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Burkhart L, Skemp L, Siddiqui S. Triangulation of veteran and provider models of preventing community-acquired pressure injuries in spinal cord injury to reveal convergence and divergence of perspectives. J Spinal Cord Med 2024; 47:549-558. [PMID: 36441027 PMCID: PMC11218588 DOI: 10.1080/10790268.2022.2135714] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
CONTEXT/OBJECTIVE Community-acquired pressure injuries (CAPrI) are a common and costly complication of spinal cord injury (SCI). The majority of PrIs occur in the community, but there is little guidance in CAPrI prevention. This study describes how provider and veteran perspectives of CAPrI prevention converge and diverge. DESIGN The Farmer triangulation method was used to compare two models from previous qualitative research describing provider and veteran perspectives of CAPrI prevention based on the framework of CAPrI risks, resources, and preventive activities. The previous qualitative research revealed the provider model of CAPrI prevention using semi-structured interviews with interprofessional SCI providers at the Veteran Health Administration (VA) (n = 30). A qualitative descriptive design using photovoice (n = 30) with or without guided tours (n = 15) revealed the Veteran model of CAPrI prevention. SETTING The previous qualitative research was conducted at three geographically different VA spinal cord injury/disorder centers in the United States (north, south, west). PARTICIPANTS 30 interprofessional SCI providers; 30 Veterans living with SCI at three VA SCI Centers in the United States. INTERVENTIONS n/a. OUTCOME MEASURES Provider-Veteran perspectives of CAPrI prevention that demonstrated agreement, partial agreement, divergence, and silence. RESULTS Providers and veterans agreed on what is basic care, and the importance of family, caregiver and health provider/system supports, but they viewed motivation, veteran role, informal supports, and adequacy of supports differently. CONCLUSION Understanding how SCI providers and veterans living with SCI view prevention in the community informs how to promote preventive care in the context of veterans' lives.
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Affiliation(s)
- Lisa Burkhart
- Center of Innovation for Complex Chronic Healthcare, Hines VA, Hines, Illinois, USA
- Marcella Niehoff School of Nursing, Loyola University Chicago, Chicago, Illinois, USA
| | - Lisa Skemp
- Center of Innovation for Complex Chronic Healthcare, Hines VA, Hines, Illinois, USA
- Marcella Niehoff School of Nursing, Loyola University Chicago, Chicago, Illinois, USA
- Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Maywood, Illinois, USA
| | - Sameer Siddiqui
- Spinal Cord Injuries/Disorders System of Care, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio, USA
- Department of Physical Medicine and Rehabilitation, Case Western Reserve University, Cleveland, Ohio, USA
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Van Beest D, Koh SJ, Tzen YT, Wang J, Moore-Matthews D, Kargel JS, Cutrell JB, Bedimo RJ, Bennett BR, Tan WH. Healthcare utilization and outcomes of spinal cord injured veterans with stage 3-4 pressure injuries. J Spinal Cord Med 2024; 47:345-353. [PMID: 35377296 PMCID: PMC11044724 DOI: 10.1080/10790268.2022.2052500] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Pressure injuries (PI) are a significant source of morbidity for individuals with spinal cord injury/disease (SCI/D). They are also associated with significant healthcare resource utilization including prolonged hospitalizations. However, the long-term outcomes in terms of wound recurrence-free survival, hospital readmission rates, and all-cause mortality in this population remain largely unknown. OBJECTIVE To examine the clinical characteristics, healthcare utilization and outcomes of SCI Veterans hospitalized at the VA North Texas Health Care System (VANTHCS) SCI inpatient unit with stage 3 and 4 PI, and compare these between those who received a myocutaneous flap surgery (flap patients (FP)) and those treated medically (non-flap patients (NFP)). METHODS A retrospective chart review was conducted of all adult patients admitted to the VANTHCS SCI/D unit with stage 3 or 4 pelvic PI between 1/1/2013 and 12/31/2018. Healthcare utilization and outcome information was extracted for pre-specified time points. RESULTS 78 patients met criteria (113 hospitalizations; 27 FP; 51 NFP). Average length of stay (LOS) was 122 days; FP had a significantly higher LOS than NFP (P = 0.01). Average number of consults was 24. Estimated cost per hospitalization was $175,198. Readmission rate within 30 days was 12.39%. The mortality rate within 1 year of discharge was 21.57% for NFP, as opposed to 3.70% in the FP group. Only 5.00% of NFP wounds were healed at discharged with sustained healing at 1 year, significantly less than FP wounds (55.26%, P < 0.01). CONCLUSIONS Despite the high investment in terms of healthcare utilization, outcomes in terms of wound healing are poor. Additionally, nearly 22% of NFP died within one year of discharge. This calls into question the utility of prolonged hospitalizations for PI in the SCI/D population in terms of wound treatment efficacy, healthcare costs, and patient morbidity/mortality.
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Affiliation(s)
- Dominique Van Beest
- Physical Medicine & Rehabilitation, VA North Texas Health Care System, Dallas, Texas, USA
| | - Shannon J. Koh
- Infectious Disease, Texas Health Resources, Dallas, Texas, USA
| | - Yi-Ting Tzen
- Physical Medicine & Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jijia Wang
- Physical Medicine & Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | - Jennifer S. Kargel
- Plastic Surgery, VA North Texas Health Care System, Dallas, Texas, USA
- Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - James B. Cutrell
- Infectious Disease, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Roger J. Bedimo
- Infectious Disease, VA North Texas Health Care System, Dallas, Texas, USA
- Infectious Disease, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Bridget R. Bennett
- Physical Medicine & Rehabilitation, VA North Texas Health Care System, Dallas, Texas, USA
- Physical Medicine & Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Wei-Han Tan
- Physical Medicine & Rehabilitation, VA North Texas Health Care System, Dallas, Texas, USA
- Physical Medicine & Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Siddiqui S, Skemp L, Burkhart L. Provider perspectives of community-acquired pressure injury prevention in veterans with spinal cord injury. J Spinal Cord Med 2024; 47:168-180. [PMID: 35796672 PMCID: PMC10795618 DOI: 10.1080/10790268.2022.2088505] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
CONTEXT/OBJECTIVE Community-acquired pressure injuries (CAPrI) are a common and costly complication of spinal cord injury (SCI). Most studies and interventions focus on the prevention of pressure injuries acquired in the hospital. The goal of this study is to better understand SCI provider perspectives of the risks, actions and resources needed to prevent CAPrIs. DESIGN Qualitative descriptive, semi-structured interviews of SCI providers analyzed using a deductive-inductive approach. SETTING Three geographically different veteran health administration spinal cord injury/disorder centers. PARTICIPANTS 30 interprofessional SCI providers. INTERVENTIONS Not applicable. OUTCOME MEASURES Provider perspective of risks, actions and resources for CAPrI prevention in veterans with SCI. RESULTS 30 interviews revealed a model of provider perspectives of CAPrI prevention including veteran risk characteristics, veteran preventive activities and provider, family, community caregiving resources. CONCLUSION Understanding provider perspectives of Veteran CAPrI preventive risks, actions and resources guides more appropriate interventions to prevent CAPrIs in individuals living with SCI.
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Affiliation(s)
- Sameer Siddiqui
- Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
- Department of Physical Medicine and Rehabilitation, Case Western Reserve University, Cleveland, OH, USA
| | - Lisa Skemp
- Marcella Niehoff School of Nursing, Loyola University Chicago, Chicago, IL, USA
- Center of Innovation for Complex Chronic Healthcare, Hines VA, Hines, IL, USA
- Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Chicago, IL, USA
| | - Lisa Burkhart
- Marcella Niehoff School of Nursing, Loyola University Chicago, Chicago, IL, USA
- Center of Innovation for Complex Chronic Healthcare, Hines VA, Hines, IL, USA
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Celeste-Villalvir A, Kovic C, Argüelles F. The Intersectional Impact of Disability and Immigration on Health: A Health Needs Assessment of Immigrants Living With Spinal Cord Injury in Houston, Texas. COMMUNITY HEALTH EQUITY RESEARCH & POLICY 2024; 44:209-218. [PMID: 36670517 DOI: 10.1177/2752535x221132445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Immigrants with spinal cord injury (SCI) experience challenges with co-morbidities and lack of access to medical supplies and equipment. Much of the current disability and SCI literature does not include Latinx immigrants with SCI. To address this gap in knowledge, the present study explores the intersectional impact of disability and immigration on health as well as the health status and health needs of immigrants living with SCI. METHODS This community-partnered study is a secondary analysis of needs assessment data collected in February 2019 with 24 of the members of Living Hope Wheelchair Association, a nonprofit organization serving Latinx immigrants living with SCI in Houston, Texas. RESULTS Participants shared challenges with accessing healthcare, comorbidities, mental illness, transportation, and discrimination by healthcare professionals. They also shared difficulties accessing medical supplies, medical equipment, and the need for adaptations in their homes and vehicles. CONCLUSION The findings corroborate those of previous studies with people with SCI, but highlights additional layers of marginalization and challenges faced by immigrants living with SCI. More research is needed to understand the health needs and health status of this population, including their access to care and management of chronic diseases such as diabetes and heart disease. Findings support the need for public health and immigration policies to promote inclusion and equitable access to services as well as improve the health and quality of life of immigrants.
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Affiliation(s)
- Alane Celeste-Villalvir
- The University of Texas Health Science Center at Houston (UTHealth) School of Public Health, Houston, TX, USA
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Câmara Gradim LC, Santana ALM, Archanjo José M, Zuffo MK, Lopes RDD. An Automated Electronic System in a Motorized Wheelchair for Telemonitoring: Mixed Methods Study Based on Internet of Things. JMIR Form Res 2023; 7:e49102. [PMID: 37776327 PMCID: PMC10666020 DOI: 10.2196/49102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/20/2023] [Accepted: 09/12/2023] [Indexed: 10/02/2023] Open
Abstract
BACKGROUND Wheelchair positioning systems can prevent postural deficits and pressure injuries. However, a more effective professional follow-up is needed to assess and monitor positioning according to the specificities and clinical conditions of each user. OBJECTIVE This study aims to present the concept of an electronic system embedded in a motorized wheelchair, based on the Internet of Things (IoT), for automated positioning as part of a study on wheelchairs and telemonitoring. METHODS We conducted a mixed methods study with a user-centered design approach, interviews with 16 wheelchair users and 66 professionals for the development of system functions, and a formative assessment of 5 participants with descriptive analysis to design system concepts. RESULTS We presented a new wheelchair system with hardware and software components developed based on coparticipation with singular components in an IoT architecture. In an IoT solution, the incorporation of sensors from the inertial measurement unit was crucial. These sensors were vital for offering alternative methods to monitor and control the tilt and recline functions of a wheelchair. This monitoring and control could be achieved autonomously through a smartphone app. In addition, this capability addressed the requirements of real users. CONCLUSIONS The technologies presented in this system can benefit telemonitoring and favor real feedback, allowing quality provision of health services to wheelchair users. User-centered development favored development with specific functions to meet the real demands of users. We emphasize the importance of future studies on the correlation between diagnoses and the use of the system in a real environment to help professionals in treatment.
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Affiliation(s)
- Luma Carolina Câmara Gradim
- Polytechnic School, Interdisciplinary Center for Interactive Technologies and Institute of Advanced Studies, University of Sao Paulo, São Paulo, Brazil
| | - André Luiz Maciel Santana
- Polytechnic School, Interdisciplinary Center for Interactive Technologies and Institute of Advanced Studies, University of Sao Paulo, São Paulo, Brazil
- Instituto de Ensino e Pesquisa Insper, São Paulo, Brazil
| | - Marcelo Archanjo José
- Polytechnic School, Interdisciplinary Center for Interactive Technologies and Institute of Advanced Studies, University of Sao Paulo, São Paulo, Brazil
| | - Marcelo Knörich Zuffo
- Polytechnic School, Interdisciplinary Center for Interactive Technologies and Institute of Advanced Studies, University of Sao Paulo, São Paulo, Brazil
| | - Roseli de Deus Lopes
- Polytechnic School, Interdisciplinary Center for Interactive Technologies and Institute of Advanced Studies, University of Sao Paulo, São Paulo, Brazil
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Graves LY, Schwartz KR, Shiff J, Chan ER, Galea M, Henzel MK, Olney C, Bogie KM. Genomic Biomarkers Can Provide a Deeper Understanding of Recurrent Pressure Injuries. Adv Skin Wound Care 2023; 36:534-539. [PMID: 37729163 PMCID: PMC10545060 DOI: 10.1097/asw.0000000000000041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 07/12/2023] [Indexed: 09/22/2023]
Abstract
OBJECTIVE To identify genetic biomarkers predisposing individuals with spinal cord injury (SCI) to recurrent pressure injuries (PIs). METHODS Repeated measures of the transcriptome profile of veterans with SCI at three Veterans Spinal Cord Injuries and Disorders Centers. Exclusion criteria included having significant active systemic disease at time of enrollment. Researchers obtained comprehensive profiles of clinical and health factors and demographic information relevant to PI history at enrollment and at each follow-up visit by reviewing patients' medical charts. Whole blood samples were collected at 6- to 12-month intervals for 2 to 4 years. In addition to DNA profiling with whole genome sequencing of the patients, RNA sequencing was performed to assess pathways associated with PI risk. RESULTS Whole genome sequencing analysis identified 260 genes that showed increased prevalence of single-nucleotide variations in exonic regions with high (>20) combined annotation-dependent depletion scores between persons with high versus low intramuscular adipose tissue levels when cross-referenced with persons who had recurrent PIs. Gene set enrichment analysis using Hallmark and KEGG (Kyoto Encyclopedia of Genes and Genomes) gene sets of these candidate genes revealed enrichment in genes encoding proteins involved in fatty acid metabolism (P < .01). Further, RNA sequencing revealed upregulated activity in biological senescence pathways and downregulated activity in antimicrobial protection pathways. CONCLUSIONS Genomic biomarkers may complement electronic health records to support management of complex interactive health issues such as risk of recurrent PIs in people with SCI. These findings may also be leveraged for homogeneous phenotypic grouping of higher-risk individuals.
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Affiliation(s)
- Letitia Y Graves
- Letitia Y. Graves, PhD, RN, is Assistant Professor, School of Nursing, University of Texas Medical Branch, Galveston, Texas, and Research Health Scientist, Louis Stokes Cleveland Veterans Affairs Medical Center. Katelyn R. Schwartz, MPH, BSN, RN, is Research Nurse, Cleveland VA Medical Center, Cleveland, Ohio. Josie Shiff, MS, is Research Assistant, Cleveland VA Medical Research & Education Foundation. Ernest R. Chan, PhD, is Research Scientist, Case Western Reserve University, Cleveland. Marinella Galea, MD, is Chief, Spinal Cord Injuries and Disorders, James J. Peters VAMC, Bronx, New York, and Associate Professor, Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York. Mary K. Henzel, MD, PhD, is Assistant Chief, Spinal Cord Injuries and Disorders, and Spinal Cord Injury Physiatrist, Louis Stokes Cleveland VA Medical Center. Christine Olney, PhD, RN, is Nurse Scientist, Minneapolis VA Health Care System, Minneapolis, Minnesota. Kath M. Bogie, DPhil, FAIMBE, is Research Career Scientist, Louis Stokes Cleveland Veterans Affairs Medical Center, and Professor, Department of Orthopedics, Case Western Reserve University
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Wang T, Luo C, Xie S, Tang J, He Z, Li K. Skin self-management of community-dwelling patients with spinal cord injury: A cross-sectional study. J Tissue Viability 2023:S0965-206X(23)00060-8. [PMID: 37246018 DOI: 10.1016/j.jtv.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 04/06/2023] [Accepted: 05/10/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND community-acquired pressure injury is one of the most common and troublesome complications of discharged patients with spinal cord injury. Previous studies have shown that pressure injury can not only increase the financial burden and care burden of patients, but also seriously affect their quality of life. AIM To evaluate the skin self-management of community-dwelling patients with spinal cord injury and to explore the related independent influencing factors. METHODS This was a cross-sectional survey study. A convenience sample of 110 community-dwelling patients with spinal cord injury recruited from three rehabilitation centers in Guangzhou and Chengdu in China completed the survey from September 2020 to June 2021. They were asked about their demographic data, skin self-management, knowledge about skin self-management, attitude to skin self-management, self-efficacy, and functional independence. Univariate analysis and multiple linear regression were performed to isolate the most important relationships. RESULTS The skin self-management of community-dwelling patients with spinal cord injury was relatively low, and they also performed poorly in the three categories of: skin check, preventing pressure ulcer, and preventing wounds. Skin self-management was found to be most often associated with level of knowledge about skin self-management, higher reimbursement and self-efficacy. CONCLUSION Community-dwelling patients with spinal cord injury with lower level of knowledge about skin self-management, with lower self-efficacy, and those with higher reimbursement have worse skin self-management.
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Affiliation(s)
- Tong Wang
- School of Nursing, Sun Yat-sen University, Guangzhou, China; Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chunxiao Luo
- The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Sumei Xie
- Guangdong Provincial Work Injury Rehabilitation Hospital, Guangzhou, China
| | - Jie Tang
- Sichuan Provincial Rehabilitation Hospital, Chengdu, China
| | - Zheng He
- Guangdong Provincial Work Injury Rehabilitation Hospital, Guangzhou, China
| | - Kun Li
- School of Nursing, Sun Yat-sen University, Guangzhou, China.
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Schubert S, Marzloff G, Ryder S, Ott K, Hutton J, Becker M. Establishing a Comprehensive Wound Care Team and Program. Phys Med Rehabil Clin N Am 2022; 33:805-810. [DOI: 10.1016/j.pmr.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Spinal Cord Injury Patient's Physical and Psychological Care Needs at Home from Patients’ and Caregivers’ Perspectives: A Qualitative Study. ARCHIVES OF NEUROSCIENCE 2022. [DOI: 10.5812/ans-123462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Karamian BA, Siegel N, Nourie B, Serruya MD, Heary RF, Harrop JS, Vaccaro AR. The role of electrical stimulation for rehabilitation and regeneration after spinal cord injury. J Orthop Traumatol 2022; 23:2. [PMID: 34989884 PMCID: PMC8738840 DOI: 10.1186/s10195-021-00623-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 12/27/2021] [Indexed: 12/26/2022] Open
Abstract
Electrical stimulation is used to elicit muscle contraction and can be utilized for neurorehabilitation following spinal cord injury when paired with voluntary motor training. This technology is now an important therapeutic intervention that results in improvement in motor function in patients with spinal cord injuries. The purpose of this review is to summarize the various forms of electrical stimulation technology that exist and their applications. Furthermore, this paper addresses the potential future of the technology.
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Affiliation(s)
- Brian A Karamian
- Rothman Orthopaedic Institute at Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA, 19107, USA.
| | - Nicholas Siegel
- Rothman Orthopaedic Institute at Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA, 19107, USA
| | - Blake Nourie
- Rothman Orthopaedic Institute at Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA, 19107, USA
| | | | - Robert F Heary
- Department of Neurological Surgery, Hackensack Meridian School of Medicine, Nutley, NJ, 07110, USA
| | - James S Harrop
- Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - Alexander R Vaccaro
- Rothman Orthopaedic Institute at Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA, 19107, USA
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Fecal diversion does not support healing of anus-near pressure ulcers in patients with spinal cord injury-results of a retrospective cohort study. Spinal Cord 2022; 60:477-483. [PMID: 34621008 PMCID: PMC9209324 DOI: 10.1038/s41393-021-00717-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 09/19/2021] [Accepted: 09/20/2021] [Indexed: 11/28/2022]
Abstract
STUDY DESIGN Retrospective cohort study including spinal cord injured patients with anus-near pressure ulcers. OBJECTIVE The primary objective was to evaluate the impact of stool diversion via stoma on the decubital wound healing. Secondary objectives included the risk of complications and ulcer recurrence. Associations between the wound healing and potentially interfering parameters were determined. SETTING University hospital with a spinal cord injury unit. METHODS A total of 463 consecutive patients who presented with a decubitus were retrospectively included. Patients with and without a stoma were compared using descriptive and explorative statistics including multiple regression analysis. RESULTS The severity of the pressure ulcers was determined as stage 3 in two-thirds and stage 4 in one-third of all cases. The wound healing lasted longer in the 71 stoma-presenting patients than in the 392 patients with undeviated defecation (77 vs. 59 days, p = 0.02). The age (regression coefficient b = 0.41, p = 0.02), the ASA classification (b = 16.04, p = 0.001) and the stage of the ulcers (b = 19.65, p = 0.001) were associated with prolonged ulcer treatment in the univariate analysis. The multiple regression analysis revealed that the fecal diversion (b = -18.19, p = 0.03) and the stage of the ulcers (b = 21.62, p = 0.001) were the only predictors of delayed wound healing. CONCLUSION The presence of a stoma is not related to improved wound healing of ulcers near the anus. On the contrary, stoma patients needed more time until complete wound healing, conceivably related to selection bias. Nonetheless, we currently do not recommend fecal diversion to be the standard concept for decubitus treatment.
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Policy analysis on power standing systems. Prev Med Rep 2021; 24:101601. [PMID: 34976658 PMCID: PMC8683940 DOI: 10.1016/j.pmedr.2021.101601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 10/06/2021] [Accepted: 10/09/2021] [Indexed: 11/27/2022] Open
Abstract
Power wheelchairs provide people with mobility disabilities opportunities for independence in mobility and repositioning themselves. However, current power wheelchair power options covered by Medicare limit the person to a horizontal plane. In the home, access to the vertical plane is also required for mobility related activities of daily living. Power standing systems on power wheelchairs are one option for providing access to the vertical environment, although currently these systems are not covered by Medicare. Power standing systems also aid in medical management and in preventing common comorbidities associated with chronic neurological and congenital healthcare conditions. Therefore, a legal group led an interdisciplinary effort to change Medicare policy on power standing systems. A policy analysis using Bardach’s Eightfold policy framework was conducted to analyze a clinical groups’ action within this interdisciplinary team. The clinical team considered three viable options to address the problem and evaluated these options against five criteria. Ultimately, a national coverage determination reconsideration would provide a needed opportunity for the coverage of power standing systems. Suggested coverage criteria for power standing systems, based on existing literature and expert clinical experience, are proposed.
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The Persistence of Staphylococcus aureus in Pressure Ulcers: A Colonising Role. Genes (Basel) 2021; 12:genes12121883. [PMID: 34946833 PMCID: PMC8701790 DOI: 10.3390/genes12121883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 11/19/2021] [Accepted: 11/22/2021] [Indexed: 11/17/2022] Open
Abstract
Decubitus pressure ulcers (PU) are a major complication of immobilised patients. Staphylococcus aureus is one of the most frequently detected microorganisms in PU samples; however, its persistence and role in the evolution of these wounds is unknown. In this study, we analysed S. aureus strains isolated from PU biopsies at inclusion and day 28. Eleven S. aureus (21.1%) were detected in 52 patients at inclusion. Only six PUs (11.5%) continued to harbour this bacterium at day 28. Using a whole genome sequencing approach (Miseq®, Illumina), we confirmed that these six S. aureus samples isolated at D28 were the same strain as that isolated at inclusion, with less than 83 bp difference. Phenotypical studies evaluating the growth profiles (Infinite M Mano, Tecan®) and biofilm formation (Biofilm Ring Test®) did not detect any significant difference in the fitness of the pairs of S. aureus. However, using the Caenorhabditis elegans killing assay, a clear decrease of virulence was observed between strains isolated at D28 compared with those isolated at inclusion, regardless of the clinical evolution of the PU. Moreover, all strains at inclusion were less virulent than a control S. aureus strain, i.e., NSA739. An analysis of polymicrobial communities of PU (by metabarcoding approach), in which S. aureus persisted, demonstrated no impact of Staphylococcus genus on PU evolution. Our study suggested that S. aureus presented a colonising profile on PU with no influence on wound evolution.
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Singh G, Borah D, Khanna G, Jain S. Efficacy of Local Autologous Platelet-Rich Plasma in the Treatment of Pressure Ulcer in Spinal Cord Injury Patients. Cureus 2021; 13:e18668. [PMID: 34790446 PMCID: PMC8583427 DOI: 10.7759/cureus.18668] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2021] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Pressure ulcer is one of the common complications occurring in spinal cord injury (SCI) patients. Platelet-rich plasma (PRP) has been found useful in the treatment of pressure ulcers in few studies. The purpose of this study was to evaluate the role of PRP in pressure ulcer healing in comparison to hydrogel dressing in SCI patients. METHODS In this randomized interventional study, 52 patients of SCI having pressure ulcers of grade III/IV were randomized into two groups of 26 each. In group A patients, hydrogel dressing was done while freshly prepared PRP was used in patients of group B. Pressure ulcers were evaluated at baseline and after three weeks and six weeks in terms of ulcer surface area, volume, Pressure Ulcer Scale for Healing (PUSH) score, histopathology, and ulcer healing parameters. Data were collected and quantitative variables were compared using unpaired t-test or Mann-Whitney test between the two groups and qualitative variables were compared using the chi-square test or Fisher's exact test. A p-value of <0.05 was considered statistically significant. RESULTS Baseline characteristics were comparable in both groups. There was a significant improvement in ulcers in terms of surface area, volume, and PUSH score in both the groups but it was comparable (p-value >0.05). There was a significant improvement in the PRP group as compared to the other group in terms of epithelization, granulation, and neovascularization at three and six-week follow-up. CONCLUSIONS This study suggests that PRP is a possible and better alternative to conventional dressing methods for the treatment of pressure ulcers.
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Affiliation(s)
- Gurpreet Singh
- Physical Medicine and Rehabilitation, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, IND
| | - Diganta Borah
- Physical Medicine and Rehabilitation, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, IND
| | - Geetika Khanna
- Pathology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, IND
| | - Sakshi Jain
- Physical Medicine and Rehabilitation, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, IND
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15
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Abstract
Bacterial species and their role in delaying the healing of pressure ulcers (PU) in spinal cord injury (SCI) patients have not been well described. This pilot study aimed to characterise the evolution of the cutaneous microbiota of PU in SCI cohort. Twenty-four patients with SCI from a French neurological rehabilitation centre were prospectively included. PU tissue biopsies were performed at baseline (D0) and 28 days (D28) and analysed using 16S rRNA gene-based sequencing analysis of the V3–V4 region. At D0, if the overall relative abundance of genus highlighted a large proportion of Staphylococcus, Anaerococcus and Finegoldia had a significantly higher relative abundance in wounds that stagnated or worsened in comparison with those improved at D28 (3.74% vs 0.05%; p = 0.015 and 11.02% versus 0.16%; p = 0.023, respectively). At D28, Proteus and Morganella genera were only present in stagnated or worsened wounds with respectively 0.02% (p = 0.003) and 0.01% (p = 0.02). Moreover, Proteus, Morganella, Anaerococcus and Peptoniphilus were associated within the same cluster, co-isolated from biopsies that had a poor evolution. This pathogroup could be a marker of wound degradation and Proteus could represent a promising target in PU management.
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16
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Burkhart L, Skemp L, Siddiqui S, Bates-Jensen B. Developing a decision support tool to prevent community-acquired pressure injuries in spinal cord injury in ambulatory care: A nurse-led protocol for mix methods research. Nurs Outlook 2021; 69:127-135. [PMID: 33583605 DOI: 10.1016/j.outlook.2021.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 12/13/2020] [Accepted: 01/10/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is a lack of formal guidelines and decision support tools to prevent community-acquired pressure injuries (CAPrIs) in Veterans with spinal cord injury (SCI). PURPOSE In this article we present our research protocol that describes our plans to create and test a decision support tool to prevent CAPrIs in SCI. METHODS In Aim 1, we identified mental-models of CAPrI prevention from the perspectives of Veterans (using photovoice, guided tours), and Veterans Health Administration SCI providers (using interviews), and triangulation to compare the two mental-models. This led to a decision support tool developed and validated using Delphi approaches in Aim 2 and will be followed by tool automation and system redesign for pilot implementation in Aim 3. FINDINGS The nurse-led research protocol provides a map to systematically explore, address and translate research into evidence-based practice. DISCUSSION Refinement of the protocol will guide future research and implementation.
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Affiliation(s)
- Lisa Burkhart
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. Hospital, Hines, IL; Marcella Niehoff School of Nursing, Loyola University Chicago, Chicago, IL.
| | - Lisa Skemp
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. Hospital, Hines, IL; Marcella Niehoff School of Nursing and Parkinson School of Health Sciences and Public Health, Maywood, IL
| | | | - Barbara Bates-Jensen
- School of Nursing and David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
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17
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Gelis A, Morel J, Amara B, Mauri C, Rouays H, Verollet C, Almeras I, Frasson N, Dupeyron A, Laffont I, Daures JP, Herlin C. "Doctor, how long will it take?" Results from an historical cohort on surgical pressure ulcer healing delay and related factors in persons with spinal cord injury. J Tissue Viability 2021; 30:237-243. [PMID: 33579584 DOI: 10.1016/j.jtv.2021.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 01/29/2021] [Accepted: 02/01/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Flap surgery for deep pelvic pressure ulcers has already shown its effectiveness. Most studies relating to the postoperative period assessed complications rates and associated risk factors, but none focused on delayed wound healing. The objective of this study was to describe wound healing delay after primary flap surgery in patients with spinal cord injury (SCI) and to assess associated risk factors. METHODS This observational retrospective study based on medical charts included all persons with SCI operated for primary flap surgery for pelvic PU in the Hérault department of France between 2006 and 2014. Overall, 100 biomedical, psychological, socioeconomics and care management factors were studied. The primary outcome was wound healing delay, defined as time from surgery to complete cutaneous closure. RESULTS 85 patients were included. Median healing time was 48 days (R: 20-406). Healing rate was 70% at 3 months and 90% at 4 months. After a multivariate analysis three factors were significantly associated with delayed wound healing: duration of hospitalization in the acute care unit (HR = 2.68; p = 0.004), local post-operative complication (HR = 10.75; p = 0.02), and post-operative sepsis (HR = 2.18; p = 0.02). CONCLUSION After primary skin flap surgery for PU in persons with SCI, delayed wound healing is related to local or general complications as well as care management organization. The risk of delayed wound healing justifies the implementation of a coordinated pre-operative management to prevent complications and a structured care network for an earlier transfer to a SCI rehabilitation center.
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Affiliation(s)
- Anthony Gelis
- Centre Mutualiste Neurologique Propara, 263 Rue Du Caducée, 34090, Montpellier, France.
| | - Juliette Morel
- Institut de Rééducation, CHU des Alpes, Avenue de Kimberley, 38130, Echirolles, France
| | - Bouali Amara
- Service de Chirurgie Plastique, Clinique Clémentville, 25 Rue de Clementville, 34070, Montpellier, France
| | - Cécile Mauri
- Centre Mutualiste Neurologique Propara, 263 Rue Du Caducée, 34090, Montpellier, France
| | - Hélène Rouays
- Centre Mutualiste Neurologique Propara, 263 Rue Du Caducée, 34090, Montpellier, France
| | - Christine Verollet
- Centre Mutualiste Neurologique Propara, 263 Rue Du Caducée, 34090, Montpellier, France
| | - Isabelle Almeras
- Clinique Du Dr Ster, 9 Avenue Dr Jean Ster, 34240, Nîmes, France
| | - Nicolas Frasson
- Clinique Du Dr Ster, 9 Avenue Dr Jean Ster, 34240, Nîmes, France
| | - Arnaud Dupeyron
- Département de Médecine Physique et de Réadaptation, CHU Carémeau, 2 Rue Du Pr Debré, 30029, Nîmes, France
| | - Isabelle Laffont
- Département de Médecine Physique et de Réadaptation, CHU Lapeyronie, 371 Avenue Du Doyen Gaston Giraud, 34090, Montpellier, France
| | - Jean-Pierre Daures
- Institut Universitaire de Recherche Clinique, 75 Rue Professeur Truc, 34090, Montpellier, France
| | - Christian Herlin
- Département de Chirurgie Plastique, CHU Lapeyronie, 371 Avenue Du Doyen Gaston Giraud, 34090, Montpellier, France
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18
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Rotation advancement V-Y posterior thigh flap combined with a biceps femoris muscle flap for reconstruction of a recurrent ischial pressure sore in pediatric patients. EUROPEAN JOURNAL OF PLASTIC SURGERY 2021. [DOI: 10.1007/s00238-020-01684-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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19
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Gourlan M, Pellechia A, Robineau S, Foulon B, Gault D, Lefort M, Goossens D, Mathieu S, Laffont I, Dupeyron A, Ninot G, Gelis A. "What pressure ulcers mean to me?" Representations of pressure ulcer in persons with spinal cord injury: A qualitative study. J Tissue Viability 2020; 29:324-330. [PMID: 32830010 DOI: 10.1016/j.jtv.2020.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 07/13/2020] [Accepted: 07/16/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Explore the perceptions and beliefs related to pressure ulcers (PU), their prevention and treatment strategies, in order to discuss potential learning objectives for PU-related therapeutic education in persons with spinal cord injury (SCI). DESIGN Qualitative study, using grounded theory for the analysis of data collected via a questionnaire. SETTING Nine SCI referral centers, inpatient care. PARTICIPANTS 131 persons with SCI were included. 76% were male, and 65% presented with paraplegia. The median age was 48 years (33.5; 58) and median time since injury was 11 years (3; 24.5). 70% had experience with PU. INTERVENTIONS None. MAIN OUTCOME MEASURES Data collection via an open-ended questionnaire on the representation of PU, its prevention and life experience of having a PU. RESULTS Six categories were identified: (1) identifying what might become problematic, (2) daily preventive actions, (3) detecting the early signs, (4) managing the early signs, (5) need for care, (6) experience with PU and being bedridden. Pressure ulcers have dramatic consequences on psychosocial health. Prevention and treatment require self-management skills, such as self-risk assessment abilities, self-detection skills and problem-solving strategies, to optimise daily PU prevention in persons with SCI. CONCLUSION PU prevention tackled by persons with SCI bears some specificities that the physician must take into account in the construction of a self-management program in this high-risk population.
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Affiliation(s)
- Mathieu Gourlan
- Laboratoire Epsylon EA 4556, Université de Montpellier, University, Rue Henri Serre, Montpellier, France
| | - Alessandra Pellechia
- Unité Transversale D'éducation Du Patient (UTEP), CHU Montpellier, Hôpital La Colombière, 39 Avenue Charles Flahault, 34295, Montpellier, Cedex 5, France
| | - Sandrine Robineau
- Pôle de Médecine Physique et de Réadaptation Saint Helier, 54 Rue Saint Helier, Rennes, France
| | - Bernard Foulon
- Association des Paralysés de France, 1620 Rue de Saint Priest, 34090, Montpellier, France
| | - Dominique Gault
- Centre de Rééducation Clemenceau, 45 Boulevard Clemenceau, 67000, Strasbourg, France
| | - Marc Lefort
- Département de Médecine Physique et de Réadaptation, CHU Saint Jacques, 85 Rue Saint-Jacques, 44093, Nantes, France
| | - David Goossens
- Centre de Rééducation de La Tour de Gassies, 33520, Bruges, France
| | - Sarah Mathieu
- Centre de Rééducation Fonctionnelle de Kerpape, Ploemeur, 92 Rue de L'Anse Du Stole, 56270, France
| | - Isabelle Laffont
- Département de Médecine Physique et de Réadaptation, CHU Lapeyronie, 371 Avenue Du Doyen Gaston GIRAUD, Montpellier, France
| | - Arnaud Dupeyron
- Département de Médecine Physique et de Réadaptation, CHU Caremeau, 4 Rue Du Pr Debré, Nîmes, France
| | - Gregory Ninot
- Laboratoire Epsylon EA 4556, Université de Montpellier, University, Rue Henri Serre, Montpellier, France
| | - Anthony Gelis
- Laboratoire Epsylon EA 4556, Université de Montpellier, University, Rue Henri Serre, Montpellier, France; Département de Médecine Physique et de Réadaptation, CHU Lapeyronie, 371 Avenue Du Doyen Gaston GIRAUD, Montpellier, France; Centre Mutualiste Neurologique PROPARA, 263 Rue Du Caducée, Montpellier, France.
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20
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White BAB, Rivers CS, Chisholm JA, Willms R, Papp A, Sproule S, McMurtry H. Community acquired pressure injuries in a work-related spinal cord injury population: Problem characterization and assessment of a working solution. J Tissue Viability 2020; 29:348-353. [PMID: 32921549 DOI: 10.1016/j.jtv.2020.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 05/06/2020] [Accepted: 07/21/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND To characterize the problem of community-acquired pressure injuries (CAPIs) in a work-related spinal cord injury (SCI) population in Canada and assess the benefits of a person-centered solution. Characterization of the problem and a solution, albeit in an insured Worker's Compensation Board of British Columbia (WorkSafeBC) cohort, may inform the supply of solutions in the larger SCI population with disparate access to healthcare. METHODS For this observational study, data on 244 WorkSafeBC clients, who received an intervention featuring pressure injury (PI) assessment between 2011 and 2015, were used to characterize the problem. Data on observed injuries, risk, referrals, and outcomes were linked to healthcare service claims. Employing an activity-based costing methodology, total expenditures on attributed services were calculated for clients with 1 or more PIs. Intervention cost and benefits from the insurer's perspective are considered. RESULTS 84 of 244 clients had 1 or more PIs at assessment, with attributed mean cost of $56,092 in 2015 Canadian dollars (CAD). Mean cost by PI severity range from $9580 to $238,736. At an intervention cost of $820,618, detection of less severe injuries provided an opportunity to prevent progression and achieve $3 million in cost avoidance. Follow-up data suggest reasonable returns. Reductions in the incidence, number, and risk of pressure injuries were also observed. CONCLUSIONS The analysis establishes the cost of CAPIs in a Canadian-based work-related SCI population and suggests preventative and early intervention is not only feasible but also practical. Results are relevant to decisions regarding the use of proactive prevention-based treatment models as opposed to reactive, solutions in the larger SCI population.
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Affiliation(s)
| | | | | | - Rhonda Willms
- Medical Manager of the Spinal Cord Injury Program, GF Strong Rehabilitation Centre, Vancouver, BC, Canada
| | - Anthony Papp
- University of British Columbia, Vancouver, BC, Canada
| | - Shannon Sproule
- Physiotherapist SCI and Wound Specialist, PABC, Access Therapist, UBC Clinical Instructor, Vancouver, BC, Canada
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21
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Tchouaket É, Kilpatrick K, Jabbour M. Effectiveness for introducing nurse practitioners in six long-term care facilities in Québec, Canada: A cost-savings analysis. Nurs Outlook 2020; 68:611-625. [PMID: 32713732 DOI: 10.1016/j.outlook.2020.06.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 05/31/2020] [Accepted: 06/06/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Internationally, most studies have focused on quality and safety in long-term care. However, studies focusing on the economic evaluation of quality and security in long-term care are sparse. Moreover, the economic evaluation of nurse practitioner care in long-term care is lacking, particularly in Québec Canada where roles are new. PURPOSE To evaluate the effectiveness of introducing nurse practitioners in six long-term care facilities in Québec using a cost-savings analysis in terms of reduction of nurse practitioner sensitive events (NPSEs). METHODS A cost savings analysis was completed using a prospective observational study. All residents (n = 538) under the care of teams that included nurse practitioners who experienced at least one of the following NPSEs: falls, pressure ulcers, short-term transfers, and a change in the time needed to administer the medications consumed were included. Data were collected from September 1st 2015 to August 31st 2016. Descriptive statistics identified numbers of cases for falls, pressure ulcers, short-term transfers, and the number of medications consumed. A literature analysis was used to estimate excess median long-term care facility related costs of these NPSEs. Costs were calculated in 2016 Canadian dollars. The cost savings with the reductions that occurred for falls, pressure ulcers, short term transfers, and the time needed to administer medications after the implementation of a primary healthcare nurse practitioner role in the six long term care facilities were also estimated. FINDINGS The median cost of 341 cases of falls, 32 cases of pressure ulcers and 53 cases of short-term transfers in the six long-term facilities would range between CAD 4,516,337.8 and CAD 5,281,824.4. Moreover, the total costs savings from the reduction of adverse events including the reduction of nursing administration time for medications would be between CAD 1,942,533.6 and CAD 3,254,403.4. DISCUSSION This is the first study to present the financial consequence of adverse events sensitive to nurse practitioner care in long-term care. Important cost savings were generated from the reduction of adverse events after the implementation of nurse practitioner roles in long-term care. Government should consider these results for prevention and improvements in quality and safety in long-term care.
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Affiliation(s)
- Éric Tchouaket
- Department of Nursing, Université du Québec en Outaouais, Saint-Jérôme, Canada.
| | - Kelley Kilpatrick
- Susan E. French Chair in Nursing Research and Innovative Practice, Ingram School of Nursing, McGill University, Montreal, Canada; Centre Intégré Universitaire de Santé et de Services Sociaux de l'Est-de-l'Île-de-Montréal-Hôpital, Maisonneuve-Rosemont (CIUSSS-EMTL-HMR), Montréal, Canada
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22
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Chan B, Cadarette S, Wodchis W, Wong J, Mittmann N, Krahn M. Cost-of-illness studies in chronic ulcers: a systematic review. J Wound Care 2019; 26:S4-S14. [PMID: 28379102 DOI: 10.12968/jowc.2017.26.sup4.s4] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To systematically review the published academic literature on the cost of chronic ulcers. METHODS A literature search was conducted in MEDLINE, EMBASE, HealthSTAR, Econlit and CINAHL up to 12 May 2016 to identify potential studies for review. Cost search terms were based on validated algorithms. Clinical search terms were based on recent Cochrane reviews of interventions for chronic ulcers. Titles and abstracts were screened by two reviewers to determine eligibility for full text review. Study characteristics were summarised. The quality of reporting was evaluated using a modified cost-of-illness checklist. Mean costs were adjusted and inflated to 2015 $US and presented for different durations and perspectives. RESULTS Of 2267 studies identified, 36 were eligible and included in the systematic review. Most studies presented results from the health-care public payer or hospital perspective. Many studies included hospital costs in the analysis and only reported total costs without presenting condition-specific attributable costs. The mean cost of chronic ulcers ranged from $1000 per year for patient out of pocket costs to $30,000 per episode from the health-care public payer perspective. Mean one year cost from a health-care public payer perspective was $44,200 for diabetic foot ulcer (DFU), $15,400 for pressure ulcer (PU) and $11,000 for leg ulcer (LU). CONCLUSIONS There was large variability in study methods, perspectives, cost components and jurisdictions, making interpretation of costs difficult. Nevertheless, it appears that the cost for the treatment of chronic ulcers is substantial and greater attention needs to be made for preventive measures.
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Affiliation(s)
- B Chan
- Leslie Dan Faculty of Pharmacy, University of Toronto, Canada
| | - S Cadarette
- Leslie Dan Faculty of Pharmacy, University of Toronto, Canada
| | - W Wodchis
- Institute of Health Policy, Management and Evaluation, University of Toronto, Canada
| | - J Wong
- Toronto Health Economics and Technology Assessment Collaborative, University of Toronto, Canada
| | - N Mittmann
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Canada
| | - M Krahn
- Toronto Health Economics and Technology Assessment Collaborative, University of Toronto, Canada
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23
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Pressure Injury Documentation Practices in the Department of Veteran Affairs: A Quality Improvement Project. J Wound Ostomy Continence Nurs 2019; 46:18-24. [PMID: 30608336 DOI: 10.1097/won.0000000000000492] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Evidence suggests that inaccurate and incomplete pressure injury (PI) documentation threatens the validity of treatment and undermines policy and quality improvement. This quality improvement project sought to identify barriers and facilitators when conducting and documenting the daily comprehensive skin assessment in 31 Department of Veterans Affairs (VA) facilities. Evaluators in this 1-year, cross-sectional quality improvement project, using a qualitative approach, interviewed nurses of medical-surgical and critical care units. Participants (N = 62) from 12 high reassessment units (HRUs) and 13 low reassessment units (LRUs) were interviewed using telephone focus groups. Staff from HRUs reported 9 activities that ensured consistency in clinical practices, in validating data, and in correcting inaccuracies. The LRU staff tended to report performing only 2 of the 9 activities. The main barriers to accurate documentation were lack of knowledge, poor templates, and staffing issues such as understaffing and turnover, and main facilitators were an internal data validation process and a documentation template to local practices. Findings from this project led to increased VA leadership engagement, development of 3 innovative, award-winning VA mobile PI prevention and management applications, updated policies and directives on PI prevention, and upgrading of the national VA HAPI workgroup to an advisory committee and improved collaboration between the PI advisory committee and nursing informatics.
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24
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Lefèvre C, Bellier-Waast F, Lejeune F, Duteille F, Kieny P, Le Fort M, Perrouin-Verbe B. Ten years of myocutaneous flaps for pressure ulcers in patients with spinal lesions: Analysis of complications in the framework of a specialised medical-surgical pathway. J Plast Reconstr Aesthet Surg 2018; 71:1652-1663. [DOI: 10.1016/j.bjps.2018.07.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 05/09/2018] [Accepted: 07/27/2018] [Indexed: 11/25/2022]
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25
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Bogie KM, Zhang GQ, Roggenkamp SK, Zeng N, Seton J, Tao S, Bloostein AL, Sun J. Individualized Clinical Practice Guidelines for Pressure Injury Management: Development of an Integrated Multi-Modal Biomedical Information Resource. JMIR Res Protoc 2018; 7:e10871. [PMID: 30190252 PMCID: PMC6231753 DOI: 10.2196/10871] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 06/22/2018] [Indexed: 11/23/2022] Open
Abstract
Background Pressure ulcers (PU) and deep tissue injuries (DTI), collectively known as pressure injuries are serious complications causing staggering costs and human suffering with over 200 reported risk factors from many domains. Primary pressure injury prevention seeks to prevent the first incidence, while secondary PU/DTI prevention aims to decrease chronic recurrence. Clinical practice guidelines (CPG) combine evidence-based practice and expert opinion to aid clinicians in the goal of achieving best practices for primary and secondary prevention. The correction of all risk factors can be both overwhelming and impractical to implement in clinical practice. There is a need to develop practical clinical tools to prioritize the multiple recommendations of CPG, but there is limited guidance on how to prioritize based on individual cases. Bioinformatics platforms enable data management to support clinical decision support and user-interface development for complex clinical challenges such as pressure injury prevention care planning. Objective The central hypothesis of the study is that the individual’s risk factor profile can provide the basis for adaptive, personalized care planning for PU prevention based on CPG prioritization. The study objective is to develop the Spinal Cord Injury Pressure Ulcer and Deep Tissue Injury (SCIPUD+) Resource to support personalized care planning for primary and secondary PU/DTI prevention. Methods The study is employing a retrospective electronic health record (EHR) chart review of over 75 factors known to be relevant for pressure injury risk in individuals with a spinal cord injury (SCI) and routinely recorded in the EHR. We also perform tissue health assessments of a selected sub-group. A systems approach is being used to develop and validate the SCIPUD+ Resource incorporating the many risk factor domains associated with PU/DTI primary and secondary prevention, ranging from the individual’s environment to local tissue health. Our multiscale approach will leverage the strength of bioinformatics applied to an established national EHR system. A comprehensive model is being used to relate the primary outcome of interest (PU/DTI development) with over 75 PU/DTI risk factors using a retrospective chart review of 5000 individuals selected from the study cohort of more than 36,000 persons with SCI. A Spinal Cord Injury Pressure Ulcer and Deep Tissue Injury Ontology (SCIPUDO) is being developed to enable robust text-mining for data extraction from free-form notes. Results The results from this study are pending. Conclusions PU/DTI remains a highly significant source of morbidity for individuals with SCI. Personalized interactive care plans may decrease both initial PU formation and readmission rates for high-risk individuals. The project is using established EHR data to build a comprehensive, structured model of environmental, social and clinical pressure injury risk factors. The comprehensive SCIPUD+ health care tool will be used to relate the primary outcome of interest (pressure injury development) with covariates including environmental, social, clinical, personal and tissue health profiles as well as possible interactions among some of these covariates. The study will result in a validated tool for personalized implementation of CPG recommendations and has great potential to change the standard of care for PrI clinical practice by enabling clinicians to provide personalized application of CPG priorities tailored to the needs of each at-risk individual with SCI. Registered Report Identifier RR1-10.2196/10871
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Affiliation(s)
- Kath M Bogie
- Louis Stokes Cleveland VA Medical Center, Cleveland, OH, United States.,Department of Orthopaedics, Case Western Reserve University, Cleveland, OH, United States
| | - Guo-Qiang Zhang
- Institute for Biomedical Informatics, University of Kentucky, Lexington, KY, United States.,Department of Computer Science, University of Kentucky, Lexington, KY, United States
| | - Steven K Roggenkamp
- Institute for Biomedical Informatics, University of Kentucky, Lexington, KY, United States.,Department of Computer Science, University of Kentucky, Lexington, KY, United States
| | - Ningzhou Zeng
- Institute for Biomedical Informatics, University of Kentucky, Lexington, KY, United States.,Department of Computer Science, University of Kentucky, Lexington, KY, United States
| | - Jacinta Seton
- Louis Stokes Cleveland VA Medical Center, Cleveland, OH, United States
| | - Shiqiang Tao
- Institute for Biomedical Informatics, University of Kentucky, Lexington, KY, United States.,Department of Computer Science, University of Kentucky, Lexington, KY, United States
| | - Arielle L Bloostein
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, United States
| | - Jiayang Sun
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, United States
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26
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Porter‐Armstrong AP, Moore ZEH, Bradbury I, McDonough S. Education of healthcare professionals for preventing pressure ulcers. Cochrane Database Syst Rev 2018; 5:CD011620. [PMID: 29800486 PMCID: PMC6494581 DOI: 10.1002/14651858.cd011620.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Pressure ulcers, also known as bed sores or pressure sores, are localised areas of tissue damage arising due to excess pressure and shearing forces. Education of healthcare staff has been recognised as an integral component of pressure ulcer prevention. These educational programmes are directed towards influencing behaviour change on the part of the healthcare professional, to encourage preventative practices with the aim of reducing the incidence of pressure ulcer development. OBJECTIVES To assess the effects of educational interventions for healthcare professionals on pressure ulcer prevention. SEARCH METHODS In June 2017 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. SELECTION CRITERIA We included randomised controlled trials (RCTs) and cluster-RCTs, that evaluated the effect of any educational intervention delivered to healthcare staff in any setting to prevent pressure ulceration. DATA COLLECTION AND ANALYSIS Two review authors independently assessed titles and abstracts of the studies identified by the search strategy for eligibility. We obtained full versions of potentially relevant studies and two authors independently screened these against the inclusion criteria. MAIN RESULTS We identified five studies that met the inclusion criteria for this review: four RCTs and one cluster-RCT. The study characteristics differed in terms of healthcare settings, the nature of the interventions studied and outcome measures reported. The cluster-RCT, and two of the RCTs, explored the effectiveness of education delivered to healthcare staff within residential or nursing home settings, or nursing home and hospital wards, compared to no intervention, or usual practices. Educational intervention in one of these studies was embedded within a broader, quality improvement bundle. The other two individually randomised controlled trials explored the effectiveness of educational intervention, delivered in two formats, to nursing staff cohorts.Due to the heterogeneity of the studies identified, pooling was not appropriate and we have presented a narrative overview. We explored a number of comparisons (1) education versus no education (2) components of educational intervention in a number of combinations and (3) education delivered in different formats. There were three primary outcomes: change in healthcare professionals' knowledge, change in healthcare professionals' clinical behaviour and incidence of new pressure ulcers.We are uncertain whether there is a difference in health professionals' knowledge depending on whether they receive education or no education on pressure ulcer prevention (hospital group: mean difference (MD) 0.30, 95% confidence interval (CI) -1.00 to 1.60; 10 participants; nursing home group: MD 0.30, 95% CI -0.77 to 1.37; 10 participants). This was based on very low-certainty evidence from one study, which we downgraded for serious study limitations, indirectness and imprecision.We are uncertain whether there is a difference in pressure ulcer incidence with the following comparisons: training, monitoring and observation, versus monitoring and observation (risk ratio (RR) 0.63, 95% CI 0.37 to 1.05; 345 participants); training, monitoring and observation, versus observation alone (RR 1.21, 95% CI 0.60 to 2.43; 325 participants) or, monitoring and observation versus observation alone (RR 1.93, 95% CI 0.96 to 3.88; 232 participants). This was based on very low-certainty evidence from one study, which we downgraded for very serious study limitations and imprecision. We are uncertain whether multilevel intervention versus attention control makes any difference to pressure ulcer incidence. The report presented insufficient data to enable further interrogation of this outcome.We are uncertain whether education delivered in different formats such as didactic education versus video-based education (MD 4.60, 95% CI 3.08 to 6.12; 102 participants) or e-learning versus classroom education (RR 0.92, 95% CI 0.80 to 1.07; 18 participants), makes any difference to health professionals' knowledge of pressure ulcer prevention. This was based on very low-certainty evidence from two studies, which we downgraded for serious study limitations and study imprecision.None of the included studies explored our other primary outcome: change in health professionals' clinical behaviour. Only one study explored the secondary outcomes of interest, namely, pressure ulcer severity and patient and carer reported outcomes (self-assessed quality of life and functional dependency level respectively). However, this study provided insufficient information to enable our independent assessment of these outcomes within the review. AUTHORS' CONCLUSIONS We are uncertain whether educating healthcare professionals about pressure ulcer prevention makes any difference to pressure ulcer incidence, or to nurses' knowledge of pressure ulcer prevention. This is because the included studies provided very low-certainty evidence. Therefore, further information is required to clarify the impact of education of healthcare professionals on the prevention of pressure ulcers.
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Affiliation(s)
| | - Zena EH Moore
- Royal College of Surgeons in IrelandSchool of Nursing & Midwifery123 St. Stephen's GreenDublinIrelandD2
| | | | - Suzanne McDonough
- Ulster UniversityCentre for Health and Rehabilitation Technologies (CHaRT), Institute of Nursing and Health ResearchSchool of Health SciencesRoom 1F118NewtownabbeyCo AntrimUKBT37 0QB
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Furlan JC, Fehlings MG, Craven BC. Economic Impact of Aging on the Initial Spine Care of Patients With Acute Spine Trauma: From Bedside to Teller. Neurosurgery 2018; 84:1251-1260. [DOI: 10.1093/neuros/nyy180] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 04/06/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- Julio C Furlan
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
- Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Michael G Fehlings
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
- Spinal Program, Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - B Catharine Craven
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
- Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
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Evardone M, Wilson CS, Weinel D, Soble JR, Kang Y. Does attendance in SCI education courses impact health outcomes in acute rehabilitation? J Spinal Cord Med 2018; 41:17-27. [PMID: 27146326 PMCID: PMC5810801 DOI: 10.1080/10790268.2016.1177269] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE Though education about secondary complications following spinal cord injury (SCI) is a component of many rehabilitation programs, there is little research on their success in promoting healthier outcomes. This study examined 1) whether greater education course attendance was associated with improved health outcomes and quality of life and 2) whether completion of bladder management and skin care courses was associated with decreased incidence of urinary tract infections (UTIs) and pressure ulcers (PUs). DESIGN Retrospective medical record review. SETTING AND PARTICIPANTS Patients (N = 106) in a Veterans Administration (VA) SCI rehabilitation program who completed at least one education class from August 2008 to September 2012. METHODS AND OUTCOME MEASURES Records were reviewed to determine the number of education courses completed and patients' responses to the Satisfaction with Life Survey (SWLS), the short form of the Craig Handicap and Assessment Reporting Technique (CHART-SF), and Short Form Health Survey (SF-8) at admission, discharge, and 90 days post-discharge. Records were reviewed to determine frequency of UTIs and PUs from admission to discharge and from discharge to 90-day follow-up. RESULTS Regression analyses revealed no association between number of classes and self-reported health and quality of life. Skin care class attendance was associated with a decreased number of PUs. Greater overall attendance at education courses was unexpectedly associated with a higher number of UTIs from admission to discharge. CONCLUSION Results of the study are mixed. Multiple factors appear to impact the success of education interventions. Future research is needed to clarify the best approach.
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Affiliation(s)
- Milagros Evardone
- Mental Health & Behavioral Service, James A. Haley Veterans Hospital & Clinics, Tampa, FL, USA
- Milagros Evardone is now affilitiated with MH Service, Orlando VA Medical Center, Orlando, FL, USA
| | - Catherine S. Wilson
- Mental Health & Behavioral Service, James A. Haley Veterans Hospital & Clinics, Tampa, FL, USA
| | - Diana Weinel
- Spinal Cord Injury Nursing Service, James A. Haley Veterans Hospital & Clinics, Tampa, FL, USA
| | - Jason R. Soble
- Mental Health & Behavioral Service, James A. Haley Veterans Hospital & Clinics, Tampa, FL, USA
- Jason Soble is now affiliated with Psychology Service, South Texas Veterans' Healthcare System, San Antonio, Texas, USA
| | - Younghee Kang
- Spinal Cord Injury Nursing Service, James A. Haley Veterans Hospital & Clinics, Tampa, FL, USA
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Furlan JC, Gulasingam S, Craven BC. The Health Economics of the spinal cord injury or disease among veterans of war: A systematic review. J Spinal Cord Med 2017; 40:649-664. [PMID: 28874099 PMCID: PMC5778929 DOI: 10.1080/10790268.2017.1368267] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
CONTEXT Information on health-care utilization and the economic burden of disease are essential to understanding service demands, service accessibility, and practice patterns. This information may also be used to enhance the quality of care through altered resource allocation. Thus, a systematic review of literature on the economic impact of caring for SCI/D veterans would be of great value. OBJECTIVE To systematically review and critically appraise the literature on the economics of the management of veterans with SCI/D. METHODS Medline, EMBASE and PsycINFO databases were searched for articles on economic impact of management of SCI/D veterans, published from 1946 to September/2016. The STROBE statement was used to determine publication quality. RESULTS The search identified 1,573 publications of which 13 articles fulfilled the inclusion/exclusion criteria with 12 articles focused on costs of management of SCI/D veterans; and, one cost-effectiveness analysis. Overall, the health care costs for the management of SCI/D veterans are substantial ($30,770 to $62,563 in 2016 USD per year) and, generally, greater than the costs of caring for patients with other chronic diseases. The most significant determinants of the higher total health-care costs are cervical level injury, complete injury, time period (i.e. first year post-injury and end-of-life year), and presence of pressure ulcers. CONCLUSIONS There is growing evidence for the economic burden of SCI/D and its determinants among veterans, whereas there is a paucity of comparative studies on interventions including cost-effectiveness analyses. Further investigations are needed to fulfill significant knowledge gaps on the economics of caring for veterans with SCI/D.
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Affiliation(s)
- Julio C. Furlan
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, Canada
- Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Sivakumar Gulasingam
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, Canada
- Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - B. Catharine Craven
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, Canada
- Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
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White BA, Dea N, Street JT, Cheng CL, Rivers CS, Attabib N, Kwon BK, Fisher CG, Dvorak MF. The Economic Burden of Urinary Tract Infection and Pressure Ulceration in Acute Traumatic Spinal Cord Injury Admissions: Evidence for Comparative Economics and Decision Analytics from a Matched Case-Control Study. J Neurotrauma 2017; 34:2892-2900. [DOI: 10.1089/neu.2016.4934] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
| | - Nicolas Dea
- Service de Neurochirurgie, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - John T. Street
- Vancouver Spine Surgery Institute, Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | - Najmedden Attabib
- Dalhousie University, Halifax, Nova Scotia; Horizon Health Network, Division of Neurosurgery, Saint John Regional Hospital, Saint John, New Brunswick, Canada
| | - Brian K. Kwon
- Vancouver Spine Surgery Institute, Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Charles G. Fisher
- Vancouver Spine Surgery Institute, Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marcel F. Dvorak
- Vancouver Spine Surgery Institute, Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
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Luther SL, Thomason SS, Sabharwal S, Finch DK, McCart J, Toyinbo P, Bouayad L, Matheny ME, Gobbel GT, Powell-Cope G. Leveraging Electronic Health Care Record Information to Measure Pressure Ulcer Risk in Veterans With Spinal Cord Injury: A Longitudinal Study Protocol. JMIR Res Protoc 2017; 6:e3. [PMID: 28104580 PMCID: PMC5290296 DOI: 10.2196/resprot.5948] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 09/09/2016] [Accepted: 10/30/2016] [Indexed: 12/05/2022] Open
Abstract
Background Pressure ulcers (PrUs) are a frequent, serious, and costly complication for veterans with spinal cord injury (SCI). The health care team should periodically identify PrU risk, although there is no tool in the literature that has been found to be reliable, valid, and sensitive enough to assess risk in this vulnerable population. Objective The immediate goal is to develop a risk assessment model that validly estimates the probability of developing a PrU. The long-term goal is to assist veterans with SCI and their providers in preventing PrUs through an automated system of risk assessment integrated into the veteran’s electronic health record (EHR). Methods This 5-year longitudinal, retrospective, cohort study targets 12,344 veterans with SCI who were cared for in the Veterans Health Administration (VHA) in fiscal year (FY) 2009 and had no record of a PrU in the prior 12 months. Potential risk factors identified in the literature were reviewed by an expert panel that prioritized factors and determined if these were found in structured data or unstructured form in narrative clinical notes for FY 2009-2013. These data are from the VHA enterprise Corporate Data Warehouse that is derived from the EHR structured (ie, coded in database/table) or narrative (ie, text in clinical notes) data for FY 2009-2013. Results This study is ongoing and final results are expected in 2017. Thus far, the expert panel reviewed the initial list of risk factors extracted from the literature; the panel recommended additions and omissions and provided insights about the format in which the documentation of the risk factors might exist in the EHR. This list was then iteratively refined through review and discussed with individual experts in the field. The cohort for the study was then identified, and all structured, unstructured, and semistructured data were extracted. Annotation schemas were developed, samples of documents were extracted, and annotations are ongoing. Operational definitions of structured data elements have been created and steps to create an analytic dataset are underway. Conclusions To our knowledge, this is the largest cohort employed to identify PrU risk factors in the United States. It also represents the first time natural language processing and statistical text mining will be used to expand the number of variables available for analysis. A major strength of this quantitative study is that all VHA SCI centers were included in the analysis, reducing potential for selection bias and providing increased power for complex statistical analyses. This longitudinal study will eventually result in a risk prediction tool to assess PrU risk that is reliable and valid, and that is sensitive to this vulnerable population.
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Affiliation(s)
- Stephen L Luther
- Center of Innovation on Disability and Rehabilitation Research, Health Services Research and Development, Department of Veterans Affairs, Tampa, FL, United States.,College of Public Health, University of South Florida, Tampa, FL, United States
| | - Susan S Thomason
- Center of Innovation on Disability and Rehabilitation Research, Health Services Research and Development, Department of Veterans Affairs, Tampa, FL, United States.,Tampa VA Research and Education Foundation, Inc, Tampa, FL, United States
| | - Sunil Sabharwal
- VA Boston Healthcare System, VA New England Healthcare System, Department of Veterans Affairs, West Roxbury, MA, United States
| | - Dezon K Finch
- Center of Innovation on Disability and Rehabilitation Research, Health Services Research and Development, Department of Veterans Affairs, Tampa, FL, United States
| | - James McCart
- Center of Innovation on Disability and Rehabilitation Research, Health Services Research and Development, Department of Veterans Affairs, Tampa, FL, United States.,Muma College of Business, University of South Florida, Tampa, FL, United States
| | - Peter Toyinbo
- Center of Innovation on Disability and Rehabilitation Research, Health Services Research and Development, Department of Veterans Affairs, Tampa, FL, United States
| | - Lina Bouayad
- Center of Innovation on Disability and Rehabilitation Research, Health Services Research and Development, Department of Veterans Affairs, Tampa, FL, United States
| | - Michael E Matheny
- Geriatrics Research Education and Clinical Care, Tennessee Valley Healthcare System, Department of Veterans Affairs, Nashville, TN, United States.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, United States.,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States.,Division of General Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Glenn T Gobbel
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, United States.,Research and Development Service, Tennessee Valley Healthcare System, Department of Veterans Affairs, Nashville, TN, United States
| | - Gail Powell-Cope
- Center of Innovation on Disability and Rehabilitation Research, Health Services Research and Development, Department of Veterans Affairs, Tampa, FL, United States.,College of Public Health, University of South Florida, Tampa, FL, United States.,College of Nursing, University of South Florida, Tampa, FL, United States
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Dowling AV, Eberly V, Maneekobkunwong S, Mulroy SJ, Requejo PS, Gwin JT. Telehealth monitor to measure physical activity and pressure relief maneuver performance in wheelchair users. Assist Technol 2016; 29:202-209. [PMID: 27687753 DOI: 10.1080/10400435.2016.1220993] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
This study demonstrated the feasibility of a device for monitoring pressure relief maneuvers and physical activity for wheelchair users. The device counts the number of wheel pushes based on wheelchair acceleration and measures pressure relief maneuvers using a seat sensor consisting of three force sensing resistors (FSRs). To establish the feasibility of the seat sensor for the detection of pressure relief maneuvers, 10 wheelchair users and 10 non-disabled controls completed a series of wheelchair depression raises, forward trunk leans, and lateral trunk leans. The seat sensor was placed underneath the user's seat cushion. To establish the feasibility of wheel push counting, 10 full-time wheelchair users navigated a flat 50-m outdoor track and a 100-m outdoor obstacle course during self-propulsion (e.g., wheel pushes) and during assisted-propulsion (e.g., no wheel pushes). Of the 240 performed pressure relief, 225 were properly classified by the seat sensor (accuracy: 94%, sensitivity: 96%, specificity: 80%). Sensitivity was highest for depression raises (98%) and lowest for front lean maneuvers (80%). The wheelchair activity monitor measured 2,112 pushes during the self-propulsion trials compared to 2,162 pushes measured with the instrumented push-rim (97.7%). During assisted-propulsion trials, there were 477 incorrectly identified pushes (8.0 per trial).
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Affiliation(s)
| | - Valerie Eberly
- b Pathokinesiology Laboratory , Rancho Los Amigos National Rehabilitation Center , Downey , California , USA
| | - Somboon Maneekobkunwong
- b Pathokinesiology Laboratory , Rancho Los Amigos National Rehabilitation Center , Downey , California , USA
| | - Sara J Mulroy
- b Pathokinesiology Laboratory , Rancho Los Amigos National Rehabilitation Center , Downey , California , USA
| | - Philip S Requejo
- b Pathokinesiology Laboratory , Rancho Los Amigos National Rehabilitation Center , Downey , California , USA
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33
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Guihan M, Sohn MW, Bauman WA, Spungen AM, Powell-Cope GM, Thomason SS, Collins JF, Bates-Jensen BM. Difficulty in Identifying Factors Responsible for Pressure Ulcer Healing in Veterans With Spinal Cord Injury. Arch Phys Med Rehabil 2016; 97:2085-2094.e1. [PMID: 27373743 DOI: 10.1016/j.apmr.2016.05.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 04/29/2016] [Accepted: 05/26/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To identify characteristics associated with pressure ulcer (PrU) healing for individuals with spinal cord injury (SCI). DESIGN Secondary analysis of a large clinical trial's data for healing PrUs in individuals with SCI; prospective Delphi process was conducted with SCI and/or PrU experts. SETTING Spinal cord injury centers. PARTICIPANTS There were 629 screening and 162 treatment participants (N=791); 185 SCI clinicians/national PrU/wound care experts participated in the Delphi process. INTERVENTIONS None. MAIN OUTCOME MEASURE PrU healing of 50% and 100% at weeks 4 and 12. RESULTS Poisson regression models using the top Delphi-recommended factors found that only ulcer stage consistently predicted 50% and 100% healing at weeks 4 and 12. Additionally, ischial/perineal location was associated with 33% higher likelihood of 50% healing at week 4. Patient noncompliance with treatment recommendations, the top-ranked Delphi factor, did not predict healing at week 4 or 12. Expanded models found that at week 4, baseline PrU size, PrU stage IV, PrU pain, and American Spinal Injury Association grade A significantly predicted 100% healing, while at week 12, only PrU stage (IV) significantly predicted 100% healing. Significant predictors of 50% healing at week 4 included baseline PrU size, stage, ischial/perianal location body mass index >30kg/m2, foul odor, and signs of infection. At week 12, PrU duration, paraplegia predicted 50% healing. SCI center identifiers consistently showed 2- to 5-fold variation in predicting 50% PrU healing at weeks 4 and 12. CONCLUSIONS Delphi panel-recommended factors (eg, patient compliance) did not predict PrU healing. Reducing center-level variability in wound healing by learning from best practices should be a health system goal. PrU healing in SCI is still poorly understood, and future studies should focus on as yet unidentified or underappreciated factors.
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Affiliation(s)
- Marylou Guihan
- Spinal Cord Injury Quality Enhancement Research Initiative, Edward Hines Jr Veterans Administration Hospital, Hines, IL; Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL.
| | - Min-Woong Sohn
- Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, VA
| | - William A Bauman
- Veterans Administration Rehabilitation Research and Development National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters Veterans Administration Medical Center, Bronx, NY; Department of Medicine and Rehabilitation Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ann M Spungen
- Veterans Administration Rehabilitation Research and Development National Center for the Medical Consequences of Spinal Cord Injury, James J. Peters Veterans Administration Medical Center, Bronx, NY; Department of Medicine and Rehabilitation Medicine, The Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gail M Powell-Cope
- Center of Innovation for Disability and Rehabilitation Research, Tampa, FL; School of Nursing, University of South Florida, Tampa, FL
| | - Susan S Thomason
- Center of Innovation for Disability and Rehabilitation Research, Tampa, FL
| | - Joseph F Collins
- Cooperative Studies Program Coordinating Center, Perry Point Veterans Administration Medical Center, Perry Point, MD
| | - Barbara M Bates-Jensen
- Spinal Cord Injury Quality Enhancement Research Initiative, Edward Hines Jr Veterans Administration Hospital, Hines, IL; School of Nursing, University of California at Los Angeles, Los Angeles, CA; David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA
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A Multisite Quality Improvement Project to Standardize the Assessment of Pressure Ulcer Healing in Veterans with Spinal Cord Injuries/Disorders. Adv Skin Wound Care 2016; 29:269-76. [DOI: 10.1097/01.asw.0000482283.85306.8f] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Tung JY, Stead B, Mann W, Ba'Pham, Popovic MR. Assistive technologies for self-managed pressure ulcer prevention in spinal cord injury: a scoping review. ACTA ACUST UNITED AC 2016; 52:131-46. [PMID: 26237111 DOI: 10.1682/jrrd.2014.02.0064] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 01/26/2015] [Indexed: 11/05/2022]
Abstract
Pressure ulcers (PUs) in individuals with spinal cord injury (SCI) present a persistent and costly problem. Continuing effort in developing new technologies that support self-managed care is an important prevention strategy. Specifically, the aims of this scoping review are to review the key concepts and factors related to self-managed prevention of PUs in individuals with SCI and appraise the technologies available to assist patients in self-management of PU prevention practices. There is broad consensus that sustaining long-term adherence to prevention regimens is a major concern. Recent literature highlights the interactions between behavioral and physiological risk factors. We identify four technology categories that support self-management: computer-based educational technologies demonstrated improved short-term gains in knowledge (2 studies), interface pressure mapping technologies demonstrated improved adherence to pressure-relief schedules up to 3 mo (5 studies), electrical stimulation confirmed improvements in tissue tolerance after 8 wk of training (3 studies), and telemedicine programs demonstrated improvements in independence and reduced hospital visits over 6 mo (2 studies). Overall, self-management technologies demonstrated low-to-moderate effectiveness in addressing a subset of risk factors. However, the effectiveness of technologies in preventing PUs is limited due to a lack of incidence reporting. In light of the key findings, we recommend developing integrated technologies that address multiple risk factors.
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Affiliation(s)
- James Y Tung
- Department of Mechanical and Mechatronics Engineering, University of Waterloo, Waterloo, Canada
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36
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Ljung AC, Stenius MC, Bjelak S, Lagergren JF. Surgery for pressure ulcers in spinal cord-injured patients following a structured treatment programme: a 10-year follow-up. Int Wound J 2016; 14:355-359. [PMID: 27146601 DOI: 10.1111/iwj.12609] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 03/29/2016] [Accepted: 04/05/2016] [Indexed: 11/30/2022] Open
Abstract
With the aim to improve the outcomes for spinal cord-injured patients undergoing surgery for pressure ulcers, a structured treatment programme regulating pre- and postoperative care and rehabilitation was introduced in 2002 in Stockholm. Fifty-one consecutive patients operated on between 2002 and 2007 were included in a 10-year follow-up to evaluate the programme regarding initial healing results and long-term ulcer and health status. At one month postoperatively, 49 out of 51 (96%) patients were completely healed. Five patients (5/44, 11%) developed recurrent or new ulcers within 3 years of surgery. Two patients were re-operated on (2/44, 5%). Between 3 and 10 years after surgery, 9 patients (9/33, 27%) had a history of recurrent ulcers, and 6 (6/33, 18%) had a history of new ulcers, a total of 15 patients (15/33, 45%). Of these, three needed re-operation (3/33, 9 %). The health status values using a visual analogue rating scale were 70 (median) at 3 and 10 years compared with 30 (median) preoperatively. The good initial healing, the low ulcer recurrence rate and the raise in health status indicate the value of a structured treatment programme, especially for the first few postoperative years.
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Affiliation(s)
- Anders C Ljung
- Department of Reconstructive Plastic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Madeleine C Stenius
- Rehab Station Stockholm/Spinalis, Research and Development Unit, Stockholm, Sweden
| | - Sabahudin Bjelak
- Rehab Station Stockholm/Spinalis, Research and Development Unit, Stockholm, Sweden.,Department of Neurobiology, Care Sciences and Society, Division of Neurodegeneration, Section Neurorehabilitation, Karolinska Institute, Stockholm, Sweden
| | - Jakob F Lagergren
- Department of Reconstructive Plastic Surgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
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Guihan M, Murphy D, Rogers TJ, Parachuri R, SAE Richardson M, Lee KK, Bates-Jensen BM. Documentation of preventive care for pressure ulcers initiated during annual evaluations in SCI. J Spinal Cord Med 2016; 39:290-300. [PMID: 26763668 PMCID: PMC5073760 DOI: 10.1080/10790268.2015.1114225] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE Community-acquired pressure ulcers (PrUs) are a frequent cause of hospitalization of Veterans with spinal cord injury (SCI). The Veterans Health Administration (VHA) recommends that SCI annual evaluations include assessment of PrU risk factors, a thorough skin inspection and sharing of recommendations for PrU prevention strategies. We characterized consistency of preventive skin care during annual evaluations for Veterans with SCI as a first step in identifying strategies to more actively promote PrU prevention care in other healthcare encounters. DESIGN/SETTING/PARTICIPANTS Retrospective cross-sectional observational design, including review of electronic medical records for 206 Veterans with SCI admitted to 2 VA SCI centers from January-December, 2011. OUTCOME MEASURES Proportion of applicable skin health elements documented (number of applicable elements/skin health elements documented). RESULTS Our sample was primarily white (78%) male (96.1%), and mean age = 61 years. 40% of participants' were hospitalized for PrU treatment, with a mean of 294 days (median = 345 days) from annual evaluation to the index admission. On average, Veterans received an average of 75.5% (IQR 68-86%) of applicable skin health elements. Documentation of applicable skin health elements was significantly higher during inpatient vs. outpatient annual evaluations (mean elements received = 80.3% and 64.3%, respectively, P > 0.001). No significant differences were observed in documentation of skin health elements by Veterans at high vs. low PrU risk. CONCLUSION Additional PrU preventive care in the VHA outpatient setting may increase identification and detection of PrU risk factors and early PrU damage for Veterans with SCI in the community, allowing for earlier intervention.
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Affiliation(s)
- Marylou Guihan
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. VA Hospital, Hines, IL, USA,Spinal Cord Injury Quality Enhancement Research Initiative (SCI QUERI), Edward Hines Jr. VA Hospital, Hines, IL, USA,Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA,Correspondence to: Marylou Guihan, Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines, Jr. VA Hospital (151-H), 5000 S. 5th Avenue, Hines, IL 60141–3030, USA.
| | - Deidre Murphy
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. VA Hospital, Hines, IL, USA
| | - Thea J. Rogers
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. VA Hospital, Hines, IL, USA
| | - Ramadevi Parachuri
- Spinal Cord Injury Service, Edward Hines Jr. VA Hospital, Hines, IL, USA
| | | | - Kenneth K. Lee
- Clement J. Zablocki VA Medical Center, Spinal Cord Injury Center, Milwaukee, WI, USA
| | - Barbara M. Bates-Jensen
- Spinal Cord Injury Quality Enhancement Research Initiative (SCI QUERI), Edward Hines Jr. VA Hospital, Hines, IL, USA,UCLA School of Nursing & David Geffen School of Medicine, Los Angeles, CA, USA
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Ghaisas S, Pyatak EA, Blanche E, Blanchard J, Clark F. Lifestyle changes and pressure ulcer prevention in adults with spinal cord injury in the pressure ulcer prevention study lifestyle intervention. Am J Occup Ther 2015; 69:6901290020p1-10. [PMID: 25553751 DOI: 10.5014/ajot.2015.012021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Pressure ulcers (PrUs) are a major burden to patients with spinal cord injury (SCI), affecting their psychological, physical, and social well-being. Lifestyle choices are thought to contribute to the risk of developing PrUs. This article focuses on the interaction between lifestyle choices and the development of PrUs in community settings among participants in the University of Southern California-Rancho Los Amigos National Rehabilitation Center Pressure Ulcer Prevention Study (PUPS II), a randomized controlled trial of a lifestyle intervention for adults with SCI. We conducted a secondary cross-case analysis of treatment notes of 47 PUPS II participants and identified four patterns relating PrU development to lifestyle changes: positive PrU changes (e.g., healing PrUs) with positive lifestyle changes, negative or no PrU changes with positive lifestyle changes, positive PrU changes with minor lifestyle changes, and negative or no PrU changes with no lifestyle changes. We present case studies exemplifying each pattern.
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Affiliation(s)
- Samruddhi Ghaisas
- Samruddhi Ghaisas, OTD, OTR/L, is Director of Rehabilitation, Alhambra Healthcare and Wellness Center, Alhambra, CA. When this article was written, she was Occupational Therapy Doctorate Resident, Mrs. T. H. Chan Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles
| | - Elizabeth A Pyatak
- Elizabeth A. Pyatak, PhD, OTR/L, is Assistant Professor, Mrs. T. H. Chan Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles
| | - Erna Blanche
- Erna Blanche, PhD, OTR/L, FAOTA, is Associate Professor of Clinical Occupational Therapy, Mrs. T. H. Chan Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles
| | - Jeanine Blanchard
- Jeanine Blanchard, PhD, OTR/L, is Project Coordinator, Mrs. T. H. Chan Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles;
| | - Florence Clark
- Florence Clark, PhD, OTR/L, FAOTA, is Professor and Associate Dean and Chair, Mrs. T. H. Chan Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles
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Porter-Armstrong AP, Moore ZEH, Bradbury I, McDonough S. Education of healthcare professionals for preventing pressure ulcers. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [DOI: 10.1002/14651858.cd011620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Alison P Porter-Armstrong
- University of Ulster; School of Health Sciences; Shore Road Newtownabbey Belfast Co Antrim UK BT37 0QB
| | - Zena EH Moore
- Royal College of Surgeons in Ireland; School of Nursing & Midwifery; 123 St. Stephen's Green Dublin Ireland D2
| | - Ian Bradbury
- University of Ulster; CHART; Shore Road Jordanstown UK
| | - Suzanne McDonough
- University of Ulster; Health and Rehabilitation Sciences; School of Health Sciences Room 14J15 Newtownabbey Co Antrim UK BT37 0QB
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Dana AN, Bauman WA. Bacteriology of pressure ulcers in individuals with spinal cord injury: What we know and what we should know. J Spinal Cord Med 2015; 38:147-60. [PMID: 25130374 PMCID: PMC4397196 DOI: 10.1179/2045772314y.0000000234] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Individuals with spinal cord injury (SCI) are at increased risk for the development of pressure ulcers. These chronic wounds are debilitating and contribute to prolonged hospitalization and worse medical outcome. However, the species of bacteria and the role that specific species may play in delaying the healing of chronic pressure ulcers in the SCI population has not been well characterized. This study will review the literature regarding what is known currently about the bacteriology of pressure ulcers in individuals with SCI. An electronic literature search of MEDLINE (1966 to February 2014) was performed. Eleven studies detailing bacterial cultures of pressure ulcers in the SCI population met inclusion criteria and were selected for review. Among these studies, bacterial cultures were often polymicrobial with both aerobic and anaerobic bacteria identified with culture techniques that varied significantly. The most common organisms identified in pressure ulcers were Staphylococcus aureus, Proteus mirabilis, Pseudomonas aeruginosa, and Enterococcus faecalis. In general, wounds were poorly characterized with minimal to no physical description and/or location provided. Our present understanding of factors that may alter the microbiome of pressure ulcers in individuals with SCI is quite rudimentary, at best. Well-designed studies are needed to assess appropriate wound culture technique, the impact of bacterial composition on wound healing, development of infection, and the optimum medical and surgical approaches to wound care.
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Affiliation(s)
- Ali N. Dana
- Correspondence to: Ali N. Dana, Dermatology Service, Suite 2F, James J. Peters Veterans Affairs Medical Center, 130 West Kingsbridge Road, Bronx, NY 10468, USA. Ali.Dana.@va.gov
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Gould LJ, Olney CM, Nichols JS, Block AR, Simon RM, Guihan M. Spinal Cord Injury survey to determine pressure ulcer vulnerability in the outpatient population. Med Hypotheses 2014; 83:552-8. [PMID: 25241921 DOI: 10.1016/j.mehy.2014.08.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 08/14/2014] [Accepted: 08/24/2014] [Indexed: 10/24/2022]
Abstract
Pressure ulcers are one of the most common causes of morbidity, mortality and rehospitalization for those living with Spinal Cord Injury (SCI). Literature examining risk and recurrence of pressure ulcers (PrUs) has primarily focused on the nursing home elderly who do not have SCI. More than 200 factors that increase PrU risk have been identified. Yet unlike the elderly who incur pressure ulcers in nursing homes or when hospitalized, most persons with SCI develop their pressure ulcers as outpatients, while residing in the community. The Veterans Health Administration (VHA) provides medical care for a large number of persons with chronic SCI. Included in the VHA SCI model of chronic disease management is the provision of an annual Comprehensive Preventive Health Evaluation, a tool that has potential to identify individuals at high risk for PrUs. This research was motivated by the clinical observation that some individuals appear to be protected from developing PrUs despite apparently 'risky' behaviors while others develop PrUs despite vigilant use of the currently known preventative measures. There is limited literature regarding protective factors and specific risk factors that reduce PrU occurrence in the community dwelling person with chronic SCI have not been delineated. The purpose of this study is to examine the preliminary hypothesis that there are biological and/or psychosocial factors that increase or reduce vulnerability to PrUs among persons with SCI. A limited number of refined hypotheses will be generated for testing in a prospective fashion. A retrospective cross-sectional survey of 119 randomly selected Veterans with SCI undergoing the Comprehensive Health Prevention Evaluation during the year 2009 was performed. Factors that differed between patients with 0, 1 or ⩾2 PrUs were identified and stratified, with an emphasis on modifiable risk factors. Three hypotheses generated from this study warrant further investigation: (1) cumulative smoking history increases the risk of PrUs independent of co-morbidities, (2) being moderately overweight, BMI>25, with or without spasticity, is a modifiable factor that may be protective and (3) increased use of a caregiver does not reduce PrU risk. Prospective studies that focus on these hypotheses will lead to evidence-based risk assessment tools and customized interventions to prevent PrUs in persons with SCI in the outpatient setting.
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Affiliation(s)
- Lisa J Gould
- James A Haley Veterans Hospital, 13000 Bruce B. Downs Blvd, Tampa, FL 33612, United States.
| | - Christine M Olney
- James A Haley Veterans Hospital, 13000 Bruce B. Downs Blvd, Tampa, FL 33612, United States
| | - Jane S Nichols
- James A Haley Veterans Hospital, 13000 Bruce B. Downs Blvd, Tampa, FL 33612, United States
| | - Aaron R Block
- James A Haley Veterans Hospital, 13000 Bruce B. Downs Blvd, Tampa, FL 33612, United States
| | - Ross M Simon
- James A Haley Veterans Hospital, 13000 Bruce B. Downs Blvd, Tampa, FL 33612, United States
| | - Marylou Guihan
- James A Haley Veterans Hospital, 13000 Bruce B. Downs Blvd, Tampa, FL 33612, United States
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Hitzig SL, Balioussis C, Nussbaum E, McGillivray CF, Catharine Craven B, Noreau L. Identifying and classifying quality-of-life tools for assessing pressure ulcers after spinal cord injury. J Spinal Cord Med 2013; 36:600-15. [PMID: 24090238 PMCID: PMC3831321 DOI: 10.1179/2045772313y.0000000129] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
CONTEXT Although pressure ulcers may negatively influence quality of life (QoL) post-spinal cord injury (SCI), our understanding of how to assess their impact is confounded by conceptual and measurement issues. To ensure that descriptions of pressure ulcer impact are appropriately characterized, measures should be selected according to the domains that they evaluate and the population and pathologies for which they are designed. OBJECTIVE To conduct a systematic literature review to identify and classify outcome measures used to assess the impact of pressure ulcers on QoL after SCI. METHODS Electronic databases (Medline/PubMed, CINAHL, and PsycInfo) were searched for studies published between 1975 and 2011. Identified outcome measures were classified as being either subjective or objective using a QoL model. RESULTS Fourteen studies were identified. The majority of tools identified in these studies did not have psychometric evidence supporting their use in the SCI population with the exception of two objective measures, the Short-Form 36 and the Craig Handicap Assessment and Reporting Technique, and two subjective measures, the Life Situation Questionnaire-Revised and the Ferrans and Powers Quality of Life Index SCI-Version. CONCLUSION Many QoL outcome tools showed promise in being sensitive to the presence of pressure ulcers, but few of them have been validated for use with SCI. Prospective studies should employ more rigorous methods for collecting data on pressure ulcer severity and location to improve the quality of findings with regard to their impact on QoL. The Cardiff Wound Impact Schedule is a potential tool for assessing impact of pressure ulcers-post SCI.
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Affiliation(s)
- Sander L. Hitzig
- Lyndhurst Centre, Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario; and Division of Clinical Pharmacology, Health Outcomes and PharmacoEconomics (HOPE) Research Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada,Correspondence to: Sander L. Hitzig, Lyndhurst Centre, Toronto Rehabilitation Institute-University Health Network, 520 Sutherland Drive, Toronto, ON, Canada M4G 3V9.
| | - Christina Balioussis
- Lyndhurst Centre, Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario
| | - Ethne Nussbaum
- Lyndhurst Centre, Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario; and Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Colleen F. McGillivray
- Lyndhurst Centre, Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario; and Department of Medicine, Division of Physiatry, University of Toronto, Toronto, Ontario, Canada
| | - B. Catharine Craven
- Lyndhurst Centre, Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario; and Department of Medicine and Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Luc Noreau
- Centre Interdiscipinaire de Recherche en Réadaptation et Intégration Sociale (CIRRIS), Québec, Québec, Canada; and Departement de Réadaptation, Faculté de Médicine, Université Laval, Québec, Québec, Canada
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Stinson M, Gillan C, Porter-Armstrong A. A Literature Review of Pressure Ulcer Prevention: Weight Shift Activity, Cost of Pressure Care and Role of the Occupational Therapist. Br J Occup Ther 2013. [DOI: 10.4276/030802213x13651610908371] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Introduction: Pressure ulcers are a major concern for those who spend a prolonged period of time sitting. Weight shifts are one prevention strategy used to reduce the risk of tissue damage. Currently, the prevalence of pressure ulcers is high, suggesting that concordance with preventative methods is poor. Occupational therapy focuses on the use of functional activity to promote health and wellbeing. The aim of this literature review was to evaluate the role of functional activity in reducing seated interface pressure. Method: A comprehensive search of nine electronic databases (AMED, CINAHL, Ovid MEDLINE, SportDiscus, EMBASE, British Nursing Index, Cochrane Library, Google Scholar and OTDBASE) was conducted between January 2000 and October 2011. Findings: From the 24 articles included in the review, there is limited evidence evaluating the role of functional activity and weight shifts in reducing seated interface pressure. Limited evidence suggests poor concordance with weight shifts, with wheelchair users repositioning on average once every 1–2 hours. The cost of pressure ulcer care is considerable, with an average annual cost of £1.7 billion in the United Kingdom. Occupational therapists have a key preventative role. Conclusion: Further research is needed to explore the role of functional activity and to determine the effectiveness of weight shift activity in reducing seated interface pressure.
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Affiliation(s)
- May Stinson
- Lecturer in Occupational Therapy, School of Health Sciences, University of Ulster, Newtownabbey, Co. Antrim, Northern Ireland
| | - Catherine Gillan
- Formerly Research Assistant, School of Health Sciences, University of Ulster, Newtownabbey, Co. Antrim, and currently Occupational Therapist, Belfast Health and Social Care Trust, Belfast, Northern Ireland
| | - Alison Porter-Armstrong
- Senior Lecturer in Rehabilitation Sciences, Health and Rehabilitation Sciences Research Institute, University of Ulster, Newtownabbey, Co. Antrim, Northern Ireland
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Pyatak EA, Blanche EI, Garber SL, Diaz J, Blanchard J, Florindez L, Clark FA. Conducting intervention research among underserved populations: lessons learned and recommendations for researchers. Arch Phys Med Rehabil 2012; 94:1190-8. [PMID: 23262157 DOI: 10.1016/j.apmr.2012.12.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 11/15/2012] [Accepted: 12/05/2012] [Indexed: 11/17/2022]
Abstract
Randomized controlled trials (RCTs) are considered the criterion standard in research design for establishing treatment efficacy. However, the rigorous and highly controlled conditions of RCTs can be difficult to attain when conducting research among individuals living with a confluence of disability, low socioeconomic status, and being a member of a racial/ethnic minority group, who may be more likely to have unstable life circumstances. Research on effective interventions for these groups is urgently needed, because evidence regarding approaches to reduce health disparities and improve health outcomes is lacking. In this methodologic article, we discuss the challenges and lessons learned in implementing the Lifestyle Redesign for Pressure Ulcer Prevention in Spinal Cord Injury study among a highly disadvantaged population. These issues are discussed in terms of strategies to enhance recruitment, retention, and intervention relevance to the target population. Recommendations for researchers seeking to conduct RCTs among socioeconomically disadvantaged, ethnically diverse populations are provided.
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Affiliation(s)
- Elizabeth A Pyatak
- Division of Occupational Science and Occupational Therapy, Ostrow School of Dentistry, University of Southern California, Los Angeles, CA 90089, USA.
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Guilcher SJT, Craven BC, Lemieux-Charles L, Casciaro T, McColl MA, Jaglal SB. Secondary health conditions and spinal cord injury: an uphill battle in the journey of care. Disabil Rehabil 2012; 35:894-906. [PMID: 23020250 PMCID: PMC3665227 DOI: 10.3109/09638288.2012.721048] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To understand the journey of care in the prevention and management of secondary health conditions (SHCs) following spinal cord injury (SCI). METHOD This was a case study design with 'Ontario' as the case. The Network Episode Model was used as the conceptual framework. Data sources included in depth interviews with persons with SCI, care providers, and policy and decision makers. Document analysis was also conducted on relevant materials and policies. Key informants were selected by purposeful sampling as well as snowball sampling to provide maximum variation. Data analysis was an iterative process and involved descriptive and interpretive analyses. A coding structure was developed based on the conceptual framework which allowed for free nodes when emerging ideas or themes were identified. RESULTS Twenty-eight individuals were interviewed (14 persons with SCI and 14 persons representing care providers, community advocacy organization representatives, system service delivery administrators and policy-makers). A major over-arching domain that emerged from the data was the concept of 'fighting'. Eleven themes were identified: at the micro-individual level: (i) social isolation and system abandonment, (ii) funding and equitable care, (iii) bounded freedom and self-management; at the meso care provider level: (iv) gender and caregiving strain, (v) help versus disempowerment, (vi) holistic care-thinking outside the box, (vii) poor communication and coordination of care; and at the macro health system level: (viii) fight for access and availability, (ix) models of care tensions, (x) private versus public tensions and (xi) rigid rules and policies. CONCLUSIONS Findings suggest that the journey is challenging and a persistent uphill struggle for persons with SCI, care providers, and community-based advocates. If we are to make significant gains in minimizing the incidence and severity of SHCs, we need to tailor efforts at the health system level. IMPLICATIONS FOR REHABILITATION • Secondary health conditions are problematic for individuals with a spinal cord injury (SCI). • This study aimed to understand the journey of care in the prevention and management of secondary health conditions (SHCs) following SCI. • Findings suggest that the journey is challenging and a persistent uphill struggle for persons with SCI, care providers, and community-based advocates. • All stakeholders involved recognized the disparities in access to care and resources that exist within the system. We recommend that if we are to make significant gains in minimizing the incidence and severity of SHCs, we need to tailor efforts at the health system level.
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Affiliation(s)
- Sara J T Guilcher
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
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Abstract
BACKGROUND Pressure ulcer development is a common, serious complication after spinal cord injury (SCI). Although many biophysical agents are available for treatment, few randomized controlled trials of their efficacy have been done. OBJECTIVE The study objective was to examine the efficacy of low-pressure pulsatile lavage treatment for stage III and IV pressure ulcers in people with SCI. DESIGN This study was a randomized controlled trial. Participants and assessors were unaware of intervention assignments. SETTING This study was conducted in an SCI tertiary care center inpatient unit. PARTICIPANTS Participants were 28 people with SCI and stage III and IV pelvic pressure ulcers; 14 participants each were randomly assigned to treatment and control (sham treatment) groups. INTERVENTION Daily low-pressure pulsatile lavage treatment with 1 L of normal saline at 11 psi of pressure was applied to the treatment group along with standard dressing changes. The control group received only sham treatment and standard dressing changes. MEASUREMENTS Linear and volume measurements of pressure ulcer dimensions were obtained weekly for 3 weeks. RESULTS Statistical analysis with the t test revealed no statistically significant difference in demographics between groups. Random-coefficient models for analysis of linear and volume measurements revealed improvements over time for both groups. Time trend analysis revealed greater measurement decreases for the treatment group. Differences in rates of change (with 95% confidence intervals) for treatment and control groups, respectively, were: depth, -0.24 (0.09 to -0.58) cm/wk; width, -0.16 (0.06 to -0.39) cm/wk; length, -0.47 (0.18 to -1.12) cm/wk; and volume, -0.33 (0.13 to -0.80) cm(3)/wk. LIMITATIONS Study limitations were small sample size and inclusion of only one site. Additionally, participants were not queried about their group assignments. CONCLUSIONS Pulsatile lavage enhanced stage III and IV pelvic pressure ulcer healing rates in people with SCI relative to standard pressure ulcer treatment alone.
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Guihan M, Bates-Jenson BM, Chun S, Parachuri R, Chin AS, McCreath H. Assessing the feasibility of subepidermal moisture to predict erythema and stage 1 pressure ulcers in persons with spinal cord injury: a pilot study. J Spinal Cord Med 2012; 35:46-52. [PMID: 22330190 PMCID: PMC3240916 DOI: 10.1179/204577211x13209212104141] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Persons with spinal cord injury (SCI) are at high risk for pressure ulcers (PrUs) throughout their lifetime due to decreased mobility, lack of sensation, and other physiological changes. The high prevalence and recurrence rates, and costs associated with PrUs in veterans with SCI indicate the need for a reliable and practical method of detecting early PrUs. OBJECTIVE To assess the feasibility of obtaining biophysical measures of sub-epidermal moisture (SEM) using a handheld dermal phase meter to predict PrUs. DESIGN/METHODS Prospective observational design. Thirty-four veterans at two VA SCI centers (Hines, Long Beach) received daily (n = 12) or weekly (n = 22) SEM and concurrent visual skin assessment (VSA) across nine anatomic locations for up to 6 weeks. Outcome measures: SEM, visual skin assessment (VSA), and stage I PrUs. FINDINGS/RESULTS SEM was lowest for normal skin (39.3 dermal phase units (DPU), SD = 12.6) and higher for erythema/stage 1 PrUs (40.8 DPU, SD = 10.4) across all anatomic sites. Buttocks SEM were different between normal skin (40.5 DPU, SD = 10.3) and erythema/stage1 PrUs (43.8, SD = 9.5). SEM taken at heels were lower across all skin conditions (normal skin 28.2 DPU; erythema/stage 1 PrUs 34.7 DPU). SEM was taken when generalized edema present was lower than without generalized edema. CONCLUSIONS Preliminary results of using SEM to detect early PrU damage may translate from nursing home (NH) residents to persons with SCI. This study provides a foundation for a larger study to implement and assess SEM use as a method of prevention of PrUs.
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Affiliation(s)
- Marylou Guihan
- VA SCI QUERI Research Coordinating Center, Edward Hines Jr. VA Hospital, Hines, IL, USA.
| | - Barbara M. Bates-Jenson
- UCLA School of Nursing, Los Angeles, CA, USA,David Geffen School of Medicine, Los Angeles, CA, USA
| | - Sophia Chun
- VA Long Beach Healthcare System, CA, USA,Department of Physical Medicine and Rehabilitation, University of California, Irvine, CA, USA
| | - Rama Parachuri
- VA SCI QUERI Research Coordinating Center, Edward Hines Jr. VA Hospital, Hines, IL, USA
| | - Amy S. Chin
- VA SCI QUERI Research Coordinating Center, Edward Hines Jr. VA Hospital, Hines, IL, USA
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