Déclaration de conflits d’intérêt réels ou potentiels Nom du conférencier/modérateur: Cynthia Thompson

Je n’ai aucun conflit d’intérêt réels ou potentiel en lien avec le contenu de cette présentation

Factors predicting the delay between trauma and surgery in a

prospective cohort admitted with a traumatic spinal cord injury

Cynthia Thompson, Debbie E. Feldman,

Jean-Marc Mac-Thiong

Introduction

Early surgery for traumatic spinal cord injury (t-SCI) Improved neurological recovery

Less complications

Decreased costs

Shorter length of hospital stay

Early surgery typically <24hrs of injury

Early surgery typically <24hrs of injury

Recent studies with surgery <8hrs or <4hrs <8hrs vs 8-24hrs (Jug et al., J Neurotrauma 2015)

26/48 (55%) with cervical SCI had surgery <8hrs

Neurological recovery 6 months post-SCI if surgery <8hrs

<4hrs vs 4-24hrs (Biglari et al., Ther Clin Risk Manag 2016)

29/51 (57%) with surgery <4hrs

No benefit for surgery <4hrs vs surgery 4-24hrs

Early surgery <24hrs in t-SCI

1994-1995 (Tator et al., J Neurosurg 1999)

585 patients from 36 centers in North America

23.5% with early surgery <24hrs

34.8% with surgery 24hrs – 96hrs

41.7% with surgery >5 days

Early surgery <24hrs in t-SCI

2005-2014 (Dvorak et al., J Neurotrauma 2015)

888 patients from 31 Canadian centers

40% with early surgery <24hrs

60% with surgery between 24hrs up to 7 days

Trend for early surgery <24hrs 100%

0

10

20

30

40

50

60

1994-1995 2000-2011 2005-2014 2011-2012 2011-2016 2015-2016

24% 20% 40% 45% 56% 59%

Trend for early surgery <24hrs 100%

0

10

20

30

40

50

60

1994-1995 2000-2011 2005-2014 2011-2012 2011-2016 2015-2016

24% 20% 40% 45% 56% 59%

2009-2011 (Wilson et al., J Neurosurg 2016)

369 patients

53.3% with surgery <24hrs

46.6% with surgery >24hrs

Main factors predicting late surgery # of stops at intermediate health centers before SCI

center admission

Age

Cervical injury

No hospital-specific wait times considered

Factors of surgical delay (≥24hrs)

Factors of surgical delay (≥24hrs)

Furlan et al., J Neurotrauma 2013 Main factors Waiting for assessment by spine surgeon Waiting for surgical decision

Limitations Only cervical SCI

No consideration of OR wait

No consideration of level of SCI, comorbidities, trauma severity

Objective

Investigate the factors contributing to surgical delay >24hrs for t-SCI Identify opportunities for reducing surgical

delay Consideration of patient-related (non-

modifiable) and healthcare-related (modifiable) factors

M&M – Cohort of t-SCI

Prospective cohort of 144 t-SCI patients

Enrolled between 2010-2015

Surgery at single Level I trauma center

Traumatic SCI C2 to L1-L2

Exclusion of central cord syndrome

M&M – Specialized SCI center

SCI referral center ≈5M population

• ER physicians • Trauma/ICU team ER

• Surgical team • OR coordinator OR

• Trauma/ICU team • Surgical team ICU

• Surgical team • Rehabilitation team WARD

Trauma site

Functional Rehab

Community Hospital

M&M – Data collection

Patient-related factors Age

Sex

Level of SCI (cervical vs. thoracic/lumbar)

Severity of SCI (AIS A vs. B/C/D)

Charlson comorbidity index (CCI)

Injury severity score (ISS)

M&M – Data collection

HEALTHCARE-RELATED FACTORS – TIME DELAYS

I. Trauma – SCI center (HSCM)

Direct transfer A) Trauma site – SCI-center (HSCM)

Transfer to other hospital

B) Trauma – Community hospital C) Community hospital – SCI center (HSCM)

II. At SCI center (HSCM)

D) ER of SCI center – 1st MD assessment in ER E) 1st MD assessment in ER – Finalization of surgical plan (surgical request received in OR) F) Finalization of surgical plan – Skin incision

III. Trauma – Surgery A+D+E+F (Direct transfer) B+C+D+E+F (Prior transfer to other hospital)

M&M – Data collection

Other healthcare-related factors Distance between community hospital and SCI

center

Day of arrival at SCI center (weekday vs. WE)

Day of finalization of surgical plan (weekday vs. WE)

Specialty of MD performing 1st assessment (ER vs. Trauma vs. Spine)

M&M – Data analysis

Surgical delay – Early vs. Late Early surgery group <24hrs after trauma

Late surgery group ≥24hrs after trauma

Statistical analysis Continuous data: Mann-Whitney U tests

Categorical data: Chi-square tests

M&M – Data analysis

Multivariate logistic regression Dependent variable: Early vs. Late surgery

Independent variables Patient-related factors of delay

Healthcare-related factors of delay

Results – Descriptive

Results – Time delays

Results – Time delays

Results – Complete vs. Incomplete SCI

• No difference for cervical vs. thoracic-lumbar SCI

Results – Complete vs. Incomplete SCI

• No difference for cervical vs. thoracic-lumbar SCI

Results – Other healthcare factors

Day of arrival at SCI center not significant

Day of finalization of surgical plan WE: 75% had early surgery Weekday: 50% had early surgery

MD performing 1st assessment – not significant

Results – Other healthcare factors

Similar distance between community hospital and SCI center Early group: 83 ± 98 km (40:30-96)

Late group: 67 ± 128 km (67:34-145)

Results – Multivariate analysis

No significant patient-related factor

Discussion

Main factors of surgical delay Modifiable healthcare-related Surgical planning

Waiting for OR Transfer from community hospital

to SCI center

Predictor 1: Delay for surgical planning

Furlan et al.

Our study

Early surgery: 4hrs

Late surgery: 14hrs

Early surgery: 6hrs

Late surgery: 23hrs

Had the surgical planning been completed 9hrs faster in late surgery patients –

17 additional pts with surgery <24hrs

12% increase in early surgery rate <24hrs

Delay for surgical planning

Main contributor of trauma-surgery delay 56% total delay when early surgery

70% total delay when late surgery

Potential causes Treatment of associated injuries (but similar ISS...)

Imaging

Time/day of the week (earlier planning on WE)

Surgeon-related

Need for dedicated on-call surgical team?

Predictor 2: Delay from OR availability

Furlan et al.; Noonan et al.

Our study

Not considered

Early surgery vs Late surgery: 3hrs shorter

waiting time for OR

If we consider a 3-hrs shorter delay for OR availability in late surgery patients –

4 additional pts with surgery <24hrs

3% increase in early surgery rate <24hrs

Delay from OR availability

Need for adequate prioritization Transfer knowledge to administrators Consensus among all surgeons

Surgeon availability? Earlier surgery on WE

Predictor 3: Time of transfer CH to HSCM

Noonan et al.

Our study

Direct transport when trauma site within 20-min drive of SCI center – results in 4hrs shorter surgical delay

54 pts to CH within 40km of HSCM – increased rate of direct admission 10% to 42% if direct admission

If we consider the surgical delay to be 4hrs shorter in those 54 pts – 5 would have had surgery <24hrs if direct admission to HSCM

4% increase in early surgery rate <24hrs

Transfer delays from community hospitals to SCI center

Improve awareness from community hospitals Transfer delay increased for incomplete patients

Teaching to community hospitals Knowledge transfer about need for early surgery

Development of E-learning tutorial for acute SCI care

Direct transfer to SCI center whenever possible Currently only 10% direct transfer

38% transferred to community hospital within 40km of SCI center (54/144 pts)

Acknowledgments