Pressure ulcers are a high risk, high volume, high cost problem for persons with spinal cord impairment (SCI). Currently, there is significant variation in practice related to pressure ulcer assessment and monitoring. The investigators analyzed published tools and identified the following limitations: Tools (1) lack established validity, reliability and/or sensitivity for persons with SCI; (2) are designed predominantly for use in elderly populations; (3) are applicable to acute rather than chronic wounds; (4) contain abbreviated assessment variables or are too lengthy to be practical in busy clinical settings; and (5) omit important clinical characteristics that are unique to assessing and monitoring pressure ulcers in persons with SCI.
To establish the validity (content, construct and predictive), reliability (inter- and intra-rater, and internal consistency), and sensitivity of a new tool, the SCI Pressure Ulcer Monitoring Tool (PUMT) designed to monitor pressure ulcer healing over time in persons with spinal cord impairment (SCI).
Expert Panels developed an item pool of SCI-specific variables for assessing pressure ulcer healing that was supplemented by items from two recognized pressure ulcer healing tools. Subjects were recruited, enrolled in the 3-year longitudinal cohort study, and assessed weekly for 28 pressure ulcer variables over a 12 week period. A convenience sample of 66 veterans with SCI was recruited from Tampa VA inpatient and outpatient settings; eligible subjects had SCI for more than 1 year and had one or more pressure ulcers. The unit of analysis was the pressure ulcer; data collection was completed on 167 ulcers. Once the SCI-PUMT was validated and finalized, 26 SCI staff nurses were trained in use of the tool. After 2 months of using the tool in clinical practice, we selected 6 SCI nurses to examine the inter- and intra-rater reliability of the tool; each RN assessed 16 ulcers twice.
A panel of experts established a valid pool designed to measure pressure ulcer healing. Based on exploratory factor analysis and clinical judgment a parsimonious set of seven items was identified to be included in the final version of the SCI-PUMT. In support of predictive validity, the score of SCI-PUMT was found to explain 65% of the variance of surface area and volume of the ulcers at baseline, based on the VeV MD Software and Digital Imaging Camera. In support of sensitivity of the SCI-PUMT, mixed regression found that total score was associated with the measure of area or volume across the 12 week follow-up period of the study (p < .0001). Chronbach's alpha for the tool was found to be .74, inter-rater reliability is 0.79 and intra-rater reliability was found to range from 0.81- 0.99. Because the item pool developed include items form the PUSH and Bates-Jensen Wound Assessment Tool (BWAT) Bates-Jensen we were able to compare results form the SCI-PUMT with these tools. At baseline the BWAT accounted for 49% and the PUSH accounted for 46% of the variance in surface area and volume variable compared with 65% for the SCI-PUMT. For mixed model analysis, the SCI-PUMT model accounted for a reduction of 55% of unexplained variance while the models with the BWAT and PUSH scores reduced unexplained variance by 33% and 27% respectively, adjusting for age and gender.
Clinicians in healthcare settings are currently using a wide array of tools to monitor pressure ulcer healing. An evidence-based outcome tool (i.e., the SCI-PUMT) will be invaluable to improve communication among healthcare providers throughout the VA system and form the basis for making changes to treatment plans and monitoring patient outcomes. A standardized monitoring system will allow comparisons across sites and serve as a foundation for future studies to evaluate the effectiveness of treatment options for pressure ulcers.
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