Does the Acute Care Spinal Cord Injury Setting Predict the Occurrence of Pressure Ulcers at Arrival to Intensive Rehabilitation Centers?

Complications Associated with Preventive Management to Reduce the Risk of COVID-19 Spread After Surgery for Spinal Cord Injury

BACKGROUND

Preventive management to reduce the risk of coronavirus disease-2019 (COVID-19) spread led to delays in active rehabilitation, which may have negatively impacted the outcomes of patients with traumatic spinal cord injury (SCI). Therefore, the aim of this study was to clarify the influence of preventive management on the rate of perioperative complications after surgical treatment for SCI.

METHODS

This single-center retrospective study examined the cases of 175 patients who had SCI surgery between 2017 and 2021. We could not continue early rehabilitation interventions starting on April 30, 2020, because of our preventive management to reduce the risk of COVID-19 spread. Using a propensity score-matched model, we adjusted for age, sex, American Spinal Injury Association impairment scale score at admission, and risk factors for perioperative complications described in previous studies. Perioperative complication rates were compared between the COVID-19 pandemic and prepandemic groups.

RESULTS

Of the 175 patients, 48 (the pandemic group) received preventive management. The preliminary analysis revealed significant differences between the unmatched pandemic and prepandemic groups with respect to age (75.0 versus 71.2 years, respectively; p = 0.024) and intraoperative estimated blood loss (152 versus 227 mL; p = 0.013). The pandemic group showed significant delays in visiting the rehabilitation room compared with the prepandemic group (10 versus 4 days from hospital admission; p < 0.001). There were significant differences between the pandemic and prepandemic groups with respect to the rates of pneumonia (31% versus 16%; p = 0.022), cardiopulmonary dysfunction (38% versus 18%; p = 0.007), and delirium (33% versus 13%; p = 0.003). With a propensity score-matched analysis (C-statistic = 0.90), 30 patients in the pandemic group and 60 patients in the prepandemic group were automatically selected. There were significant differences between the matched pandemic and prepandemic groups with respect to the rates of cardiopulmonary dysfunction (47% versus 23%; p = 0.024) and deep venous thrombosis (60% versus 35%; p = 0.028).

CONCLUSIONS

Even with early surgical intervention, late mobilization and delays in active rehabilitation during the COVID-19 pandemic increased perioperative complications after SCI surgery.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Guidelines for management of pediatric acute hyperextension spinal cord injury

Pediatric acute hyperextension spinal cord injury (SCI) named as PAHSCI by us, is a special type of thoracolumbar SCI without radiographic abnormality and highly related to back-bend in dance training, which has been increasingly reported. At present, it has become the leading cause of SCI in children, and brings a heavy social and economic burden. Both domestic and foreign academic institutions and dance education organizations lack a correct understanding of PAHSCI and relevant standards, specifications or guidelines. In order to provide standardized guidance, the expert team formulated this guideline based on the principles of science and practicability, starting from the diagnosis, differential diagnosis, etiology, admission evaluation, treatment, complications and prevention. This guideline puts forward 23 recommendations for 14 related issues.

Frequency of turning in bed at home in persons with chronic spinal cord injury

Objective: To determine the routine turning frequency of persons with chronic spinal cord injury (SCI) in bed at night in their home environment.Design: An online questionnaire consisting of 22 questions.Setting: Free standing SCI rehabilitation facility.Participants: Persons between ages 18-75 with a traumatic SCI for ≥3 months, and living at home.Interventions: None.Outcome measures: Questionnaire-based evaluation of turning frequency of persons with SCI.Results: 86 subjects (70 men) with traumatic SCI completed the survey; 66.3% with tetraplegia and 41.9% with a neurological complete SCI. Almost every participant (96%) recalled being counseled on the importance of turning in bed at night upon discharge from their rehabilitation facility with 48.4% recalling the frequency recommended as every 2 h. At present, 25.6% of subjects reported turning every 2 h, 15.1% every 3 h, 15.1% every 4 h, 3.5% every 6 h, and 40.7% of respondents stated that they do not turn regularly at night.Conclusion: Although frequently recommended for repositioning at night in bed every two hours for persons with chronic SCI, especially for those at risk for pressure injuries, only 25.6% of individuals report turning at this frequency and 40.7% report not turning at night time regularly. The reasons for limited turning may be multi-factorial, however, this finding may serve as a call to practitioners to best determine the most appropriate turning frequency that can meet compliance of the individual with SCI, as well as maintain skin protection in the chronic period after injury.

Exploring the first pressure injury and characteristics of subsequent pressure injury accrual following spinal cord injury

Context/Objective: Clinicians have guidance on prevention and treatment of pressure injuries, but little is known regarding characteristics of patients who develop additional pressure injuries. Thus, our objective was to explore the first pressure injury and characteristics of individuals who develop subsequent pressure injuries during acute care and inpatient rehabilitation following spinal cord injury.Design: Secondary analysis of longitudinal data from a cohort of adults following initial traumatic spinal cord injury.Setting: Urban acute care hospital and inpatient rehabilitation facilities.Participants: A convenience sample of adults (n = 38) who developed at least one pressure injury during acute care and inpatient rehabilitation.Interventions: Not applicable.Outcome Measures: The primary outcomes were number of additional pressure injuries and stage of care during which they occurred, prior to community discharge.Results: A covariate-adjusted model revealed that participants with ASIA D injury had a 67% decrease in the rate of additional pressure injury incidence compared to participants with ASIA A injury (Rate Ratio = .33, 95% CI [0.13, 0.88]). The severity of the first pressure injury had no significant association with subsequent pressure injury incidence (P = .10).Conclusion: These findings indicated that individuals with greater sensory and motor loss had an increased risk of developing additional pressure injuries compared to individuals with less impairment. These results are meaningful for stakeholders interested in understanding factors associated with developing subsequent pressure injuries during the index rehabilitation stay and provide a foundation for future research in this area.

Decreasing pressure injuries and acute care length of stay in patients with acute traumatic spinal cord injury

OBJECTIVES

Identifying factors associated with the occurrence of pressure injuries (PI) during acute care and with longer length of stay (LOS), focusing on modifiable factors that can be addressed and optimized by the acute rehabilitation team.

DESIGN

Prospective cohort study.

SETTING

A single Level-1 trauma center specialized in SCI care.

PARTICIPANTS

A cohort of 301 patients with acute TSCI was studied.

OUTCOME MEASURES

The primary outcome was the occurrence of PI during acute care stay. The secondary outcome was acute care LOS. Bivariate and multivariate logistic or linear regression analyses were performed to determine the association between non-modifiable factors and outcomes (PI of any stage and acute LOS), whereas bivariate and hierarchical multivariate logistic or linear regression analyses were used for modifiable factors.

RESULTS

When controlling for the level and severity of the TSCI, the occurrence of pneumonia (OR = 2.1, CI = 1.1-4.1) was significantly associated with the occurrence of PI. When controlling for the level and severity of the TSCI, the occurrence of medical complications (PI, urinary tract infection and pneumonia) and lesser daily therapy resulted in significantly longer acute care LOS (P < .001).

CONCLUSIONS

Prevention of PI occurrence and the optimization of the acute care LOS represent crucial challenges of the acute rehabilitation team, as they are significantly associated with higher functional outcomes. Patients who develop pneumonia may benefit from more aggressive prevention strategies to reduce PI occurrence. Systematic protocols for the prevention of complications as well as greater volume of therapy interventions should be considered to optimize the acute care LOS.

Surgical reconstruction of pressure ulcers in spinal cord injury individuals: A single- or two-stage approach?

INTRODUCTION

There are two surgical approaches to reconstruct a pressure ulcer (PU): one-stage reconstruction or two-stage reconstruction. One stage reconstruction consists of surgical debridement and flap reconstruction during one operation. Two-stage surgery consist of a surgical debridement and a final reconstruction in two different sessions, with approximately six weeks between both sessions.

OBJECTIVE

The aim of this study was to compare the results of single stage surgery and two-stage surgery on the PU recurrence rate and other important post operative complications.

METHOD

A retrospective, comparative study in Spinal Cord Injured (SCI) individuals with a single- or two stage surgical reconstruction between 2005 and 2016 was designed. A total of 81 records were included for analysis.

RESULTS

The primary outcome, the difference in occurrence of a recurrent PU in the reconstructed area (33.3% versus 31.6%), is not statistically significant between one-and two-stages reconstruction. Also, the mean duration to develop a recurrent PU between both surgical reconstructions is not statistically significant. Other surgical complications in the reconstructed area like wound hematoma, hemorrhage, seroma or (partial) flap failure did not differ significantly between both groups, apart and in total. We calculated the additional costs in case of a two-stage approach compared with a single-stage reconstruction at EUR 16,362.

CONCLUSIONS

There are no statistical significant differences in PU recurrence rate or other post operative complications between SCI patients who have undergone one- or two stage PU reconstructive surgery. The most obvious choice for a one-stage approach in case of PU reconstructive surgery has great positive implications for the patient, family, health care providers and the health care system.

Development of the spinal cord injury pressure sore onset risk screening (SCI-PreSORS) instrument: a pressure injury risk decision tree for spinal cord injury rehabilitation

STUDY DESIGN

Psychometric study based on retrospectively collected data.

OBJECTIVE

Development of a pressure injury (PI) risk screening instrument for use during spinal cord injury (SCI) rehabilitation.

SETTING

Tertiary rehabilitation center.

METHODS

Medical charts of 807 inpatients participating in SCI rehabilitation were reviewed. Two models (recursive partitioning and logistic regression) were developed with demographic and Functional Independence Measure (FIM) variables and compared with the SCI Pressure Ulcer Scale (SCIPUS, n = 603) and Braden scale (n = 100) using modeling (n = 615) and validation (n = 192) datasets. Sensitivity and specificity analyses were completed for each model. Models yielding high sensitivity and area under the curve (AUC), while minimizing false negatives (FN < 0.5%) were preferred.

RESULTS

In the modeling dataset, a single dichotomized FIM variable, Bed/Chair Transfers <4, was predictive of PI incidence (sensitivity = 97%, AUC = 74%, FN = 0.49%) and had similar metrics as the logistic regression model (sensitivity = 97%, AUC = 76%, FN = 0.49%). The recursive partitioning model had fewer FN (sensitivity = 98%, AUC = 75%, FN = 0.33%). When applied to the validation dataset, both models performed similarly. The SCIPUS performed poorly (AUC < 70%). When analyses were limited to cases with available Braden data and no admission PI, recursive partitioning outperformed the other methods for PI risk screening.

CONCLUSION

A recursive partitioning model, named the SCI-PreSORS (SCI Pressure Sore Onset Risk Screening), demonstrated promise for PI risk screening during inpatient SCI rehabilitation. Prospective validation of the new model is warranted.

The global burden of pressure ulcers among patients with spinal cord injury: a systematic review and meta-analysis

BACKGROUND

Pressure ulcers (PU), one of the common challenging public health problems affecting patient with spinal cord injury. PUs occurs over bony areas of the body where pressure and tissue distortion is greatest. It has a significant impact to the patient and health care system. Moreover, it has psychological, physical, social burden and decrease the quality of life (QoL) of patients. Despite its serious complications, limited evidence is available on the global magnitude of pressure ulcers among patient with spinal cord injury. Hence, this review and meta-analysis aimed to estimate the global magnitude of pressure ulcers among patient with spinal cord injury.

METHODS

PubMed, Scopus, Google Scholar, African Journals Online, PsycINFO, and Web of Science were systematically searched to retrieve related articles. The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guideline was followed. DerSimonian and Laird random-effects model was applied to obtain the pooled effect size. To investigate heterogeneity across the included studies, I2 test was employed. Publication bias was examined using funnel plot and Egger's regression test statistic. Sensitivity analysis was deployed to see the effect of a single study on the overall estimation. Analysis was done using STATA™ Version 14 software.

RESULTS

A total of 24 studies which comprises of 600,078 participants were included in this study. The global pooled magnitude of pressure ulcers among patients with spinal cord injury was 32.36% (95% CI (28.21, 36.51%)). Based on the subgroup analysis, the highest magnitude of pressure ulcer was observed in Africa 41.19% (95% CI: 31.70, 52.18).

CONCLUSION

This systematic review and meta-analysis revealed that about one in three patients with spinal cord injury had pressure ulcers. This implies that the overall global magnitude of pressure ulcer is relatively high. Therefore, policy maker and other concerned body should be design country context- specific preventive strategies to reduce the burden of pressure ulcers in patients with spinal cord injury.

Development of Tissue Integrity indicators to advance the quality of spinal cord injury rehabilitation: SCI-High Project

Objective: To establish structure, process and outcome indicators to evaluate tissue integrity in Canadians with spinal cord injury or disease (SCI/D) in the first 18 months following inpatient rehabilitation admission. Method: A Working Group comprised of Canadian subject matter experts in the Domain of Tissue Integrity was formed to define the construct of tissue integrity. A literature review was conducted and a Driver diagram produced to identify factors that influence tissue integrity in individuals with SCI/D. Facilitated meetings were conducted to identify and achieve consensus on structure, process and outcome indicators. Rapid cycle testing was used to pilot test proposed indicators for face validity and feasibility within a quality improvement context. Results: The structure indicators are the proportion of patients with SCI/D who have access to a mirror for skin checks and the proportion of patients who have access to patient education on tissue integrity; the process indicator is the proportion of patients who completed daily head-to-toe skin checks; the intermediary outcome indicator is pressure injury (PI) incidence during inpatient rehabilitation; and the final outcome indicator is the proportion of individuals with intact skin at 18 months following rehabilitation admission. Conclusion: The set of indicators established for the Domain of Tissue Integrity are specifically focused on aspects of care that can impact the maintenance of tissue integrity and the prevention of PI and align with current practice guidelines. The implementation and evaluation of these indicators nationally have the potential to improve care for Canadians with SCI/D.

The Spinal Cord Injury Pressure Ulcer Scale (SCIPUS): an assessment of validity using Rasch analysis

STUDY DESIGN

Secondary analysis of retrospective data.

OBJECTIVE

The aim of this study was to further validate the Spinal Cord Injury Pressure Ulcer Scale (SCIPUS) using Rasch analysis.

SETTING

Two rehabilitation centers in Canada.

METHOD

Data were collected as part of the Spinal Cord Injury Knowledge Mobilization Network (SCI KMN) initiative. The SCIPUS was completed within 72 h of inpatient admission. Persons admitted for initial rehabilitation in two inpatient spinal cord rehabilitation programs were included in the project.

RESULTS

Data from 886 participants were analyzed, approximately 60% of whom were males. Rasch analyses demonstrated that the SCIPUS, in its current format did not meet criteria required for true measurement. A transformed version of the SCIPUS obtained by deletion of misfitting items and modification of the response scales improved fit to the model and showed preliminary evidence of unidimensionality. The person separation index, however indicated that the scale requires further adjustments of its scoring options.

CONCLUSIONS

In its original form, the SCIPUS does not meet the requirements of the Rasch model and its total score should be used cautiously. However, following some adjustments to the items such as addressing DIF between sites to insure a standardized assessment across sites and adding response options to some of the items, interval-scale measurement should be possible.

Determining Pressure Injury Risk on Admission to Inpatient Spinal Cord Injury Rehabilitation: A Comparison of the FIM, Spinal Cord Injury Pressure Ulcer Scale, and Braden Scale

OBJECTIVE

Assess the utility of the admission Spinal Cord Injury Pressure Ulcer Scale (SCIPUS), Braden Scale, and the FIM for identifying individuals at risk for developing pressure injury during inpatient spinal cord injury (SCI) rehabilitation.

DESIGN

Retrospective cohort.

SETTING

Two tertiary rehabilitation centers.

PARTICIPANTS

Individuals (N=754) participating in inpatient SCI rehabilitation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Logistic regression analysis was performed to determine the utility of the SCIPUS, Braden Scale, and FIM for identifying individuals at risk for developing pressure injury (PI) during inpatient SCI rehabilitation. Sensitivity, specificity, positive predictive value, negative predictive value, false negative rate, odds ratio, likelihood ratio, and area under the curve (AUC) are reported.

RESULTS

The SCIPUS total score and its individual items did not demonstrate acceptable accuracy (AUC≥0.7) whereas the Braden Scale (0.73) and the FIM score (0.74) did. Once items were dichotomized into high and low risk categories, 1 Braden item (friction and shear), 5 FIM items (bathing, toileting, bed/chair transfer, tub/shower transfer, toilet transfer), the FIM transfers subscale, FIM Motor subscale, and the FIM instrument as a whole, maintained AUCs ≥0.7 and negative predictive values ≥0.95. The FIM bed/chair transfer score demonstrated the highest likelihood ratio (2.62) and overall was the most promising measure for determining PI risk.

CONCLUSION

Study findings suggest that a simple measure of mobility, admission FIM bed/chair transfer score of 1 (total assist), can identify at-risk individuals with greater accuracy than both an SCI specific instrument (SCIPUS) and a PI specific instrument (Braden). The FIM bed/chair transfer score can be readily determined at rehabilitation admission with minimal administrative and clinical burden.

The impact of acute management on the occurrence of medical complications during the specialized spinal cord injury acute hospitalization following motor-complete cervical spinal cord injury

CONTEXT/OBJECTIVE

Determine the impact of early admission and complete perioperative management in a specialized spinal cord injury (SCI) trauma center (SCI-center) on the occurrence of medical complications following tetraplegia.

DESIGN

A retrospective comparative cohort study of prospectively collected data involving 116 individuals was conducted. Group 1 (N=87) was early managed in a SCI-center promptly after the trauma, whereas Group 2 (N=29) was surgically and preoperatively managed in a non-specialized (NS) center before being transferred to the SCI-center. Bivariate comparisons and multivariate logistic regression analyses were used to assess the relationship between the type of acute care facility and the occurrence of medical complications. Length of stay (LOS) in acute care was also compared.

SETTING

Single Level-1 trauma center.

PARTICIPANTS

Individuals with acute traumatic motor-complete cervical SCI.

INTERVENTIONS

Not applicable Outcome measures: The occurrence of complications during the SCI-center stay.

RESULTS

There was a similar rate of complications between the two groups. However, the LOS was greater in Group 2 (p=0.04). High cervical injuries (C1-C4) showed an important tendency to increase the likelihood of developing a complication, while high cervical injuries and increased trauma severity increased the odds of developing respiratory complications.

CONCLUSION

Although complication rates were similar in non-specialized and specialized centers, peri-operative management in a non-specialized center required a longer length of stay. Prompt transfer to a SCI-center may optimize the care trajectory by favoring earlier transfer to rehabilitation.

Effectiveness of a multi-layer foam dressing in preventing sacral pressure ulcers for the early acute care of patients with a traumatic spinal cord injury: comparison with the use of a gel mattress

Individuals with spinal cord injury are at risk of sacral pressure ulcers due to, among other reasons, prolonged immobilisation. The effectiveness of a multi-layer foam dressing installed pre-operatively in reducing sacral pressure ulcer occurrence in spinal cord injured patients was compared to that of using a gel mattress, and stratified analyses were performed on patients with complete tetraplegia and paraplegia. Socio-demographic and clinical data were collected from 315 patients admitted in a level-I trauma centre following a spinal cord injury between April 2010 and March 2016. Upon arrival to the emergency room and until surgery, patients were transferred on a foam stretcher pad with a viscoelastic polymer gel mattress (before 1 October 2014) or received a multi-layer foam dressing applied to their sacral-coccygeal area (after 1 October 2014). The occurrence of sacral pressure ulcer during acute hospitalisation was similar irrespective of whether patients received the dressing or the gel mattress. It was found that 82% of patients with complete tetraplegia receiving the preventive dressing developed sacral ulcers as compared to only 36% of patients using the gel mattress. Although multi-layer dressings were suggested to improve skin protection and decrease pressure ulcer occurrence in critically ill patients, such preventive dressings are not superior to gel mattresses in spinal cord injured patients and should be used with precaution, especially in complete tetraplegia.