Toward a System That Ensures Quality Care for Patients With Spinal Cord Injuries
With a financial penalty from the Centers for Medicare and Medicaid Services (CMS) associated with an above-average rate of catheter-associated urinary tract infections (CAUTIs), hospitals around the country have focused their attention on reductions in this core measure, one of many created by the Centers for Disease Control and Prevention and the National Quality Forum – and enforced by CMS.
The best way to reduce CAUTIs in non-paralyzed patients is by removing the catheter. Hospitals and other care facilities around the country have lowered their CAUTI rates by paying closer attention to whether patients actually need a Foley catheter. If a patient is in a nursing home and the catheter stays in only because staff members are too busy to help the patient to the bathroom, that’s bad. But in the case of spinal cord injury patients, the bladder works differently.
Most individuals with SCI suffer from neurogenic bladder, which affects the ability to voluntarily store urine and empty the bladder. Bladder function is managed either by indwelling catheters or by intermittent catheterization. Despite advances in bladder and medical management strategies, urinary complications and autonomic dysreflexia represent a major cause of morbidity and mortality among SCI patients. Premature catheter removal, when combined with poorly implemented intermittent catheterization, can have disastrous consequences.
Staff members in most acute care hospitals are not well versed in bladder management in patients with SCI. When they remove the indwelling catheter, they often fail to appropriately implement alternatives. In this situation it is safer to leave the catheter in place. The potential complications of a poorly managed bladder in a patient with SCI can be far worse than those of a CAUTI.
The CDC/NQF measure was intended to ensure hospital accountability for high rates of CAUTIs and reduce their prevalence. In the SCI population, this measure does not have its intended effect and is a clear and concrete example of the discrepancy between quality health care for most patients versus a small subset of the population – those with SCI.
To protect our patients, frontline providers who are experts in the field of spinal cord injury must speak up in a unified effort to create consensus about what constitutes quality care for patients with SCI, with an eye toward advancing policymaking at the national level. Many of our guidelines are in need of updates. Paralyzed Veterans of America, which, over the course of a decade, coordinated the original efforts to establish clinical practice guidelines for medical care of people with SCI, has renewed its efforts to update these guidelines, some of which are 10 to 20 years old.
Clinicians in the inpatient rehabilitation setting follow these guidelines well, but in general, they are not adhered to in other settings, including acute care, long-term acute care and skill nursing facilities. As rehabilitation professionals we have the opportunity to do our patients an enormous service by participating in the renewed effort to define quality care for spinal cord injury.
Many clinicians among us are asking if there’s a way to direct patients with spinal cord injury to centers where staff members have a solid knowledge of best practices. With only 17,000 new cases each year, SCI is a rare diagnosis. If cases were clustered in designated facilities rather than spread out geographically and administratively, researchers could collect more accurate data to define best treatment practices and create standardized order sets.
Physiatrists across the country are banding together to look for solutions, including the possibility of working with The Joint Commission to develop an advanced disease-specific certification for spinal cord injury that includes a volume requirement, which would help ensure that clinicians who care for these patients have the knowledge and clinical processes in place to produce the best outcomes. Accreditation of facilities as Tier 1, Tier 2 and so on would allow us to funnel patients with SCI to the centers equipped to care for them properly. This would provide the added benefit of allowing researchers to collect the data we need to define quality care for SCI and create evidence-based clinical practice guidelines.
Dr. Matthew Davis joined the medical staff of TIRR Memorial Hermann as an affiliated physician in 2011. He is clinical medical director of the Spinal Cord Injury Program at the rehabilitation hospital and an assistant professor of physical medicine and rehabilitation at McGovern Medical School at UTHealth.