skip to page content
Talk to the Veterans Crisis Line now
U.S. flag
An official website of the United States government

Health Services Research & Development

Go to the ORD website
Go to the QUERI website

Spotlight: Improving Care for Veterans with Spinal Cord Injuries and Disorders

April 2013

VA provides care for approximately 26% of individuals with spinal cord injury and disorders (SCI/D) in the United States, making it the single largest network of care for persons with SCI/D. In 2011, VA provided a full range of care to more than 27,000 Veterans with SCI/D. Although the number of SCI/D cases is relatively small compared to many other chronic conditions, it is a complex condition with costs 6.5 times greater than the average Veteran receiving VA healthcare. The annual cost per VA patient with SCI/D is $44,696; however, new onset SCI/D and higher level injuries (especially ventilator dependent tetraplegia, and institutional long-term care) are much more costly. For example, the average cost for a Veteran with high tetraplegia (C1-C4) is $801,161 in the first year, and $143,507 in each subsequent year.

Complications and Clinical Conditions

The Spinal Cord Injury Quality Enhancement Research Initiative (SCI-QUERI) focuses on several complications and comorbidities associated with SCI/D. Prevention and management of infections has been one critical and ongoing area of research and implementation efforts for SCI-QUERI due to their impact on morbidity and mortality among Veterans with SCI/D.


Weak respiratory muscles, impaired cough, and less effective clearance of secretions are common sequelae following SCI/D.1 Due to this impaired respiratory function, individuals with SCI/D are at extremely high risk from respiratory complications that occur as a result of contracting influenza or other respiratory illnesses.2 The single most effective way to prevent influenza, or severe consequences from influenza, is vaccination. SCI-QUERI's efforts have made, and continue to make significant contributions to patient safety and healthcare quality by improving vaccination and respiratory infection control practices in VA SCI/D healthcare settings. These include:

  • Increasing influenza rates from 28% in 2000 to 79% in 2010, and pneumococcal pneumonia rates from 40% in 2000 to 94% in 2010 in Veterans with SCI/D;
  • Developing and disseminating educational materials that clarify misconceptions regarding respiratory infections and vaccinations in Veterans with SCI/D and healthcare workers (toolkit and DVD for Veterans with SCI/D);
  • Facilitating the modification of the VA computerized clinical reminder for vaccination to include all Veterans with SCI/D, regardless of age;
  • Providing the impetus for VA to include SCI/D in its list of high-priority groups for vaccination in annual influenza vaccine policy memos and for the Centers for Disease Control and Prevention (CDC) 2005 influenza prevention guidelines to identify SCI/D as one of the high-risk categories for influenza vaccination.

SCI-QUERI also has taken steps to improve healthcare worker (HCW) vaccination rates, however, they remain low. VA's goal for influenza vaccination of HCWs is 85%. Although national rates are slowly increasing, the rates for SCI healthcare workers have been consistently at about 50% for several years, 3,4 and were even lower during a pandemic season when HCWs were prioritized for vaccine receipt. For example, the 2009-2010 seasonal fCWs ext steps are to e focused on assessing current HCW vaccination rates. d their ty of additional venues. itted his first Iinfluenza vaccination rate for healthcare workers of Veterans with SCI/D was 48%.5,6 A study is underway (LaVela, RRP 12-515), in collaboration with SCI/D Services and the Office of Public Health, to implement a declination form program strategy to improve influenza vaccination acceptance among VA HCWs.


In the U.S., an estimated 1.7 million healthcare-associated infections (HAIs) lead to more than 98,000 deaths each year. Infection with multidrug-resistant organisms (MDROs), such as Methicillin-resistant Staphylococcus aureus (MRSA), complicate the management and prevention efforts for HAIs due to increased resistance to first-line antibiotics and their increasing spread across healthcare facilities and community settings.

Individuals with SCI/D have an especially high risk of HAIs because of frequent and prolonged hospitalizations, use of invasive devices, chronic pressure ulcers, and frequent antibiotic use. MRSA and Clostridium difficile (a diarrheal infection) are frequent causes of infection and are associated with increased morbidity, mortality, and healthcare costs. In the VA, MRSA colonization prevalence at acute care admission of Veterans with SCI/D is approximately 38%, which is significantly higher than the general Veteran population.

SCI-QUERI is collaborating with the VA SCI/D Services and the VA MDRO Program Offices to evaluate VA's National MRSA Prevention Initiative in SCI units. The Prevention Initiative was rolled out to all VA acute care facilities in 2007 and includes a bundled strategy of:

  • Identifying patients colonized with MRSA at hospital admission,
  • Placing colonized patients in contact precaution where providers wear gowns and gloves,
  • Emphasizing hand hygiene, and
  • Supporting culture change to reduce MRSA infection and transmission.

In collaboration with these operations partners, SCI-QUERI has evaluated current practices and barriers with implementation of the MRSA Prevention Program.

QUERI also developed, tested and disseminated the SCI/D MRSA educational toolkit (called the SCI/D MET - available on the intranet only at for providers to use to educate Veterans with SCI/D and their informal caregivers about MRSA.7 Some of the findings from these collaborations are highlighted in a recently published article8 showing MRSA infection rates have declined by 81% in this patient population.

SCI-QUERI continues to conduct work to reduce HAIs and transmission of MDROs, and is currently developing a study to improve contact precautions adherence and efficiency in the use of gowns and gloves, as well as an implementation study to roll-out the SCI/D MET nationally.


  • For more information related to spinal cord injury, please visit SCI-QUERI 'links'


  • Wilmot C and Hall K. The respiratory system. In: Whiteneck GG, Charlifue SW, Gerhart KA, Lammertse DP, Manley S, Menter RR, Seedroff KR. Aging with Spinal Cord Injury. Demos Publications, New York; 1993:93-104.
  • DeVivo M, Black K, and Stover S.Causes of death during the first 12 years after spinal cord injury. Arch Phys Med Rehabil.1993;74(3):248-54.
  • LaVela S, Goldstein B, Smith B, and Weaver M. Working with symptoms of a respiratory infection: Staff who care for high-risk individuals . Am J Infect Control. 2007;35(7):448-54.
  • LaVela S, Smith B, Weaver F, et al. Attitudes and practices regarding influenza vaccination among healthcare workers providing services to individuals with spinal cord injuries and disorders . Infect Control Hosp Epidemiol. 2004;25(11):933-40.
  • LaVela S. 2009 H1N1 Pandemic and Seasonal Influenza in SCI/D: Infection Control Strategies ( RRP 10-046). Final Report. Hines, IL: Hines Veterans Affairs Hospital; 2011.
  • LaVela S, Goldstein B, Etingen B, et al. Factors associated with H1N1 influenza vaccine receipt in a high risk population during the 2009-2010 H1N1 influenza pandemic . Topics in Spinal Cord Injury Rehabilitation. 2012;18(4):306-314
  • Hill J, Evans C, Cameron K, et al. Patient and provider perspectives on methicillin-resistant Staphylococcus aureus: A qualitative assessment of knowledge, beliefs, and behavior. J Spinal Cord Med. 2013;36(2):82-90.
  • Evans M, Kralovic S, Simbartl L, et al. Prevention of methicillin-resistant Staphylococcus aureus infections in spinal cord injury units . Am J Infect Control, 2012;Nov doi: 10.1016/j.ajic.2012.06.006. [Epub ahead of print].
  • For more information, please contact SCI-QUERI's Administrative Coordinator, Dolores Ippolito, M.P.H., at 708-202-5896 or

    Questions about the HSR&D website? Email the Web Team

    Any health information on this website is strictly for informational purposes and is not intended as medical advice. It should not be used to diagnose or treat any condition.