Reflections on Outpatient follow-up in Spinal Cord Injury

Posted on 22nd Apr 2016

A spinal cord injury may result in nerve damage to different systems of the body, thus affecting the ability to feel, walk, pass urine, open the bowels or engage in intimate relationship.

Since their inception, spinal cord centres in the UK have been providing a comprehensive teaching on how to deal with the effects of an acute injury.  
Even after discharge from the spinal centres, patients were provided with support for life. The reasoning is that with the passage of time, the effects of the neurological damage could lead to more complications; by offering life-long monitoring spinal centres may help minimise them.

Is this system sustainable today? What are the solutions ahead?

In this section I reflect on the challenges that Spinal Centres face today and how they impact on care being provided.

The challenges

• When initially set up, Spinal Cord Injury Units in the UK have traditionally been offering lifetime follow-up for patients under their care.
• They were expected to see patients in the outpatient setting once every one or two years, depending on clinical needs.
• Patients would have renal ultrasound and abdominal xray during those visits to monitor bladder and bowels.
• Patients, who develop complications at home, could often be readmitted to deal with increased spasticity, bladder stones or stool impaction.  As the numbers grew over the years this service may have become unsustainable for a few centres for many reason.
  - Increasing number of outpatients: on average a spinal centre would now deal with about 2500 to 3000 outpatients each year.
  - Throughput of patient: A clinic manned by one person will see 6 to 8 patients in 4 hours, given the time it takes for a spinal patient to be transferred / hoisted onto a bed and examined.
  It takes 4 additional hours per clinic to deal with administrative matters (write letters to General Practitioners, refer patients to other specialists or for further investigations, like MRI).
  Basic mathematics shows us that it would take 300 to 400 ‘4 hour sessions’ to see 2500 patients each year, i.e. 10 sessions per week over 40 weeks (excluding administrative time). There is no capacity for such a high demand on the services.
  - Lack of human resources and access to specialist staff:  they represent other challenges as a result of conflicting needs within a unit. Staffs have to provide outpatient services in addition to dealing with their daily routines: visit new referrals in neighbouring hospitals ‘within 5 days of injury’, admit new patients, deal with emergencies on the ward and look after patients with complex needs.
• The outpatient assessment may not be comprehensive, as only one or two members of the multi-disciplinary team would see patients during their visit. As a result not all their problems are addressed: spasticity, bladder, bowels, sexual function, general health, breathing, change in neurology, pressure ulcers, seating and cushion, advice on wheelchairs, contractures, just to name a few issues.
• Outpatient visits may therefore represent a missed opportunity for patients, as they travel long distances at huge physical, monetary and emotional costs. As a result they may not go back home really satisfied with the outcome of the visit.

The Solutions:

• Spinal centres cannot rely on extra government resources as budgets are limited.
• They will have to redefine themselves, innovate and generate their own funds.
• Spinal Units can make money by teaching, training and increasing capacity using a ‘hub and spoke’ model.
• Spinal Centres would exert their authority as the centres of knowledge for everything regarding spinal injury care, for acute to long-term care.
• In the acute setting, spinal centres can show how patients can best be managed by spinal surgeons working alongside Consultants in Spinal Injuries and Rehabilitation, on spinal units and benefit from the multi-disciplinary expertise available within a spinal centre.
• The spinal centre could provide support to patients who cannot be admitted to a spinal centre due to bed capacity.
• In the medium and long term the spinal centre could provide teaching on many aspects of spinal injury care, especially with regards to bladder, bowels, spasticity and mobility.
• The spinal centre could organise face-to-face outreach clinics (nearer the homes of patients) in addition to virtual outpatient clinics via Telemedicine.
• Ideally outpatient clinics should be ‘one-stop clinics’ to avoid many trips back for patients. The journeys back can be time consuming and disruptive for many.
• I foresee an important role for Telemedicine, as I do not consider that its huge potential has been tapped.
  
  
  

Conclusion

Offering long-term follow-up of patients represents an increasing challenge for spinal centres. Could digital technology help to generate funds, increase ‘capacity’ to treat and follow-up patients and participate in training local hospitals to raise standards of care in spinal cord injury?