Many clinicians believe that optimal treatment of SCI lies in the development of special centers or systems geographically dispersed according to population density and other factors, including health care resources. This philosophy is not based on strong scientific data, although several such regional systems have reported improvement in morbidity, mortality, and patient care costs compared to so-called nonsystems in their areas. However, these studies have not been well controlled. We thus hesitate to argue for the systems approach based on these studies and would rather base it on our personal experience. The key to system care is not necessarily the skill of a surgeon or the use of experimental drugs. It lies in the development of a multidisciplinary team of physicians, nurses, and allied health professionals committed to and specializing in the treatment of this disease. This team provides a continuity of care to SCI victims beginning at the accident scene and extending through their acute triage, intensive care, and rehabilitation inpatient programs, and beyond to their lifelong care. This last phase can begin at home or in a transitional living facility or communal living facility and should include semiannual outpatient visits to the SCT clinic. The establishment and identity of this multidisciplinary team provides the SCI victim with a group of professionals committed to all aspects of his disability. The second important factor supporting the use of the systems approach is volume experience. In Florida, for example, the average hospital admits 1 or 2 SCI victims a year compared to our regional system, which admits over 150 new injuries each year. Therefore, just from the numbers of victims treated, large SCI centers would develop experience that could be applied toward minimizing the morbidity and mortality associated with these complex injuries. Another advantage of a systems approach is the elimination of needless duplication of costly resources, including, in the acute phase, the Roto Rest treatment tables used in intensive care management, and in the rehabilitation phase, recreational therapy programs. These cannot be reasonably offered in a hospital setting where only 1 or 2 such patients are seen annually. Each SCI victim has a financial impact on society estimated to be greater than one million dollars. This cost translates into a multibillion dollar annual economic impact, which, along with high morbidity and mortality, has led SCI to be federally designated as a catastrophic disease. A systems approach to SCI may be divided into the following major phases of care: (1) prevention, (2) prehospital management, (3) acute care, (4) rehabilitation, and (5) lifelong follow-up. The major causes of death in the prehospital phase are aspiration and shock. The major causes of death in the acute inpatient phase are cardiopulmonary complications, and in the rehabilitation and life-long follow-up phases, mortality is most often associated with renal failure and decubitus ulcers.
ASJC Scopus subject areas
- Clinical Neurology