An Evidence-based Pressure Ulcer Monitoring Tool for Spinal Cord Injury/Disease - PowerPoint Presentation

Slide1

An Evidence-based Pressure Ulcer Monitoring Tool for Spinal Cord Injury/Disease (SCI-PUMT)

Gail Powell-Cope PhD, ARNP, FAANActing Director, HSR&D/RR&D Center of ExcellenceTampa, FLGail.powell-cope@va.govSlide2

Monitoring Pressure Ulcer Healing in Persons with Spinal Cord Impairment

Funded by VA Health Services Research and Development Service (HSR&D)

Nursing Research Initiative 03-245, IRB#: 104145, 2006

– 2008

These findings and conclusions do not necessarily represent the

Department of Veteran Affairs or HSR&D Slide3

Investigators

Co-Principal InvestigatorsSusan S. Thomason DNP, MN, RN

Audrey Nelson PhD, RN, FAAN (Retired)

Co-Investigators

Steven Luther PhD

Jeffrey J. Harrow MD, PhD, FACPSlide4

Study Staff

Polly Placios, MS (Project/Data Manager)Data CollectorsStephanie McGovern, RNFrancis Hernandez, RN

Suk Tomlinson, RN

Olivia Monteso-Smithson, RN

Linda Smith, RN

Mary Reeder, BIS (Program Assistant)Slide5

Conclusion

This study found that the SCI-PUMT was a reliable, valid, and sensitive instrument for measuring PrU healing in persons with SCI in a 100 bed VHA SCI/D Center.Slide6

“Problems” (or challenges)

Clinical ProblemPressure ulcers are a high volume, high cost condition in Spinal Cord ImpairmentImplementationTranslating consistent and quality pressure ulcer monitoring into clinical practice, across all 32 SCI/D Centers, is a challenge.It takes 17 years from for new knowledge generated by a randomized controlled trial to be incorporated into practice, and even then, the application is highly uneven (Balas & Boren, 2000).Slide7
Slide8

Options for Implementing Changes

Dissemination Alone (journal articles, distribution of printed materials, CME) (not effective)Educational Outreach (Academic Detailing and

Local Opinion Leaders

)

(promising and mixed evidence)

Computer-based decision support systems

(mixed)

Audit and Feedback

(mixed evidence)

Patient-mediated Interventions such as education, reminders

(promising)

Patient-specific clinical reminders

(promising) Slide9

PARiHS FrameworkPromoting Action on Research Implementation in Health Services

Successful implementation is a function of: the nature and type of evidence qualities of the context

in which

the evidence is being introduced, and

the

way

implementation is

facilitatedSlide10

Evidence (Strong)

Evidence

(Weak)

Context

(Strong)

Context

(Weak)

Ideal Situation for Implementation

Innovation

Kitson, A. L.,

et al., (

2008). Evaluating the successful implementation of evidence into practice using the PARiHS framework: theoretical and practical challenges.

Implementation Science: IS

,

3

, 1. doi:

10.1186/1748-5908-3-1

Innovation

Innovation

Facilitation

Facilitation

FacilitationSlide11

Clinical Problem

Persons with spinal cord impairment (SCI) are at extreme risk for PrU due to immobility, lack of sensation, collagen degradation, moisture, nutritional status, transfers, decreased ability to self-perform pressure redistribution, pain, and other risk factors.PrU prevalence is 14-32%. PrU affect morbidity, mortality, function, quality of life, and economics. Slide12

Clinical Practice GuidelinesConsortium for Spinal Cord Medicine (2000

) Recommendations:Modify the treatment plan if the ulcer shows no evidence of healing within 2-4 weeks.Evaluate healing progress using an instrument or other quantitative measurements.Slide13

Clinical Practice Guidelines

National Pressure Ulcer Advisory Panel (NPUAP) European Pressure Ulcer Advisory Panel (EPUAP) (2009) Recommendations:Assess progress toward healing…use a validated tool…Re-evaluate the PrU, the plan of care, and individual if the PrU does not show progress toward healing within 2 weeks…Slide14

SettingMichael Bilirakis

Spinal Cord Injury/Disorders CenterJames A. Haley Veterans HospitalTampa, Florida100 inpatient beds CARF-accredited)Large outpatient patient populationHome Care (CARF-accredited)Long Term CareSlide15

However…

Variations in how PrU healing is measured varies across sites.Bates-Jensen Wound Assessment Tool (BWAT)Pressure Ulcer Scale for Healing (PUSH)Hybrid tools with little psychometric evaluationThese variations limit the ability to conduct comparable trials of interventionsSlide16

Research Questions

Is the SCI-PUMT valid for measuring PrU healing?Is the SCI-PUMT reliable for measuring PrU healing?How sensitive is the SCI-PUMT for measuring healing over time?Slide17

SCI-PUMT Phases

Development of item poolDevelopment and testing of SCI-PUMTAnalysis and SCI-PUMT refinementAssessment of SCI-PUMT reliabilitySlide18

Development of item pool

Phase 1Slide19

Development of Item Pool

Expert Panel #1Aim: Identify measures and variables important and/or specific to PrU healing in SCI population1 day on-site, Tampa, Florida9 interdisciplinary experts (MDs, RNs, OT, PT, RD)Variables then sent to EP for comment Expert Panel #2

Aim: Obtain content validity (all relevant concepts) for item pool

11 interdisciplinary experts (MDs

, RNs, RD

)

Aggregated variables sent to EP for commentSlide20

Item Pool

Consisted of 30 itemsItems from two established PrU healing assessment tools (PUSH, BWAT)Additional items identified by Expert Panels Slide21

Development and Testing of SCI-PUMT

Phase IISlide22

SubjectsRecruited from Inpatient, Outpatient, Home Care

3-year longitudinal cohort studyAssessed 30 PrU variablesPrU unit of analysis Slide23

Inclusion CriteriaEnrolled in SCI/D Registry and receiving primary care from JAHVA SCI primary physician

Primary or secondary diagnosis of Stages II-IV PrUSCI duration more than 12 monthsSlide24

Exclusion Criteria

Immune compromised Severely mentally ill or cognitively impairedTerminally illSlide25

Subject

ProfileSample Size 66 Unique Patients167 Pressure Ulcers

Age

60 years (mean)

Gender

Male 98%

Level of

Injury

Tetra 49%; Para 46%

ASIA

A 58%; B 20%; Other 23%

Years since

SCI onset

23

Years (mean)

High School Graduate

80%Slide26

Pressure Ulcer

Characteristic

Findings

Number PrU / subject

1 – 9 (mean

2.5)

Previous PrU

77%

Prior PU surgery

53%

Location

Ischia

43%

Sacrococcygeal 26%

Trochanter 8%

Heel 8%

Stage

II 20%; III

38%;

IV 42%

Ulcer Pain

18%

Chronic Osteomyelitis

33%Slide27

Co-Morbidity

IncidenceDiabetes Mellitus26%

Anemia

24%

Peripheral

Vascular Disease

11%

Chronic Obstructive

Pulmonary

Disease

9%

Congestive

Heart Failure

8%

Heterotopic Ossification

8%Slide28

Other Baseline Factors

IncidenceImmunosuppressant Medications12%

Spasticity

Interference with Function

(1 = none; 5 = maximum)

2.4

mean (SD 1.6)

Spasticity

Modified Ashworth Scale

(1 = sl

ight ↑ tone; 5 = rigidity)

2.1 mean (SD 1.2)

Pain

(0

= none; 10 = severe)

3.9 (SD = 2.6)

Mean Body Weight

175 lb (SD 36.4)

Nicotine

Preceding Week

Substance Abuse

29%

6%Slide29

Data Collection6 Registered Nurse Data Collectors

13 time points: 30 variables + VeV PhotographBaseline and 12 weeks orComplete healingPatient withdrawalHospital discharged and lived >40 milesPlastic surgery interventionSlide30

VeV Measurement Documentation Software

Digital images used to calculate:VolumeSlide31

Intra- and Inter-Rater Reliability Ranges

4 RN Data CollectorsIntra-Rater Reliability1 DCSame PrUTwice 1 ½ hours apartInter-Rater Reliability4 DC

Same PrU

Consecutively

TOOL

Intra-

Rater

ICC

Inter-Rater ICC

PUSH

0.88

0.996

0.76 – 0.96

BWAT

0.87 –

0.99

0.69 –

0.91Slide32

Analysis and SCI-PUMT Refinement

Phase IIISlide33

Statistical Analysis

Construct validityPredictive validitySensitivity to changeInternal consistency reliabilitySlide34

Construct ValidityExploratory Factor Analysis (EFA)

N = 167 PrUPrincipal factor extraction with Promax (orthogonal rotation)Items removed from analysis based on: Values in correlation matrixFactor loadings of similar items (from 2 tools)Items not well defined by factors (low communalities) Slide35

Variable

Source

Geometric Factor

Substance

Factor

Depth

PUMT

.82

-

Tunneling

PUMT

.77

-

Edges

PSST

.55

-

Undermining

PUMT

.48

Surface area

PUSH

.35

.51

Necrotic amount

PSST

-

.52

Exudate type

PUMT

-

.40

*

Factor loading < |.30| have been replaced with “-“for ease of reading

Factor Analysis ResultsSlide36

Predictive Validity

Outcome variables to represent PrU healing: Surface Area & Volume Criterion Validity - VeV MD Software (within limits)Correlates with the gold standardRegression analyses – SCI-PUMT at baselineSlide37

Predictive Validity

Explains outcome variationsDependent variable: Volume (VeV Camera)Predictor variables: Factor analysis itemsSCI PUMT explained an estimated59% of the variance in volume over the course of the studySlide38

Comparison of Scales:

Volume (by VeV) Regression

SCI-PUMT

PUSH

(Pressure Ulcer Scale for Healing)

BWAT

(Bates-Jensen

Wound Assessment Tool)

R

2

(estimated

based on proportional reduction in mean squared prediction error as per

Snijders

&

Bosker

, 1994

)

59%

57%

24%Slide39

Assessment of SCI-PUMT Reliability

Phase IVSlide40

Internal Consistency Reliability

Cronbach’s alpha = 0.74 (using study data)Slide41

SCI-PUMT ReliabilityAim:

Evaluate intra- and inter-rater reliability of in a clinical setting 26 Nurses trained in SCI-PUMT at Tampa VA SCI/D CenterTwo months later, two sets of 3 SCI RNs evaluated 16 ulcers twice with an interval of 1½ hours between assessmentsSlide42

ResultsClinician Reliability

Intra-rater reliability 0.81 – 0.99Inter-rater reliability 0.79All reliability measures found to be above our established acceptability thresholdSlide43

Variables and Scoring

SCI-PUMTSlide44

Pressure Ulcer

Site

:



Sacrum

or

Coccyx



Trochanter



Ischium



Heel



Other ______

Body

Side:



Right



Left



Midline

Orientation

:



Medial



Lateral

Positioning

Upper

Leg Flexed When Turned:



Yes



No

Surface

Turned Onto

:



Right



Left



Back



Abdomen

Spinal Cord Impairment Pressure Ulcer Monitoring Tool (SCI-PUMT

)

Patient ___________________

SS

#______________________ Ulcer

# ______Slide45

Variable

Score Options

Score

Geometric

Factor

Surface Area

(L x W)

1

2

3

4

5

<

1 cm

2

>1 -

<

2.5 cm

2

>2.5 -

<

5 cm

2

>5 -

<

10 cm

2

>10 -

<

15 cm

2

6

7

8

9

10

>15 -

<

25 cm

2

>25 -

<

35 cm

2

>35 -

<

55 cm

2

>55 -

<

85 cm

2

>85 cm

2

Depth

0

1

2

3

4

0 cm

>0 -

<

1 cm

>1 -

<

2 cm

>2 -

<

3 cm

>3 cm

Edges

1

Indistinct, diffuse, none clearly visible

Distinct, outline clearly visible, attached, even with ulcer base

Well-defined, not attached to ulcer base

2

Well-defined, not attached to base, rolled under, thickened

Well-defined, fibrotic, scarred, or

hyperkeratotic

Tunneling

0

None

1

≤ 2 cm

2

> 2 - ≤ 4 cm

3

>4 cm

Undermining

0

None

1

≤ 2 cm

2

> 2 - ≤ 4 cm

3

>4 cm

S

ub-total

Score

Geometric Factor

Substance FactorExudate Type0None1Serous/Sanguineous2Green/PurulentNecrotic Tissue Amount0None1<25%2>25%Sub-total Score Substance FactorTOTAL SCORE (Total of Geometric and Substance Sub-totals)

_______________________________ ____________________

Maximum score =

26

The HIGHER the score, the more severe the ulcer.

Evaluator: _________________________________________ Date ___________________________Slide46

SCI-PUMT Scoring

Each variable assigned ordinal valueData & clinical judgment to develop cut-points and weights for individual items and total scales scoreDetermined total score for SCI-PUMT = 26Assigned proportion of total score to each sub-scaleSlide47

SCI-PUMT

ScoringSlide48

Study Limitations

Sample stratification excluded patients who had multiple etiologies of SCI; differentiation of ulcer etiology and ulcer stages were too small for computationHealing process could be altered by tissue type and ulcer depthSample included persons with SCI from one SCI/D Center.Slide49

Continuing Psychometric Analysis

Can results of regression model be replicated over timeDoes weighting of items improve the SCI-PUMT’s predictive value?Do subscale scores have clinical utility?Slide50

Implications

SCI-PUMT can:Help to improve communication among SCI healthcare providers.Form basis for outcomes monitoring of PrU healing in persons with SCI.Assist clinician in critical decisions affecting overall PrU management.Slide51

Implications

Allow for comparisons of healing rates within facilities and across sites. Contribute to performance improvement initiatives and local and national performance measures.Provide foundation to conduct treatment effectiveness studies of PrUs in multi-site VA SCI/D Center studies.Slide52

Conclusions

This study found that the SCI-PUMT was a reliable, valid, and sensitive instrument for measuring PrU healing in persons with SCI in a 100 bed VHA SCI/D Center.Slide53

The Challenge—Full Implementation of the SCI-PUMT in the VA!