SPINAL CORD INJURY: THE NEW POLITICAL PERSPECTIVE

1
SPINAL CORD INJURY THE NEW
POLITICAL PERSPECTIVE
2
SPINAL CORD INJURY WHO CARES?

• Asking the right questions

3
IN THE BEGINNING

• 1948 NHS created by Health Act
• 1952 Health Act amended to allow development of
  specialist services providing for less than 1
  million UK citizens each year
• 2003 Review of Specialist Services
• 2006 Parliamentary Investigation
• (Carter Report)

4
THE FINDINGS

• Specialities listed on NHS website for
  reference purposes
• Specialist Commissioners for strategic services
  (pan-regional) at mercy of Regional bodies, PCTs
  and individual trusts
• Some specialist funding being diverted by PCTs
  and hospital trusts
• Specialist services often isolated or bypassed by
  expansive generalist services
• Misperception of care closest to home.

5
PARLIAMENTARY GROUP

• SIA, MASCIP, BASCIS Parliamentary Disability
  Group
• 3-year project funded in 2006 Preserving
  Developing National SCI Service
• New group, has cross-party support
• 2009 Secretary of State accepts findings, and
  agrees initial action plan
• Action Plan to commence in 2010/2011

6
THE NEW AGENDA

• Confirm Government support for National SCI
  Service
• Streamline Specialist Commissioning for strategic
  services at national level
• Audit use of specialist funding
• Define Spinal Cord Injury for purposes of
  creating an NHS Pathway
• Define and develop a Model service.

7
New Commissioning Pathway
8
THE NEW AGENDA

• Define a Model SCI Centre
• Audit current SCI Centres against this model and
  plan for future development
• Calculate accurate annual incidence of SCI using
  NHS codes
• Fund the development of a national SCI database
  and reporting centre
• Consider additional SCI Centre beds

9
WHAT IS A SPINAL CORD INJURY?

• NHS Definition Set
• Audit Criteria 2010/2011

10
ACTUAL SCI

• Spinal cord injury worthy of referral to a
  specialist SCI Service is defined when one of the
  following ICD-10 codes is recorded in primary
  diagnosis field (ie first 10 documented
  problems)
• 5140 Concussion and oedema of cervical spinal
  cord5141 Other and unspecified injuries of
  cervical spinal cord5142 Injury of nerve
  root of cervical spine5240 Concussion and
  oedema of thoracic spinal cord5241 Other and
  unspecified injuries of thoracic spinal
  cord5242 Injury of nerve root of thoracic
  spine5340 Concussion and oedema of lumbar
  spinal cord5341 Other injury of lumbar spinal
  cord

11
ACTUAL SCI

• 5342 Injury of nerve root of lumbar and sacral
  spine5343 Injury of cauda equina5344 Injury
  of lumbosacral plexusT060 Injuries of brain and
  cranial nerves with injuries of nerves and
  spinal cord at neck levelT061 Injuries of
  nerves and spinal cord involving other
  multiple body regionsT093 Injury of spinal
  cord, level unspecifiedT094 Injury of
  unspecified nerve, spinal nerve root and
  plexus of trunk.
• Statement to the House on behalf of DoH in
  response to Parliamentary Question How does DoH
  define Spinal Cord Injury July 2009

12
New SIA Publicationwww.spinal.co.uk
13
SCI Incidence UpdateEngland Wales 2007-8

• 744 admissions to SCI Centres
• 71 male
• Average age at injury 44 years old
• Range 3 103 years old
• Largest group (20) aged 21-30 years old
• 20 of traumatic SCI not referred to SCI Centre

C1 - 4 C5-8 T1-12 L1-5 S1-5 Not Given
24 26 37 11 0.1 1.9
14
SCI Incidence UpdateEngland Wales 2007-8

• 71 of SCI due to trauma
• 27 due to Moving Vehicle Collision
• 26 due to Falls
• Non-traumatic patients significantly older than
  traumatic cases (Plt0.01)

15
ADMISSION POTENTIAL

• 450 SCI centre beds, 300 dedicated beds for
  first-time admissions
• Increased length of stay
• Increased discharge delays
• Immediate need for additional beds in Southern
  England
• Preventable complications linked to admission
  delays

16
SCI Incidence UpdateEngland Wales 2007-8

• 24 of traumatic SCI cases sustained
• accompanying trauma
• Chest injuries (39)
• Upper limb injuries (30)
• Pelvis and lower limb injuries (28)
• Head injury (19)

17
SCI Incidence UpdateEngland Wales 2007-8

• 44 of the patients were reported to have
• significant pre-existing medical conditions
• Cardiovascular (26)
• Respiratory (16)
• Neurological (12)
• Diabetes (13)
• Mental health problems (9)

18
SECONDARY SCI

• Secondary neurological deterioration can
  occur due to
• natural pathological processes
• inappropriate moving and handling
• surgical interventions
• poor systems management post-trauma
• Inappropriate early mobilisation

19
THE UK SCI CARE PATHWAY
20
NHS COMMISSIONERS SERVICE REVIEW 2003

• A coordinated care pathway from AE
• Early recognition of SCI
• Referral to SCI Centre within 24 hours
• Transfer to SCIC if appropriate
• SCI Centre liaison if transfer delayed
• Support and education for PTH staff
• Referral to SCIC if patient readmitted

21
(No Transcript)
22
WHO INFORMS SCI CARE

• Department of Health
• NHS Specialised Services Commissioners
• Local Commissioning Groups
• Multidisciplinary Association of SCI
  Professionals (MASCIP)
• British Association of SCI Specialists (BASCIS)
• Spinal Injuries Association (SIA)
• Spinal Injuries Scotland (SIS)
• International Spinal Research Trust (Spinal
  Research)
• International Spinal Cord Society (ISCoS)
• Parliamentary All-Party Working Party on Spinal
  Cord Injury
• work under development

• National Patient Safety and Modernisation Agency
• Joint Royal Colleges Ambulance Liaison Committee
• British Trauma Society
• British Orthopaedic Association
• Royal College of Nurses
• Royal College of Physicians
• Royal College of Surgeons
• British Society for Rehabilitation Medicine
• Intensive Care Society
• British Association of Neuroscience Nurses

23
DELAYS IN TRANSFER

• Critically Unstable for Transfer
• Mental Health / Self-Harm Risk
• Needing Mechanical Ventilation
• Lack of Specialist Bed in SCIC
• Post-Admission Complications!

24
SCI CENTRE DEVELOPMENT 1

• Map activity to capacity and admission criteria
• All Acute SCI Centres to be on site of University
  Teaching Hospital with Level 1 Trauma Centre
• ? Separate acute and rehabilitation capacity
• ? Expand ventilator beds and dedicated ICU beds
  in parent trust (Mbro Model)
• Plan to provide ideal number of SCI beds per
  capita against current regional populations

25
SCI CENTRE DEVELOPMENT 2

• Consider separate paediatric SCI service
• Audit outcomes of older patients against care
  pathway options available
• Expand SCI Liaison Service
• Expand OPD for Outreach Services
• Invest in Hospital and Community Link-Workers
• Develop collaborative care guidelines with key
  professional bodies
• Invest in telemedicine and new health support
  technologies

26
READMISSION TO SCIC

• Most appropriate for the assessment or treatment
  of SCI-related problems and complications, where
  the appropriate clinical expertise and experience
  is not available in a local hospital.

27
READMISSION POTENTIAL

• 3 days per patient per year after discharge
• More frequent for patients with early
  preventable complications
• 303 bed nights per year needed
• 150 SCI centre readmission beds
• Currently 42 of these episodes admitted to local
  general hospital

28
READMISSION TO DGH

• Most appropriate for the assessment or treatment
  of problems /complications unrelated to SCI,
  where appropriate clinical expertise and
  experience is not available in a SCI Centre

29
READMISSION POTENTIAL

• 5 days per patient per year after discharge
• More frequent for patients with early
  preventable complications
• 500 bed nights per year needed
• 150 SCI centre readmission beds
• At least 30 of these episodes admitted to SCI
  Centre instead

30
Any Questions?