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RRP 09-133 – HSR&D Study

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RRP 09-133
Practice Variation in Postoperative Care of Pressure Ulcers in SCI
Jeffrey John Harrow MD PhD
James A. Haley Veterans' Hospital, Tampa, FL
Tampa, FL
Funding Period: April 2010 - September 2011

BACKGROUND/RATIONALE:
Post-operative immobilization is defined as the number of days from the day of surgery to the day the mobilization protocol begins. Published recommendations vary and range from 2-8 weeks. Shorter immobilization time will reduce complications associated with immobility, but may be associated with adverse events such as suture line dehiscence, partial or complete flap loss, edge necrosis, formation of hematoma or seroma, surface ulceration, and infection. Postoperative management varies significantly among providers and sites. Practice variation includes (1) type of specialty bed surface prescribed, (2) duration of postoperative immobilization (bedrest), (3) criteria to begin progressive mobilization, (4) protocol for progressive mobilization, and (5) time to complete progressive mobilization.

OBJECTIVE(S):
1. Describe the extent of variation in practice for post-operative management of flap surgery across five SCI Centers, focusing on post-operative immobilization and mobilization.
2. Delineate patient, provider, and organization factors associated with post-operative management of flap surgery across SCI Centers.

METHODS:
This qualitative study used focus groups and individual/small group interviews, using a purposive sample of five SCI Centers. At each site, we conducted individual/small group interviews and focus groups to determine policies and practices associated with pressure ulcer flap surgery postoperative care. We conducted individual/small group interviews with SCI physicians and plastic surgeons, and focus groups with 10-12 nurses and physical therapists per group.
A total of 75 clinicians participated in individual/small group interviews and focus groups at the five sites.

To avoid the bias of a convenience sample we purposively chose sites rather than rely on volunteer attendees at national conferences. Based on an informal survey of SCI centers, SCI Centers fell into 3 classes - post-operative mobilization that began at 6 weeks (6 sites), mobilization that began at 5 weeks (2 sites), and mobilization that began on a "case-by-case" (2 sites). We picked 3 sites from the 6-week group, 1 from the 5-week group, and 1 from the case-by-case group. The sites included Seattle, Cleveland, and Hines VA for the 6 week sites, Craig Hospital for the 5 week site, and Miami for the case-by-case site. The inclusion of one non-VA site provided preliminary information on the differences between VA and non-VA practices, although with only 1 non-VA site, this information was pilot level only.

FINDINGS/RESULTS:
This study looked at the current practice variations for postoperative management of flap surgery across SCI Centers, including bed surface, duration of postoperative immobilization, criteria to begin mobilization, protocol for progressive mobilization, and duration to complete progressive mobilization.

Variations in immediate post-surgery bed surfaces were identified. Four of the five centers used air-fluidized beds. Of those centers, three used the Hill-Rom Clinitron , and one used the KCI FluidAir Elite Air-fluidized system. The fifth center used the Wound Systems Dolphin Bed immediately postoperatively, which is not an air-fluidized bed, but rather a fluid immersion bed. The four centers using air-fluidized beds immediately postoperatively transition the patient at the beginning of progressive mobilization period to either a low-air-loss bed or to a fluid-immersion bed (the Dolphin Bed). The low-air-loss beds transitioned to include the Hill-Rom RiteHite, Cardinal MaxiFloat, and the KCI KinAir.

Significant diversity exists in who makes decisions regarding post-operative bed surface and when the patient should transition to a different bed surface. In some facilities, the plastic surgeon makes both decisions; in others, the plastic surgeon makes the initial decision, but the decision of when to transition is made by the physical therapists and the skin care team. In some settings, these decisions are made by the head SCI physician; in others, the decision is made by the SCI wound nurse or by a combination of the SCI physician and physical therapy. The duration of immobilization lasts from four to six weeks. Two of the centers immobilize their patients for a minimum of six weeks, two centers immobilize patients from four to six weeks and one center immobilizes patients from four to five weeks.

In all cases, the duration of immobilization depended on individual patient factors related to the healing process. Thus the protocol for post-operative bed rest served as a guideline, rather than a hard and fast rule. Decisions about the length of post-operative bed rest varied minimally across the five sites. The plastic surgeon alone or in conjunction with the SCI physician or SCI nurse makes decisions about the length of bed rest. The end of bed rest is determined by the characteristics of the wound; the wound should be closed, stable, no sign of dehiscence.

Variation in mobilization start-up procedures and tests across the sites was identified. At one site a "butt box" was used for progressive stretching (patient is lying down) to ensure skin integrity before starting the sitting protocol. In another site a hover test (putting patient in sling) is used to test for skin integrity before starting the sitting protocol. At another site, physical therapy staff perform pressure mapping of the patient in the wheelchair along with looking at skin integrity to help determine when to start the sitting protocol.

All of the sitting protocols across the research sites are very similar, with only slight variation. In general, mobilization starts out at 15-minute increments three times a day; advancing to 30-minutes three times a day; then to 1 hour three times a day. After a patient reaches the 1-hour mark they can progress in half-hour increments or 1-hour increments based on recommendations of the physical therapy staff and the SCI physician or nurse. In all the research sites, the advancement of the sitting protocol was based on intense observation, skin integrity tests, ultrasound, manual scar mobility, and vital sign (BP) tests before and after each session. In some cases periodic pressure mapping tests were done; these were often used as a tool for patient education.

The goal or objective of the progressive mobilization protocol varied greatly by research site; from 4 hours of sitting at one site to 8 hours or more of sitting time at another site. The objective of the progressive mobilization protocol is often tailored to patients' needs, and in some cases based on simulating the patients' home environment as much as possible. For example, if patients are generally up in their chairs at home for 8 hours a day, then the objective of the protocol would be to get that patient to sit for 8 hours. In other sites, the objective of the protocol was to advance the sitting protocol to the point where the patient could safely travel home. For example, if the patient lived 6 hours away, the objective of the sitting protocol would be to get the patient to sit for at least 6 hours.

Summary
Significant diversity exists on choice of surface, who makes decisions, time of immobilization, and initiating progressive mobilization.
The immobilization period in this group ranged from 4-6 weeks; in preliminary work, range throughout VA was 2-6 weeks.
The results of this study will be useful in designing an RCT looking at immobilization times and other factors influencing flap success.

IMPACT:
This study was designed to determine the extent and associated factors of variation in practice in post-operative management of flap surgery among SCI Centers. We plan to use this information to design a randomized clinical trial that would yield valid evidence to support a standard, optimal immobilization time after surgery for pressure ulcers in SCI. The impact of this line of research is to reduce the morbidity and mortality associated with pressure ulcers, and in so doing, to improve the quality of life of persons with SCI.

PUBLICATIONS:

Conference Presentations

  1. Harrow JJ, Lind J, Gutmann J, Mutolo S, Olney C, Powell-Cope GM. Practice Variation in Post-Operative Care of Pressure Ulcers in SCI. Presented at: Academy of Spinal Cord Injury Professionals Annual Meeting; 2011 Sep 6; Las Vegas, NV.


DRA: Brain and Spinal Cord Injuries and Disorders
DRE: Treatment - Observational, Prevention, Treatment - Comparative Effectiveness
Keywords: Practice patterns, QUERI Implementation, Spinal cord injury
MeSH Terms: none

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