Risk Analyses of Pressure Ulcer in Tetraplegic Spinal Cord-Injured Persons: A French Long-Term Survey

Implementation and clinical impact of an interdisciplinary tool to promote skin integrity after flap surgery in Veterans with spinal cord injury

CONTEXT/OBJECTIVE

Pressure injury (PrI) recurrence is common among persons with spinal cord injury and disorders (SCI/D) who undergo reconstructive flap surgery for pelvic stage 4 PrI (S4PrI). This paper describes the development and implementation of the Minneapolis Spinal Cord Optimization, Rehabilitation and Empowerment (SCORE), a preoperative interdisciplinary tool for risk assessment and mitigation, and reports its effect on the one-year flap failure rate (significant breakdown).

DESIGN

Retrospective review.

SETTING

Minneapolis Veterans Affairs Health Care System (MVAHCS) SCI/D Center, a tertiary care center.

PARTICIPANTS

141 Veterans with SCI/D and pelvic S4PrI underwent 204 interdisciplinary assessments for flap surgery.

INTERVENTIONS

The Minneapolis SCORE was developed by the MVAHCS SCI/D Center and first implemented in 2012. The eight domains of the tool and continuous improvements in tool implementation for risk assessment and mitigation are described.

OUTCOME MEASURES

Per-year incidence rate of flap failures within one year of surgery from 2009 to 2019.

RESULTS

48.3% (28/58) of S4PrI assessments during 2009-2011 (pre-SCORE) led to flap surgery the same year, increasing to 59.6% (87/146) of assessments after SCORE implementation during 2012-2019. The one-year flap failure rate abruptly decreased from 40.5% (15/37) of the 2009-2012 surgeries to 7.7% (6/78) of the 2013-2019 surgeries (P < .0001). Characteristics of patients by time period, operative status, and flap outcome are presented.

CONCLUSION

After an initial learning curve in tool implementation and subsequent tool refinement, the use of the Minneapolis SCORE before flap surgeries was associated with improved flap integrity at one year. Successful use of the tool requires collaborative problem-solving between the patient and interdisciplinary team.

Incidence of pressure injuries in patients with spinal cord injury: A systematic review and meta-analysis

OBJECTIVE

To systematically evaluate the incidence of pressure injuries (PIs) in patients with spinal cord injury (SCI) and to provide a basis for preventing and treating PIs.

METHODS

A systematic review and meta-analysis were performed according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. Electronic databases such as PubMed, Embase, Cochrane Library, Web of Science, China Knowledge Resource Integrated Database (CNKI), Wan-fang Database, Weipu Database (VIP), and the China Biomedical Database (CBM) were searched to collect cross-sectional and cohort studies related to PIs in SCI patients. All electronic literature sources were searched for relevant articles from inception to July 2024. Studies were independently assessed by two researchers and reviewed by a third. Data were extracted and presented in tabular form. The risk of bias was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist and the Agency for Healthcare Quality and Research (AHRQ) Cross-Sectional Study Evaluation Criteria. All data were analysed using Stata 16.0. The I2 statistics and random effects models were used to determine heterogeneity, and results were expressed as incidence with 95 % confidence intervals (CI).

RESULTS

11,754 articles were screened, and 35 studies involving 150,391 patients were finally included. The combined incidence of PIs in SCI patients was 28.8 % (95%CI: 24.2 to 33.4). For different genders, the incidence of PIs in male SCI patients was 29.2 % (95 % CI: 20.4 to 38.1), while for female SCI patients, it was 25.2 % (95 % CI: 16.1 to 34.3). The PI incidence rate in patients with SCI was 33.9 % (95 % CI: 27.1 to 40.7) before 2005, 29.4 % (95 % CI: 19.1 to 39.7) from 2006 to 2015, and 27.1 % (95 % CI: 20.8 to 33.3) from 2016 to 2024. According to regional distribution data by country, the combined incidence of PIs in SCI patients was 34.3 % (95 % CI: 21.0 to 47.6) in European countries, 20.9 % (95 % CI: 12.8 to 28.9) in Asian countries, 43.3 % (95 % CI: 16.5 to 70.1) in African countries, 25.0 % (95 % CI: 15.9 to 34.0) in North American countries, and 65.3 % (95 % CI: 55.9-74.7) in South American countries. In 12 studies that reported the anatomical location of PIs in patients with SCI, 1113 patients developed 1836 PIs. The sacrococcygeal region had the highest number of these injuries, totalling 521 (28.8 %), followed by the sciatic tuberosity, with 233 (12.9 %), then, the heel, with 221 (12.3 %).

CONCLUSION

The study's results showed an overall incidence of PIs in patients with SCI of 28.8 %, significantly exceeding the average incidence rate in adults. We found that the incidence of PIs was higher in men than in women in patients with SCI. Therefore, clinical care staff needs to adopt effective preventive and therapeutic measures and strategies to reduce the occurrence of PIs. Additionally, the risk factors for PIs in patients with SCI can be further investigated to prevent and treat PIs effectively.

Personal risk factors for pressure injuries among wheelchair users: an umbrella review of new insights in 2024

Purpose:Pressure injuries (PrI) are a prevalent and serious health issue for wheelchair users. This study aims to identify the personal factors associated with PrI occurrence and their significance by synthesizing existing literature.

Materials and methods:We conducted an umbrella review, systematically searching four databases for reviews published from 2007 to May 2024. The search terms were selected by an independent, experienced librarian. To evaluate the risk of bias and methodological quality of the included studies, we applied the ROBIS tool and the GROOVE procedure. Identified risk factors were categorized into relevant groups.

Results:After an assessment of 5,797 potential articles, 21 studies met the inclusion criteria. Among these, 43% were systematic reviews, 24% meta-analyses, 19% literature reviews, 9% scoping reviews, and 5% narrative reviews. The findings revealed 33 individual personal factors, categorized into the general health, clinical condition, initial pathology, environment/lifestyle, person-related, and combined risk factor groups. Key individual risk factors frequently encountered among wheelchair users included advanced age, obesity, spinal cord injury (SCI), higher levels of SCI, diabetes, infections, incontinence, immobility, respiratory and perfusion impairments, sensory perception issues, and low physical activity.

Conclusions:This study is the first to synthesize literature on internal risk factors associated with PrI among wheelchair users. It confirmed well-established factors such as SCI, diabetes, and aging. The findings provide healthcare professionals and decision-makers with critical information for the prevention and management of PrI in this population, offering new insights into adopting a holistic approach to assessing and addressing individual risks factors.

Differences in personal characteristics and health outcomes between ambulatory and non-ambulatory adults with traumatic spinal cord injury

Objective: To identify differences in personal characteristics, health outcomes, and hospital utilization as a function of ambulatory status among adults with chronic SCI.Design: Prospective cohort study linked to state administrative billing data.Setting: Population-based SCI Registry from the Southeastern United States.Participants: 1,051 adults (>18 years old) with chronic (>1-year), traumatic SCI.Outcome Measures: The self-report assessment (SRA) included demographic, injury and disability characteristics, health status, psychological and behavioral factors, and participation and quality of life (QOL) variables. We linked cases to administrative billing data to assess hospital utilization, including Emergency Department (ED) visits and inpatient (IP) admissions (through the ED and direct IP) in non-federal state hospitals within the year following the SRA.Results: There were 706 ambulatory and 345 non-ambulatory participants. We found significant differences across all sets of factors and significant differences in hospital utilization metrics. Ambulatory adults had fewer ED visits (36% vs 44%), IP admissions through the ED (11% vs 25%) and IP only admissions (9% vs 19%) and spent fewer days in the hospital for both admissions through the ED (0.9 vs 4.6 days) and IP only admissions (0.7 vs 3.1 days). They also reported having fewer past year ED visits (44% vs 62%) and IP admissions (34% vs 52%).Conclusions: We identified differences in personal characteristics, ED visits and IP admissions between ambulatory and non-ambulatory adults with SCI, providing a better understanding of the characteristics of those with SCI. The findings suggest the need for separate analyses based on ambulatory status when assessing long-term health outcomes including hospital utilization.

Pressure Ulcers-A Longstanding Problem: A 7-Year Neurorehabilitation Unit Experience of Management, Care, and Clinical Outcomes

BACKGROUND

Neurological disease patients present an increased risk of developing pressure ulcers. The primary aim of this study is to evaluate the incidence and prevalence of pressure ulcers and their impact on length of stay and functional recovery.

METHODS

A retrospective study was conducted in a neurorehabilitation unit over a seven-year period. Data collected include demographic data, length of stay, functional evaluation, risk of pressure ulcers development, nutritional status, and skin. Pressure ulcers were classified according to the European Pressure Ulcer Advisory Panel System.

RESULTS

Data from 816 patients were analyzed. On admission, the authors found 236 pressure ulcers in 131 patients (about 16%), divided into stage I (25%), stage II (50%), and stage III-IV (25%). The most common sites were the heel (36%) and sacrum (29%). Among the risk factors for the development of pressure ulcers, malnutrition played a significant role, with approximately 76% of patients with pressure ulcers having mild to moderate malnutrition.

CONCLUSION

The presence of pressure ulcers seems to have a negative impact on the functional recovery of patients, as shown by the outcome scales and the average length of stay: 51 days versus 36 days (p < 0.01).

Social disconnectedness and perceived social isolation in persons with spinal cord injury/dysfunction living in the community: A scoping review

Context: Persons with spinal cord injury/dysfunction (SCI/D) are particularly at risk for social disconnectedness and/or perceived social isolation, which are key components to overall well-being. However, there is limited evidence that aims to understand these phenomena in this population.Objective: To investigate what is known about social disconnectedness and perceived social isolation for adults with SCI/D living in the community.Methods: A scoping review was conducted. A computer assisted search of four online databases was completed on all articles published until May 18th, 2021. Gray literature and key agencies were also searched for relevant documents. Two key concepts (spinal cord injury/dysfunction and social disconnectedness/perceived social isolation) and associated terms were used. All articles were double screened for inclusion by two reviewers.Results: Following deduplication, title and abstract screening and full-text screening, 37 articles met the criteria for inclusion in this review. Most of the included articles were published in North America, used quantitative methods and a cross-sectional design. Articles identified several factors that influenced social disconnectedness and perceived social isolation including participant characteristics, social support, psychological well-being, participation in activities, the built environment and physical health.Conclusion: The current literature suggests that issues with social disconnectedness and perceived social isolation exist for persons living with SCI/D in the community. More work is needed to better understand the relationship between these constructs. A more nuanced understanding can inform targeted interventions to help mitigate the impact of these phenomena on the SCI/D population.

Orthotic walking outcome of persons with motor complete low thoracic spinal cord injury-a retrospective study

STUDY DESIGN

Retrospective study.

OBJECTIVE

To analyse the orthotic walking outcome of patients with Low Thoracic Spinal Cord Injury (LT-SCI).

SETTING

The Rehabilitation Institute at Christian Medical College, Vellore, India.

METHODS

Data between January 2005 and June 2015 were retrospectively collected from electronic medical reports of patients with motor complete LT- SCI who were admitted for the comprehensive rehabilitation program. The orthotic walking outcome of these patients was measured by the Walking index for SCI version II (WISCI II). Demographical and clinical parameters were measured and their association with the walking outcome was analyzed using regression analysis.

RESULTS

A total of 430 patients were identified within the study period. Eighty-five percent of people (n = 365) achieved walking at the time of discharge (WISCI II level 12 = 260 and level 9 = 105). Out of 11 demographical and clinical parameters considered, eight of them were found to be significant predictors of walking in the univariate analysis. Age less than 30 years had the highest odds of predicting WISCI II level 9 and level 12 than those older in the multivariate analysis (OR 17.58; 95% CI 7.35-42.03). Single neurological level T12 increased the chance of achieving WISCI II level 12 by 10 times (OR 10.2; 95% CI 3.8-27.36).

CONCLUSIONS

Orthotic walking for persons with motor complete low thoracic spinal cord injury is an achievable goal through a comprehensive rehabilitation program. The factors identified in this study will help rehabilitation professionals strategically select the ideal candidate for orthotic gait training.

The functioning of social support in long-term prevention after spinal cord injury. A qualitative study

BACKGROUND

The impact of social support on the long-term condition after a spinal cord injury (SCI) varies across studies mainly involving self-report questionnaires.

OBJECTIVE

We aimed to establish the common factors associated with social support leading individuals with an SCI to the effective prevention of secondary complications, including via adherence to medical follow-up.

METHODS

Inclusion criteria were a history of acquired SCI of any etiology, wheelchair use, and age≥18 years at the time of the study. Participants should have completed their initial rehabilitation program in France≥1 year earlier and were also enrolled according to 2 related study variables: routine medical follow-up (patients were or were not followed up) and the medically supervised reporting of a pressure ulcer after the initial rehabilitation session (0 or≥1 pressure ulcers). We performed a preparatory quantitative and qualitative literature review to identify factors affecting long-term follow-up after SCI, then adopted a narrative design with semi-structured interviews, transcribed and analyzed progressively by using qualitative analysis software.

RESULTS

We included 32 participants. We categorized our results based on the knowledge, attitudes, beliefs and practices of participants with respect to pressure ulcer prevention and long-term medical follow-up. Our narrative approach allowed us to identify 3 main domains relevant to social support: reciprocity, self-management and timing related to social support.

CONCLUSIONS

Our study showed social support as a dynamic process, a reciprocal phenomenon evolving in variations over time. These findings should be central to short- and long-term therapeutic education programs for patients and for people providing social support. Effective changes should also be implemented through the concept of the Learning Health System.

Association of Pressure injury with body care activities in nursing homes

Frequent repositioning and skin examinations are the cornerstone of many pressure injury prevention programs. This study explores the hypothesis that frequent skin-exposing body care activities are protective against pressure injuries in residents of long-term care facilities. We designed a cross-sectional observational cohort study of 381 residents from 13 such facilities. Data were collected on resident characteristics and nursing care activities for each resident. We analyzed those data, looking for an association between skin-exposing body care and the presence of a pressure injury of stage 1 or greater. Body-exposing care activities were divided into high- and low-frequency groups. A logistic regression model was developed to include confounding variables. The odds ratio associated with body care and pressure injury was calculated. Fifteen percent of the residents in our study had pressure injuries. Confounders were activities of daily living score, heart failure, recent hospitalization, and stool incontinence. The adjusted odds ratio for body care as a risk factor was 4.9 (95% CI, 2.4, 10.4), indicating that residents with more than five body care needs are approximately five times more likely to have a pressure injury. Our results fail to support our hypothesis that frequent skin-exposing body care activities protect against pressure injury. Further exploration is needed to understand the resident characteristics and co-morbid conditions associated with the persistent risk for pressure injury despite frequent skin examinations.

Health characteristics and health care trajectory of polyhandicaped person before and after 1990

INTRODUCTION

Polyhandicap is defined as the combination of severe mental impairment and severe motor deficit resulting in reduced mobility and an extreme reduction in autonomy. Over the last 20years, care management for these patients has become more structured, however, their care pathway is not always optimal.

OBJECTIVE

To describe/compare the health characteristics, treatment and history of the care pathways of subjects who received care before and after 1990.

METHOD

Multicentre cross-sectional study, population studied: patients with polyhandicap: (i) causal brain damage<3years, (ii) severe mental impairment, (iii) motor disability, (iv) reduced mobility, (v) extreme restriction of autonomy.

DATA COLLECTED

clinical and medical, care procedures, treatments, history of care pathways.

RESULTS

Patients are divided into 2 groups: 545 patients who received care after 1990 and 330 before 1990. Older patients present more recurrent urinary infections, slow transit, behavioural disorders and pain, and are prescribed a greater number of drugs. For those who received care before 1990, the age of admission to an establishment is lower, with one-third receiving a consultation dedicated to the transition from paediatric to adult teams.

DISCUSSION/CONCLUSION

The care sector for patients with polyhandicap makes it possible to meet their needs throughout their lives, however, there is still progress to be made in terms of formalisation and of coordinating the care pathway in order to facilitate the transition from paediatric to adult services/establishments.

Incisional negative pressure therapy reduces complications and costs in pressure ulcer reconstruction

Complications after pressure ulcer reconstruction are common. A complication rate of 21% to 58% and a 27% wound recurrence has been reported. The aim of this study was to decrease postoperative wound-healing complications with incisional negative pressure wound therapy (iNPWT) postoperatively. This was a prospective non-randomised trial with a historic control. Surgically treated pressure ulcer patients receiving iNPWT were included in the prospective part of the study (Treatment group) and compared with the historic patient cohort of all consecutive surgically treated pressure ulcer patients during a 2-year period preceding the initiation of iNPWT (Control). There were 24 patients in the Control and 37 in the Treatment groups. The demographics between groups were similar. There was a 74% reduction in in-hospital complications in the Treatment group (10.8% vs 41.7%, P = 0.0051), 27% reduction in the length of stay (24.8 vs 33.8 days, P = 0.0103), and a 78% reduction in the number of open wounds at 3 months (5.4 vs 25%, P = -0.0481). Recurrent wounds and history of previous surgery were risk factors for complications. Incisional negative pressure wound therapy shortens hospital stay, number of postoperative complications, and the number of recurrent open wounds at 3 months after reconstructive pressure ulcer surgery, resulting in significant cost savings.