Hospital Programs
Discussion
Overall, hospital programs for respiratory management have been shown to benefit individuals more so than traditional hospital care. These programs reduce length of hospital stay and ventilator days (Cameron et al. 2009; Vitaz et al. 2001; Richard-Denis et al. 2018), help individuals gain independence by initiating speaking valves sooner (Wong et al. 2012) and reduce the incidence of pulmonary complications (Vitaz et al. 2001). Although Wong et al. (2012) did not perform statistical analyses to compare the efficacy of their program, the patients who received all three respiratory management therapies had less complications than those who did not.
A newer case control study, of moderate size, found that patients admitted early to a specialized level-1 trauma center had over all fewer procedures and complications (Richard-Denis et al., 2018). Early admission to this center significantly decreased the rates of tracheostomies, as well as the total number of days in hospital. Early admitted patients spent on average 50 fewer days on ventilation (Richard-Denis et al. 2018). Another study examining specialized care by Romero-Ganuza et al. (2015) found that a third of patients were able to be weaned at the hospital, and 63/68 individuals were discharged to the community and not long-term care. All of these patients treated with a specialized respiratory care protocol, however more research is needed to determine how this level of specialized care compares to other standards of care.
Conclusion
There is level 4 evidence (from one post test: Wong et al. 2012) that the implementation of specialized respiratory management results in stabilization and improvement of respiratory status in acute SCI patients.
There is level 2 evidence (from one cohort study: Cameron et al. 2009) that the tracheostomy review and management service reduces length of hospital stay and duration of cannulation while increasing speech valve usage compared to those who do not receive tracheostomy review and management in acute SCI patients.
There is level 2 evidence (from one cohort study: Vitaz et al. 2001) that the use of a clinical care pathway reduces length of hospital stay and results in fewer complications compared to those who received regular care in acute SCI patients.
There is level 3 evidence (from one case control study: Richard-Denis et al. 2018) that early admission to a level-1 trauma center results in lower rates of tracheostomies, as well as fewer ventilator days for acute SCI patients, compared to late admission.
There is level 4 evidence (from one pre-post test: Romero-Ganuza et al. 2015) that specialized respiratory care results in a high number of community discharges in acute SCI patients.
Author Year Country Research Design Sample Size |
Methods | Outcomes |
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Richard-Denis et al. (2018) Canada Case Control N=81 |
Population: (Group 1): Mean age: 43.6 yr; Gender: male=75.4%, female=24.6%; Injury severity: Mean ISS= 35.3. (Group 2): Mean age; 42.5yr; Gender: male=83.3%, female=16.7%; Injury severity: Mean ISS=42.7%. Intervention: Patients in group 1 were transferred early to a level-1 trauma center for surgical management of SCI. Patients in Group 2 were transferred late (postoperatively) to the same SCI trauma center for care. Outcome Measures: Tracheostomy requirement, mechanical ventilation requirement, ventilation support duration, Chronicity: Patient population was defined as acute SCI. |
1. Group 2 had significantly higher rates of required tracheostomies (p=0.004). 2. There were no significant differences between groups in terms of the number of patients who required mechanical ventilation support. 3. There was a significant difference between groups for the number of days spent on ventilation, with Group 2 spending on average 50 more days on ventilation (p=0.006). |
Romero-Ganuza et al. (2015) Spain Pre-Post Test N=68 |
Population: Mean age: 53.8 yr; Gender: male=49, female=19; Level of SCI: C1- C4=44, C5-C8=11, thoracic=13. Intervention: Patients were treated with a specific respiratory care comprehensive rehabilitation program. Outcome Measures: Hospital mortality, length of stay, discharged to community, discharged home, discharge to extended care facilities, discharge to acute care hospital, weaned from ventilation, patients with permanent respiratory support. Chronicity: Patients were admitted within 3 months of injury. |
1. Five patients died in hospital. 2. The average length of stay for survivors was 195.6 days. 3. 63/68 of patients were discharged to the community, 47 patients were discharged home, 13 were discharged to extended-care facilities, and 3 were sent to an acute care hospital setting. 4. 23 patients were weaned at the hospital. 5. 20 patients had permanent respiratory support. |
Wong et al. (2012) USA Post Test N=24 |
Population: Mean age: 33 yr; Gender: male=22, female=2; Level of injury: C1-C4; Severity of injury: complete=79%, incomplete=21%; AIS A-D. Intervention: Retrospective analysis of patients who received a hospital program at an SCI specialty unit of high tidal volume ventilation, high frequency percussive ventilation, and mechanical insufflationexsufflation were compared before and after the program. Outcome Measures: Occurrence of high tidal ventilation, high frequency percussive ventilation, mechanical insufflationexsufflation, initiating a speaking valve, ventilator weaning attempts, time from admission to ventilator wean Chronicity: Average time from injury to transfer to the SCI unit was 33.8 days. |
1. In 14 patients who were weaned off the ventilator, the average day to be weaned from the time of admission was 27.6 days (SD 12.9 days). 2. Three individuals with C3 AIS A were ventilator weaned in 24 to 62 days (average 43.67 days). Eight individuals with C4 AIS A were ventilator weaned in 14 to 31 days (average 22.13 days). Two individuals with C4 AIS B were weaned from the ventilator in 19 to 22 days (average 20.5 days). One individual with C4 AIS C was weaned in 37 days. 3. Six subjects were decannulated prior to discharge to home, and the average days to be decannulated after admission was 42.0 days (SD 16.6 days). |
Cameron et al. (2009) Australia Cohort N=102 |
Population: Age range: 24-52 yr; Gender: male=78, female=24; Level of injury: C4-C8. T1-T5, T6 and below; Severity of injury: complete=44, incomplete=58; AIS A-D. Intervention: Patients either received tracheostomy review and management services (post-TRAMS group, 2003-2006) or did not receive tracheostomy review and management services (pre-TRAMS group, 1991-2001). Outcome Measures: Hours mechanically ventilated, hours in intensive care unit (ICU), length of hospital stay, duration of cannulation, initiation of communication through a one-way speaking valve, deaths. Chronicity: Length of acute hospital stay was a median of 60 days (pre-TRAMS group) and 41.5 days (post-TRAMS group); time since injury was not specified. |
1. There were no significant differences with regards to hours mechanically ventilated (p=0.71) and hours in ICU (p=0.60) between pre-TRAMS patients and post-TRAMS patients. 2. Post-TRAMS patients had a significantly shorter hospital stay compared to pre-TRAMS patients (p=0.03). 3. Post-TRAMS patients had a significantly shorter duration of cannulation compared to pre-TRAMS patients (p=0.03). 4. Post-TRAMS patients began using one-way speaking valves significantly earlier than pre-TRAMS patients (p<0.01). 5. There were no tracheostomy-related deaths in either group. |
Vitaz et al. (2001) USA Cohort N=58 |
Population: Mean age: 33 yr; Gender: not specified; Level of injury: C1-T5; Severity of injury: not specified. Intervention: Patients either received treatment according to the clinical care pathway (Group 1) or received regular treatment (Group 2; control). Outcome Measures: The following during hospital stay: episodes of pneumonia, length of hospital stay, length of intensive care unit (ICU) stay, days on ventilator. Chronicity: Average overall length of hospital stay was 36 days and 24 days for Group 1 and Group 2 patients, respectively; time since injury was not specified. |
1. Patients in Group 1 experienced significantly fewer episodes of pneumonia compared to patients in the control group (p<0.05). 2. Patients in Group 1 experienced a significantly shorter stay in the hospital (p<0.05) and ICU (p<0.05), and required significantly fewer days on the ventilator (p<0.05) compared to patients in the control group. |