were grouped according to the type of facility that provided acute care: spinal cord injury specialized centers (SCI centers); trauma care facilities that provide neurosurgery services - TCFn, including secondary regional level and tertiary level trauma centers; and primary or secondary level trauma care facilities (TCF). A literature review, as well as consultations with key stakeholders such as individuals living with spinal cord injuries and healthcare providers, helped contextualize the results

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/continuum-de-soins-et-services-pour-les-personnes-ayant-une-blessure-medullaire-traumatique-au-quebec-caracteristiques-trajectoires-de-soins-et-resultats-cliniques-pour-la-clientele-adulte-de-2014-a-2020.html

Year Published: 2023

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/continuum-de-soins-et-services-pour-les-personnes-ayant-une-blessure-medullaire-traumatique-au-quebec-caracteristiques-trajectoires-de-soins-et-resultats-cliniques-pour-la-clientele-adulte-de-2014-a-2020.html

English language abstract: An English language summary is available

Publication Type: Other

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: Gouvernement du Québec