Specialized vs General SCI Units (Acute Care)
Donovan et al. (1984) contend that best practice for SCI care consists of every individual with SCI being admitted to an integrated, comprehensive system where expertise, facilities, and equipment are focused on optimal patient care and cost-effectiveness. Alternatively, Bedbrook and Sedgley (1980) recommend piecemeal care for those with SCI characterized by “the occasional patient being treated by the occasional doctor.” In practice, care provided by most SCI centers likely falls somewhere in between these extremes of ideal, specialized care and non-specific, general care. The present section outlines the studies that are focused on examining the hypothesis that care provided in specialized SCI centers is more efficient and effective than that delivered at general centers. Although the majority of these studies were conducted within rehabilitation centers, this section includes studies that evaluated the impact of specialist SCI care that is delivered in the acute care following SCI and/or in post-acute care inpatient rehabilitation.
Discussion
Most studies examining the effect of specialist versus general SCI care settings focused on the acute period of care only, with the primary outcome measures being taken at admission to rehabilitation and no follow-up after this point. Of the studies reviewed, two investigated the results associated with a specialized, integrated unit comprised of both acute and rehabilitation services (Donovan et al. 1984; Smith 2002). Donovan et al. (1984) noted rates of six of seven different medical secondary complications typically encountered by individuals with SCI were lowest for the cohort admitted initially (i.e., typically within 48 hours post-injury) to the specialist SCI center. This cohort was analyzed retrospectively with complication rates determined at various times throughout rehabilitation (i.e., 1-15, 16-30, 31-45, and 46-60 days) and compared to those admitted to specialist SCI centers from more general care settings at similar time periods. Most striking was the absence of decubitus ulcers during any time period for those under more specialized care compared to a progressively increasing incidence for those patients who spent greater time in general care. No statistical analysis was conducted for this study. Smith (2002) conducted a postal survey (i.e., cross-sectional, self-reported survey) of 800 persons who had received care through either a specialist spinal injury unit (n=701) or in a general setting (n=99) within the UK. This cross-sectional sample reported significantly improved outcomes for 10 of 18 health outcomes, 16 of 18 functional outcomes, and 5 of 10 social outcomes for those who had received care from the specialist versus non-specialist setting. Notable findings included reduced pressure sores (p=0.048), and a lower level of required assistance for the group who had received specialist care, and there was a trend but no statistically significant difference noted between the groups for life satisfaction (p=0.07).
The remaining studies compared specialized SCI care to general care and were retrospective in nature. Three studies (Heinemann et al. 1989; Tator et al. 1995; Yarkony et al. 1985) evaluated the impact of specialized acute care SCI units on patient outcomes. Yarkony et al. (1985) compared joint contracture and time to rehabilitation admission outcomes for patients with SCI treated in a specialized acute care SCI unit to those with SCI treated in a general acute care unit. Heinemann et al. (1989) found that a specialized acute care unit reduced acute care LOS, and promoted earlier transfer to rehabilitation. Tator et al. (1995) evaluated the seven-year experience of a newly developed acute SCI care unit and compared outcomes to historical data from pre-existing general trauma units (Tator et al. 1995). In all three studies, patients were transferred significantly faster to comprehensive inpatient rehabilitation from more specialized acute care settings than from general hospital settings, resulting in a reduced LOS in acute care. The two remaining studies compared subjects who received comprehensive, specialized SCI rehabilitation to those who received general rehabilitation (Cheng et al. 2017; McKechnie et al. 2019). Cheng et al. (2017) evaluated the discharge destination for patients with SCI admitted to specialized SCI rehabilitation compared to general rehabilitation in a multi-centered retrospective cohort study of nine Canadian rehabilitation centers and found significantly higher rates of discharge home to independent living for patients who received specialized SCI rehabilitation. McKechnie et al. (2019) compared outcomes for patients with SCI and brain injury in specialized and non-specialized rehabilitation units over 10 years retrospectively; most patients with SCI received care in non-specialized units. Patients with SCI who received care in specialized SCI rehabilitation had greater levels of impairment on admission (lower FIM scores, higher burden of care) and achieved greater functional outcomes (absolute functional gains) but had a near-double length of stay in rehabilitation.
In general, studies of specialized acute care demonstrated improved medical outcomes associated with more specialized care. In addition to the reduced complication rates noted above by Donovan et al. (1984) and Smith (2002), others have noted that more specialized acute care resulted in less spine instability (Heinemann et al. 1989) and significantly improved joint motion with reduced incidence of contractures (Yarkony et al. 1985) upon admission to a comprehensive rehabilitation program. Chang et al. (2020) found that specialized rehabilitation significantly improved basic life skills, motor scores, and social life. In addition, reduced mortality and improved neurological recovery (as demonstrated by higher scores on the Cord Injury Neurological Recovery Index) were seen in the newly developed specialist SCI unit as compared to the data from pre-existing general trauma units (Tator et al. 1995). It should be noted that a gradual reduction of mortality was seen over the entire study period and that reductions attributed to the specialist unit might also be due to many general gradual improvements in medical care, especially as a historical control was used as the primary basis for comparison.
Only two studies examined the functional benefits realized during rehabilitation associated with SCI-specific acute care. Heinemann et al. (1989) used the MBI to show that those individuals receiving specialist care made functional gains during subsequent rehabilitation with significantly greater efficiency (i.e., functional change/LOS) than those referred from general settings. No statistically significant differences were seen between the specialist versus general groups for either admission or discharge functional levels, nor were significant differences seen with LOS. However, there was a significant reduction in the time from injury to rehabilitation admission for those receiving care in the specialist SCI unit. This implies an overall reduced length of total hospitalization for this group, although this data was not reported. In comparison, Pattanakuhar et al. (2019) found that patients discharged from specialized rehabilitation facilities demonstrated greater improvement on the Spinal Cord Independence Measure. As well, rehabilitation conducted at a specialized facility was an independent predictive factor of SCIM improvement at discharge. Functional benefits associated with early admission and reduced LOS will be reviewed in the next section.
Two studies evaluated SCI-specific rehabilitation care and identified several beneficial patient outcomes. Cheng et al. (2017) found that patients who received SCI-specific rehabilitation care were much more likely to be discharged home than those who received general rehabilitation: for every 100 patients who received specialized rehabilitation care, 11 more were able to return home (rather than nursing or other non-home destinations) compared to general rehabilitation. Similarly, McKechnie et al. (2019) reported significant functional gains for patients who received specialized SCI rehabilitation care compared to those who did not, but these patients also had a longer rehabilitation LOS.
A primary limitation of all studies reported here was the use of retrospective data collection methods and in the case of Tator et al. (1995), the use of historical controls. Another important limitation of some of these studies is the failure to control for (or at least adequately describe) the time to admission to initial care following injury, especially with respect to control subjects (e.g., Donovan et al. 1984; Heinemann et al. 1989; McKechnie et al. 2019; Tator et al. 1995; Yarkony et al. 1985). This is an important confounding variable as early admission to a specialized system of care is likely associated with better outcomes as demonstrated in the following section. Therefore, the present conclusions are limited to level 3 evidence and some findings have been reduced to level 4, if not corroborated by or had inadequate controls. While more carefully controlled prospective studies would be difficult to implement, they would be required to strengthen the evidence in this area.
Conclusions
There is level 3 evidence (from three case control studies: Heinemann et al. 1989; Tator et al. 1995; Yarkony et al. 1985) that individuals cared for in interdisciplinary, specialist SCI acute care units soon after injury (most being admitted within 48 hours) begin their rehabilitation program earlier.
There is level 3 evidence (from one case control: Donovan et al. 1984) and level 5 evidence (from one observational study: Smith 2002) that individuals cared for in interdisciplinary, specialist acute care SCI units have fewer complications upon entering and during their rehabilitation programs.
There is level 2 evidence (from two cohort studies: McKechnie et al. 2019; Pattanakuhar et al. 2019), level 3 evidence (from Heinemann et al. 1989) and level 4 evidence (from one pre-post test: Chang et al. 2020) that individuals cared for in interdisciplinary, specialist SCI units make more efficient functional gains during rehabilitation (i.e., more or faster improvement).
There is level 3 evidence (from one case control study: Tator et al. 1995) that individuals cared for in interdisciplinary, specialist SCI units have reduced mortality.
There is level 2 evidence (from one cohort study: Cheng et al. 2017) that individuals who receive inpatient rehabilitation in specialist SCI rehabilitation units are more likely to be discharged home than those who do not.
