Pressure ulcers (PrU) are a frequent problem in Veterans with spinal cord injury (SCI), causing significant morbidity and mortality and negatively impacting quality of life. The average annual VA healthcare costs for a Veteran with SCI and PrUs was>$100,000. Guidelines recommend changing treatment for non-healing PrUs every 2-4 weeks. Research on PrU treatment effectiveness has been limited by the lack of standardized tools to measure PrU healing in SCI. The SCI Pressure Ulcer Monitoring Tool (SCI-PUMT) is an evidence-based tool for assessing PrU healing and its adoption supports implementation of VHA PrU Handbook 1180.02.
In 2011, VA SCI/D Services sponsored a Train-The-Trainer Collaborative that used evidence-based strategies, including a year of monthly post-Collaborative facilitation calls, to implement the SCI-PUMT in VA SCI centers. In August 2012, a survey of SCI-PUMT clinical champions indicated that about half of the 24 SCI centers were consistently using the SCI-PUMT to evaluate PrU treatment. The goal of this study was to further evaluate implementation of the SCI-PUMT.
Objectives included: 1) to characterize the variability in SCI-PUMT adoption and 2) understand barriers/facilitators to successful SCI-PUMT implementation at high/low adopting sites. A secondary aim was to describe wound care team characteristics (e.g., structure, practices, culture, etc.) to better understand SCI-PUMT implementation.
Mixed methods were used to evaluate SCI-PUMT implementation at 7 VA SCI centers.
Interviews: In-person interviews were conducted with SCI clinicians participating in wound care teams (n=49) at high (n=4) and low (n=3) adopting SCI-PUMT sites. Wound care rounds were observed at each site.
Medical record reviews: A cohort of SCI patients admitted to the 7 sites with a 707.x ICD code (pressure ulcer) was identified during the study period (1/13-9/13). Using random selection (with replacement), we obtained information on 5 patients per month of the study period. Each patient was followed for 8 weeks after the start of the observation month. Observation periods were excluded if the patient was hospitalized for less than 3 days or had a multiple sclerosis diagnosis (N=29). We identified all ulcers for each patient during the observation period. Ulcers not present during the observation period were excluded (N=69). One facility did not record any SCI-PUMT data during the study period and was excluded from analysis (N=41 ulcers). This yielded a sample of 206 unique PrUs in 83 unique patients (mean = 2.5 ulcers/patient) with SCI-PUMT data.
Interview participants reported that the main barrier to SCI-PUMT implementation was the lack of a standardized database for storing SCI-PUMT data. Factors complicating or impeding SCI-PUMT implementation included staff turnover, inadequate staffing and/or lack of leadership support for staff training, duplicate documentation and/or perceptions about too much documentation, perceived SCI-PUMT limitations and/or staff resistance.
High-adopting sites reported that using the SCI-PUMT helped to formalize the wound care process, and improved consistency in wound assessment and treatment. A formalized wound process enhanced continuity of care and communication, even when there were changes in wound team members. Sites also noted the benefits of sharing objective scores to track wound healing and the ability to use data to assess treatment outcomes.
Leadership and staff buy-in were important facilitators of SCI-PUMT implementation. SCI-PUMT Implementation was most successful at sites with a strong collaborative approach to wound care. Creation of a local template in CPRS also improved data collection/documentation and supported SCI-PUMT adoption. The availability of experienced staff and a strong interprofessional wound care process developed before or around the introduction of the SCI-PUMT were also important facilitators. Interprofessional wound care rounds were labor intensive and team leadership and composition varied widely across sites. The wound care nurse was often the team leader, but other leaders included a physical therapist, SCI physicians and/or surgeons. The number of disciplines (e.g., dietary, Management of Information and Outcomes [MIO] coordinators, psychologists, infectious disease physicians, etc.) typically included on wound rounds ranged from 5 to 10. The two high-adopting sites routinely had 9-10 disciplines participating on rounds.
Field observations indicated that sites varied in who participated in wound assessment, measurement and data collection and strategies (computers on wheels, laptops vs. handwritten forms stored in binders). High-adopting sites were successful in getting all team members involved in wound care, while wound rounds in low-adopting sites had fewer participants. Interviews revealed that high-adopting sites had refined their data collection processes through multiple iterations to arrive at a process they viewed as effective and efficient. SCI-PUMT scores were discussed during wound care rounds at most sites but scores were used to guide treatment decisions at only one site.
We reviewed a random sample of medical records of Veterans with PrUs at each center that participated in the site visits. Of the 206 unique PrUs identified, 79% were Stage III or IV and 68% were located on the trunk. In assessing SCI-PUMT completion for these patients, we found that only 25% of PrUs had the expected number of weekly SCI-PUMTs documented. Severe PrUs (Stage III-IV) were twice as likely to have completed SCI-PUMTs documented than less severe (Stage I-II) PrUs (mean=40% vs. 19%, range 15%-66%).
Discussion: Clinical champions encountered a number of challenges to SCI-PUMT implementation at their sites. Our data suggest that sites with strong interprofessional wound teams were better able to implement the SCI-PUMT. But these high-adopting sites are the exception. We found that even high-adopting sites reporting high SCI-PUMT use are really "collecting" rather than "using" scores to guide treatment decisions. Further, many sites did not evidence a strong interprofessional wound team.
SCI-PUMT implementation efforts to date have focused on the planning and educating phases. Future projects to move SCI-PUMT implementation forward through the restructuring process will require the resolution of data documentation/storage issues. Once these issues are addressed, quality management activities, including data use to guide treatment decisions, can proceed. Long term gains in PrU treatment in SCI require implementation and sustained use of the SCI-PUMT.
- Guihan M, Bates-Jensen BM, Hill JN, Khan HT, Thomason S, Powell-Cope G. Evaluating the Implementation of the Pressure Ulcer Monitoring Tool. Paper presented at: Paralyzed Veterans of America Summit; 2015 Sep 1; Jacksonville, FL.
- Evans (Mayfield) C, Guihan M, LaVela SL, Weaver FM. SCI Quality Enhancement Research Initiative (QUERI): Building and Implementing. Presented at: Academy of Spinal Cord Injury Professionals Annual Meeting; 2013 Sep 2; Las Vegas, NV.