The primary and secondary causes of hospitalizations during the first five years after spinal cord injury

Prevalence, causes, and risk profile of rehospitalizations in persons with spinal cord injury within the first 10 years after primary rehabilitation

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

This study aims to identify the prevalence, causes, time pattern and risk profile of rehospitalizations in persons with spinal cord injury (SCI) within a 10-year period following primary rehabilitation and identify most common secondary health conditions (SHCs) and risk profile leading to rehospitalizations.

SETTING

Specialized hospital and rehabilitation center for SCI in Switzerland.

METHODS

A retrospective analysis was conducted on clinical data from persons with SCI, discharged from initial rehabilitation between January 1, 2010, and December 31, 2012, and followed up over a period of ten years post-discharge. Descriptive statistical methods were utilized to compute the rehospitalization prevalence and to identify the primary reasons.

RESULTS

225 participants were included, 70% were male (n = 179), and the mean age was 50 years (SD 19, Range 17-88). 54% were classified as having paraplegia (n = 122), and 77% incomplete injuries (n = 180). Over the 10-year observation period post-discharge, 120 were readmitted at least once, (prevalence 53%). In total, 66 persons (29%) were rehospitalized once or twice, while 54 persons (24%) were rehospitalized three or more times, with a maximum of 14 times. In the 10-year period, the most common SHCs leading to rehospitalization were infections (19%), pressure injuries (18%), and gastrointestinal problems (16%). During the study period, 57 persons (25%) passed away.

CONCLUSIONS

Rehospitalization after primary rehabilitation is frequent and in the majority of the cases due to SHCs. The study findings are valuable for resource planning in healthcare and can guide the implementation of preventive measures to avoid SHCs.

Pressure ulcers acquired during inpatient rehabilitation after spinal cord injury, characterization and predictors: A 15-years' experience

BACKGROUND

Most studies focus on the risk factors associated with the development of pressure ulcers (PUs) during acute phase or community care for individuals with spinal cord injury (SCI).

OBJECTIVES

This study aimed to i) compare clinical and demographic characteristics of inpatients after SCI with PUs acquired during rehabilitation vs inpatients without PUs and ii) evaluate an existing PU risk assessment tool iii) identify first PU predictors.

METHODS

Individuals (n = 1,135) admitted between 2008 and 2022 to a rehabilitation institution within 60 days after SCI were included. Admission Functional Independence Measure (FIM), American Spinal Injury Association Impairment Scale (AIS) and mEntal state, Mobility, Incontinence, Nutrition, Activity (EMINA) were assessed. Kaplan-Meier curves and Cox proportional hazards models were fitted.

RESULTS

Overall incidence of PUs was 8.9%. Of these, 40.6% occurred in the first 30 days, 47.5% were sacral, 66.3% were Stage II. Patients with PUs were older, mostly with traumatic injuries (67.3%), AIS A (54.5%), lower FIM motor (mFIM) score and mechanical ventilation. We identified specific mFIM items to increase EMINA specificity. Adjusted Cox model yielded sex (male), age at injury, AIS grade, mFIM and diabetes as PUs predictors (C-Index = 0.749).

CONCLUSION

Inpatients can benefit from combined assessments (EMINA + mFIM) and clinical features scarcely addressed in previous studies to prevent PUs.

Impact of a sustained, collaborative antimicrobial stewardship programme in spinal cord injury patients

Background

In patients with spinal cord injuries (SCIs), infections continue to be a leading cause of morbidity, mortality and hospital admission.

Objectives

This study evaluated the long-term impact of a weekly, multidisciplinary Spinal/Antimicrobial Stewardship (AMS) meeting for acute-care SCI inpatients, on antimicrobial prescribing over 3 years.

Methods

A retrospective, longitudinal, pre-post comparison of antimicrobial prescribing was conducted at our tertiary hospital in Melbourne. Antimicrobial prescribing was audited in 6 month blocks pre- (25 April 2017 to 24 October 2017), immediately post- (27 March 2018 to 25 September 2018) and 3 years post-implementation (2 March 2021 to 31 August 2021). Antimicrobial orders for patients admitted under the spinal unit at the meeting time were included.

Results

The number of SCI patients prescribed an antimicrobial at the time of the weekly meeting decreased by 40% at 3 years post-implementation [incidence rate ratio (IRR) 0.63; 95% CI 0.51-0.79; P ≤ 0.001]. The overall number of antimicrobial orders decreased by over 22% at 3 years post-implementation (IRR 0.78; 95% CI 0.61-1.00; P = 0.052). A shorter antimicrobial order duration in the 3 year post-implementation period was observed (-28%; 95% CI -39% to -15%; P ≤ 0.001). This was most noticeable in IV orders at 3 years (-36%; 95% CI -51% to -16%; P = 0.001), and was also observed for oral orders at 3 years (-25%; 95% CI -38% to -10%; P = 0.003). Antimicrobial course duration (days) decreased for multiple indications: skin and soft tissue infections (-43%; 95% CI -67% to -1%; P = 0.045), pulmonary infections (-45%; 95% CI -67% to -9%; P = 0.022) and urinary infections (-31%; 95% CI -47% to -9%; P = 0.009). Ninety-day mortality rates were not impacted.

Conclusions

This study showed that consistent, collaborative meetings between the Spinal and AMS teams can reduce antimicrobial exposure for acute-care SCI patients without adversely impacting 90 day mortality.

Unplanned hospital admissions due to secondary health conditions after spinal cord injury: a population-based description of determinants of length of stay

STUDY DESIGN

Population-based prospective study.

OBJECTIVES

To provide a population-based description of length of stay (LOS) and person-related risk factors following unplanned hospital admission due to a secondary health condition (SHC) in persons with spinal cord injury (SCI).

SETTING

Specialized SCI hospital and rehabilitation center in Switzerland.

METHODS

Descriptive analysis of LOS using routine clinical data of persons with SCI, who were acutely hospitalized between 01.01.2017-30.06.2018. Multivariable regression analysis was used to derive marginal predictions of LOS by acute SHCs and person characteristics.

RESULTS

The study included 183 persons, 83% were male, and the median age was 57 years (interquartile range, IQR, 49-67 years). SCI cause was traumatic in 160 (88.4%) cases, 92 (50.3%) were persons with tetraplegia, 147 (80.3%) were classified as motor complete lesions (American Spinal Injury Association Impairment Scale (AIS) A or B) and median time since injury (TSI) was 24 (IQR 13-34) years. Median LOS was 19 (IQR 9-39) days, varying from 74 (IQR 39-92) days for pressure ulcers, 13 (IQR 8-24) days for urinary tract infections (UTI), to 27 (IQR 18-47) days for fractures. LOS was prolonged in persons with multiple co-morbidities or those developing complications during hospitalization. Sex, SCI etiology and lesion level were not associated with LOS.

CONCLUSIONS

This population-based description identified substantial variation in LOS between acute SHCs and clinical complications as the main, potentially modifiable, person-related risk factors for extended hospital stay.

The Relationship of Secondary and Chronic Health Conditions With Emergency Department Visits and Related Hospitalizations Among People With Traumatic Spinal Cord Injury

OBJECTIVE

Identify the relationship of health conditions with self-reported emergency department (ED) visits and ED-related hospitalizations among people with traumatic spinal cord injury (SCI), while controlling for demographic, injury, and socioeconomic factors.

DESIGN

Cross-sectional.

SETTING

A regional SCI model system in the Southeastern United States.

PARTICIPANTS

Participants (N=648) were adults with chronic traumatic SCI at least 1 year postinjury who were identified through their Form II annual follow-up within the SCI Model Systems.

INTERVENTIONS

N/A.

MAIN OUTCOME MEASURES

Self-reported ED visits and ED-related hospitalizations within the 12 months prior to the study.

RESULTS

Several types of factors were significantly related to ED visits, with fewer related to ED hospitalizations. Men (odds ratio [OR]=1.58); those divorced, widowed, or separated (OR=1.57); and those with more severe SCI (C1-C4, or American Spinal Injury Association Impairment Scale A/B) had greater odds of having at least 1 ED visit; education and employment factors were not significant. Of health conditions, acute secondary health conditions including falls (OR=1.45), urinary tract infections (UTIs; OR=2.40), and pressure injuries (OR=1.58) were all associated with a greater odds of ED visits, whereas chronic health conditions were not. Being unemployed was associated with greater odds of an ED hospitalization (OR=1.79), as was having at least 1 UTI (OR=2.24) and at least 1 pressure injury (OR=2.37).

CONCLUSIONS

The current findings suggest acute secondary health conditions, particularly UTIs and pressure injuries, were much more highly related to ED visits and related hospitalizations compared to chronic health conditions (eg, diabetes, hypertension). Greater attention needs to be paid to fall, UTI, and pressure injury prevention to reduce the ED burden related to SCI.