New Zealand Spinal Cord Injury Destination Policy

This document is for the use of prehospital personnel when determining the destination of patients with spinal cord injury in New Zealand. It has been developed by the National Spinal Cord Impairment Governance Committee.

Publication date June 2015 Spinal Cord Injury Destination Policy Flowchart for Prehospital Personnel

Does the patient have acute spinal cord NO This policy does not apply. See the injury with signs of paraplegia District Destination Policy. or quadriplegia?

YES

YES Does the patient have signs of major Transport the patient to the most trauma in addition to spinal cord injury? appropriate major trauma hospital

YES Does the patient have inadequate breathing or shock?

Is it feasible to transport the patient YES Transport the patient directly to a directly to a SCI centre* by road? SCI centre* by road

Is it feasible to y the patient directly to a YES Fly the patient directly to the most SCI centre*? appropriate SCI centre*

Transport the patient to the most appropriate major trauma hospital * Spinal Cord Impairment (SCI) Centres Middlemore Hospital (adults) Christchurch Hospital (adults and children) Starship Children’s Hospital (children)

Page 1 of 6 Spinal Cord Injury Destination Policy | 2015 Spinal CordSpinal Injury Cord DestinationSpinal Injury Cord Destination Policy Injury Destination Policy Policy Additional InformationAdditional InformationAdditional Information

Introduction Introduction Introduction This information complementsThis information the spinal complementsThis cord information injury the destination complements spinal cord policy injury the flowchart spinaldestination cord for injuryprehospital policy destination flowchart personnel for policy prehospital flowchart personnel for prehospital personnel and should be read inand conjunction should be withreadand it.in This shouldconjunction policy be readdescribes with in it.conjunction This the processpolicy with describes for it. prehospital This the policy process personnel describes for prehospital tothe process personnel for prehospital to personnel to determine which hospitaldetermine patients which with hospitaldetermine spinal cordpatients which injury withhospital should spinal patients be cord transported injury with spinalshould to. cord be transported injury should to. be transported to. One of the main principlesOne of within the main the principles NationalOne of the Spinal within main Cord theprinciples National Impairment within Spinal Action the Cord National Plan Impairment is Spinalthat patients CordAction Impairment withPlan is that Action patients Plan with is that patients with spinal cord impairmentspinal (SCI) cord following impairmentspinal trauma (SCI)cord should followingimpairment be treated trauma (SCI) in followingshoulda designated be trauma treated SCI centreshould in a designated as be soon treated as SCI in centre a designated as soon SCI as centre as soon as possible after their injury.possible Patient after outcomes theirpossible injury. are Patient after optimised their outcomes injury. when Patientsurgeryare optimised outcomes (if indicated) when are surgery tooptimised decompress (if indicated) when the surgery to decompress (if indicated) the to decompress the spinal cord is performedspinal urgently cord is andperformed spinalthis is usuallycord urgently is performedonly and feasible this isurgently usuallywhen patients andonly this feasible are is usually transported when only patients feasible directly are when totransported a patients directly are transported to a directly to a designated SCI centre.designated From a prehospital SCI centre.designated perspective From a SCI prehospital centre. this means From perspective that: a prehospital this means perspective that: this means that: Patients with spinal cordPatients injury with and spinal no Patients other cord signsinjury with ofspinaland major no cord other trauma injury signs willand of be no major transported other trauma signs directly ofwill major be fromtransported trauma will directly be transported from directly from the scene to a SCI centre,the scene whenever to a SCI this thecentre, is scenefeasible. whenever to Thisa SCI means centre,this is thatfeasible. whenever even This in this a means metropolitan is feasible. that even This setting inmeans a metropolitan that that even insetting a metropolitan that setting that is close to another majoris close hospital, to another patientsis major close will hospital,to be another transported patients major directly hospital,will be totransported patients a SCI centre will directly beeven transported ifto that a SCI SCI centre directly even to ifa SCIthat centre SCI even if that SCI centre is a significantcentre distance is a away. significantcentre distance is a significant away. distance away. Patients with other signsPatients of majorwith other trauma Patients signs in additionofwith major other to trauma spinalsigns ofcordin additionmajor injury trauma willto spinal be in transported additioncord injury to to spinalwill the be cord transported injury will to bethe transported to the most appropriate majormost trauma appropriate hospital mostmajor and appropriate traumathen secondarily hospital major and referredtrauma then hospitaltosecondarily a SCI centreand referredthen when secondarily to clinically a SCI centre referred when to a clinically SCI centre when clinically appropriate. appropriate. appropriate.

Patients not coveredPatients by this notpolicy covered Patients by this not policy covered by this policy Patients with non-traumatic Patients spinal with non-traumatic cord Patients impairment with spinal non-traumatic are cordnot covered impairment spinal by this arecord policy. not impairment covered They will by are bethis not policy. covered They by will this be policy. They will be transported to the mosttransported appropriate to the hospitaltransported most appropriateand then to the secondarily mosthospital appropriate and referred then hospitaltosecondarily a SCI centreand referredthen when secondarily to a SCI centre referred when to a SCI centre when clinically appropriate.clinically appropriate.clinically appropriate. Inter-hospital referrals Inter-hospital and inter-hospital referrals Inter-hospital transfers and inter-hospital are referrals not covered and transfers inter-hospital by this are policy. not covered transfers by are this not policy. covered by this policy.

Defining spinal cordDefining injury in spinal the prehospital cordDefining injury spinal setting in the cord prehospital injury in setting the prehospital setting For the purposes of thisFor policy,the purposes signs of ofFor spinal this the policy, purposescord injury signs of requireof this spinal policy, the cord patient signs injury of to spinalrequire have cordsigns the injurypatient of paralysis require to have the signs patient of paralysis to have signs of paralysis with either paraplegiawith or quadriplegia.either paraplegiawith oreither quadriplegia. paraplegia or quadriplegia. Altered sensation and/or Altered weakness sensation (without Alteredand/or paralysis) weaknesssensation are (withoutand/or not sufficient weakness paralysis) because (without are not it issufficientparalysis) relatively becauseare common not sufficient it is relatively because common it is relatively common for patients in the prehospitalfor patients setting in the tofor prehospital have patients these in setting symptoms the prehospital to have in the these setting absence symptoms to of have spinal in these the cord absencesymptoms injury. of spinalin the absencecord injury. of spinal cord injury. Transporting such patientsTransporting directly such to aTransporting patientsSCI centre directly risks such large to patients a SCI numbers centre directly of risks patients to largea SCI numbersbeingcentre inappropriately risks of patientslarge numbers being inappropriatelyof patients being inappropriately transported to a SCI centretransported that do to nota SCItransported require centre it. that to do a SCI not centre require that it. do not require it.

Mechanism of injuryMechanism of injuryMechanism of injury The decision to transport The decision a patient to directly transportThe decision to aa SCIpatient centreto transport directly is not toaaffected patient a SCI centre by directly the is mechanism not to a affected SCI centre of by injury. isthe not mechanism affected by of the injury. mechanism of injury. However, if the mechanism However, involves if the mechanism highHowever, velocity ifinvolves the(for mechanismexample high velocity a high involves speed (for examplehigh road velocity crash) a high and(for speed exampleanother road a crash) high speed and another road crash) and another major trauma hospitalmajor is significantly trauma hospital closermajor is to trauma significantly the scene hospital than closer is a significantlySCI to thecentre, scene it closer is than vital toa to SCI the exclude centre, scene other thanit is vital a SCI to centre, exclude it isother vital to exclude other signs of major traumasigns prior of to major making trauma signsa decision prior of major to to making transport trauma a priordecision the patientto making to transport directly a decision to the a SCIpatient to centre. transport directly the to patient a SCI centre. directly to a SCI centre.

Page 2 of 6 Page 2 of 6 Page 2 of 6 Spinal Cord Injury DestinationSpinal Policy Cord | 2015Injury DestinationSpinal Cord Policy Injury | 2015 Destination Policy | 2015 Other signs of major trauma in addition to spinal cord injury The patient must be transported to the most appropriate major trauma hospital (and then secondarily referred to a SCI centre when clinically appropriate) if there are any signs of major trauma in addition to that of spinal cord injury. Personnel must seek clinical advice if they are uncertain. All of the SCI centres are within hospitals that are also designated as major trauma hospitals and thus patients with additional injuries will receive appropriate treatment at the SCI centres. See the major trauma destination policy for further details.

The adequacy of breathing If breathing is clinically inadequate the patient must be transported to the most appropriate major trauma hospital and then secondarily referred to a SCI centre when clinically appropriate. Clinically inadequate breathing is uncommon in the prehospital setting following spinal cord injury and usually only occurs with a high cervical cord injury. Most patients with diaphragmatic breathing following spinal cord injury have clinically adequate breathing but an inadequate cough. In this setting the patient should be transported directly to a SCI centre provided this is feasible, the patient has adequate oxygenation with supplemental oxygen and their breathing is not deteriorating.

Shock If shock is present the patient should be transported to the most appropriate major trauma hospital (and then secondarily referred to a SCI centre when clinically appropriate) because the patient should be presumed to have hypovolaemic shock until proven otherwise. Loss of sympathetic outflow from the spinal cord following spinal cord injury can cause shock and in this setting the patient is usually vasodilated below the site of injury. It is appropriate to consider transporting the patient directly to a SCI centre if personnel are confident the patient has spinal shock (particularly if the mechanism of injury involved low velocity) and the patient is clearly not deteriorating, but personnel must seek clinical advice in this setting.

Transport to a SCI centre by road It is usually only feasible to transport a patient directly to a SCI centre by road when the patient is injured in, or around the fringes of, the Auckland district and the Canterbury district. In the Auckland district: – Adults should be transported to Middlemore Hospital unless there is a compelling clinical reason to transport them to Auckland City Hospital instead. – Children should be transported to Starship Hospital unless there is a compelling clinical reason to transport them to Middlemore Hospital instead. On the fringes of the Auckland district (for example the southern area of Northland and the northern area of Waikato and Hauraki), if helicopter transport is not indicated (or is not available), it is preferable to transport the patient directly to a SCI centre by road, rather than transporting to Whangarei Hospital or Waikato Hospital. This is because a secondary transfer incurs a clinically significant delay that may worsen the patient’s outcome. In the Canterbury district the only hospital suitable for patients with major trauma is Christchurch Hospital and all patients should be transported there directly.

Page 3 of 6 Spinal Cord Injury Destination Policy | 2015 Transport to a SCI centre by helicopter If it is not feasible to transport a patient directly to a SCI centre by road, the patient should be transported directly to a SCI centre by helicopter, provided a helicopter is available and it is feasible to do so. This will occur even if another major hospital is substantially closer. In many metropolitan areas of New Zealand this will involve the patient being driven to a helicopter base (or rendezvous point) that may be very close to (or onsite at), a major hospital and then flying the patient directly to a SCI centre, without the patient entering that major hospital. Provided a helicopter is available and it is feasible to fly to the SCI centre, this is preferable to the patient being transported to that major hospital and then secondarily transferred. This is because such a secondary transfer incurs a clinically significant delay that may worsen the patient’s outcome. If the flight involves the patient ‘overflying’ another major trauma hospital, it is essential that helicopter personnel re-evaluate the patient prior to flight, in order to ensure that there are no other signs of major trauma in addition to spinal cord injury. Personnel must have a very low threshold for seeking clinical advice if they are uncertain. If a helicopter is not available within a suitable time frame, or it is not feasible (for example due to weather) to fly to a SCI centre, the patient will be transported to the most appropriate major trauma hospital and then secondarily referred to a SCI centre when clinically appropriate. A ‘suitable time frame’ cannot be tightly defined and requires clinical judgement. If a helicopter is not immediately available personnel should seek clinical advice regarding the options for transport and the destination. Refueling may be required en route to a SCI centre. This is preferable to flying to another major trauma hospital and the patient being secondarily transferred. It is not usually feasible to transport a patient by fixed wing aircraft. In very unusual circumstances a fixed wing aircraft may be used, but in this setting personnel must seek clinical advice. The patient must be removed from extrication devices (such as a spine board, scoop stretcher or combi- carrier) and transported directly on the stretcher, unless the total time on the extrication device is going to be less than thirty minutes. Additional care must be taken to ensure the patient is kept warm. Urinary catheterisation is not required.

Seeking clinical advice Personnel requiring advice will contact the doctor on call for the ambulance service via the Clinical Desk within the Ambulance Clinical Control Centre. In the event that further advice is required, the doctor on call for the ambulance service will contact the on call spinal consultant within the appropriate SCI centre.

Communication with receiving hospital staff No specific additional communication is required with receiving hospital staff other than the usual notification process for a patient with major trauma, however this notification should occur with as much advance warning as possible.

Page 4 of 6 Spinal Cord Injury Destination Policy | 2015 SCI centre catchment areas and transport destination New Zealand has three designated SCI centres and each has an associated catchment area. They are: – Middlemore Hospital for adults (15 years or older) from the upper two thirds of the North Island (the area marked in orange on the map on the next page). – Christchurch Hospital for adults (15 years or older) from the lower third of the North Island (the area marked in blue on the map on the next page) and all of the South Island. – Starship Hospital for children (younger than 15 years) from all areas of New Zealand. Patients will be preferably transported to the catchment area SCI centre, provided it is feasible to do so. This means that some patients will be own to a SCI centre that is not the closest SCI centre to the scene, particularly when the scene is in the upper part of the area marked in blue on the map. This is preferable to always ying to the closest SCI because it is important to balance the patient load between the SCI centres and this reduces secondary inter-hospital transfers. It will not always be feasible to y the patient to the catchment area SCI centre. In particular, it is not always feasible to y an adult from the lower third of the North Island to Christchurch Hospital and it is rarely feasible to y a child from the South Island directly to Starship Hospital. Thus, for the purposes of prehospital decision making, the patient will be transported to the most appropriate SCI centre and then referred (if required) to the catchment area SCI centre. The following will be taken into account when determining which SCI centre the patient is transported to: –T he catchment area boundaries and the location of the scene. –T he location and availability of helicopters. –T he weather. –W here the patient lives. Examples: –A n adult in the orange area will usually be own to Middlemore Hospital. –A n adult in the blue area will usually be own to Christchurch Hospital. –A n adult in the South Island will usually be own to Christchurch Hospital. –A child in the North Island will usually be own to Starship Hospital. –A child in the South Island will usually be own to Christchurch Hospital and then secondarily referred to Starship Hospital when clinically appropriate. This is because Christchurch Hospital is a SCI centre with the sta and facilities to provide urgent decompressive surgery if required. It may seem counterintuitive for adult patients from the lower North Island to be own to Christchurch but it is important to balance the workload between the SCI centres. In addition, patients that are transported to a SCI centre that does not align with their catchment area will be subsequently referred to the appropriate SCI centre and it is more ecient for the healthcare system if patients are transported directly to their catchment area SCI centre whenever this is feasible.

Personnel must seek clinical advice if they are uncertain which SCI centre the patient should be transported to.

Page 5 of 6 Spinal Cord Injury Destination Policy | 2015 Spinal Cord Injury Destination Policy Catchment Area Boundaries

Key

Middlemore Hospital Christchurch Hospital Whangarei Starship Hospital (all of NZ)

Middlemore Hospital Hamilton

Taupo

Mokau Gisborne Turangi

Palmerston North

Wellington Nelson

Kaikoura

Greymouth

Christchurch Hospital

Timaru

Queenstown

Te Anau Dunedin

Invercargill

Page 6 of 6 Spinal Cord Injury Destination Policy | 2015 New Zealand Spinal Cord Injury Destination Policy

Publication date June 2015