The CCM 2012 Study:

Preliminary General Presentation

MARCO FRANCESCHINI

I.R.C.C.S. SAN RAFFAELE-PISANA, ROMA

marco.franceschini@sanraffaele.it

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