Focus Issue

The ACT Focus Issue is a collaboration of more than 50 researchers and clinicians across Canada. Published in the prestigious Journal of Neurotrauma, the Focus Issue contains 13 peer-reviewed articles based on the ACT project and uses clinical and demographic data collected from individuals who participate in the Rick Hansen SCI Registry. All articles are freely available on the journal's website.

This work is an important theme in RHI's Care Program which aims to provide equitable care for all Canadians with SCI.

Below are some key questions the Focus Issue addresses (click on the questions to find the answer):

What level of care can Canadians with traumatic SCI expect to receive at SCI-specialized hospitals?

What level of care can Canadians with traumatic SCI expect to receive at SCI-specialized hospitals?

Read the full article: Noonan et al. 2017

Based on a review of 26 acute and rehabilitation hospitals in 8 Canadian provinces, results revealed similarities in the basic structure and provision of general services (e.g. having spine surgeon on call 24/7 and physiatry consultation in acute centres), but also some differences in the degree of specialization of care for the traumatic SCI patient population (e.g. rehabilitation admission criteria). Future research is needed to examine the impact of specialized care for both the patient and healthcare system.

Does it matter where you get injured? How does it impact the care you receive?

Does it matter where you get injured? How does it impact the care you receive?

Read the full article: Cheng et al. 2017

 

Yes, the closer you are to a specialized acute hospital when injured, the more likely the ambulance will send you directly to that hospital to receive specialized care sooner. Patients who are older and injured slightly farther away, are more likely to be sent to a non-specialized hospital before being transferred to a specialized hospital. These individuals don't get specialized care until an average of 7 hours later. This is important as quick access to specialized care is key to better recovery. This study supports further research into factors that influence medical response protocols in the hours following injury.

 

Geomapping of traumatic spinal cord injury admitted to Rick Hansen SCI Registry acute facilities in 2010-2013

 

Is the reporting of hospitalization (length of stay (LOS)) the same across Canada?

Is the reporting of hospitalization (length of stay (LOS)) the same across Canada?

Read the full article: Burns et al. 2017

No, surprisingly, there is considerable variation in the definitions and methods used to determine LOS following SCI in different jurisdictions. There are also many factors that influence how long a patient will stay in a hospital after injury. To optimize healthcare system efficiencies, future research is required to identify and improve understanding of what factors contribute to LOS. Work in this area will be facilitated by the adoption of common terminology and definitions, as well as the use of simulations and modeling.

Does specialized rehabilitation improve the chances of returning home after traumatic SCI?

Does specialized rehabilitation improve the chances of returning home after traumatic SCI?

Read the full article: Cheng et al. 2017

Yes, our data shows that people who receive specialized rehabilitation as part of inpatient treatment are six times more likely to return home after hospitalization. Those who do not get specialized rehabilitation are more likely to live in a nursing home or places other than home after the injury. Many other factors can influence whether people return home after SCI, and these factors require further investigation.

What if patients with SCI receive the same amount of inpatient rehabilitation therapy but in a shorter time?

What if patients with SCI receive the same amount of inpatient rehabilitation therapy but in a shorter time?

Read the full article: Truchon et al. 2017

In a hypothetical situation, patients recover their motor function faster and finish their rehabilitation program sooner if the therapy intensity is increased. This also implies that there is potential for reduced resource utilization and increased cost savings. The results highlight the importance of monitoring patients' recovery progress and the need for different strategies for patients who are not progressing through standard therapy.

How does living in rural setting compare to urban settings after SCI?

How does living in rural setting compare to urban settings after SCI?

Read the full article: Glennie et al. 2017

Based on data from one province (BC) so far, our results suggest that people living in rural and urban settings face similar challenges in terms of accessibility and health after SCI. The results also revealed that individuals living in an urban setting were more likely to report depression. Future research should expand to other provinces for their rural and urban trends.

How can secondary complications after SCI be mitigated?

How can secondary complications after SCI be mitigated?

Read the full article: Marion et al. 2017

We found that certain patients are more likely to develop secondary complications after SCI. These patients are often older, are more severely injured, have psychiatric conditions and issues with substance abuse or withdrawal. More research is needed to validate these results, but by knowing who are more at risk in developing secondary complications after SCI, we can proactively pay closer attention to these patients and prevent secondary complications from developing or worsening.

How costly are hospital-acquired pressure injuries (PI) and urinary tract infections (UTI)?

How costly are hospital-acquired pressure injuries (PI) and urinary tract infections (UTI)?

Read the full article: White et al. 2017

PI and UTI are two of the more common secondary complications that can occur within the days and weeks after a SCI. Even a relatively minor UTI or PI added approximately $8,000 and $19,000 (2013 CAD) respectively, to the direct cost of acute SCI admission. For health economists and researchers, this information will facilitate comparative economic analyses and decision analytic modeling in SCI to help make healthcare decisions informed by evidence.

What financial resources are required for future traumatic SCI care needs?

What financial resources are required for future traumatic SCI care needs?

Read the full article: Ahn et al. 2017

Our general population is aging and people who get injured are also getting older. The number of people age 60 and older getting injured will double, costing the healthcare system an additional of $16.4 million (CAD) by 2032 due to the complex medical conditions with advancing age. Prevention and awareness will be key to battle the imminent increase in traumatic SCI.

How can SCI care be improved?

How can SCI care be improved?

Read the full article: Dvorak et al. 2017

Research has come a long way in improving SCI care but knowledge gaps still exist. Gaps include lack of accurate information on injury severity, protocols and costs, and lack of connection throughout the SCI care continuum (prehospital, acute, rehab, and community), which prevents a comprehensive understanding of healthcare system performance. Addressing these gaps will further improve standards of care. Some recommendations to reduce these gaps are to standardize data element collection and facilitate database linkages; validate and adopt more outcome measures for SCI and; increase opportunities for collaboration with stakeholders from diverse backgrounds.

What can we, the Canadian SCI Network, do to enhance the quality of traumatic SCI care?

What can we, the Canadian SCI Network, do to enhance the quality of traumatic SCI care?

Read the full article: Fehlings et al. 2017

There is national consensus from the Canadian SCI Network to collect national, system level indicators to monitor performance of healthcare system for SCI care. Collecting indicators (e.g. time from injury to rehabilitation admission, meaningful community participation) can help establish a baseline to measure improvement and evaluate the access and timing of care for people with traumatic SCI.

Qmentum Accreditation

What is Accreditation Canada's Qmentum Program?

Most hospitals and inpatient facilities in Canada participate in accreditation using the Accreditation Canada Qmentum Program. The Qmentum Accreditation Program is designed to focus on quality and safety throughout all aspects of an organization’s services—from governance and leadership to direct care and infrastructure—to benefit patients, clients, residents, staff and volunteers. Following a site visit, an organization may be awarded an accreditation designation of “accredited”, “accredited with commendation”, or “accredited with exemplary status” for the next four years.

Qmentum provides a wide variety of service excellence standards that describe best practices at the point of care in a multitude of different services, settings and populations. The standards are kept current thanks to regular revisions through national consultation with field experts. The latest versions of the standards, which will apply to site visits starting in 2015, were released in January 2014.

To assess quality and compliance with the standards, Accreditation Canada surveyors observe day to day processes through a number of tracers. For example, in an Episode of Care tracer, surveyors follow the path of a patient through its interactions with a particular team or service, from first point of contact to end of service. The tracer is an opportunity for the surveyor to view services through the eyes of the patients, focusing on their experience with transitions of care, effective information transfer, continuity of care, efficient flow, and patient/family involvement.

The Acute and Rehabilitation SCI Standards of Care, developed through a partnership between the RHI and Accreditation Canada, are an example of service excellence standards that are part of the Qmentum Program. The intent of the standards was to provide content that is tailored to reflect the unique needs and journeys of care of persons with SCI and to incorporate current evidence-informed best practice in SCI care. This specialized content will help centres better pinpoint where to focus their efforts to advance practice, with an added richness when compared to the more generic service standards.

Learn more about the Acute and Rehab SCI Standards.

Measuring improvement

The reporting of indicators has not traditionally been a part of the Qmentum accreditation program: at this time it is not required to submit indicator data to Accreditation Canada to be accredited under Qmentum. However, centres do need to successfully demonstrate that they have robust processes around measuring for improvement.

This content has been significantly strengthened in the latest version of service excellence standards released in January 2014. Therefore, for site visits starting in 2015, the criteria language now requires organizations to provide more specific detail around how they select meaningful indicators of both process and outcome, how they are measured over time, how they benchmark against peers, and more importantly, how they use the data to drive improvement.

A nationally coordinated strategy for common key performance indicators would not only help each centre to demonstrate compliance with the standards around measurement for improvement, but it would also represent a Leading Practice (a Leading Practice is an innovative example of leadership and service delivery that has been recognized by Accreditation Canada). This will establish the SCI community of care as leaders and innovators amongst other program areas that have not yet developed this level of robustness for measuring improvement.

How is this related to the National Action Plan?

During the ACT workshop, the Accreditation Canada Trauma Distinction Program indicators were proposed for measuring the SCI system of care (pre-hospital through to the community) as part of the ACT data collection process in the National Action Plan. Collection of indicators could help facilities meet the requirements for successfully demonstrating that facilities have robust processes around measuring for improvement (see above).

For more information on the Qmentum program or the Acute and Rehabilitation SCI Standards of Care, please visit Qmentum Accreditation Program on the Accreditation Canada website or visit RHI's clinical resource site, SCI², for the standards (login required), tools and resources on the SCI Standards in Acute and Rehab Care.

Trauma Distinction Program

What is the Trauma Distinction Program?

Trauma Distinction Program is a service that Accreditation Canada offers, and that has inspired the content of the Access to Care and Timing (ACT) Workshop. Distinction designation is on a separate, independent cycle from Qmentum accreditation: it is every two years, with different deliverables and milestones. Rather than designating a site as meeting standards of best practice, this designation is of a centre of excellence, an innovator and a leader in the field.

Distinction is awarded for an area of specialized care, rather than to the entire organization like Qmentum accreditation. Currently, Accreditation Canada has a distinction program for stroke care and is also working to release a Trauma distinction program in collaboration with the Trauma Association of Canada, which is targeted for September 2014.

What is particularly exciting about the Trauma distinction program is that it will focus on trauma care throughout the continuum, as an integrated network, effectively following the entire journey of trauma patients, from pre-hospital care, to emergency care, critical care, acute and sub-acute care, and through to rehabilitation and reintegration into the community. Access and flow through all of these transitions is an integral component of understanding and evaluating the patient journey to recognize true excellence and innovation.

Indicator collection is one of the core elements of the distinction program: if an organization chooses to apply for trauma distinction, they will have to demonstrate that they collect the data on an ongoing basis, and that they meet the thresholds, or have initiatives in place to work on meeting the thresholds, for each indicator as defined by Accreditation Canada for their integrated trauma system.

How is this related to the National Action Plan?

The goal of the ACT Workshop was to adapt a number of proposed draft Trauma distinction indicators with revisions to address the particular lens of the SCI population. They will provide a starting point to craft a national strategy to “measure for improvement” that will help better describe and improve the journey of care for persons with SCI across Canada.

For more information on the Trauma Distinction Program, please visit the Accreditation Canada website: accreditation.ca/distinction

Access to Care and Timing

Providing expert and timely specialized care results in better patient outcomes, but knowing how to make this a reality remains a constant challenge in health care management.

This is why RHI embarked on the Access to Care and Timing (ACT) project, which is a national, multi-centre research study describing the processes of health care delivery for persons sustaining a traumatic spinal cord injury (tSCI) in Canada. The investigators on this project include Drs. Marcel Dvorak (Vancouver General Hospital), Michael Fehlings (Toronto Western Hospital), Anthony Burns (Toronto Rehabilitation Institute), Derek Atkins (UBC Sauder School of Business) and Vanessa Noonan (RHI).

The first phase of the ACT project produced a computer simulation model of the national tSCI continuum of care using information related to patient flow, resources and processes of care as well as data from Rick Hansen Spinal Cord Injury Registry sites across Canada. The ACT model is a tool designed to inform clinical and administrative decision making that optimizes patient outcomes for persons sustaining a tSCI. Through the development of the ACT model, we obtained a national perspective of tSCI care and insight into important similarities and differences, trends over time and opportunities to optimize care. In addition, we identified important gaps in the measurement and reporting of patient flow throughout the continuum of care for persons sustaining a tSCI, which led to the development of some proposed recommendations to enhance existing data sources.

For more information about ACT and its related initiatives, please peruse the links on the right hand column.

ACT Focus Issue

The ACT Focus Issue is a collaboration of more than 50 researchers and clinicians across Canada. Published in the prestigious Journal of Neurotrauma, the Focus Issue contains 13 peer-reviewed articles based on the ACT project.

Read the key questions and answers the ACT Focus Issue addresses.

National Action Plan

Developing a national action plan to improve patient flow, access to services, and monitor health system performance in spinal cord injury care

To accelerate the translation of knowledge obtained through the ACT project into improved patient outcomes and care, RHI, in partnership with the Canadian Institutes for Health Research (CIHR), the Ontario Neurotrauma Foundation (ONF) and the Ontario Spinal Cord Injury Research Network (OSCIRN) hosted a one-day workshop on April 25, 2014 in Toronto, Ontario. With over 85 participants from across Canada, the workshop brought together multiple stakeholders including persons with SCI, clinicians, administrators, policy-makers, researchers, community partners, health economists, SCI-affiliated organizations and national organizations to discuss the development of a national action plan to improve patient flow, access to services and monitor health system performance in SCI care.

The objectives of the workshop were to:

> Share lessons learned from the ACT project, "Time is Spine", benchmarking in Quebec centres of expertise, and SCI Ontario Client Services in the areas of patient flow, access to services, metrics and their impact on patient and system outcomes;

> Identify ways for the ACT model, RHSCIR and other data sources to compare (benchmark) and optimize SCI patient flow;

> Discuss the adoption and operationalization of indicators related to patient flow and access to services through the SCI continuum;

> Identify key partners and create a national working group for the implementation of the national action plan.

Although there are a number of initiatives to advance SCI care at a system level (e.g. ACT, SCI Ontario regional services coordination), fragmentation still exists and work is needed to ensure all Canadians with SCI receive optimal care. The major take home message from this workshop is the need to look at SCI care in Canada from a system point of view. To improve overall care for persons with tSCI, it is not sufficient to view each phase of care as a separate entity. Accurately measuring performance across the continuum of care and determining the impact on short-term and long-term outcomes will help to drive policy and/or practice change.

Incorporating existing standards of data collection

During the workshop, the Accreditation Canada Trauma Distinction Program indicators were proposed for measuring the SCI system of care (pre-hospital through to the community). These indicators were selected since they monitor flow at a system level and could build from the extensive work done to date in trauma (Santana & Stelfox, 2014; Stelfox et al., 2013), as tSCI is a "special population". Following the workshop, the national working group (see more on this below) will revisit the proposed indicators to see if all indicators are still relevant and appropriate to include in the ACT project.

Collection of indicators could help facilities meet the requirements for acute and rehabilitation SCI designation through Accreditation Canada's Qmentum Program.

Developing a National Action Plan

The diverse perspectives and opinions of the workshop participants led to rich discussions and provided valuable insight on how to advance SCI care. It also generated a long list of recommendations to move SCI care in Canada forward. Immediate next steps following the workshop is the development of a National Action Plan that will inform decision-making and optimize SCI patient flow. This National Action Plan will be guided by a National Working Group which will act as a steering committee to move the National Action Plan forward in efforts to improve the efficiency, efficacy and effectiveness of care along the SCI continuum. Outcomes from the ACT Workshop and the National Working Group will also help to inform a number of manuscripts that will be published as part of a focus issue devoted to the topic of optimizing care for tSCI.

The vision, objectives and scope of the National Action Plan is:

> Vision:  To optimize patient flow and access to services throughout the SCI continuum.

> Objectives  To measure national health system performance and to monitor patient flow across the SCI continuum with appropriate indicators.

> Scope:  Adoption and operationalization of selected indicators at pilot sites in the first year.

Membership of the National Working Group will consist of representatives from a number of stakeholders including, but not limited to:

> Consumers/persons with SCI

> Clinicians from all phases of SCI continuum

> Researchers

> SCI community organizations (e.g. SCI Canada and provincial affiliations and chapters)

> SCI-affiliated organizations (e.g. ONF, RHI)

> Database & registry holders (e.g. Canadian Institute for Health Information)

> Administrators & policy-makers

> Trauma partners

> Evaluation bodies

> Accreditation bodies

> Health economists

Funding and support for this workshop provided by: Canadian Institutes of Health Research, Ontario Spinal Cord Injury Research Network, Ontario Neurotrauma Foundation and the Rick Hansen Institute