THE INTERACTION BETWEEN ACUTE

CARE AND REHABILITATION FOR NEW

TRAUMATIC SCI
The Jamaican Model

Dr. Rory Dixon MB.,BS.,DM (Ortho)/ Dr. Reddy Yerreddu MB., BS.
Sir John Golding Rehabilitation Centre
Kingston

ACKNOWLEDGMENTS
Dr. Ian Neil, Consultant Orthopaedic Surgeon,
Kingston Public Hospital (Supplied data from the 2009
paper Mortality Among Spine Injury Patients in a
Tertiary Hospital in Jamaica)
Records office and medical staff, Sir John Golding
Rehabilitation Centre

MAJOR WEAKNESSES

Record storage and quality of recording

questionable and not standardized e.g. (ICD
system of disease classification not used,
uncertainties with diagnoses and definitions, field
workers not trained
No formal functional outcome system is presently
in place
No national spinal registry in place so only cases
that presented to the Rehab Hospital were
represented

BACKGROUND

Population 2009:
3 million

One Rehab Centre

(30 adult beds)

Large number of
trauma cases

Population 1954:
1.6million
One Rehab Centre
located in Kingston
Up to 1980s mostly
Polio and non
traumatic disorders

Sir John Golding Rehabilitation Center (SJGR

Est. 1954
The SJGRC is the only rehab centre
of its kind in the English speaking
Caribbean.

REFERRALS TO SJGRC

SJGRC
KPH
UHWI

CRH

STH

MPH

OTHERS

KINGSTON PUBLIC HOSPITAL

located in inner city,

kingston
455 beds (505)
80 orthopaedic beds
3 surgeons
Major referral centre
for spine trauma
pts.

REFERRAL PROCESS

Post surgery/stabilization patients are

referred to the Rehab Centre (SJGRC)
There is one screening clinic at SJGRC held
each ordinary Tuesday
Patients are encouraged to have a responsible
caregiver/relative accompany them
Clinical and social assessment are performed
Admission then follows after fulfilment of
admission criteria and availability of beds
Patients are placed on the waiting list if
immediate admission is not possible

REFERRAL PROCESS

The Rehab Process does not begin until

patients are admitted to SJGRC
Patients awaiting admission usually receive
chest physiotherapy and some limb therapy
Patients requiring ventilatory support remain
in the acute care centre until stable
Patients of all AIS grades are usually
discharged home from the acute care centre
if transfer to SJGRC is not immediately
possible

ACUTE SPINE TRAUMA

CASES

Patients admitted to KPH ortho

1/1/2005-31/12/2008, mechanical spine
disorder with or without neurological
deficit).
This provided data for the acute spinal
cord injured patients

( KPH ACUTE CARE 2005Mechanism

2008)

Total

Dead

Alive

Mortality
risk

224

38

186

17.0%

MVA

104

12

92

11.5%

Falls

87

21

66

24.1%

Other

33

28

15.2%

224

38

186

17%

Trauma

Total

ACUTE CARE (2005 2008)

Variables

Male(%)

Female(%)

Total(%)

Sex

75.7

24.3

100

Type of spinal cord

injury
None
Brown-Sequard
Cauda Equina
Paraplegia
Central cord syndrome
Tetraplegia

25.1
0.0
8.7
21.7
10.4
34.2

30.7
2.7
8.0
30.7
9.3
18.7

26.5
0.7
8.5
23.9
10.1
30.4

Level of spinal injury

L2-S1
T2-L1
C6-T1
C3-5
C1-2
Other

10.6
22.9
11.0
36.2
0.9
18.4

15.7
32.9
2.9
24.3
0.0
24.3

11.8
25.4
9.0
33.3
0.7
19.8

Variables Male (%)

Female(%)

Total (%)

29.4
16.5
14.2
18.8
21.1

21.4
15.7
10.0
22.9
30.0

27.4
16.3
13.2
19.8
23.3

47.1
20.0
13.5
19.4

43.8
16.7
20.8
18.8

46.3
19.3
15.1
19.3

Alive 82.0
Dead 18.0

82.7
17.3

82.1
17.9

Severity of Injury
ASIA D
ASIA C
ASIA B
ASIA A
Other
Complications
No complication
One complication
Two complication
> three
complications
Disposal

Mean age (yrs)

53.5 (males)

43.5 (females)

Mean time to
specialist(days)#

5.7 days

6.9 days

Mean time to
surgery (days)

14.1

20.2

Mean LOHS
(days)
Surgery

30.4

33.1

Yes

19

168

No

36

85

0-14 days

30.6%

69.4%

15-28 days

9.4%

90.6%

29-90 days

10.5%

89.5%

>90 days

30%

70%

P= 0.001
Length of
hospital stay
(%)

COMPLICATIONS OF ACUTE SCI

PATIENTS
Complications

Male

Female

Respiratory

26

22

Septicaemia

UTI

15

30

Decubitus Ulcers

10

17

Anaemia

13

Others

18

47

COMPLICATIONS OF ACUTE SCI

PATIENTS
Table
: Causes of Death Among Spine Injured
Patients
Respiratory

17 (30.9%)

Sepsis/septicaemia

18 (32.7%)

Pulmonary Embolism

11(20.0%)

Cardiac

6 (10.9%)

Other*

3 (5.5%)

Other causes

Perforated gastric ulcer, Massive upper GI bleed,

Fluid and electrolyte imbalance

ADMISSIONS TO REHAB CENTRE (SJGRC)

Mechanism
2004

2005

2011

2012

39

42

48

30

MVA

16

11

11

Falls

10

GSI

15

20

31

12

Stab

Tumour

10

Degenerative/
other

CVA

Total

48

50

60

49

Trauma

ADMISSIONS TO SJGRC

Cord
Syndrome

2004

2005

2011

2012

Tetraplegia

19

19

19

14

Paraplegia

27

23

37

22

Time to Rehab
admission from
injury
(Days)

2011

2012

Total Referrals Post Surgery

from KPH (52) KPH (26)

12
20

13
19

11

20

17

28

23

30 90 days

12

21

10

90 180 days
> 180 days

20
17

26
13

28

10

16

13

30
30 90
90

16

Length of
rehab
hospital
stay

Complications
Decubitus
ulcers

11 (42%)

DISCHARGE PLANNING

Begins within two weeks of each

admission when Goal Sheet meeting is
held

Is reviewed weekly and may be

affected by special
needs/circumstances

WHEELCHAIR
ACQUISITION/USE

No precise data
Usually occurs after admission to rehab
centre (after control of orthostatic
hypotension)
Paraplegics with delayed admission
may come with own chair
Acquisition highly dependent on donor
availability (Food for the Poor)

OUTCOMES

No formal outcome scores utilized

Follow up is limited as patients don't
return often for review and community
based follow up is fragmented
No 1 year rehab mortality available
A look at social outcomes was done in
2012

One hundred and four SCI patients who had

been discharged from the Sir John Golding
Rehabilitation Centre between 2010 and the
first six months of 2012 were identified.

Contact was made with these persons and an

interview conducted by telephone.

LIFE STATUS

Number alive: 74% n=77

Number deceased: 15% n=16
Number we lost contact with: 11% n=11

Under 20: 13% n=13

41-60: 30% n=31

20-40: 45% n=47

Over 60: 13% n=13

ASSISTANCE AT HOME
60%
50%
40%
30%
20%

ASSISTANCE AT HOME

10%
0%

Live-in Relative: 81% n=62 Live out relative: 4% n=3

Live in Friend: 4% n=3
Live-out Friend: 12% n=9

Caregiver: 58% n=7

Health Centre: 33% n=4

Visiting Nurse: 8% n=1

EARN AN INCOME: 10% n=8

DO NOT EARN AN INCOME: 90% n=69

Never: 25% n=19

Hardly: 44% n=34

Once/month: 9% n=7

Fortnightly: 6% n=5

Weekly: 10% n=8

Daily: 5% n=4

DISCUSSION (ACUTE SCI PATIENTS)

Mortality risk high: 23.8 (17.9)

Complication rate high (46.4%)
Complication strongly associated with
death
Level and severity of injury also
strongly associated.
Complications strongly related to LOHS
and therefore cost of care

ARE WE DOING ENOUGH??

Not enough rehab/physiotherapy care

in the acute centre
Delays in acute surgery are due mainly
to limited theatre space
Not enough rehab beds (waiting list of
more than 30 patients)
Less than 30% of post SCI injured
patients get admitted for rehab!
42% of post surgery cases 2011/2012
had bed sores!

THANK YOU