JOINT COMMITTEE ON HEALTH AND CHILDREN debate -
Thursday, 9 Nov 2006

National Spinal Injuries Centre: Presentation.

Chairman

We will now have a discussion with the National Spinal Injuries Centre, Mater Hospital, in respect of additional resources for the centre. I welcome Mr. Frank McManus, Mr. Ashley Poynton and Mr. Keith Synnott. I ask the delegation to commence its presentation on additional resources for the National Spinal Injuries Centre.

I draw the delegation's attention to the fact that while members of the committee have absolute privilege this same privilege does not apply to witnesses appearing before the committee. Members are also reminded of the long-standing parliamentary practice to the effect that members should not comment on, criticise or make charges against a person outside the House or an official by name or in such a way as to make him or her identifiable. The delegation will make a ten-minute presentation, followed by a 30-minute discussion with members and questions

Mr. Frank McManus

I thank the committee for inviting us to appear before it. Along with Martin Walsh, I was probably one of the founding surgeons of the centre approximately 20 years ago. Times have moved on and my colleague, Mr. Ashley Poynton, is now our lead surgeon and will make the presentation.

Mr. Ashley Poynton

I thank the committee for giving me the opportunity to present these data and discuss this issue with it. I will highlight the evolution of spinal surgery in Ireland and elsewhere. This puts the current issue in context.

In the past ten years, spinal surgery has advanced tremendously, both from a technical perspective and an expectation of outcome perspective. Both patients and surgeons have extremely high expectations of outcome in spinal surgery. Spinal surgery has become a specific subspecialty within orthopaedic surgery and surgeons are now specifically trained in spinal surgery. As with other forms of surgery, case mix and case volume are very important and determine surgical outcome. Surgeon competency is also very important which brings into question risk management issues. This is obviously very dependent on case mix, case volume and surgeon competency.

It is also evident both nationally and internationally that general orthopaedic surgeons are uncomfortable with spinal surgery and most are not willing to perform even basic spinal surgery. Many spinal surgeons are not prepared to perform highly complex, high risk spinal surgery because of case volume issues. In a country like Ireland, which has a population of approximately 4 million, the case volume in terms of highly complex spinal surgery is not significant. Therefore, only one, two or possibly three surgeons in a country this size are prepared to carry this type of surgery. It is well recognised both internationally and nationally that centralisation of specialist services is important, particularly where such services are high-tech and high cost. In respect of the Hanly report, centralisation of a subspecialty such as spinal surgery is important.

Spinal surgery is, in many cases, technically demanding. It requires a high level of training, and the complications associated with spinal surgery can be devastating and have major social and economic implications. Spinal surgery is also expensive both from a technical and implant perspective. Spinal implants, screws and rods are very expensive. It is high-tech surgery that demands high-tech equipment and instruments such as spinal cord monitoring. For an appropriate outcome, it must be carried out in a multidisciplinary environment, which requires a large team and appropriate infrastructure. Due to this evolution, there has been a centralisation of spinal surgery in Ireland. Many cases are now referred to tertiary referral centres and there are fewer of these centres performing complex spinal surgery.

The first page of this presentation broadly outlines the history of the National Spinal Injuries Centre. In 1990, Comhairle na nOspidéal recommended that the treatment of spinal injuries, particularly spinal cord injuries, be centralised into one unit. This report centred almost exclusively on spinal cord injury. It was estimated that the unit which would arise from this report would deal with 30 to 40 cases per annum. It would cater solely for spinal cord injuries. It made no provision for spinal trauma with neurological deficit and other spinal non-traumatic cases, including spinal cancer. Therefore, this centre evolved beyond what the unit was set up to do.

Over the past five years, our admissions have increased dramatically, as shown in the histograms in the presentation. We are currently dealing with approximately 300 admissions per annum, as opposed to what the unit was designed for, namely, 30 cases per annum. We have approximately 280 operative cases of spinal surgery, 185 of which are complex. Many of them are non-traumatic and many of them take considerable periods of time. Some cases will take an entire day to do and some complex deformity cases take over ten hours. We also provide other services, such as an emergency telephone contact service which receives approximately 50 referrals per month. These referrals are prioritised depending on whether patients need to be transferred urgently or whether they can be deferred to an outpatients department or a less acute environment.

Our case mix has changed from predominantly trauma to a 50:50 mix, with trauma and non-traumatic spinal conditions that are all acute. It is a consultant-delivered, 24-hour, seven-day, year-round service. No other centre in Ireland provides or can provide such a service. The benefits of this service are high quality expertise in spinal surgery performed in a single unit. It is also a single cost base. The purpose of this presentation is to highlight what we do as a unit, what we could provide and what we need.

We face certain logistical issues due to the following: increased workload, particularly in the past three years; increased case mix; an increase in the complexity of cases; and a rapidly changing surgical subspecialty. Major issues have arisen. The first issue is access to the unit. Patients with a neurological deficit related to trauma are immediately transferred, regardless of bed capacity. They are still transferred even if we do not have a bed. We deal with this situation and it does work. However, in respect of cases of acute, traumatised spinal injuries with neurology, for example, a person with an unstable cervical spine fracture or other associated injuries, the average delay in getting these patients to the unit is three days, which is considerable.

We also face issues relating to access to theatre because of the increased volume over a short period of time. Theatre access is now becoming a problem. It also has ramifications for non-spinal orthopaedic cases because we have one theatre for everything. This theatre deals with 1,600 cases per annum. Therefore, other cases, such as hip fractures, can be delayed for several days because of the significant impact of acute spinal cases on our surgical services. Our costs and staffing requirements have increased and our outflow is a major problem. We can touch on this matter later. Outflow, particularly of spinal cord injury patients, is a considerable problem and our average hospital stay for a person with a high spinal cord injury now runs at 71.7 days before the patient is transferred to rehabilitation services. Internationally, it should be approximately 20 days.

The question arises as to how we and the institution have responded to this increase in throughput. I must point out that this is a fairly recent event which took place over three to five years, particularly the past three years.

The hospital has prioritised spinal services in the 2005-07 corporate plan as an area requiring specific attention. A phased development plan has been drawn up and we are working with the HSE to implement it over a number of years. The new hospital will address many of these issues by increasing theatre capacity and potentially increasing bed capacity, but there will be a significant time lag before it is in place.

There are issues concerning acute rehabilitation. The National Rehabilitation Centre in Dún Laoghaire receives all our spinal cord injury cases, but it is not set up to take medically unstable patients or patients requiring significant assisted ventilation, such as occurs with high spinal cord injuries, etc. Therefore, those patients must be stabilised in the Mater Hospital, weaned off the ventilators and so on before they can be sent for rehab.

There is an urgent need for acute rehabilitation services in the general hospital setting so that patients can be stepped down to acute rehabilitation units and begin the rehabilitation process within what would be an internationally acceptable period after being injured, for example, 21 days. Most rehabilitation programmes should start soon after the injury occurs.

The last page of our submission contains a list of the categories into which our requirements can be put. Issues include staffing, the number of multidisciplinary teams must be increased substantially, infrastructure, bed capacity, operating theatre capacity, the need for an acute rehabilitation unit on site or on campus and ring-fenced annual funding that can lead to an expansion of services.

Deputy Connolly

I thank our guests for the presentation. While we have often been accused of looking for centres of excellence for everywhere, I agree that this type of work belongs at national level.

When discussing spinal injuries, we hear about hope, cures, stem cell research, etc. Will our guests comment on whether we can give people any hope because it is a significant issue for people who are injured and become paraplegics or whatever? We read about famous cases that can give us hope. Are our guests satisfied that the volume of work done by the national unit is sufficient? Does "national" refer to Northern Ireland?

Mr. Poynton

No.

Deputy Connolly

During the height of the Troubles, it was said that Belfast was the place to have surgery because of its volume of work. Will our guests elaborate on the matter of telephone X-ray consultations? How extensive is the waiting list and what further damage can accrue through waiting for spinal surgery? It is a traumatic experience, but there are times when people must wait to be dealt with in national units.

If the National Spinal Injuries Centre is looking for a consultant neurological spinal surgeon with a fixed sessional commitment to the unit, should I take it that the unit has none currently? That a consultant clinical psychologist, a clinical nurse specialist in spinal injuries and a critical care consultant are also being sought indicates that the centre has none. Are these not basic positions in a national unit?

Deputy McManus

I thank our guests for the presentation and congratulate them on their work, which is obviously difficult. The change that has taken place in a short period of time must put great pressure on staff and resources. Do our guests wish to comment in respect of the prevention of spinal injuries?

We are discussing doubling the number of beds to 20, which is not a significant increase. In itself, that would be manageable, but how have the Minister and the HSE responded? When I visited an oncology unit in Letterkenny, I was surprised to learn that it had been provided in just 18 months through fast systems of construction. I appreciate that this is not just a question of beds.

Why has access to theatres been reduced? I presume the centre does not expect to get its full complement of staff immediately, but we are not discussing a large number of consultants. The rehabilitation unit proposal for the Mater Hospital is essential. We have all encountered difficulties in enabling people to access the National Rehabilitation Centre at Rochestown Avenue. It is an ongoing problem. If a good rehabilitation unit is close to a hospital, one would have a better chance of reducing the average time spent in hospital and getting more throughput.

I am opposed to the focus on private hospitals on public lands. Building this type of rehab facility to ensure that the acute hospital is working well is the way to use public lands.

Mr. Keith Synnott

The comments on giving patients hope are relevant. Much of the changes taking place revolve around patient expectations. When the unit was developed two decades ago, patients' expectations were low and our provisions for them were limited, surgical options were often not availed of because they did not make significant differences to patients' outcomes and relatively low-tech nursing care was required. This is the background to the process.

As Mr. Poynton pointed out, the situation has changed dramatically in terms of what we can provide surgically, but much of it focuses on the mechanics of stabilising the spine to create an optimal environment in which to recover. Stem cells are an exciting development. I have liaised with Spinal Injuries Ireland, a patient group located at Rochestown Avenue, and the REMEDY institute in Galway, which is involved in a great deal of exciting stem cell research. While it focuses primarily on other areas of stem cell research, such as cartilage work, it is examining whether to conduct spinal cord injury work.

A reason to have a national unit that concentrates resources and has high volumes is to allow this kind of research and development to take place. We see patients who ask the questions asked by the Deputy, namely, what is the hope of recovery, will they walk again, what are we doing and how will it make a difference. Many of them are disappointed by how pessimistic we are, but thanks to these links, they are also reassured by how we know what is going on. Due to the existence of a centre that deals with stem cell research and these types of patients, we know what is happening in the academic world.

When REMEDY reaches the point of clinical trials, it will need centres like ours because we are in a good position — REMEDY is excited by the national centralised aspect. Any research it must do can be done in a controlled fashion. It has made further progress than companies which have invested in stem cell research would have us believe. We hope to provide a system to help develop this research. Stem cell research is at the exciting, sexy end of the hope one can offer patients with these devastating, life-threatening injuries. Hope is also provided by our expert multidisciplinary team for patients transferred to the Mater Hospital. Mr. Poynton does fantastic work but nurses, even though they are not psychologists, can also provide psychological support for patients. The porters can turn patients in a confident, competent manner, giving them hope. We must develop these ancillary services, a matter on which we are focused.

The services we provide have accelerated dramatically recently. We can provide an overview of where high-tech stem cell research is involved. Our nurses ensure patients do not get potentially devastating contractures or pressure sores. They also provide hope in respect of the rehabilitating function. Patients with high spinal cord injuries, who spend 77 days in the Mater, do not have access to someone who can teach them to drive again or get around the house. This function is as important as helping patients to walk again, which is often the main focus.

Mr. McManus

Deputy Connolly asked about the position in Northern Ireland. Very little expertise is passed from North to South — it never has and never will.

On staffing and the neurosurgeon post, a neurosurgeon has to make a two session commitment, primarily for consultation. He or she does not have a permanent list. We have been seeking a neurosurgeon for 20 years. When the previous neurosurgeon died, the neurosurgery system was restructured. Two centres, at St. Vincent's Hospital and the Richmond Hospital, were amalgamated at Beaumont Hospital. We require a neurosurgeon, as everyone knows. We also seek an additional orthopaedic spinal surgeon and a clinical psychologist. If one is paraplegic and lying in a bed in the Mater Hospital for 77 days, all one does is think about what has happened and what will happen. Male patients are rendered impotent. This requires much support to deal with the awful implications. We are not critical of the system and understand the great demands made on the health system but these patients are a subset who require tender loving care. I do not mean this in a condescending way.

Mr. Poynton

I will elaborate on the issue of telephone consultations. The unit is contacted by telephone. Hospitals contact the specialist registrar on call about the acute problems they encounter. The specialist registrar determines what is to be done in consultation with the consultant surgeon on call. Patients with serious spinal injuries and a neurological deficit are transferred immediately to the hospital. If the injury is serious but non-neurological, the arrival of the patient is dependent on the availability of a bed. We write up a list of cases on a board, deciding on the order by the level of injury. In many cases we ask to see X-rays before determining how urgent the case is and the manner by which the patient should be transferred. The X-rays are usually sent by courier. The consultant on call analyses them and determines a course of action. Many patients do not need to be transferred immediately and can be sent by ambulance to the fracture clinic the next day. They are placed in a brace, often custom made, and returned to the referring hospital on the same day. We deal with some 140 such cases per year.

In respect of cases that need to be transferred urgently, their arrival is dependent on bed availability. The lowest level is non-acute. Such cases are brought to the outpatient unit within one week. They are divided into surgical and non-surgical cases. Many are non-traumatic such as patients with secondary cancer in the spine and potentially unstable spines related to spinal cord compression. Many need to be dealt with surgically. We also deal with other disorders in the acute and non-acute setting. The telephone service is a method of providing a triage service. On Monday morning there are often between five and seven cases, with which we deal at a conference that morning.

We seek to increase our case volume and although it has increased significantly in recent years, it should be higher. Many cases that need surgical treatment are not being treated. This applies to spinal conditions such as deformity and spinal tumours rather than spinal trauma cases. With a high volume turnover in the unit and a low inpatient stay figure we can handle this.

Regarding waiting times and the harm that may be caused while patients are on a waiting list, there is a priority list in our unit's office rather than a waiting list in the acute services unit. The cases are not registered on the hospital list. Sometimes there are ten patients on the list and these are dealt with quickly. However, others take several days to reach us. Non-acute cases will be placed on an elective list in the Mater Hospital or Cappagh Hospital, where most non-urgent cases are handled.

A patient is admitted to the hospital if we believe he or she is at risk of neurological deterioration because of a spinal condition. In the majority of cases it is achieved. I frequently admit three urgent cases for surgery from my clinic on a Monday. The hospital is able to facilitate surgery that week, even in the current crisis. This is owing to bed management, the orthopaedic unit and the turnover of beds. Once we have dealt with a patient referred from another hospital, we transfer him or her to the hospital within several days of his or her surgical status stabilising, unless there is a neurological injury.

Prevention of injury is important and must be considered under national strategies. The most common reason for a spinal injury is a road traffic accident. This is linked to road safety awareness. Many of our cases were unrestrained passengers, while many have alcohol related injuries. The second most common cause of an injury is a fall. Some occur in industrial accidents, which is also linked to awareness. Domestic accidents are more common than industrial accidents, while sports injuries are a minority category.

Mr. Synnott

Prevention is a double edged sword. Death is often prevented but injuries occur. The increased workload is the result of people, who would not have survived in the past, using seat belts and airbags. Now they survive but suffer serious injuries. In the past, persons with significant high spinal cord injuries who could not breathe for themselves, such as Christopher Reeve, did not survive. These must be dealt with and acute rehab care has become a greater issue.

Several members focused on the issues of bed numbers and acute rehab, which are interrelated. The number of beds required does not seem excessive. However, high spinal cord injuries take up a great deal of bed-time. If we could use those beds more efficiently a bed which now treats one patient a month could treat ten patients a month. Accessing, stabilising and providing appropriate rehabilitation to patients are all related issues. If beds were used more efficiently we would not need as many as we do and it would become less of an issue.

A range of issues exist. They include prevention, acute care and how it can be best delivered locally, transfer to tertiary referral units and expeditious management of patients there, transfer to an appropriate place such as Rochestown Avenue or directly home from an acute centre with appropriate care. Patients face a broad range of implications.

Chairman

I will now take questions.

Deputy Devins

Like other members I welcome the delegation. On a personal level, I am delighted to see my former neighbour and fellow countyman leading the deputation. I also congratulate the unit. I am aware of the wonderful work done at the Mater. The public is not as aware as it might be of the work being done. As many of the questions I intended to ask have already been asked, I will be brief.

Mr. Synnott alluded to the average stay of 44 days. I presume patients are in acute surgical beds during that time but would be better served in a rehabilitative bed. At present, funding is through the Mater Hospital budget. Would the delegation prefer dedicated funding from the HSE? If so, the list included in section 5 of the delegation's requirements is necessary. How much will what is needed cost?

Deputy Twomey

Deputy Devins may have his next-door neighbour leading the delegation, but two of my former classmates make up the rest. I welcome the delegation. In 1990, Comhairle na nOspidéal wrote its report and estimated 40 cases per year. It seems amazing how far off it was. Does the delegation have an idea why it came about? Mr. Synnott suggested part of the reason was the dramatic increase in the number of cases that went through the unit between 1999 and 2005. Is that increase due to survival of patients at the primary site before transfer to the unit or has the number of cases increased because of survival from road traffic accidents? Does it have a major impact on the unit?

The committee would like a more overall picture of the situation. How does the Mater compare with international units? Many of the delegation's comments indicate the unit would be found deficient in an exact comparison with units in the United States. It was pointed out major problems exist in rehabilitation, not only with beds but also with the allied health professionals required to make the unit work to the best possible standard.

It seems almost ridiculous the unit does not have dedicated intensive care beds when we consider the unit carries out spinal surgery, ventilates patients and conducts extremely complex procedures. Across the spectrum, from intensive care unit beds to the most basic rehabilitation services, it seems the unit is dramatically under resourced.

There was a reference to the necessity of a neurosurgeon. Should the National Spinal Injuries Centre, the neurosurgical unit in Beaumont, and a rehabilitation unit all be at one site? Is that a way forward for tertiary services and the type of work done? Should tertiary services be more amalgamated and take in what is done by the spinal injuries centre, neurosurgeons and other specialised services scattered throughout the acute hospitals in Dublin?

The unit conducts general orthopaedic work along with spinal work in one theatre. Approximately 40 cases are dealt with per week in that theatre and the spinal unit accounts for five or six of those. How does the unit prevent hospital acquired infections? One of the greatest fears about orthopaedic surgery, particularly where the site has a poor blood supply, is MRSA. A good deal is stated about MRSA. Does the unit have a problem with hospital acquired infections, particularly MRSA, and how are they prevented?

They are my basic questions and I appreciate they are on a broad range of issues. I hope the delegation will deal with them.

Mr. McManus

I do not wish to be critical but one of the differences between orthopaedic surgeons and others is that we grew up in the era when orthoplasty was introduced. Orthoplasty is an aseptic technique. It is traditional and carried out extremely carefully. That has spilled over into other areas of implantation, particularly in the spine. We take great care to eliminate hospital acquired infection. Ward rules on procedures are laid down carefully. We have all had cases of MRSA infection but it is not a significant problem.

It goes back to basic principles of good surgical technique, almost old-fashioned total asepsis. It is the way we have always worked when putting in a hip or a knee. It is not a casual procedure and the technique falls into other procedures where metal is implanted. That is the main reason we do not have as large a problem as one might think with MRSA. Implanting a typical plate is an extremely delicate, precise and non-agressive surgery. It is not forced, it is gentle. Tissue damage is minimised.

Mr. Poynton

I will also comment on this. Due to heightened awareness of hospital acquired infection we established an infection control subcommittee for orthopaedic and spinal injuries. It has been in place since the start of this year. The hospital provided us with an infection control nurse to institute a surveillance programme of infection in the unit. We addressed our antibiotic prophylactics specifically with regard to spinal cases and we changed our policy to be in line with that of the cardiothoracic unit. We also specifically examined our practice in theatre. We were proactive as well as having the usual orthopaedic paranoia about infection.

Mr. Synnott

It is correct to state we do not have dedicated intensive care beds. However we are lucky because the Mater has a large intensive care unit, probably because it is allied to the national cardiothoracic centre. Our intensivists are excellent and they show great commitment to spinal injuries patients. These patients have major intensive care requirements, particularly the high quads. Our intensivists take more than a passing interest in aggressively weaning tracheostomised patients. We are also moving towards designation of high dependency unit beds in our spinal unit. They do not yet have ventilation capacity but we are introducing less invasive respiratory systems such as the Nippy ventilator and continuous positive airway pressure, CPAP, which offer more support in that regard. One of the needs outlined by Mr. Poynton was for an intensive care or respiratory specialist with an interest in weaning because a patient who needs a ventilator or has received a tracheotomy has greater requirements than someone who is paraplegic or low quadriplegic.

With regard to the number of cord injuries, the discrepancy between the 1990 report and what we see now reflects an expansion in the type of work being carried out rather than a change in absolute numbers. The incidence of spinal cord injuries has probably increased in proportion to demographic increases. The unit was not set up to take patients with non-cord injury spinal trauma because the idea was that patients who suffered unstable spinal column injuries but did not have neurological complications would be treated elsewhere. However, changes in medicine and societal expectations mean that virtually all spinal trauma cases present to the Mater Hospital. That would account for a significant percentage of the numbers.

It was also intended that patients suffering acute disc prolapses without significant neurological complications would be treated locally. However, such patients are also presenting to the Mater because we have 24-hour surgery facilities and the only MRI scanner in the country available 24 hours per day, seven days per week. We now recognise that tumour cases, which were traditionally regarded with a certain degree of therapeutic nihilism, can benefit from aggressive surgical intervention, and that is also increasing our workload. The numbers, therefore, reflect an expansion of the range of cases treated rather than an increase in the numbers of cord injuries.

Mr. McManus

With regard to Deputy Devin's observation on the 44 days and the average day, changes have taken place in the National Rehabilitation Hospital. When I started practising in 1978, the NRH had an intensive care unit because it took all the spinal cord injuries in the country. It had to provide ventilation because patients used to be treated conservatively. With the evolution of care, that facility is no longer available in the NRH, which means that it can no longer look after patients who require ventilation. The patients who were previously treated there are now sent to the Mater, with the result that their stays are prolonged.

The original concept was that patients who had unstable spinal injuries without neurological complications would be sent to the spinal injuries unit to have their fractures stabilised, which allowed for rapid rehabilitation. Healing of even partial damage would have been accelerated because the spine would have been stabilised and the patient would not have been forced to lie in bed for four months before standing up. The reason that has not come to pass is because of the inevitable evolution of care in the two institutions.

Deputy Devins

To clarify the matter, the patient will move to a rehabilitation unit after having surgery.

Mr. McManus

We do not have the ability we originally thought we would possess in terms of being able to stabilise patients so that they could be rapidly transferred to the NRH, which would have been able to care for them even if they needed ventilation. The ability of the NRH to provide that service has diminished as a result of the evolution of medical care and the changing roles of nurses and intensive care specialists. Major changes have taken place since the first spine was instrumented in 1983, in societal expectations as well as in medicine.

Deputy Twomey

What is Mr. McManus's opinion of the amalgamation of tertiary services?

Mr. McManus

It depends on the side of the fence on which one wishes to sit. I presume neurosurgeons centralise their services for the same reasons we centralise spinal trauma treatment. Centralisation permits a group of specialists to work together and build relationships through case conferences and consultations. While we do not need a neurosurgeon seven days per week, we need a formal staff member who would, if necessary, become involved in cases. Deputy Twomey's suggestion on amalgamating neurosurgery, spinal surgery and rehabilitation services is reasonable and was briefly mentioned in the HSE report on services in the north east, but its implementation would require significant work.

Chairman

We thank the witnesses for their presentations. I wish this committee had the authority to increase the budget for health services, but it does not. We will, however, send a transcript of the presentations to the Minister for Health and Children for her consideration as she begins her Estimates campaign. We hope to meet either the Minister or Professor Drumm in the next few weeks, so we will express our support for the witnesses' requests at that meeting.

Sitting suspended at 10.35 a.m. and resumed at 10.40 a.m.