[State of knowledge: organizational models for the management of spinal cord injuries]

De Verteuil D, Tran I
Record ID 32018005237
Original Title: État des connaissances - Modèles organisationnels pour la prise en charge des blessures médullaires
Authors' objectives: A spinal cord injury occurs when damage to the spinal cord’s nerve fibers interrupts nerve impulse transmission, leading to sensory, motor and autonomic dysfunction. These lesions can lead rapidly to paraplegia or tetraplegia. Several secondary conditions and medical complications often follow spinal cord injuries, such as recurrent pneumonia and urinary tract infections, neuropathic pain, spasticity, sexual dysfunction, bladder and bowel disorders, autonomic dysreflexia, and more. Therefore, although the incidence of spinal cord injury is relatively low compared with other types of injury, the clinical, functional and economic impacts are disproportionately high. Spinal cord injuries require a high level of specialized multidisciplinary care throughout the various stages of the care pathway: acute care, rehabilitation and community reintegration. The level of functional independence and autonomy that a person with a spinal cord injury can regain will depend on the quality of care and the services received throughout their entire care process. In 2023, INESSS published an overview of the management of adults with traumatic spinal cord injuries in Quebec. As a complement to this work, the aim of the current report is to describe different models of care and services for this particular clientele in other countries or provinces. It will describe their organizational structure, the characteristics of units or centers specializing in the care of spinal cord injuries, as well as highlight the issues and facilitating factors associated with those different models. The findings from this report aim to support the ministère de la Santé et des Services sociaux (the Ministry) in its efforts to improve the quality of care and services for individuals with spinal cord injuries.
Authors' results and conclusions: RESULTS: (#1 ORGANIZATIONAL STRUCTURES): Three types of structural models have been identified from the literature, categorized according to their level of specialized care. It should be noted that these do not represent a complete review of existing models, and that this synthesis is limited to information made publicly available in the different countries. 4. Specialized centers (i.e., spinal cord injury centers of expertise), as in Canada, Australia, New Zealand, Switzerland, and Germany: patients with a spinal cord injury are referred, if possible, directly to the center (or unit) of expertise for multidisciplinary care which, in some cases, integrates rehabilitation. 5. Trauma centers with the support of a specialized unit, as in England and Ireland: the injured person is first referred to a trauma center, and the specialized unit is either called in as a consultant or, for more serious cases, admits patients by inter-hospital transfer for further patient management. 6. Trauma centers without specialized units, as in France and the Netherlands: patients are treated in high-level trauma centers for their entire continuum of care. (#2 CHARACTERISTICS OF SPINAL CORD INJURY CENTERS, ACCREDITATION AND QUALITY IMPROVEMENT): Limited information is available in the literature about the designation criteria used for facilities specialized to treat spinal cord injuries - e.g., minimum annual patient volume or required number and/or type of professionals or technical resources. However, a variety of factors characterize the clientele treated in these specialized centers: • The location of the accident, in models where each specialized unit serves a defined geographical area, as in Quebec, New Zealand, Australia and England; • The type of injury, for centers that exclusively treat isolated spinal cord injuries (i.e., without concomitant injury) or polytrauma, as one center in Toronto and another in the state of Victoria in Australia, or centers that treat non-traumatic injuries, as the specialized unit outside a major trauma center in New South Wales, Australia; • The volume of patients, which varies according to the number of designated acute-care centers per region, ranging from less than 20 to more than 100 people treated annually, depending on the centers surveyed. Although the difficulty of maintaining expertise has been stressed by low-volume centers in Canada, no minimum threshold has yet been established for maintaining expertise in spinal cord injury. Accreditation programs and quality improvement initiatives are also listed: • The Qmentum Accreditation program in Canada, created in partnership between Accreditation Canada and the Praxis Spinal Cord Institute, as well as the standards jointly developed by the Praxis Institute and the Health Standards Organization; • The SCI IEQCC (Spinal Cord Injury Implementation and Evaluation Quality Care Consortium), a Canadian network that develops quality indicators with a particular focus on rehabilitation; • Requirements and quality indicators evaluation cycles of the Quebec trauma network; • The British Orthopaedic Association practice standards and National Health Service (NHS) quality indicators in England; • The SCIMS (Spinal Cord Injury Model Systems), the specialized centers of the U.S. Department of Veterans Affairs, and the guidelines from the American College of Surgeons (ACS) and the American Congress of Rehabilitation Medicine (ACRM), in the United States; • The Advanced Certification in Spine Surgery program of the Joint Commission in collaboration with the American Academy of Orthopaedic Surgeons, in the United States; • The CARF (Commission on Accreditation of Rehabilitation Facilities), which covers programs worldwide (including in Canada), and its Spinal Cord Specialty Program; • The initiatives resulting from a collaboration between the International Spinal Cord Society (ISCoS) and the World Health Organization (WHO), and from AO Spine. (#3 CHALLENGES AND FACILITATING FACTORS): Several issues raised in the 2023 report on current practices in Quebec are also described in the literature. These include: • Equity of access to specialized care for the entire clientele, including geriatric patients, the vulnerable and those living in remote areas, as well as patients with non-traumatic injuries; • Efficiency and fluidity of care, including the cohesion and uniformity of care offered between regions, as well as the continuity of services between acute care, rehabilitation, transition to home and long-term community care; • Quality of care, which may be compromised by a lack of resources or knowledge gaps regarding this particular clientele; and • Placing patients at the heart of the care continuum. The initiatives or facilitating factors reported concerning these issues are mainly circumscribed in the following keywords: • Continuity, through clearly defined care trajectories; systems of coordination between services; and the availability of material and human resources, which continue beyond discharge from the care center; • Integration, through multidisciplinary care and services throughout the continuum; initiation of rehabilitation during acute care and its long-term upkeep; involvement of patients and their families in the care process; and support by peer mentors; • Education, including training for general care staff, patients, and their families. The various accreditation and quality improvement programs also bring together common elements, such as the presence of multidisciplinary, coordinated services that promote an integrated, patient-centred approach; the presence of quality of care assessment systems; contributions to national databases; and the provision of services based on clinical practice guidelines and scientific evidence. These are the basic ingredients of a Learning Health System. CONCLUSION: This overview of the literature has allowed us to appreciate the diversity of spinal cord injury management models worldwide. Three types of structural models have been highlighted, depending on the level of specialization involved. Models with specialized centers, such as in Quebec, also differ in several aspects, notably in terms of patient orientation according to injury etiology, geographic location, and the number of designated acute care centers per region. In addition, several common issues were identified in the various models. Some of the solutions proposed by foreign initiatives could serve as a starting point for the Ministry's reflections on improving the continuum of care for individuals who have suffered a spinal cord injury in Quebec.
Authors' methods: An overview of the grey and scientific literature was conducted to identify information on different structural models for the organization of care and the delivery of services for people with a spinal cord injury. Any relevant document describing an organizational structure, continuum or system of care for people with a spinal cord injury was included. Relevant documents selected from the grey literature included expert consensus and standards and practice guidelines from government agencies and associations specializing in spinal cord injury. In total, information from 63 publications (scientific reports or articles) and 31 Web sites from government agencies or other relevant associations was included. The extracted data was analyzed descriptively, then summarized in a narrative synthesis. Due to the descriptive nature of the information extracted from various data sources, the quality of the articles was not assessed.
Project Status: Completed
Year Published: 2023
English language abstract: An English language summary is available
Publication Type: Other
Country: Canada
Province: Quebec
MeSH Terms
  • Spinal Cord Injuries
  • Trauma, Nervous System
  • Trauma Centers
  • Patient Care Management
  • Models, Organizational
  • Delivery of Health Care, Integrated
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: L'Institut national d'excellence en sante et en services sociaux (INESSS)
This is a bibliographic record of a published health technology assessment from a member of INAHTA or other HTA producer. No evaluation of the quality of this assessment has been made for the HTA database.