Pressure ulcers (PrUs) are recognized as an important determinant of patient suffering and health care costs, and there is an urgent need to improve ulcer prevention in all settings, including the community. National initiatives to implement ulcer prevention guidelines have decreased hospital-acquired pressure ulcers (HAPrUs) in institutional settings, but these efforts have not been successfully translated to community settings. Up to 95% of adults with SCI have at least one severe ulcer (Stage III/IV) in their lifetime. PrUs interfere with rehabilitation, educational and vocational pursuits, and community reintegration and often lead to decreased health and increased disability, and morbidity and mortality. Because most ulcers in SCI are community-acquired, addressing barriers to community acquired pressure ulcers (CAPrUs) prevention for Veterans living at home with SCI is fundamental to improving quality of life and quality of care. This study is an important first step in identifying and adapting successful HAPrU prevention strategies to address the chronic nature of CAPrUs in Veterans with SCI.
The objective of this study is to create a decision support tool for use in the outpatient spinal cord Injury (SCI) clinic that identifies risk factors, actions, and resources needed to prevent CAPrUs in individuals living with SCI. In Aim 1, we will begin by exploring patient and caregiver perceived risk factors, actions and resources used to identify shared and divergent mental models of CAPrU prevention. In Aim 2, we will develop and validate the checklist tool. In Aim 3, the final tool will be piloted and evaluated in an SCI outpatient clinic.
Aim 1: Use participatory action research methods (photovoice, guided walks) to identify Veteran perspectives of CAPrU prevention and use individual interviews with interprofessional providers to determine provider perspectives of patient CAPrU prevention. Qualitative methods will be used to reveal stakeholder (patient, provider) convergent and divergent mental models of the challenges in addressing CAPrU risk factors, using the Farmer method. Data will be collected at 3 sites, totaling 30 Veterans and 30 providers (10 per site, respectively).
Aim 2: Convene an expert panel of relevant stakeholders (3 Veterans with SCI, 3 caregivers, 12 providers and national PrU prevention experts). Using findings of Aim 1 four national provider PrU prevention experts will draft the risk factor, actions and resources checklist. The tool will be refined and validated using a 3-round Delphi method with the Expert Panel.
Aim 3: Automate, pilot-test, refine and evaluate the CAPrU risk factor checklist tool in an outpatient SCI clinic. The tool will be automated on an iPad and iteratively tested with both Veterans (n=5-10) with SCI and providers for face validity. Providers will be trained in use of the iPad using didactic and simulation with a standardized patient. The tool will be piloted with 117 Veterans with SCI prior to and during an outpatient visit, and patient satisfaction will be evaluated immediately after the office visit using individual interview. Methods to evaluate feasibility, acceptability, workflow/patient flow integration include contextual inquiry during 4 participant visits per month. Providers will participant in monthly PDSA rapid response cycles to evaluate and refine the checklist implementation over 6 months. Provider satisfaction will be evaluated by focus group at the end of the study. After the pilot, we will examine new CAPrU incidence at the 3 study sites using secondary data extracted from the EHR. At the intervention site, we will determine if preventive actions suggested by the checklist were implemented after the pilot visit by chart review. If patients at the intervention site experienced new CAPrU(s) within 6 months, we will use root cause analysis to examine factors contributing to new CAPrUs. This will inform the final version of the checklist.
None at this time.
The anticipated impact is to integrate a Veteran-centered decision support tool to be used in the SCI clinic that prevents CAPrUs in Veterans with SCI. The tool will list CAPrU risk factors and associated evidence-based actions and needed resources. This will potentially decrease the incidence of CAPrUs in Veterans with SCI.
None at this time.
Brain and Spinal Cord Injuries and Disorders, Health Systems
Prevention, TRL - Development, Etiology
Caregiving, Health Promotion and Education, Risk Factors, Self-Care