M. G. Onesta, M.D.
Director of Spinal Unit
Cannizzaro Hospital Catania
PATHWAYS IN
SPINAL CORD
INJURY
T. Di Gregorio, MD, PhD, Physiatrist of Spinal Unit Cannizzaro Hospital Catania
Siracusa 21 – 24 Ottobre 2013
…ABOUT RULE IN ITALY
The change in the care and rehabilitation of people with spinal cord injury occurs with the publication of the "Official Gazette n. 124, in date 05.03.1998 of the Guidelines of the Minister of Health for rehabilitation activities“, where for the first time was specified that
people with spinal cord
injury had to be cared for in specific specialized unit
in the hospitals, located at emergency department, called Unipolar Spinal Unit (USU).
Guidelines of the Minister of Health for rehabilitation activities " (Published in the Official Gazette of 30 May 1998, n. 124)
SPINAL UNIT
DEFINITION
The Unipolar Spinal Unit (USU) is a multidisciplinary professional organization specialized for the needs
(therapeutic, rehabilitative and psychological-social) of people with spinal cord injury.
Basaglia N. Proposed guidelines for the organization of Rehabilitation Medicine. Working Group ministeriale.Giorn.Ital. Med Physics and Riabilit 1996. 10205-241
…WHEN ???
The care pathway starts from the earliest stages of the spinal cord injury through prevention of immediate
complications, until you reach the full recovery of the residual functions and the highest possible level of autonomy in the later stages.
…HOW?
The activities that take place within the USU affect all aspects of disability resulting from the spinal cord injury:
Respiratory neuro-motor
bladder-sphincter
psychological and sexual function
Rehabilitation in spinal cord injury . Bonavita. Masson 2004
SCI
78.2% males (mean age 37.6 years)SCI > 60 ages 10%
Incomplete quadriplegic 34.5%
Complete paraplegic 23.1 %
Complete quadriplegic 18.4 %
Incomplete paraplegic 17.5%
90% with life expectancy comparable to the reference population
Lichici, 2000
EPIDEMIOLOGY
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ACUTE ACUTE
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Michael G Fehinings et Al. Journal of neurotrauma 28, 2011
Specialized centers of care for SCI
The "Hub & Spoke“model is a system of
connections arranged like a chariot wheel, in
which all traffic moves along spokes connected to the hub at the center.
This theory expresses a dynamic idea (before structural ) of the assistance, connected to the degrees of complexity center that provides for a system of integrated services that include high specialty and emergency.
HUB & SPOKE
HUB & SPOKE
The Hub & Spoke model involves the concentration of care with higher complexity in "reference centers highly specialized" (Hub). Patients that exceed the threshold of the complexity of the interventions
possible at the peripheral level (Spoke) are sent to the Hub centers.
For each of the reference centers is neccessary to identify the geographical area:
the reference population, care pathways,
functional characteristics ,
structure and organization of the network nodes, the reference criteria among the services,
the criteria threshold for transfering patients to more specialized centre.
HUB & SPOKE
Hub (Spinal Unit)
Spoke A (Spoke for Acute patients) are divided
into;
Spoke AT (Acute Spoke – Traumatic SCI) Spoke A (Acute Spoke – Non traumatic SCI)
Spoke O (Spoke Ospedalieri - hospitals)
Spoke T (Spoke Territoriali – local services)
HUB & SPOKE
Spinal Unit
in Italy
n
°
tot.
beds 584
Spinal Units Spinal UnitsSpinal Units
Spinal Units N bedsN bedsN bedsN beds
USU Torino USU Torino USU Torino
USU Torino ---- Az. Osp. Cto/M. Adelaide Az. Osp. Cto/M. Adelaide Az. Osp. Cto/M. Adelaide Az. Osp. Cto/M. Adelaide 54545454 US Novara- Osp Maggiore della Carità 10 US Alessandria- Osp Borsalino 16 USU Pietra Ligure
USU Pietra Ligure USU Pietra Ligure
USU Pietra Ligure --- A.O. Santa Corona-A.O. Santa CoronaA.O. Santa CoronaA.O. Santa Corona 25252525 USU Milano
USU Milano USU Milano
USU Milano ---- A.O. Ospedale Niguarda Ca'GrandaA.O. Ospedale Niguarda Ca'GrandaA.O. Ospedale Niguarda Ca'GrandaA.O. Ospedale Niguarda Ca'Granda 36363636 US Ospedale CTO – Milano 21 US Sondalo - A.O. Della Vatellina e Valchiavenna 20
US Mozzo (BG) 12
US Integrata (RHO Passirana) 16 US Vicenza - Ospedale Civile - ULSS 6 di Vicenza 20 US Udine- Osp. Gervasutta 28 US Negrar - Ospedale Sacro Cuore 15 USU Firenze
USU Firenze USU Firenze
USU Firenze ---- A.O. Careggi A.O. Careggi A.O. Careggi A.O. Careggi 50505050 USU Perugia . A.O. Ospedale Silvestrini
USU Perugia . A.O. Ospedale Silvestrini USU Perugia . A.O. Ospedale Silvestrini
USU Perugia . A.O. Ospedale Silvestrini 10101010 USU Roma
USU Roma USU Roma
USU Roma ---- C.T.O. "A. Alesini"C.T.O. "A. Alesini"C.T.O. "A. Alesini"C.T.O. "A. Alesini" 16161616 US Centro Paraplegici di Ostia 23 USU Cagliari
USU Cagliari USU Cagliari
USU Cagliari --- Ospedale Marino-Ospedale MarinoOspedale MarinoOspedale Marino 15151515 US Montecatone Rehabilitation Institute
US Montecatone Rehabilitation InstituteUS Montecatone Rehabilitation Institute
US Montecatone Rehabilitation Institute 128128128128 US Villanova D’arda (PC) 10 10 US Ferrara- Osp Sant’Anna ? ? US Sulmona – Abruzzo 25 US Cassano Murge - Puglia 14
USU CATANIA USU CATANIAUSU CATANIA
USU CATANIA 20202020
Fondazione ISTUD – INAIL - 2010
The early transfer of SCI to a specialized center
of care will be organized early
to contain the
total length of hospitalization
.
The early transfer to a specialized
multidisciplinary center SCI can
reduce the
mortality of patients and the number of
complications
.
Parent et al. 2010
….PATH TO U.S.U.
USU
Valutation and treatment
from the staff of Spinal Unit Other hospitals Contact the staff of the spinal unit
CRITICAL AREA
14CARE PATHWAY
The transfer to USU starts with the emergency phase and it extends until the socio-familiar recovery . . .
It aims to obtain the recovery of maximum autonomy and independence of the patient with SCI
With the active involvement and coordination of the USU and rehabilitation in territorial structures.
EMERGENCY PHASE ACUTE PHASE
STABILIZATION PHASE
PHASE of POST-DISCHARGE or RETURNS
EMERGENCY PHASE ACUTE PHASE
STABILIZATION PHASE
PHASE of POST-DISCHARGE or RETURNS
The Physiatrist: role
The physiatrist takes care about
the patient as soon as possible (within 24 hours) after acceptance, extends the clinical level and is responsible for the single path on an individual patient
• the TEAM visit is an important moment to exchange and compare ideas between the professions
involved in the care pathway.
• The daily briefings encourage better
communication and better climate between
operators, limiting the necessity of the simultaneous presence of more professionals in selected cases, develop integrated medical record
HOSPITALIZATION Starts with defining the early interventions and objectives
During the First Day
The TEAM evaluates the case
after1 week
And every month The TEAM meeting takes place and FAMILY is informed about the
program
REHABILITATION PROJECT
Organization in unipolar spinal unit
CONCLUSIONS
A correct rehabilitation care,
based on a project and program shared by the
multidisciplinary team, may facilitate management of the patient from the acute phase to return to the home
To remember that is essential to start the transfer of a person with spinal cord injury as fast as possible ...