Guide to SCI Admission Documentation

Section I: Tips on completing documentation on a new inpatient admission

Step 1: navigate to the history tab and add in the medical, surgical and family history. If the patient is being admitted for a new traumatic brain injury and/or spinal cord injury, include these in the medical history. Add comments is always helpful. After adding a diagnosis, you have the opportunity of adding this diagnosis to the Problem list right then.

Although it may not seem important to you to include the Family History, it is a required component of admission note documentation needed to bill at any level other than the lowest level.

Step 2

Complete your H&P in the notes section

You can pull in the most recent ISAFSCI into your PE using the system ISAFSCI SmartPhrase.

You can pull in a simplified template for ISAFSCI using the ISAFSCIROS SmartPhrase (you can copy from my SmartPhrase list through your SmartPhrase manager).

Step 3

Complete the problem list section

Step 4

Complete orders appropriate for all the problems.

Some common issues seen after SCI include:

(1)    Orthostasis- for which you might order compression stockings, an abdominal binder, etc. See Section II below for more specifics.

(2)    Neurogenic Lower Urinary Tract Dysfunction (NLUTD)- for which you might order to check a post void residual, start IC, etc. See Section II below for more specifics.

(3)    Neurogenic Lower Gastrointestinal Tract Dysfunction (NLGITD)- for which you might order a bowel routine. On KCC there are 3 times of day when these are preformed 0500, 0800, and 2000. The routine will need to specify where it would be done and the technique. For instance if someone has a lower motor neuron NLGITD, they would be put on 0800 routine on a commode to minimize the chance of accidents in therapy. See Section II below for more specifics.

(4)    Pressure injuries- for which specific wound care orders should be added. The presence of a pressure injury should also impact your specific therapy orders (e.g., seating restrictions for instance). Also a special type of bed should be considered to be ordered. See Section II below for more specifics.

Therapy orders should be specific to diagnosis. If someone has a complete paraplegia without any volitional leg movement, you would not likely order gait training or stair climbing training.

A sample SCI template for PT orders in Epic is {SCI_PT_orders:48452}

A sample SCI template for OT orders in Epic is {SCI_OT_orders:48453}

Also don’t forget to always reconcile meds.

Section II - Further information on management of secondary conditions

Orthostatic Hypotension

Immediately after SCI, there is a complete loss of sympathetic tone, resulting in neurogenic shock with hypotension, bradycardia, and hypothermia. The hypotension occurs as a result of systemic loss of vascular resistance, accumulation of blood within the venous system, reduced venous return to the heart, and decreased cardiac output. Over the course of time, the sympathetic reflex activity returns, with normalization of blood pressure. Supraspinal control continues to be absent in those individuals with high-level and neurologically complete SCI, however, and they continue to be prone to orthostatic hypotension (OH). This is defined as a reduction in blood pressure when body position changes from supine to upright. The symptoms associated with OH include lightheadedness, dizziness, pallor, and syncope. One study has suggested that chronic hypotension in persons with SCI can result in cognitive deficits.106

Management of orthostatic hypotension includes application of elastic stockings and abdominal binders, adequate hydration, gradually progressive daily head-up tilt, and at times, administration of salt tablets, midodrine, or fludrocortisone. Some research has shown positive results with L-threo-3,4-dihydroxyphenylserine (droxidopa) for treating OH without causing hypertension.201

NLUTD

The goal of management of NLUTD is to achieve a socially acceptable method of bladder emptying, while avoiding complications such as infections, hydronephrosis with renal failure, urinary tract stones, and AD. During the immediate post-injury period an indwelling transurethral catheter is placed within the bladder, because virtually all persons with SCI have urinary retention. Other bladder management options are explored later on, depending on the person’s gender, level and completeness of injury, and other comorbidities.

Intermittent bladder catheterization (IC) is generally accepted as the best option, other than regaining normal voiding, for the long-term bladder management of persons who can perform IC themselves or if they are unable to do so themselves have someone who can perform IC for them. This is because of the physiologic advantage of allowing for regular bladder filling and emptying, the social acceptability of not needing a drainage appliance, and fewer complications than with other methods. In order to minimize the risk of infection it is recommended that the catheterization be performed with aseptic technique, a sterile technique which includes genital disinfection and the use of sterile catheters and gloves, rather than with clean technique, which includes only ordinary washing techniques and use of disposable or cleansed reusable catheters, the latter had been advocated for in the past as a more cost effective alternative.68 IC is usually performed several times daily with a target catheterized volume of approximately 500 mL each time, for a total fluid intake of approximately 2000 mL per day. IC often needs to be combined with anticholinergic medications (one or more) or beta-3 adrenergic agonist medications, such as mirabegron, in persons who have an UMN NLUTD, to inhibit involuntary voiding between catheterizations. To improve bladder capacity and permit successful IC when anticholinergic and beta-3 adrenergic agonist medications are unable to provide adequate bladder relaxation, or when the side effects of the oral medications are intolerable, injections of the neurotoxin botulinum toxin have been shown to be effective; however, injections must be repeated on a regular basis.111,139 A more permanent solution, augmentation cystoplasty, a procedure that involves harvesting a portion of intestine and attaching the portion of intestine to the native bladder to create a high-capacity but low-pressure reservoir, has also been shown to be effective although complication rates of the procedure are not negligable.96

Reflex voiding is another viable option for males with UMN NLUTD who are unable to perform IC themselves or who do not have someone who can regularly perform IC for them in whom bladder pressures are generated that are greater than the outlet pressures of the sphincters to allow spontaneous voiding. A condom catheter is applied to the penis and connected via tubing to a leg bag or bedside bag. Reflex voiding can sometimes be triggered by suprapubic tapping. The completeness of voiding can be determined by measurement of a post-void residual urine volume. High residual volumes predispose to urinary tract infection (UTI) and bladder stone formation. Furthermore, reflex voiding is often associated with elevated voiding pressures, which can predispose to vesicoureteral reflux, hydronephrosis, and eventual renal failure. It is critically important for reflex voiders to undergo regular imaging with a renal ultrasound (at least yearly) to identify reflux or hydronephrosis as well as to be closely monitored for signs and symptoms of autonomic dysreflexia during voiding and UTIs which could be markers that bladder pressures are elevated and that this method of management needs reevaluation.

A urodynamic study (UDS) is a procedure in which pressure sensors attached to a catheter are inserted through the urinary sphincter into the bladder and the bladder is then slowly filled with water. It can be useful in estimating relative risk of upper tract deterioration in persons who reflex void and others by quantitatively documenting the duration and pattern of detrusor pressures during bladder filling and emptying. An extended duration of detrusor contractions on UDS is associated with dilatation of the upper urinary tract in reflex voiders as well as with an increased risk of renal deterioration.71,128 If high-pressure (within detrusor) voiding is occurring, alpha adrenergic receptor antagonist medications, such as prazosin, terazosin, doxazosin, tamsulosin, or alfuzosin, are often effective in decreasing bladder outlet resistance and secondarily decreasing bladder pressures and post-void residual volumes.68 Historically transurethral surgical procedures, either sphincterotomy or placement of expandable stents within the external sphincter, have been performed to decrease bladder outlet resistance however these have fallen out of favor and are now rarely performed. Another option, botulinum toxin has also been shown to be effective in small studies when injected into the sphincter to improve bladder emptying and is sometimes used for this indication although the evidence for this is much less robust than that for injections into the bladder wall to promote bladder storage.168 Reflex voiding generally is a poor option for females with SCI, because an acceptable external collecting device for women does not exist at this time.

Long-term bladder drainage with an indwelling catheter is a reasonable option for persons with tetraplegia who are unable to perform IC and do not have a caregiver that can perform it for them and in males who are unable to effectively maintain an external catheter on their penis or in whom reflex voiding is not a recommended management method. Use of an indwelling catheter inserted through the urethra however is associated with UTI, bladder stone formation, epididymitis, prostatitis, hypospadias, and bladder cancer.204  Placement of a suprapubic cystostomy tube in persons requiring long-term indwelling catheters can avoid some of these complications, such as prostatitis, epididymitis, and hypospadias.

Although UTI is clearly a common complication, more common in those in whom NLUTD is managed with an indwelling catheter or in reflex voiders than in those in whom NLUTD is managed with IC, controversy exists concerning exactly what constitutes a UTI in persons with SCI. Symptoms of fever, spontaneous voiding between catheterizations, hematuria, AD, and increased spasticity, when associated with cloudy or foul-smelling urine and other nonspecific symptoms such as malaise or vague abdominal discomfort, strongly suggest the presence of UTI and the need for treatment. However, simply evaluating for the presence of bacteria in the urine can lead to over treatment or unnecessary treatment in persons with minimal symptoms or signs as bacteriuria is present in a majority of individuals with NLUTD managed with any type of catheter or external collecting system whether they are symptomatic or not. Frequent treatment of asymptomatic bacteriuria can lead to bacterial resistance and should be avoided. Nevertheless, simple UTIs can be complicated by the development of pyelonephritis, epididymitis, orchitis, prostatic abscesses, and urosepsis. Over the course of time, recurrent UTIs can lead to renal scarring, secondary decreased renal function, and the development of urinary tract stones.

NLGITD

A bowel program is a treatment plan for managing a neurogenic bowel, with the goal of allowing effective and efficient colonic evacuation while preventing incontinence and constipation. A bowel program should be scheduled at the same time of day, usually every day in the beginning. The program should be scheduled later on at least once every two days to avoid chronic colorectal overdistention. The scheduling of a bowel routine after a meal can take advantage of the gastrocolic response. Although a person with SCI should learn how to perform a bowel routine in bed and on a commode chair, regular performance of the routine sitting up on a commode is preferred to allow gravity to facilitate complete emptying. A diet high in fiber can help produce a bulky, formed stool and promote continence. Medications can also be used, such as stool softeners to modulate stool consistency, and stimulant and hyperosmolar laxatives to improve bowel motility. Minienemas and suppositories can be used to trigger colonic reflex evacuation in persons with an UMN bowel. Minienemas which are all liquid generally work quicker than suppositories and polyethylene glycol based suppositories work quicker than oleaginous based ones. Stimulant and hyperosmolar laxatives, if used, are usually taken 8 to 12 hours before the evacuation portion of a bowel routine. Overtime in many individuals with SCI, transit time slows resulting in constipation and irregular evacuations. Use of medications such as polyethylene glycol, linacoltide, and lubiprostone all of which promote colonic transit can be useful adjuncts.

Two mechanical methods are used to evacuate the rectum: digital stimulation and digital evacuation. Digital stimulation is dependent on the preservation of sacral reflex arcs, and is typically effective only for persons with an UMN bowel. Digital stimulation is performed by inserting a gloved, lubricated finger into the rectum and slowly rotating the finger in a circular movement until relaxation of the bowel wall is felt, flatus passes, or stool passes.44 This typically occurs within 1 minute. Digital stimulation is repeated every 10 minutes until there is cessation of stool flow, palpable internal sphincter closure, or the absence of stool results from the last two digital stimulations. In contrast, digital evacuation is not dependent on the preservation of sacral reflex arcs and is typically performed by a person with an LMN bowel. Digital evacuation is performed by inserting a gloved, lubricated finger into the rectum to break up or hook stool and pull it out. Abdominal wall massage, starting in the right lower quadrant and progressing along the course of colon, is a useful adjunct for attempting to move stool along the colon.

Pressure Injuries

Pressure injury healing comprises a sequence of loosely linked components that include inflammation, matrix synthesis and deposition, angiogenesis, fibroplasia, epithelialization, contraction, and remodeling. Growth factors are important determinants of this sequence. Different stages of wounds require different components to heal. Stage 2 injuries might need only epithelialization, whereas a stage 3 or 4 pressure injury can require matrix synthesis and deposition, angiogenesis, fibroplasia, and contraction.

Pressure injuries can acquire necrotic tissue. Necrotic tissue releases endotoxins that inhibit fibroblast and keratinocyte migration. It is also an excellent growth medium for bacteria. The bacteria produce enzymes and proteases that degrade fibrin and growth factors, leading to impaired healing. Removal of necrotic tissue can occur through autolysis as well as through chemical, sharp, and mechanical debridement. Autolysis is promoted when a moisture-retentive barrier is applied over a superficial injury, allowing endogenous enzymes to degrade the necrotic tissue. Chemical debridement refers to the application of commercially available enzymes that selectively degrade necrotic tissues. Sharp debridement refers to excision of necrotic tissue or scar with a sharp instrument, whereas mechanical debridement can be performed with application and removal of wet-to-dry dressings which non-selectively adhere to tissues, both viable and non-viable, within the wound bed after the solution saturating the dressings has evaporated away.

Dressings are topical products used for protection of a pressure injury from contamination and trauma, application of medication, debridement of necrotic tissue, and to provide an environment in which tissue hydration levels and the viability of the wound tissue are maintained by something other than the skin. The wound dressing can be viewed as the substitute skin. The major dressing categories include transparent films, hydrocolloids, hydrogels, foams, alginates, and gauze dressings. Transparent films are adhesive, nonabsorptive, semipermeable membranes, whereas hydrocolloids are adhesive wafers with water-absorbing particles that have a minimal to moderate absorptive capacity. Both allow autolytic debridement and are indicated for use in the treatment of partial-thickness wounds. Foams are non-adherent, hydrophobic or hydrophilic materials with minimal to moderate absorptive capacity. Hydrogels are water- or glycerin-based gels with minimal to moderate absorptive capacity. Alginates are soft, absorbent, nonwoven, seaweed-derived dressings that have a cotton-like appearance, with a moderate to heavy absorptive capacity. Foams, hydrogels, and alginates all fill dead space within an ulcer crater, require a secondary dressing, and are appropriate for both partial- and full-thickness wounds.

Other adjunctive therapies that have shown benefit in randomized controlled studies and case series have included electrical stimulation for which there is the most evidence and negative pressure wound therapy.6,100 Although negative pressure wound therapy is not without risk including bleeding and infection.

Adequate nutrition is essential to heal a pressure injury. Caloric requirements are increased for a person with SCI who has a pressure injuryinjury. An estimate of the difference in basal energy expenditure between persons with SCI who have severe pressure injuriesand those who do not have pressure injuriesis approximately 5 Kcal/Kg of body weight per day.83 As protein requirements are increased for a person with an SCI and pressure injuries, recommendations for increased protein requirements range from 1.25 to 2 grams protein per Kg of body weight per day with the higher requirements suggested for those with injuries of greater severity.83

Pressure redistribution support surfaces and proper positioning in them can help prevent pressure injuriesfrom developing, and help to heal them if they occur. Pressure redistribution support mattresses are typically designed to either be active with powered alternating pressure chambers or reactive with high or low air loss through a single or multiple connected porous chambers. Less effective options for pressure redistribution in bed include the use of active or reactive mattress overlays. As few people with SCI are not at risk for developing pressure injuries, some type of pressure redistribution support surface should be routinely prescribed. For those with pressure injuries, a history of pressure injuries, or multiple risk factors for the development of pressure injuries, an active or reactive pressure redistribution mattress is indicated. It has been traditionally taught that persons with SCI and poor sensation need to be repositioned onto a different support surface every 2 hours, whether or not a pressure redistributing mattress is used. One standard turning position, which redistributes pressure from both the sacrum and the greater trochanters, requires a 30-degree angled, side-lying position, with pillows behind the back and between the knees. Another standard turning position is the prone position, with pillows placed under the thorax, pelvis, thighs, and shins relieving all bony prominences.

Pressure-relieving cushions designed for wheelchairs should be used to prevent pressure injuries over the ischial tuberosities, greater trochanters, and sacrum/coccyx in those who sit in a position where these bony prominences bears weight. Cushions can be composed of air, foam, gel, or some combination of these. It is also essential when sitting that pressure reliefs be performed approximately every 15 to 30 minutes for a duration of 2 minutes.45 Effective manual pressure relief techniques include a forward lean in the chair (thought to be the most effective if performed properly), a side to side lean, or a push-up. Moreover, individualized wheelchair seating systems that tilt and/or recline or allow standing should be prescribed to all persons who are unable to effectively perform these manual pressure reliefs on their own; powered seating systems if their living environment is accessible. Some power wheelchairs allow for standing functionality that can be used to remove pressure from traditional areas such as the ischia, but it should be noted that in these cases pressure is redistributed to other parts of the body and pressure reliefs are still essential in prevent pressure injuries. Stage 3 and 4 injuries might not heal in a timely fashion, depending on their location and size, and operative repair to close the defect is often indicated. Individuals who cannot tolerate surgery for medical reasons, who have a short life expectancy, or who are unlikely to protect the area of operative repair are poor candidates for operative repair. Successful operative repairs typically include excision of the ulcer, the surrounding scar, and the underlying necrotic or infected bone. The coverage is typically a regional pedicle flap that includes muscle and its blood supply. Postoperatively a person should be positioned off the surgical site for several weeks to allow healing. During this healing period, use of an alternating air mattress or high air loss (air fluidized) bed is recommended.