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The CCM 2012 Study:
Preliminary General Presentation
MARCO FRANCESCHINI
I.R.C.C.S. SAN RAFFAELE-PISANA, ROMA
STUDY POPULATION
Spinal Cord Units/Rehabilitation Department
Abruzzo OSP. SAN RAFFAELE SULMONA (UNITA' SPINALE) Emilia-Romagna Centro di Recupero e Riabilitazione funzionale G.Verdi (UNITA' SPINALE) OSPEDALE MONTECATONE R.I. S.P.A. (UNITA' SPINALE) Friuli-Venezia Giulia IST.DI MEDICINA FISICA E RIABILITAZIONE GERVASUTTA (Medicina Fisica e Riabilitazione, Unità Spinale (US)) Lazio CENTRO PARAPLEGICI OSTIA (CENTRO SPINALE) I.R.C.C.S. S. LUCIA (Sezione Mielolesi, Unità Operativa A) OSP. C.T.O. ANDREA ALESINI (UNITA' SPINALE UNIPOLARE) Liguria OSPEDALE SANTA CORONA - PIETRA LIGURE (UNITA' SPINALE UNIPOLARE) Lombardia A.O. OSPEDALI RIUNITI - BERGAMO (MEDICINA FISICA E RIABILITAZIONE) FOND.MAUGERI-CENTRO MEDICO DI PAVIA (UNITA' SPINALE) OSP.GENERALE DI ZONA VALDUCE - COMO (MEDICINA RIABILITATIVA) OSPEDALE CA' GRANDA-NIGUARDA - MILANO (UNITA' SPINALE UNIPOLARE) OSPEDALE CIVILE G. FORNAROLI - MAGENTA (UROLOGIA E UNITA' SPINALE) OSPEDALE G.CASATI-PASSIRANA RHO (Medicina Riabilitativa) OSPEDALE MORELLI - SONDALO (UNITA' SPINALE) P.O. CENTRO TRAUMATOLOGICO ORTOPEDICO (UNITA' OPERATIVA MIELOLESI)
Marche A.O.U.OSPEDALI RIUNITI - ANCONA (SOS UNITA' SPINALE) Piemonte AOU OSP. MAGGIORE DELLA CARITA' NOVARA (RECUPERO E RIEDUCAZIONE FUNZIONALE) AZ. SS.ANTONIO E BIAGIO E C.ARRIGO - Alessandria C.T.O.-MARIA ADELAIDE (C.T.O.-MARIA ADELAIDE) Puglia AO POLICLINICO DI BARI (MEDICINA FISICA E RIABILITAZIONE) IRCSS SALVATORE MAUGERI CASSANO DELLE MURGE (MEDICINA FISICA E RIABILITAZIONE) Sicilia A.O. PER L'EMERGENZA CANNIZZARO (UNITA' SPINALE UNIPOLARE) Toscana AZ. OSPEDALIERO - UNIVERSITARIA CAREGGI (UNITA' SPINALE) Umbria AZIENDA OSPEDALIERA PERUGIA (UNITA' SPINALE) Veneto OSPEDALE CA' FONCELLO TREVISO (MEDICINA FISICA E RIABILITATIVA) OSPEDALE DON CALABRIA NEGRAR (MEDICINA FISICA E RIABILITAZIONE) OSPEDALE S. BORTOLO – VICENZA -(Medicina Fisica e Riabilitazione ) PRESIDIO OSPEDALIERO DI CAMPOSAMPIERO (Dipartimento di Riabilitazione)
STUDY POPULATION
Spinal Cord Units/Rehabilitation Department
Region N°Pt US %
Trauma
N°Read
US % Trauma
N° Total
US % Trauma
Abruzzo 9 56% 0 0% 9 56%
Emilia-Romagna 239 61% 303 74% 542 68%
Friuli-Venezia Giulia 43 37% 9 89% 52 46%
Lazio 96 36% 120 82% 216 62%
Liguria 34 71% 86 67% 120 68%
Lombardia 204 46% 375 65% 579 58%
Marche 17 82% 4 75% 21 81%
Piemonte 80 64% 144 63% 224 63%
Puglia 71 31% 25 32% 96 31%
Sicilia 34 76% 19 53% 53 68%
Toscana 58 66% 303 85% 361 82%
Umbria 23 65% 28 86% 51 77%
Veneto 101 54% 37 73% 138 59% Total 1009 53% 1453 72% 2462 64%
Gemder
Male 71% 79% 75% Age
mean (sd) 54 (19) 48 (16) 51 (17)
Preliminary Global Results
Non Traumatic Traumatic
Region N pt LoS N pt LoS
Abruzzo 4 74 5 153
Emilia-Romagna 83 94 119 140 Friuli-Venezia Giulia 22 64 10 193 Lazio 35 88 15 108 Liguria 10 125 19 145 Lombardia 98 81 73 117 Marche 2 79 12 90 Piemonte 23 145 39 167 Puglia 40 79 22 92 Sicilia 8 119 24 128 Toscana 16 103 25 97 Umbria 7 86 15 131 Veneto 41 65 47 127 Total 389 88 425 131 % non discharged 17% 21%
• 24 (86%) SCU answered a
questionnaire
• 50% located within a “DEA II
Level” hospital
• 92% functionally connected
with a DEA II hospital
• 42% located within a
specialized rehabilitation
hospital
• Type of SCU:
– 58% SU;
– 25% USU;
– 17% other rehabilitation wards;
• Setting:
– 88% cod. 28;
– 17% cod 56;
– 8% cod 75;
• Care settings:
– 100% Ordinario;
– 71% DH/MAC;
– 88% Ambulatoriale.
MAIN CHARACTERISTIS OF SPINAL CORD UNITS (self-reported)
• 100% accepts patients with tracheotomy
• 58% accepts people with complete cervical SCI C2-C3 (ventilated)
• 33% accepts patients with complete high cervical SCI only after completion of weaning
• Further services: – 100% Physiotherapy;
– 96% Occupational therapy;
– 63% Idrokinesitherapy;
– 83% Sport therapy
• 88% of pathophysiology and respiratory rehab facilities are inside the hospital;
• 96% of urodynamic facilities and neurological rehabilitation is inside the hospital;
• Sexual rehabilitation activities take place inside the hospital for about 71% (25% outside)
• 79% of Clinical Neurophysiology laboratory are inside the hospital;
MAIN CHARACTERISTIS OF SPINAL CORD UNITS self-reported (2)
2851 enrolled persons :
•1888 Traumatic SCI (TSCI)
•963 Non Traumatic SCI (NTSCI)
1009 persons enrolled post-trauma
on
First admission in Spinal Cord Unit (T1)
•539 TSCI
•470 NTSCI
815 persons
Discharged
from Spinal Cord Unit (T2)
•426 TSCI (52.3%)
•389 NTSCI (47.7%)
389 persons enrolled
on admission in
ER/Acute care (T0)
•297 TSCI
•92 NTSCI
1453 persons enrolled
on
Readmission
•1052 TSCI
•401 NTSCI
• Age of Traumatic SCI population
– Mean 48 years (SD 17)
– Median 47 years (range 3-93)
• Age of Non-Traumatic SCI population
– Mean 57 years (SD 17)
– Median 60 years (range 0-94)
• Gender
– Traumatic SCI 83% male
– Non- Traumatic SCI 60% male
NTSCI
9461
10
111
29 20
79
22 28
130
54 46
020406080
100120140
Emili
a-Rom
... Lazio
Liguria
Lom
bardia
Piem
onte
Toscana
acuti rientri
TSCI
145
35 24
9351 38
224
9858
245
90
257
050
100150200250300
Emili
a-Rom
agna
Lazio
Liguria
Lom
bardia
Piem
onte
Toscana
acuti rientri
Total
239
9634
204
80 58
303
12086
375
144
303
050
100150200250300350400
Emili
a-Rom
agna
Lazio
Liguria
Lom
bardia
Piem
onte
Toscana
acuti rientri
• The data shows different organizations in the Regions in respect to the management of people in stable clinical phase who requires more specialized interventions
• The data will be analyzed well in relation to the causes of the readmission in Rehabilitation
• The regions should also verify the appropriateness of the network at home for this people once discharged after the acute Rehabilitation phase.
Comment
• Persons with Acute Traumatic SCI
admitted in SCU:
– 539
• Discharged (T2 data) 426 (79.0%)
• T2 data not available 113 (21.0%)
• OAI (days)
– mean (sd): 30 (38)
– median (range): 18 (0-434)
• LOS (days)
– mean (sd): 130 (77)
– median (range): 120 (4-397)
TSCI Onset Admission Interval (OAI)
and Length of Stay (LoS)
Aetiology
41%
29%
13%
5%5% 4% 3%
Road Accident
Fall from heigth
Fall to the ground
Violence
Sport
Diving
Other
Road Accident Distribution
40%
24%
36%
0%
Car
Bike/Pedestrian
Motorcycle
• Suicide Attempt
– 36 (6.7%)
• Work Accident
– 60 (11.1%)
• Home Accident
– 73 (13.5%)
Neurological Level of Lesion
46%
52%
2%
Paraplegic
Tetraplegic
Uknow
ASIA admission (T1) (N=539)
A 194 36.0%
B 90 16.7%
C 130 24.1%
D 105 19.5%
E 2 0.4%
Unknown 18 3.3%
Evolution of ASIA from Admission to Discharge
Admission
Discharge
0
10
20
30
40
50
60
70
1
Delta SCIM T1-T2
SCIM mean at T1
SCIM mean at T2
SCIM median at T1
SCIM median T2
SCIM Gain mean
SCIM Gain Median
Comment
• Significant improvement both in terms
of classification ASIA both clinical
evaluation with the SCIM
• People with “ASIA A” have the greatest
difficulty in obtaining a significant
neurological improvement
Complications on Admission
35%
8%22%
12%
16%
7%
Pressure Sores
TVP/Embolism
Respiratory
Bladder
Infections
Other
Complications on Discharge
17%
7%
17%
31%
16%
12%
Pressure Sores
TVP/Embolism
Respiratory
Bladder
Infections
Other
92
136
199
164
0
20
40
60
80
100
120
140
160
180
200
1
Occurrence of Spasticity and Pain (any grade)
Spasticity at T1
Spasticity at T2
Pain at T1
Pain at T2
Destination at Discharge
72%
7%
20%1%
Home
Other Hospital
Long Term Facility
Other
Discussion – 1
• Comparison to GISEM Study (1997-99)
– The average age of people with TSCI has risen significantly
(38.5 vs 48.0 years), while it is stable in NTrSCI, so also is
stable the distribution by sex.
• This finding is probably related to changes of aetiology
– OAI has declined, but not as perhaps was expected after 15
years (36.8 vs 30.0 yrs), while the LoS is stable
Discussion – 2
• Comparison to GISEM Study (1997-99):
– Aetiology:
• Road Accident decrease significantly (53.8% vs 41.0%)
– Cycle/Pedestrian accidents enhance from 6.0% to 24%.
• Falls (from height and to the ground) differently increase
significantly (22.5% vs 42%)
• The causes of violence and suicide attempt remain limited.
– Level of lesion change in favour of people with Tetraplegia
(40% vs 52%)
Discussion – 3
• Comparison to GISEM Study (1997-99): – Increase of pressure sores at admission into rehabilitation
(27% vs 35%)
• Increase of persons with high level of lesion?
• Worsening of nursing during surgical and intensive care?
• Delayed rehabilitation intervention in the acute phase?
• Intervention is not comprehensive and continuous from the early hours of hospital admission?
• This data will have to analyse in correlation with different factors (Type of facility, level of lesion, etc.)
Discussion – 4
• Comparison to GISEM Study (1997-99):
– Reduction of people discharged to home at the end of
rehabilitative treatment (82% vs 72%)
• Increase of persons age?
• Increase of persons with high level of lesion?
GISEM Main References
• Pagliacci MC, Spizzichino L, Citterio A, Franceschini M et Al. “Spinal cord lesion management in Italy: a 2-year survey” . Spinal Cord. 2003 Nov;41(11):620-8.
• Pagliacci MC. Spizzichino L, Franceschini M et Al. “An Italian survey of traumatic spinal cord injury.” Arch Phys Med Rehabil. 2003 Sep;84(9):1266-75
• Citterio A, Franceschini M, Spizzichino L, et Al. “Nontraumatic spinal cord injury: an Italian survey". Arch Phys Med Rehabil. 2004 Sep;85(9):1483-7.
Conclusions
• It needs a strong commitment to further improve the paths of people with spinal cord injury by the administrative organization and health policy.
• It is very important to maintain a register of TSCI data collection. It is the only way to constantly monitor improvements and deteriorations of the organizational model.
• Only with this system we can inform those who manage the health care organization in Italy in order to achieve a level of excellence of TSCI care in our Country.
Si ringrazia il Ministero della Salute nello specifico
il Centro Nazionale per la Prevenzione e il Controllo delle Malattie (CCM)
per il sostegno economico fornito grazie a cui è stato
possibile organizzare questa ricerca
G R A Z I E
Dell’ A T T E N Z I O N E