Spinal cord injury in Italy: Length of Stay

[Wise Young]

Celani MG, Spizzichino L, Ricci S, Zampolini M and Franceschini M (2001). Spinal cord injury in Italy: A multicenter retrospective study. Arch Phys Med Rehabil. 82 (5): 589-96. Summary: OBJECTIVE: To investigate certain factors influencing the length of stay (LOS) in a rehabilitation center, the incidence of pressure ulcers, and the neurologic improvement of patients with traumatic (T/SCI) and nontraumatic spinal cord injury (NT/SCI). DESIGN: A multicenter retrospective study of patients with SCI admitted to rehabilitation centers between 1 January 1989 and 31 December 1994 (only first admissions). SETTING: Seven Italian rehabilitation centers. PATIENTS: A total of 859 consecutively admitted adult patients with SCI. INTERVENTION: Examined medical records of patients admitted to rehabilitation centers. MAIN OUTCOME MEASURES: Pressure ulcers on admission as an indicator of nursing care in acute phase, LOS in rehabilitation centers, and neurologic improvement on discharge (using the Frankel classification system). Other measures included level of lesion, associated lesions (if T/SCI), surgical stabilization (if T/SCI), and time from the event to admission to a rehabilitation center. RESULTS: In all cases, the time from event to admission to a rehabilitation center exceeded 30 days (average +/- standard deviation: T/SCI, 54.6 +/- 43.7d; NT/SCI, 166.9 +/- 574d); pressure ulcers on admission were present in 34.1% of T/SCI and 17.1% of NT/SCI patients. The average LOS in a rehabilitation center was 143.1 +/- 89.1 days for T/SCI and 91.7 +/- 78.9 days for NT/SCI; Frankel grades improved by 1 or more in 34.4% of T/SCI and 34.1% of NT/SCI patients. The presence of pressure ulcers on admission, rehabilitation LOS, and neurologic improvement on discharge correlated highly with severe neurologic damage on admission in both T/SCI and NT/SCI patients as well as with management of the patient immediately before admission to a rehabilitation center, mainly in NT/SCI patients. CONCLUSIONS: Severe neurologic damage is the major determining factor in predicting neurologic recovery. Pressure ulcer prevention is statistically associated with neurologic improvement and the shortening of rehabilitation LOS. Patient management immediately before admission to rehabilitation has a statistical correlation with neurologic improvement in all patients studied and on both rehabilitation LOS and incidence of pressure ulcers in the NT/SCI patients. Servizio per le Malattie Cerebrovascolari, Perugia, Dipartimento di Geriatria e Riabilitazione, Parma, Italy.

[Wise Young]

There are very interesting statistics indeed.
<UL TYPE=SQUARE> The length of stay for traumatic spinal cord injury in the acute care hospital was 54 days, much longer than in the U.S. It was 143 days in the rehab hospital, again much longer than in the U.S. [/list]
<UL TYPE=SQUARE> The decubiti rate is 34%, accounting for the long length of stay [/list]
<UL TYPE=SQUARE> About a third of the patients improved by one Frankel grade. That is surprisingly low and suggest a higher proportion of "complete spinal cord injuries" than we see in the U.S. [/list]

[Noel]

In 1974, my stay in ICU was 30 days, at this time they felt it was safe to move me to the University of Washington, Rehab hospital. Rehab for quads was projected to be 9 months to a year. However, I became seriously depressed and left after 6 months.

Noel

[Mike C]

Here in Germany, I stayed in the rehab hospital Hohe Warte in Bayreuth for just about 9 months, and that is about the normal stay. The daily and varied PT and ergo program did do me good. After a few months we were allowed to go home on the weekends. By staying in the hospital, it also allowed the families and/or the social workers time to find a new accessable place or to make modifications to their current dwelling. This is no easy task for any SCI, especially in Germany. Most para´s stay 4 to 6 months, and mobile quads, up to a year. There were some quads who were well over a year in the hospital when I was there however. Social medicine makes something like this possible. It is true about pressure sores. The only one I ever had I became in the hospital

[etexley]

I would think that getting back into the "Real world" as quickly as possible would be the best thing for spinal cord injuries. I would think that many more people would return to their jobs, and a more normal lifestyle if this were the norm.

Eric Texley

[Annabanana]

Like Mike, I was also in hospital and rehab for about 9 months. I was in ICU for the first night, but was then moved to the spinal ward and stayed there for nearly 3 months. I was then moved to rehab and was there for 6 months. It probably would of been only about 4 or 5 months but I fractured my skull at rehab doing 'stunts'. (gawd i never realised I was so accident prone!) So I was then admitted to the brain injuries unit for a week or two. Once I got back to rehab it took me several weeks to just to get my balance back. Boy was that a trying couple of weeks! http://sci.rutgers.edu/forum/images/smilies/wink.gif

In Australia at the Princess Alexandra Hospital they are now letting people do their rehab at home, and the specialists visiting them. THis can have both positives and negatives, the positives being that family can become more involved in the step by step process, and it allows families to stay together during such a stressful time.

However, I also think that a large part of being rehabilitated is seeing other SCI achieve and having a little bit of peer group pressure to do the same. Some of the people that i rehabbed with were pretty darn competitive! But I think this was a good thing for me, it encouraged me to just get on with the job at hand.

[Sue Pendleton]

I was also injured in Germany and spent 6 weeks in the acute hospital. I think in the US we have too short of stays at this point. Way too many go to rehab too weak or still suffering complications that make rehab less than useful.

My nurses thought I had a sore on my butt in the neuro ward and it took me 3 days to convince them that I had that problem everywhere I had lived where the water was hard and that plain old moisturizer would heal it up fast. They were convinced by the next morning but Iwas still put on an air bed.

Mike, I wish I had stayed in Germany for rehab. I would have gone down to Murnau. Without being drugged to the hilt like in our rehabs I might have had a chance at the first supported body weight ambulation trials. Oh well. And I got 3 months rehab here.

[SCI-Nurse]

I think there needs to be some balance between hospital and rehab LOS (length of stay) that is too long, resulting in institutionalization, depression and family separation, and too short, resulting in lack of sufficient education or skills to function at home and maintain health.

I have been in this business long enough to see the detrimental effects of continuing shorter and shorter LOS for people with SCI (forced by "managed" care), which now average around 27 days for paraplegic injuries and 45 days for those with tetraplegic injuries (in the USA). An additional trend is the reluctance of most managed care insurance companies to allow people with SCI under their plans to get appropriate long term outpatient care from physicians who are expert in SCI, often making them return to an internist or family practice phyisician only for care as soon as released from rehab. It has also resulted in more nursing home placements, either due to slow progress in rehab or insufficient time for family to arrange home accessibility and services such as PCA care.

I am seeing more and more people in the community with SCI who are unaware of the most basic ways to maintain their health, and how to problem solve common issues and maintain their health in the areas of skin, bowel, bladder, AD, and common medical complications. Either they did not get this education in their short rehab stays, or they were emotionally not prepared to learn it while they are there. I find that sexuality education and counseling during rehab is now almost non-existant for people with SCI, esp. if rehab is not received in a major SCI center.

A recent report from the Shepherd Center in Atlanta has found a direct correlation between decreased length of stays since 1991 and increased rate of pressure ulcers during the first year of follow up. I fear for the future of those who are newly injured, out in the community, and unprepared for the major efforts that are required to maintain health and function in the community.

I would be interested in hearing from those who have had their rehab in the private (non-VA) sector in the USA in the last 2 years regarding this. (KLD)

[Mike C]

The most common sense partial solution, to help the newly injured, would be to stress the importance of gaining an internet connection. Sites such as this one offer an absolute gold mine in information and prevention methods. Here you can exchange experiences, learn from other mistakes, and actually get answers to medical problems for free. Heck, if the normal family practice doctors would even bother to check sites such as this when they encounter an SCI patient, it would surely cut down on some of the misery that I´m sure is happening out there. Now I know some people will say a computer is too expensive, but the fact is an old, used and not up to date model, can be perfect for the internet and not cost more than a couple hundred dollars. New set top boxes for the TV, such as one offered by MSU Corp. (www.msucorp.com), even have a remote keyboard and cost under $200.

[M.Elston]

Hi All,
my DD14 was in acute care 20 days then transfered to rehab where she stayed 32 days. (we left a week early due to a detrimental room mate situation) I think this was about right for her with her 'minor' SCI.
While we were at Shriners, they admitted a girl that was 6 days post-injury (T11-12 complete, I think) that was literally kicked out of the acute stay hospital as soon as she was released from ICU. Poor kid was in no way ready for rehab. My heart hurt for both her and her parents, they were a long way from home. She should have been able to stay at the hospital where her family lived (major medical center in Michigan) until she was more ready for the rigors of rehab.
How irritating. http://sci.rutgers.edu/forum/images/smilies/mad.gif

M.Elston SCI Mom to 15YO incomplete L2-3

[SCI-Nurse]

At our center we have the luxury of combining acute and rehab SCI patients on the same unit, so we do take new injury patients directly from the ICU so they get SCI expert care right away. It prevents many complications such as pressure ulcers, etc. Once they are ready for rehab we officially change them over to this program without changing their team members (although they may have to change rooms). We prefer to see the patients ASAP as they do better this way and get more accurate information. If they come from a local facility I see them and their family while still in the ICU and give the family materials to read (mostly Spinal Network). Unfortunately this is rarely available anymore except at a Model SCI Center or VA SCI Center. (KLD)