"What pressure ulcers mean to me?" Representations of pressure ulcer in persons with spinal cord injury: A qualitative study

Protocol for the Development of the Fourth Edition of the Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline Using GRADE Methods

ABSTRACT

The National Pressure Injury Advisory Panel, European Pressure Ulcer Advisory Panel, and the Pan Pacific Pressure Injury Alliance are commencing a new (fourth) edition of the Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline . The fourth edition of the International Pressure Injury (PI) Guideline will be developed using GRADE methods to ensure a rigorous process consistent with evolving international standards. Clinical questions will address prevention and treatment of PIs, identification of individuals at risk of PIs, assessment of skin and tissues, and PI assessment. Implementation considerations supporting application of the guidance in clinical practice will be developed. The guideline development process will be overseen by a guideline governance group and methodologist; the guideline development team will include health professionals, educators, researchers, individuals with or at risk of PIs, and informal carers.This article presents the project structure and processes to be used to undertake a systematic literature search, appraise risk of bias of the evidence, and aggregate research findings. The methods detail how certainty of evidence will be evaluated; presentation of relative benefits, risks, feasibility, acceptability, and resource requirements; and how recommendations will be made and graded. The methods outline transparent processes of development that combine scientific research with best clinical practice. Strong involvement from health professionals, educators, individuals with PIs, and informal carers will enhance the guideline's relevance and facilitate uptake. This update builds on previous editions to ensure consistency and comparability, with methodology changes improving the guideline's quality and clarity.

A narrative review of patients' lived experience of having a pressure injury

AIM

To explore patients' experiences of living with pressure injuries.

DESIGN

A qualitative narrative review and thematic synthesis of qualitative research studies.

DATA SOURCES

Six electronic databases were searched: Medline, CINAHL, Scopus, Web of Science, Embase, and Google Scholar (for grey literature). The search was conducted between October 2022 and April 2023. Setting: Acute, community and care home settings across the UK, France, Belgium and the US.

REVIEW METHODS

The PRISMA checklist for reporting systematic reviews was used. The included studies were evaluated for quality using the CASP tool. The Joanna Briggs Institute data extraction tool was used to extract data from the included studies. Thematic synthesis was used to identify themes to present a coherent and nuanced understanding of patients' experiences of living with pressure injuries.

RESULTS

Nine studies involving 244 participants, aged 21 to 101, with pressure injuries, met the inclusion criteria. Three key themes emerged using thematic analysis: physiological, emotional and psychological, and social effects. Within these themes, subthemes such as endless pain and discomfort, loss of mobility and independence, and social isolation were dominant in all aspects of the lives of patients living with pressure injuries.

CONCLUSIONS

This narrative review gives clear and multifaceted insight into the impact of pressure injuries on individuals' lives, emphasising the necessity for patient-centred care and the integration of evidence-based tools for effective pain management and risk assessment. The impact of pain on emotional and psychological wellbeing was significant, and the financial implications are scarcely known. Future research is needed to explore the experiences of younger adults and the financial consequences of living with pressure injuries.

Pressure ulcers acquired during inpatient rehabilitation after spinal cord injury, characterization and predictors: A 15-years' experience

BACKGROUND

Most studies focus on the risk factors associated with the development of pressure ulcers (PUs) during acute phase or community care for individuals with spinal cord injury (SCI).

OBJECTIVES

This study aimed to i) compare clinical and demographic characteristics of inpatients after SCI with PUs acquired during rehabilitation vs inpatients without PUs and ii) evaluate an existing PU risk assessment tool iii) identify first PU predictors.

METHODS

Individuals (n = 1,135) admitted between 2008 and 2022 to a rehabilitation institution within 60 days after SCI were included. Admission Functional Independence Measure (FIM), American Spinal Injury Association Impairment Scale (AIS) and mEntal state, Mobility, Incontinence, Nutrition, Activity (EMINA) were assessed. Kaplan-Meier curves and Cox proportional hazards models were fitted.

RESULTS

Overall incidence of PUs was 8.9%. Of these, 40.6% occurred in the first 30 days, 47.5% were sacral, 66.3% were Stage II. Patients with PUs were older, mostly with traumatic injuries (67.3%), AIS A (54.5%), lower FIM motor (mFIM) score and mechanical ventilation. We identified specific mFIM items to increase EMINA specificity. Adjusted Cox model yielded sex (male), age at injury, AIS grade, mFIM and diabetes as PUs predictors (C-Index = 0.749).

CONCLUSION

Inpatients can benefit from combined assessments (EMINA + mFIM) and clinical features scarcely addressed in previous studies to prevent PUs.

Barriers and facilitators to implementing pressure injury prevention and management guidelines in acute care: A mixed-methods systematic review

BACKGROUND

Evidence-based pressure injury prevention and management is a global health service priority. Low uptake of pressure injury guidelines leads to compromised patient outcomes. Understanding clinicians' and patients' views on the barriers and facilitators to implementing guidelines and mapping the identified barriers and facilitators to the Theoretical Domains Framework and behaviour change techniques will inform an end-user and theoretically informed intervention to improve guideline uptake in the acute care setting.

OBJECTIVES

To synthesise quantitative and qualitative evidence on i) hospital clinicians' and inpatients' perceptions and experiences of evidence-based pressure injury practices and ii) barriers and facilitators to implementing guidelines.

DESIGN

A convergent integrated mixed-methods systematic review was conducted using the JBI approach.

DATA SOURCE

English language peer-reviewed studies published from 2009 to August 2022 were identified from MEDLINE, EMBASE, CINAHL, PsycINFO and Cochrane Central Library.

REVIEW METHODS

Included studies reported: i) acute care hospital clinicians' and patients' perceptions and experiences of evidence-based pressure injury practices and ii) barriers and facilitators to implementing guidelines. The Mixed Methods Appraisal Tool was used for critical appraisal. Quantitative data was transformed into qualitised data, then thematically synthesised with qualitative data, comparing clinicians' and patients' views. Barriers and facilitators associated with each main theme were mapped to the Theoretical Domains Framework and allocated to relevant behaviour change techniques.

RESULTS

Fifty-five out of 14,488 studies of variable quality (29 quantitative, 22 qualitative, 4 mixed-methods) met the inclusion criteria. Four main themes represent factors thought to influence the implementation of evidence-based guidelines: 1) nurse-led multidisciplinary care, 2) patient participation in care, 3) practicability of implementation and 4) attitudes towards pressure injury prevention and management. Most barriers identified by clinicians were related to the third theme, whilst for patients, there were multiple barriers under theme 2. Barriers were mainly mapped to the Knowledge domain and Environmental Context and Resources domain and were matched to the behaviour change techniques of "instruction on how to perform a behaviour" and "restructuring the physical environment". Most facilitators mentioned by clinicians and patients were related to themes 1 and 2, respectively, and mapped to the Environmental Context and Resources domain. All patient-related attitudes in theme 4 were facilitators.

CONCLUSIONS

These review findings highlight the most influential factors related to implementing evidence-based pressure injury care from clinicians' and patients' views and mapping these factors to the Theoretical Domains Framework and behaviour change techniques has contributed to developing a stakeholder-tailored implementation intervention in acute care settings.

PROSPERO REGISTRATION

CRD42021250885.

Effects of lower limb exoskeleton gait orthosis compared to mechanical gait orthosis on rehabilitation of patients with spinal cord injury: A systematic review and future perspectives

OBJECTIVE

We aimed to systematically evaluate the walking efficiency of lower limb exoskeleton gait orthosis and mechanical gait orthosis in patients with spinal cord injury.

DATA SOURCES

Databases searched included: Web of Science, MEDLINE, Cochrane Library and Google Scholar.

STUDY SELECTION

Articles published in English from 1970 to 2022 investigating the impact of lower limb exoskeleton gait orthosis versus mechanical gait orthosis on gait outcomes in patients with spinal cord injury were considered.

DATA EXTRACTION

Two researchers independently extracted data and filled out predesigned forms. Information including authors, year of study, methodological quality, participant characteristics, intervention and comparison details, outcomes and results. The primary outcomes were kinematic data; the secondary outcomes were clinical tests.

DATA SYNTHESIS

Data synthesis using meta-analysis was not possible due to the diversity of study designs, methodologies, and outcome measures.

RESULTS

A total of 11 trials and 14 types of orthotics were included. The information gathered generally supported the gait improving effects of lower limb exoskeleton gait orthosis and mechanical gait orthosis in both kinematic data and clinical tests among patients with spinal cord injury.

CONCLUSIONS

This systematic review compared walking efficiency of patients with spinal cord injury wearing powered exoskeleton gait orthosis and non-powered mechanical gait orthosis. Due to the limited quality and quantity of the included studies, more high-quality studies are needed to verify the above conclusions. Future research should focus on improving trial quality and comprehensive parametric analysis of subjects with different physical conditions.

Spinal Cord Injury Patient's Physical and Psychological Care Needs at Home from Patients’ and Caregivers’ Perspectives: A Qualitative Study

Background: Limited studies have attempted to identify the care needs of patients with spinal cord injury (SCI) and their professional caregivers at home and after discharge from the hospital. However, little information about these needs has led to increased physical and psychological complications and thus a reduced quality of life in SCI patients. Objectives: This study aimed to explain the experiences of patients and their caregivers regarding physical and psychological care needs at home. Method: This qualitative descriptive study was conducted on 24 SCI patients and their professional caregivers using the conventional content analysis. Data were collected through unstructured and semi-structured interviews. Purposeful sampling was continued until data saturation was reached. The conventional content analysis approach proposed by Graneheim and Lundman (continuous comparison) was used to analyze the data. Results: The age range of the participants was 29 - 48 years, with an average age of 37.8 years. Seven of the participants had paraplegia, and three of them had tetraplegia. The results of data analysis led to the extraction of two main categories, including physical and psychological care needs. Conclusions: By identifying the real needs of patients after discharge from the hospital, we emphasize the need to remove barriers to home health care services and provide more financial support to meet patients' needs. Therefore, policymakers are encouraged to use the results of this study to plan at-home patient care services.

Lessons learned from patients with spinal cord injury in managing pressure ulcers: A qualitative study

OBJECTIVES

To explore how individuals with spinal cord injury self-manage the prevention and treatment of pressure ulcers and to provide insight into experiences with self-management support.

DESIGN

Qualitative study using semi-structured interview and a deductive thematic analysis.

SETTING

Community.

PARTICIPANTS

Twelve of the 14 participating adults with a spinal cord injury had experience with pressure ulcers, and eight of these had a current pressure ulcer.

RESULTS

Respondents suggested to tailor treatment of pressure ulcers to patients' individual wishes and capabilities of patients. Patients and caregivers need to be aware of the importance of determining the cause of pressure ulcers to prevent deterioration. Patients often depend on informal caregivers for follow-up and prevention, and healthcare professionals in non-SCI specialties often lack the knowledge needed to manage pressure ulcers in this specific patient group. Tailored education and peer support are important for patients to set boundaries, be assertive, and cultivate a positive attitude when dealing with pressure ulcers. It is difficult to combine treatment of severe pressure ulcers and preventive measures with work roles. Managing the social impact of pressure ulcers requires more coordination with caregivers.

CONCLUSIONS

To support self-management of pressure ulcers in patients with a spinal cord injury, they must find out which preventive measures and treatments suit them best. Healthcare professionals play an important role in the self-management of pressure ulcers and can help patients deal with the emotional and social impact of pressure ulcers. To know patient's needs and tailor their education, healthcare professionals of non SCI organizations need to have knowledge of pressure ulcers management of this specific patient group.