Pressure Ulcers (PU) are a common and costly complication of spinal cord injury (SCI). The VA New England Healthcare System (VISN 1) SCI Service Line has established reduction of pressure ulcers (PU) and related costs as a top strategic goal. The Consortium for Spinal Cord Medicine has published evidence-based clinical practice guidelines on Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury. Yet the extent to which these guidelines are implemented is unknown.
With a long-term goal to identify, implement, and evaluate interventions to prevent PU, the objectives of this initial phase of the project were to:
1. Define adherence to guideline recommendations for PU prevention in 6 VA sites within VISN 1
2. Define determinants of variation from guideline recommendations and identify compliance barriers and facilitators
Retrospective medical record review was conducted to determine overall and facility-specific adherence rates to 14 PU prevention guideline recommendations. A chart abstraction tool previously developed for assessing compliance with PU prevention in nursing homes was modified to make it specific to use in SCI. 100 randomly selected patient charts were sampled using VA administrative databases. Inclusion criteria: 1) ICD-9 diagnostic codes of SCI, and 2) clinic visit or hospitalization at one of 6 VISN 1 study sites between 10/1/02 through 9/30/03 during a one-year period (Fiscal Year 2003). For patients with PU, the medical record for one year prior to the index hospitalization was also reviewed. Data from charts with outpatient visits only during the study year (OP group) was analyzed separately from those that had inpatient hospitalizations (IP group) with or without clinic visits. Focused observations conducted by a trained observer to evaluate compliance with certain elements of the guidelines (e.g. Bed Positioning) for which data was unlikely to be obtained from record review.
Focus groups were conducted with interdisciplinary providers at study sites to identify perceived facilitators and barriers to guideline adherence.
Results are based on preliminary analysis from 3 sites. Overall documentation of adherence to PU prevention guidelines was relatively low in the OP group compared to the IP group. E.g. Documented risk assessment for PU was present in 90% of IP group vs.5% of OP. Adherence to guidelines varied considerably between sites. E.g. In the OP group, documented assessment of nutritional status varied from 15% to 85% between sites, documentation of devices and techniques used by the patient for bed positioning at home varied from 5%-60%. Adherence was better for some guidelines than others. E.g. 60% of OP group charts had documentation of wheelchair cushions, but <5% addressed bed support surfaces used. Focus groups indicated that providers use the guidelines to confirm rather than to inform their practice; that standardized templates incorporating the guidelines would help not only to improve documentation, but also serve as a reminder checklist especially for those who provide SCI care as a small part of their clinical duties; and that the greatest perceived barriers to guideline adherence were patient compliance and availability of a dependable caregiver.
This project has the potential to identify, evaluate, and disseminate interventions for prevention of PU, which is an issue of vital importance for health and quality of life of veterans, and significantly impacts healthcare costs.
- Sabharwal S, Berlowitz D, Czarnowski E. Compliance with Guidelines for Preventing Pressure Ulcers after Spinal Cord Injury. Paper presented at: American Paraplegia Society Annual Meeting; 2004 Sep 6; Las Vegas, NV.