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Spinal Cord (1998) 36, 838 ± 846 Ã 1998 International Medical Society of Paraplegia All Rights Reserved 1362 ± 4393/98 $12.00

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Spinal Cord (1998) 36, 838 ± 846 Ã 1998 International Medical Society of Paraplegia All Rights Reserved 1362 ± 4393/98 $12.00 Spinal Cord (1998) 36, 838 ± 846 ã 1998 International Medical Society of Paraplegia All rights reserved 1362 ± 4393/98 $12.00 A review of the readmissions of patients with tetraplegia to the Regional Spinal Injuries Centre, Southport, United Kingdom, between January 1994 and December 1995 S Vaidyanathan1, BM Soni1, L Gopalan3, P Sett1, JWH Watt1, G Singh1, J Bingley1, Paul Mansour2, KR Krishnan1 and T Oo1 1Regional Spinal Injuries Centre and 2Department of Pathology, District General Hospital, Southport, Merseyside PR8 6PN, UK Patients with chronic tetraplegia are prone to develop unique clinical problems which require readmission to specialised centres where the health professionals are trained speci®cally to diagnose, and treat the diseases aicting this group of patients. An appraisal of the readmission pattern of tetraplegic patients will provide the necessary data for planning allocation of beds for treatment of chronic tetraplegic patients. Hospital records of patients with tetraplegia readmitted to the Regional Spinal Injuries Centre, Southport, UK between 1 January 1994 and 31 December 1995 were analyzed to ®nd out the number of tetraplegic patients who required readmission, reasons for readmission, duration of hospital stay, and mortality among patients readmitted. During the 2-year period, 155 tetraplegic patients were readmitted and 44 of them (28.4%) required more than one readmission (total readmission episodes: 221); these patients occupied 4.5 beds which is equivalent to 11.5% of the total bed capacity of the spinal unit. Among the reasons for the readmissions, evaluation and care of urinary tract disorders topped the list with 96 readmission episodes (43.43%) involving 70 patients; the median hospital stay was 3 days, and 18 patients (26%) required more than one readmission during this period. One hospital bed was occupied by the tetraplegic patients requiring treatment/evaluation of urinary tract disorders. Assessment and treatment of cardio-respiratory diseases was the second most common reason for readmission with 51 readmission episodes pertaining to 27 patients having a median hospital stay of 6 days; 13 patients (48%) were readmitted more than once within this 2-year period. Treatment of cardio-respiratory diseases in chronic tetraplegic patients required 1.2 hospital beds yearly. Only ®ve tetraplegic patients were readmitted for treatment of pressure sore(s); however they had a prolonged hospital stay (median duration: 101 days). Social reasons accounted for 13 readmission episodes concerning nine patients who stayed in the hospital for varying periods (median: 6.5 days; mean: 35 days). Four tetraplegic patients readmitted with acute chest infection expired. An 81 year-old tetraplegic died of myocardial infarction. Urinary sepsis, renal insuciency, respiratory failure and intra-cerebral haemorrhage accounted for the demise of a 41 year-old tetraplegic patient following surgical removal of a large, impacted stone at the pelviureteric junction. A tetraplegic patient who was admitted with haematuria subsequently underwent cystectomy for squamous cell carcinoma of the urinary bladder; he developed secondaries and expired 5 months later. As more patients with high cervical spinal cord injury survive the initial period of trauma, and as the life expectancy of tetraplegic patients increases, it is likely that greater numbers of tetraplegic patients will be requiring readmission to spinal injuries centre. Although it may be possible to prevent some of the complications of spinal cord injury and hence the need for a readmission, progress in medicine and rehabilitation technology will create additional demands for readmissions of chronic tetraplegic patients in order to implement the newer therapeutic strategies. Thus a change in the pattern of readmission of chronic tetraplegic patients is likely to be the future trend and this should be taken into account while making plans for providing the optimum care to chronic tetraplegic patients. Keywords: tetraplegia; readmission; spinal cord injury Correspondence: S Vaidyanathan 3Presently Consultant in Rehabilitation Medicine, Christian Medical College Hospital, Vellore, India Readmissions of patients with tetraplegia S Vaidyanathan et al 839 Introduction diagnosis of Guillain Barre syndrome exhibited a sudden rise in systolic blood pressure from Patients with tetraplegia represent a distinct category of 100 mmHg to 200 mmHg while undergoing electro- patients requiring specialised nursing and medical care. hydraulic lithotripsy of bladder stones under inhala- Many of them will require rehospitalisation after tional anaesthesia. This episode of hypertension is due discharge from initial rehabilitation. An American to the occurrence of autonomic dysre¯exia triggered study showed that as many as 39% of acute spinal by cystoscopy and bladder distension. Timely diag- cord injury patients were readmitted at least once nosis of the dysre¯exic episode and prompt treatment during the ®rst year after discharge from initial by increasing the concentration of iso¯urane from rehabilitative care.1 When tetraplegic patients require 0.65% to 1.4% in order to decrease the systemic readmission irrespective of whether the illness is a vascular resistance, averted any mishap due to complication of the spinal cord injury or unrelated to it, autonomic dysre¯exia. This case also illustrates the they should preferably go to specialised centres where point that tetraplegic patients should be treated by the health professionals are trained speci®cally to medical and nursing professionals acquainted with the diagnose, and treat the diseases aicting this group of diverse symptomatology and occurrence of illnesses in patients with special needs. Further, chronic tetraplegic spinal cord injury patients. patients will be acquainted with the spinal unit, and the In addition to the unique clinical problems exhibited health professionals working in the spinal unit will be by chronic tetraplegic patients, the symptoms and familiar with the special needs of an individual patient. clinical signs of a common illness may be quite For example, extracorporeal shock wave lithotripsy dierent in a tetraplegic patient in contrast to a (ESWL) of stone(s) in the kidney or upper ureter is an patient with intact neuraxis. A 12 year-old girl with established clinical procedure. However, in a spinal cord traumatic tetraplegia presented with increased spasms. injury patient, autonomic dysre¯exia with resulting Investigations revealed a ureteric stone causing acute rise in blood pressure may occur during hydronephrosis. The symptoms of increased spasticity lithotripsy. Such an occurrence of a dysre¯exic episode were relieved after percutaneous nephrostomy drain- during ESWL requires prompt diagnosis and immediate age in this girl. This clinical episode symbolizes the treatment with sublingual nifedipine. Similarly, in a reality that tetraplegic patients tend to exhibit atypical spinal cord injury patient who has developed a post- symptoms and signs of illnesses which may be traumatic syrinx, an acute and severe deterioration of unrelated to spinal cord injury. Moreover, this case spinal cord function may occur due to the reverberation is an example that sudden occurrence of increased generated by extracorporeal shock waves used for the spasticity in a tetraplegic patient who was in a stable lithotripsy, of the ¯uid within the thoracic post- clinical condition earlier, always demands meticulous traumatic syrinx with consequent further damage to investigations for an underlying illness. Lack of the nervous tissue.2 Chronic tetraplegic patients may familiarity with the unconventional patterns of suer from electrolyte disturbances, a common clinical presentation may lead to a delay or errors in entity being hyponatraemia. Hyponatraemia may be diagnosis and management, which could prove costly asymptomatic, or a chronic tetraplegic patient may both to the patient and to the hospital authorities. An present with restlessness, confusion and sometimes appraisal of the readmission pattern of tetraplegic convulsions. Awareness of the protean manifestations patients will help to allocate adequate budget for of hyponatraemia, and familiarity with the philosophy future treatment, so that the care of these patients who of management ie treatment of precipitating factor eg survived the initial period of physical and mental acute urinary or chest infection, ¯uid restriction, agony of paralysis of all the four limbs, chest and frusemide, cautious use of hypertonic saline, and visceral function, is not compromised due to lack of ventilatory assistance if need be, will result in a beds, facilities, or manpower. favourable outcome.3 Chronic tetraplegic patients who The objectives of this study were to ®nd out (1) have been taking large doses of senna over a long period the number of tetraplegic patients who required may suer from hypokalaemia. A female tetraplegic readmission between 1 January 1994 and 31 Decem- patient who was taking 20 ± 25 ml of senna every other ber 1995 in the Regional Spinal Injuries Centre, night for the past 4 years was admitted for explanation Southport; (2) the proportion of patients who of defunct pump and implantation of a new pump for required more than one readmission during this intrathecal delivery of baclofen for intractable spasti- period; (3) the reasons for readmission; (4) the city. During pre-anaesthetic check-up, we considered a procedures performed during the readmission; (5) possibility of
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