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February 2002


Commitment to Excellence

By C.A. Wolski


Katie Robshaw, MSPT, helps a T3 paraplegic patient, who has a previous cervical injury that affects his right arm, move from supine to a long sit and reposition his legs.
Commitment to Excellence

The Mount Sinai Spinal Cord Injury Model System uses coordination and communication to best serve patients, continue its NIDRR grant, and further groundbreaking research on spinal cord injury.

The Mount Sinai Spinal Cord Injury Model System, Mount Sinai Medical Center, New York, is more than just a coordinated collection of interdisciplinary professionals all working together. "It's a living organism almost," says Kristjan T. Ragnarsson, MD, Lucy G. Moses professor and chairman of the Department of Rehabilitation Medicine.

According to Ragnarsson, a model system has four essential components: emergency medical services that include trained emergency medical technicians, well-equipped ambulances, and an organized system of triage; a designated specialized trauma center; comprehensive rehabilitation services; and lifelong follow-up services.

"The model system means that you provide comprehensive and optimal care for people with disabling injuries from the onset of the disabling condition and throughout their lives while the disability lasts," says Ragnarsson. The Mount Sinai Model System is the only model spinal cord treatment center in New York state.

Team Approach
The comprehensive team approach continues into the rehab unit. "The way we've set [the department] up throughout the years is that physical therapy, occupational therapy, and nursing are all put together as a team," says Katie Robshaw, MSPT, advanced clinician in spinal cord injury. "I have an OT partner and I have a nurse and a secondary or associate nurse, so on the days when my primary nurse is not here, the secondary nurse or associate always has that patient...versus me having multiple occupational therapy partners and multiple nurses. It leads to more consistency of care as well as improved communication."

This coordination and commitment to communication are built into the daily life of the spinal cord unit. "We have weekly meetings where we all get together as a team-physical and occupational therapy, speech, psychology, the whole team-with a physician and a nurse to discuss patients, where they've gone functionally, where they've gone clinically, are there any equipment issues, family training, is there an issue that we're covering in therapy that isn't being followed on the floor, and vice versa," says Robshaw.

NIDRR Grant
The Mount Sinai rehabilitation department sees about 100 new spinal cases each year, which includes patients with both traumatic and nontraumatic spinal cord injuries and conditions. It has about 700 patients in its outpatient program. Patients include those with all levels of spinal cord injury. There are 11 physicians on staff, with four specializing in spinal injuries, about 170 rehab professionals, and a nursing staff of 200. The center also has a residency program with nine residents and a training program for students in the various allied health fields. The psychologists, social workers, vocational therapists, and recreational therapists on staff all have specialized training in treating spinal injuries. The department has three 25-bed rehabilitation units for spinal cord injury, traumatic brain injury, and medically complex conditions.

Reflecting the overall trends in health care, the model system's continuum of care has reduced hospital stays from an average of 4 to 6 months for paraplegics to 4 to 6 weeks and from 1 year for tetraplegics to 8 to 12 weeks. About one third of the patients are covered under Medicaid, with the balance being paid by workers' compensation or commercial insurance. "As long as the person who comes into the system is a legal immigrant or a citizen, insurance is not usually an issue," says Ragnarsson.

The facilities on each of the three rehab floors, such as patient rooms, treatment areas, and gyms, are next to each other to minimize time-consuming transport to other floors. Though the rehabilitation department is now its own care center with Ragnarsson and his colleagues taking over the duties of primary physicians, it still consults with other departments throughout the hospital. When Ragnarsson was setting up the spinal cord program, this interdependence was a necessity.

"When I first came here to Mount Sinai, this was not a hospital that treated people with spinal cord injuries; on the other hand, when we started our program here, it was not enough just to have myself and my associates in the Department of Rehabilitation Medicine," says Ragnarsson. "We had to make sure there were physicians in other departments that were skillful in treating the special problems of spinal cord injury."

Spotlight On Spinal Cord Injury
The Mount Sinai spinal cord program, one of 16 model spinal cord programs in the country funded by the National Institute on Disability and Rehabilitation Research (NIDRR), has been receiving federal funding since 1990. The 16 programs form an interconnecting web of centers that gather and pool their data at a central repository at the University of Alabama at Birmingham. The grant is between $300,000 and $400,000 per annum and is renewable every year for 5 years. Mount Sinai is currently in receipt of its third cycle of 5-year grants. The grant has two major components: the collection of information on people with traumatic spinal cord injuries for the central database at the University of Alabama, and a research study. This grant's research study is dedicated to treating the pain that develops after a spinal cord injury occurs. This pain can occur above the spinal lesion where patients still have feeling, on the lesion at the site of the injury, or below where there is no feeling, causing "phantom" pain. From 50% to 75% of spine patients develop chronic pain after their injury. Up to one half of these patients experience pain so significant that it affects their quality of life.

"For patients with spinal cord injuries, pain is one of the worst problems they deal with, and it is also one that has been the most difficult to treat," says Ragnarsson. "Clearly, if you have this intense chronic pain that never leaves you during all your waking hours, it is incredibly distracting. It's extremely taxing on you emotionally, and it is hard to get on with life when you're suffering so much." The research study has two projects. The first is to study prospectively when patients are developing specific types of pain; the second is a systematic quantitative review of the published literature on pain management in spine injuries. Each of the 16 federally funded rehab centers is engaged in its own research studies.

More than 20 different institutions competed for funding from the NIDRR during the last round of proposals. The grant process includes a description of the institution's model system both clinically and in terms of the research it is engaged in, and how outcomes are measured. The final document with appendices comprised a 200-page narrative.

Mount Sinai received its third grant for a simple reason. "First and foremost, we had the various pieces in place both clinically and in education and training so we could provide services to people with spinal cord injuries from immediately after injury through long-term community services..., and we had staff of the quality and expertise that are needed and, third, we had the proposals for research that the peer reviewers saw as valuable state-of-the art research in the area of spinal cord injury," says Marcel Dijkers, PhD, associate professor of rehabilitation medicine and day-to-day administrator of the grant.

The yearly renewal of the grant is not a given. Ragnarsson has to meet with government reviewers and submit a report. "The [government] makes sure that the leadership and the staff as well as the facilities and equipment are all in order to provide this kind of care," he says. "You have to be getting enough patients to justify your existence, and collecting all the data correctly on each patient admitted with this kind of injury into your system. And then you have to demonstrate at least some kind of outcomes that seem acceptable."

State-of-the-Art Research
The grant is not simply a means to do abstract, long-term research. During the 1995-2000 grant cycle, the Mount Sinai Spinal Cord Injury Model System instituted its Do It! outpatient program. "It's a program to help patients transition from inpatient status to functioning in a community; to transition from the more medical treatments and services to the more social," says Dijkers. "It's a program that was designed with input from consumers and is currently run with input from consumers. As a matter of fact, on a rotating basis, patients are on the payroll-we call them consultants, who for 6 months work in that program on a part-time basis, and help other patients who are [newly injured] to adjust to living with a spinal cord injury, provide administrative and technical assistance within the program, and are role models for new patients. We needed to find a way to provide a lot of the same information patients used to get when inpatient stays were still measured in months rather than weeks."

In addition to the development of new programs and treatment methods, the grant has another benefit. "It gives you an opportunity to expand programs both clinically and in terms of research, and it gives you opportunities to leverage your resources so we've been able to get some additional funding for the Do It! program from the Christopher Reeve Paralysis Foundation," says Dijkers. "This year they are paying for an expansion of the number of consumer consultants whom we employ. The same on the research side. Since we received the model system grant, there has been an expansion of research in traumatic spinal cord injury. Part of it is funded by the grant, but also part of it is funded by other sources. This has allowed us to develop ideas and bring together staff with relevant expertise."

Patients Take Precedence
The most important piece of the treatment team, says Robshaw, is the patient. "I think that's an important thing for all therapists to understand," she says. "A lot of time when you read magazine articles or books, sometimes the patient gets left out."

The spinal injuries treated at Mount Sinai range across a wide continuum from complete to incomplete paralysis. But even those who have complete paralysis tend to be healthy and require only periodic follow-up, says Ragnarsson. "Frankly, people with spinal cord injuries, even though they continue to be paralyzed, if they're not in pain and are otherwise medically stable, they're pretty healthy, and they don't have to see you that often," he says. "Sometimes I don't see a patient more often than every other year or every 5 years sometimes, because they're doing so well, albeit in a wheelchair."

With all the improvements in treating spinal injuries, there is still one frustration Ragnarsson says he has to face constantly. There is still no way to cure spinal cord injuries. However, that does not mean he is not optimistic about the future. "I'm a believer in [finding a cure]; I just can't tell you how long that is going to take," he says. "But I think one day we will have a better understanding, and once we have a better understanding, I think the cure can't be too far away."

C.A. Wolski is associate editor of Rehab Management.

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