There are approximately 12,000 new cases of traumatic spinal cord injury (SCI) annually. In 2010, there were approximately 265,000 individuals living with SCI. Over time, the average age of people with SCI has steadily risen, and it is now 40.7 years. There are multiple medical complications that are commonly seen in individuals with SCI. These include, but are not exclusively limited to, pneumonia, decubiti ulcers, undiagnosed fractures, urinary tract infections, autonomic dysreflexia, deep venous thrombosis, and pulmonary embolism. This article addresses the issue of patient safety in the care of adults living with an SCI.
There are approximately 12,000 new cases of traumatic spinal cord injury annually. In 2010, there were approximately 265,000 individuals living with SCI. Over time, the average age of people with SCI has steadily risen, and it is now 40.7 years. Males (80.7%) are more likely to suffer from an SCI. The most common cause of SCI is motor vehicle crash (40.4%), followed by falls (27.9%), violence (15.0%), and sports injuries (8.0%). While the life expectancy of someone with an SCI has steadily increased over the years, there is still a decrease in overall life expectancy. This depends on the level of injury and completeness of injury.
There are multiple medical complications that are commonly seen in individuals with SCI. These include, but are not exclusively limited to, pneumonia, decubiti ulcers, undiagnosed fractures, urinary tract infections (UTIs), autonomic dysreflexia, deep venous thrombosis, and pulmonary embolism.
Safety risks in adults with spinal cord injury
Individuals with spinal cord injury have multiple impairments that may pose safety risks. The following sections describe impairments and safety risks that are involved as a result of such impairments and some general recommendations to minimize the safety risk.
Sensory Loss
Almost all people who have sustained an injury to the spinal cord will have resultant sensory dysfunction. This can result in significant safety risks. For one, lack of sensation in the extremities can result in falls, as proprioceptive feedback will be impaired. Additionally, a person with decreased sensation will be at higher risk for burn from modalities. Due to this, these patients should not use plug-in heating pads and should be supervised when using heat modalities to prevent burns. Anecdotally, individuals with SCI have also sustained burns secondary to laptop computers. Patients should be counseled not to place laptop computers or other devices on their laps.
Weakness
Individuals who sustain SCI have varying degrees of weakness, depending on their American Spinal Injury Association (ASIA) impairment scale and level of injury. Weakness of the extremities will increase risk of falls, musculoskeletal injury, and skin breakdown. The risk of occurrence of sequelae secondary to weakness that occurs from an SCI can be minimized several ways. Use of appropriate assistive devices and orthotics may be appropriate for an individual with an incomplete injury. For individuals with complete injuries or incomplete injuries who are unable to ambulate, evaluation of an appropriate wheelchair is necessary. Patients with complete injuries should also be turned every 2 hours to prevent development of skin breakdown.
Pulmonary
Individuals with SCI have baseline respiratory compromise. As a result of weakness, these individuals have difficulty with secretion management, atelectasis, and hypoventilation. This is a result of compromised innervation to the intercostal muscles. In individuals with a T5 to T12 neurologic level of injury, the abdominal muscles and intercostal muscles are weakened, and the patient is unable to forcefully cough. From the T1 to the T5 level, there is even worse weakness, and even silent respiration may be impacted. Due to this, an individual with an SCI will have restrictive pulmonary disease with a decrease in all lung volumes. As a result, spinal cord injured individuals will have a lower threshold of pulmonary wellness and may more easily develop pneumonia.
Patient assessment with an emphasis on safety
By using the ASIA Classification for Spinal Cord Injury, one can stratify the risks involved in developing complications. The following information regarding level and classification of injury may be helpful in determining risks.
An individual with a complete injury (ASIA A) will have an increased risk of developing pressure ulcers as well as burns. This is due to the fact that these individuals are insensate below the level of the injury and therefore are unaware of a developing ulcer. As well, these individuals have no motor function below the level of injury and are unable to offload;therefore they cannot prevent breakdown as easily.
ASIA classification is also of use when stratifying risk for autonomic dysreflexia (AD). AD is present in individuals with ASIA A T6 and above injuries. This is due to the fact that this level is above the major splanchnic outflow; therefore parasympathetic flow is limited.
Incomplete spinal cord injured individuals may actually have a higher risk for falls as a result of relative weakness of the lower extremity. Additionally, individuals with incomplete SCIs are at higher risk of suicide.
Safety Risk to Adults with SCI Along the Health Care Continuum
Adults with SCI are cared for in a variety of health care settings including acute medical/surgical wards, inpatient rehabilitation facilities, subacute rehabilitation facilities, outpatient facilities, and even the home of the patient. As increasing numbers of adults with SCIs are living longer and more active lifestyles, they will periodically need health care. Risks for their safety can be encountered as the adult with SCI moves along the continuum of health care. The multiple transition points through different health care settings and multiple health care providers pose a challenge to the care of the SCI patient. Some of the issues include
Communication-related issues, especially at transition points such as admissions and discharges
Limited knowledge about the care of this population among health care providers
Limited education of patients and their families on being effective advocates for their needs
Fragmented social support systems and
Limited education and financial resources.
It is therefore very important that first and foremost, patients and their immediate family members are properly educated about SCI and its short-term and long-term consequences and recognition and management of commonly seen conditions in this population. It is also equally important that health care providers have a working knowledge about the care of the SCI patient. Health care providers should consider using a checklist format to ensure that all possible consequences of SCI are adequately addressed regardless of location of care along the health care continuum ( Appendix A ). Communication at time of transition points should follow a structured format with appropriately documented admission notes and discharge summaries with pertinent medical and surgical information relevant to the patient’s care.
Related posts:
Patient Safety and Quality Improvement in Rehabilitation Medicine
Medication Safety in Rehabilitation Medicine
Patient Safety Considerations in the Rehabilitation of the Individual with Cognitive Impairment
Patient Safety in Rehabilitation Medicine: Traumatic Brain Injury
Safety Considerations During Cardiac and Pulmonary Rehabilitation Program
Patient Safety in the Rehabilitation of Children with Spinal Cord Injuries, Spina Bifida, Neuromuscular Disorders, and Amputations
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