An Evidence-based Pressure Ulcer Monitoring Tool for Spinal
Cord Injury/Disease (SCI-PUMT) Gail Powell-Cope PhD, ARNP, FAAN
Acting Director, HSR&D/RR&D Center of Excellence Tampa, FL
[email protected]
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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
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Investigators Co-Principal Investigators Susan S. Thomason DNP,
MN, RN Audrey Nelson PhD, RN, FAAN (Retired) Co-Investigators
Steven Luther PhD Jeffrey J. Harrow MD, PhD, FACP
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Study Staff Polly Placios, MS (Project/Data Manager) Data
Collectors Stephanie McGovern, RN Francis Hernandez, RN Suk
Tomlinson, RN Olivia Monteso-Smithson, RN Linda Smith, RN Mary
Reeder, BIS (Program Assistant)
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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.
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Problems (or challenges) Problems (or challenges) Clinical
Problem Pressure ulcers are a high volume, high cost condition in
Spinal Cord Impairment Implementation Translating 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).
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Options for Implementing Changes 1. Dissemination Alone
(journal articles, distribution of printed materials, CME) (not
effective) 2. Educational Outreach (Academic Detailing and Local
Opinion Leaders) (promising and mixed evidence) 3. Computer-based
decision support systems (mixed) 4. Audit and Feedback (mixed
evidence) 5. Patient-mediated Interventions such as education,
reminders (promising) 6. Patient-specific clinical reminders
(promising)
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PARiHS Framework Promoting 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
facilitated
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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 10.1186/1748-5908-3-1 Innovation
Facilitation
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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.
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Clinical Practice Guidelines Consortium 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.
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Clinical Practice Guidelines National Pressure Ulcer Advisory
Panel (NPUAP) European Pressure Ulcer Advisory Panel (EPUAP) (2009)
Recommendations: Assess progress toward healinguse 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
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Setting Michael Bilirakis Spinal Cord Injury/Disorders Center
James A. Haley Veterans Hospital Tampa, Florida 100 inpatient beds
CARF-accredited) Large outpatient patient population Home Care
(CARF-accredited) Long Term Care
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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
evaluation These variations limit the ability to conduct comparable
trials of interventions
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Research Questions 1. Is the SCI-PUMT valid for measuring PrU
healing? 2. Is the SCI-PUMT reliable for measuring PrU healing? 3.
How sensitive is the SCI-PUMT for measuring healing over time?
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SCI-PUMT Phases I. Development of item pool II. Development and
testing of SCI-PUMT III. Analysis and SCI-PUMT refinement IV.
Assessment of SCI-PUMT reliability
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DEVELOPMENT OF ITEM POOL Phase 1
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Development of Item Pool Expert Panel #1 Aim: Identify measures
and variables important and/or specific to PrU healing in SCI
population 1 day on-site, Tampa, Florida 9 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 comment
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Item Pool Consisted of 30 items Items from two established PrU
healing assessment tools (PUSH, BWAT) Additional items identified
by Expert Panels
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DEVELOPMENT AND TESTING OF SCI-PUMT Phase II
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Subjects Recruited from Inpatient, Outpatient, Home Care 3-year
longitudinal cohort study Assessed 30 PrU variables PrU unit of
analysis
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Inclusion Criteria Enrolled in SCI/D Registry and receiving
primary care from JAHVA SCI primary physician Primary or secondary
diagnosis of Stages II-IV PrU SCI duration more than 12 months
Subject Profile Sample Size 66 Unique Patients 167 Pressure
Ulcers Age60 years (mean) GenderMale 98% Level of InjuryTetra 49%;
Para 46% ASIAA 58%; B 20%; Other 23% Years since SCI onset23 Years
(mean) High School Graduate80%
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Pressure Ulcer Characteristic Findings Number PrU / subject1 9
(mean 2.5) Previous PrU77% Prior PU surgery53% LocationIschia43%
Sacrococcygeal 26% Trochanter 8% Heel 8% StageII 20%; III 38%; IV
42% Ulcer Pain18% Chronic Osteomyelitis33%
Other Baseline FactorsIncidence Immunosuppressant
Medications12% Spasticity Interference with Function (1 = none; 5 =
maximum) 2.4 mean (SD 1.6) Spasticity Modified Ashworth Scale (1 =
slight tone; 5 = rigidity) 2.1 mean (SD 1.2) Pain (0 = none; 10 =
severe) 3.9 (SD = 2.6) Mean Body Weight175 lb (SD 36.4) Nicotine
Preceding Week Substance Abuse 29% 6%
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Data Collection 6 Registered Nurse Data Collectors 13 time
points: 30 variables + VeV Photograph Baseline and 12 weeks or
Complete healing Patient withdrawal Hospital discharged and lived
>40 miles Plastic surgery intervention
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VeV Measurement Documentation Software Digital images used to
calculate: Volume
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Intra- and Inter-Rater Reliability Ranges 4 RN Data Collectors
Intra-Rater Reliability 1 DC Same PrU Twice 1 hours apart
Inter-Rater Reliability 4 DC Same PrU Consecutively TOOLIntra-
Rater ICC Inter- Rater ICC PUSH0.88 0.996 0.76 0.96 BWAT0.87 0.99
0.69 0.91
Construct Validity Exploratory Factor Analysis (EFA) N = 167
PrU Principal factor extraction with Promax (orthogonal rotation)
Items removed from analysis based on: Values in correlation matrix
Factor loadings of similar items (from 2 tools) Items not well
defined by factors (low communalities)
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VariableSourceGeometric Factor Substance Factor DepthPUMT.82 -
TunnelingPUMT.77 - Edges PSST.55- Undermining PUMT.48 Surface area
PUSH.35.51 Necrotic amountPSST-.52 Exudate type PUMT-.40 * Factor
loading < |.30| have been replaced with -for ease of reading
Factor Analysis Results
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Predictive Validity Outcome variables to represent PrU healing:
Surface Area & Volume Criterion Validity - VeV MD Software
(within limits) Correlates with the gold standard Regression
analyses SCI-PUMT at baseline
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Predictive Validity Explains outcome variations Dependent
variable: Volume (VeV Camera) Predictor variables: Factor analysis
items SCI PUMT explained an estimated59% of the variance in volume
over the course of the study
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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%
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ASSESSMENT OF SCI- PUMT RELIABILITY Phase IV
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Internal Consistency Reliability Cronbachs alpha = 0.74 (using
study data)
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SCI-PUMT Reliability Aim: Evaluate intra- and inter-rater
reliability of in a clinical setting 26 Nurses trained in SCI-PUMT
at Tampa VA SCI/D Center Two months later, two sets of 3 SCI RNs
evaluated 16 ulcers twice with an interval of 1 hours between
assessments
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Results Clinician Reliability Intra-rater reliability 0.81 0.99
Inter-rater reliability 0.79 All reliability measures found to be
above our established acceptability threshold
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VARIABLES AND SCORING SCI-PUMT
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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 # ______
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VariableScore OptionsScore Geometric Factor Surface Area (L x
W) 12345 1 - 2.5 - 5 - 10 - 15 - 25 - 35 - 55 - 85 cm 2 Depth 01234
0 cm>0 - 1 - 2 - 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 Sub-total Score Geometric Factor Substance Factor Exudate
Type 0 None 1 Serous/Sanguineous 2 Green/Purulent Necrotic Tissue
Amount 0 None 1 25% Sub-total Score Substance Factor TOTAL SCORE
(Total of Geometric and Substance Sub-totals)
_______________________________ ____________________ Maximum score
= 26 The HIGHER the score, the more severe the ulcer. Evaluator:
_________________________________________ Date
___________________________
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SCI-PUMT Scoring Each variable assigned ordinal value Data
& clinical judgment to develop cut-points and weights for
individual items and total scales score Determined total score for
SCI-PUMT = 26 Assigned proportion of total score to each sub-
scale
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Surface Area 40% Depth 14% Tunneling and Undermining 12% each
Edges, Exudate, Necrotic Tissue 8% each SCI-PUMT Scoring
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Study Limitations Sample stratification excluded patients who
had multiple etiologies of SCI; differentiation of ulcer etiology
and ulcer stages were too small for computation Healing process
could be altered by tissue type and ulcer depth Sample included
persons with SCI from one SCI/D Center.
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Continuing Psychometric Analysis Can results of regression
model be replicated over time Does weighting of items improve the
SCI- PUMTs predictive value? Do subscale scores have clinical
utility?
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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.
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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.
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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.
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The ChallengeFull Implementation of the SCI-PUMT in the
VA!