BACKGROUND/RATIONALE:
Pressure ulcers (PrUs) are the most frequent significant medical complication after spinal cord injury (SCI). PrU prevalence, morbidity, mortality, and recurrence rates are high, and most persons with SCI will have at least one serious PrU during their lifetime. VA costs of treating the almost 3,500 unique Veterans with SCI and a severe ulcer at an SCI Center in FY10 was just under $400 million.

OBJECTIVE(S):
The primary objective of this study was to determine whether a multi-component self-management (SM) intervention increases the use of skin-protective behaviors and reduces skin worsening in Veterans with SCI, compared to an education control (ED) intervention. Secondary outcomes included PrU knowledge, self-management skills, communication with providers, self-efficacy, community integration and days on bedrest. Another objective was to conduct focus group interviews with patients and providers and to analyze transcripts of SM group sessions to determine barriers and facilitators with regard to spinal cord injury and pressure ulcer prevention.

METHODS:
This was a multi-site efficacy intervention study with a single blind prospective randomized design. Descriptive statistics were used to summarize demographic and key variables. Supplemental focus group interviews were conducted with patients with SCI (n=35) and SCI providers (n=39). Focus group interviews and SM group calls were transcribed verbatim and analyzed using constant comparative techniques.

Subjects included Veterans hospitalized for Stage III/IV PrUs at or below the level of injury, from six VA SCI Centers around the country (Long Beach, Houston, Milwaukee, Augusta, Hines and St. Louis). Prior to discharge, PrU risk factors were identified and 1:1 PrU education was provided. Randomization and the behavioral interventions began at discharge. The number of randomized subjects were 72 in the ED group and 72 in the SM group (n=144). The analytic sample included subjects with complete data (n=92).

The intervention included 8 site coordinator-initiated calls using didactic or Motivational Interviewing (MI) strategies to address PrU risk factors. The second component included telephone group calls that included either didactic information about SCI or SM skills: 1) knowledge about the medical condition; 2) self-monitoring; 3) problem-solving skills; 4) skill for managing the effects of the condition; 5) adherence to necessary health behaviors; and 6) self-advocacy with health care providers. ED subjects received general health information and were not instructed in any specific problem solving, self-monitoring or SM techniques. The ED intervention was comparable to the SM with respect to natural history/ time, dosing, measurement processes, attention, therapeutic alliance, social support, and in receiving a manualized treatment with specific therapist procedures. Self-reported outcome data were obtained by phone at 3 and 6 months, and from mailed photos of study ulcers.

FINDINGS/RESULTS:
1. Increased Skin Behaviors. At baseline, subjects in both groups reported performing about 6 positive skin behaviors. At 3 months, subjects reported performing almost 7 positive skin behaviors overall. There were no statistically significant differences between groups on the number of skin behavior items performed, at baseline, 3 months, or 6 months. Comparing the data across timepoints, we examined use of skin protective behaviors between 3 months and baseline. Overall, subjects performed an average of 5.9 (SD: 1.8, Range: 0-8) behaviors at baseline and 6.8 (SD: 1.4, Range: 0-8) at the end of the study. There was a statistically significant increase in use of skin protective behaviors in both groups from baseline to 3 months (p <.0001) and from baseline to 6 months (p<.0001). Evaluating improvement across groups from baseline to 6 months, the ED group improved on 1.2 (SD: 0.9, Range: 0-3) items and the SM group improved on 1.5 (SD: 1.6, Range: 0-5) skin behavior items; this difference between treatment groups was not statistically significant.

Specific items that showed an increase in performance from baseline to 3 months and baseline to 6 months included: daily skin inspection, weight shifts and pressure reliefs, and early reporting for skin worsening or breakdown at 3 months. While there were significant differences in skin behaviors overall over time, there were no statistically significant differences in individual behaviors, overall or between the two intervention groups.

2. Skin Worsening. Skin worsening was defined using a combination of: photo wound size; BWAT score (Bates-Jensen Wound Assessment Tool); whether the patient developed a new wound or had a skin-related hospitalization; and whether there was a report by the subject or a provider of skin worsening. Based on these indicators, 75 subjects (52.8%) with complete data experienced a skin worsening outcome. 54 (72%) of the 75 subjects experienced skin worsening in the first 3 months following discharge from their initial hospitalization, and 21 (28%) experienced a skin worsening outcome within 3-6 months of discharge. Overall, skin worsening did not differ by treatment group (p = 0.74) for those in the first 3 months (p = 0.78) or those in months 3-6 (p = 0.80).

3. SM and Focus group analyses. One theme of our qualitative analyses was that Veterans with SCI and healthcare providers all agreed that the responsibility for PrU prevention rests primarily on the Veteran. Veterans emphasized the need for self-advocacy, "routinizing" skin care activities, and engaging providers. Providers emphasized their role in educating and motivating Veterans, assessing skin management abilities, and providing appropriate support. Veterans looked to providers for their ability to listen and be open and honest and engage them in discussion. Veterans saw these discussions as opportunities for information gathering; however, some providers perceived these interactions as unidirectional and difficult. Veteran and provider perceptions converged around some barriers, including the resistant mindset of some Veterans, and providers' failure to model good behavior, but diverged for others, including difficulties coping with physiological changes. Although lack of community resources and social support were articulated as pressing challenges, both Veterans and providers described them as key facilitators to skin management activities when available.

IMPACT:
Our results suggest that the first 3 months after discharge are particularly critical, as 50% of our sample reported worsening within that time frame. We will continue to work on developing and implementing effective, consistent, and cost-effective PrU prevention protocols into routine clinical practice within VHA, enhancing veterans' general health and quality of life by reducing the need for costly hospitalizations and PrU surgery.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Guihan M, Bombardier CH, Ehde DM, Rapacki LM, Rogers TJ, Bates-Jensen B, Thomas FP, Parachuri R, Holmes SA. Comparing multicomponent interventions to improve skin care behaviors and prevent recurrence in veterans hospitalized for severe pressure ulcers. Archives of physical medicine and rehabilitation. 2014 Jul 1; 95(7):1246-1253.e3. [view]

Conference Presentations

1. Guihan M, Bates-Jensen B, Powell-Cope G, Priefer B, McIvor L. Implementing Pressure Ulcer Prevention Strategies across VA. Paper presented at: VA HSR&D National Meeting; 2012 Jul 16; National Harbor, MD. [view]
2. Guihan M, Ehde DE, Meade M. Managing Health Following SCI: Making translations between theory, research and clinical practice. Paper presented at: Academy of Spinal Cord Injury Professionals Annual Meeting; 2010 Sep 23; Las Vegas, NV. [view]
3. Guihan M. Medical, psychological and behavioral risk factors of veterans with SCI treated for severe pressure ulcers. Paper presented at: Spinal Cord Medicine and Rehabilitation Annual Congress; 2009 Sep 23; Dallas, TX. [view]
4. Guihan M, Edhe DM. Patient and Provider Perspectives of Self-Management of Ulcers in SCI/D. Paper presented at: Academy of Spinal Cord Injury Professionals Annual Meeting; 2013 Sep 4; Las Vegas, NV. [view]
5. Guihan M, Ehde DM. Patient and Provider Perspectives of Self-Management of Ulcers in SCI/D. Paper presented at: Paralyzed Veterans of America Summit; 2013 Aug 27; Orlando, FL. [view]
6. Guihan M, Holmes SA, Bombardier CH, Edhe D, Rapacki L. Self-Management to Prevent Ulcers in Spinal Cord Injury. Paper presented at: Academy of Spinal Cord Injury Professionals Annual Meeting; 2013 Sep 4; Las Vegas, NV. [view]
7. Guihan M, Holmes SA, Bombardier CH, Ehde DM, Rapacki L. Self-Management to Prevent Ulcers in Spinal Cord Injury. Paper presented at: Paralyzed Veterans of America Summit; 2013 Aug 27; Orlando, FL. [view]

DRA: Health Systems Science, Acute and Combat-Related Injury, Brain and Spinal Cord Injuries and Disorders
DRE: Prevention
Keywords: Behavior (patient), Self-care, Spinal cord injury
MeSH Terms: none