Pressure ulcer management and research priorities for patients with spinal cord injury: Consensus opinion from SCI QUERI Expert Panel on Pressure Ulcer Research Implementation

Abstract

OVERVIEW Pressure ulcers (PUs) are a serious and costly complication for many individuals with reduced mobility and sensation. Some populations, such as those with spinal cord injury and disease (SCI/D), remain at high risk throughout their lifetimes. Clinical observations and research have demonstrated staggering costs and human suffering because of PUs, including profound negative effect on general physical health, socialization, financial status, body image, and level of independence and control [1-2]. The International Pressure Ulcer Prevalence Study from 2006 to 2009 demonstrated a change in PU prevalence in the U.S. healthcare facility population. Overall, PU prevalence was slightly lower in 2009 than in 2006, but prevalence of suspected deep-tissue injuries (DTIs) increased during the same period [3]. Further investigation into the cause of these changes is warranted. DTI diagnosis frequency may have been affected by the addition of suspected DTI to the revised National Pressure Ulcer Advisory Panel (NPUAP) staging definitions in 2007 and rule changes for Centers for Medicare and Medicaid reimbursement. Consideration of current evidence-based practice (EBP) is vitally important in the development and implementation of prevention, treatment, and rehabilitation strategies for PUs. A wealth of basic science is available, and early clinical trials are being carried out in the field of PU research; many of these trials were presented at the inaugural International Evidence Based Practice in Wound Care conference in 2006. The focus of the 2nd International Conference on Evidence Based Practice in Wound Care: The Effective Implementation of Pressure Ulcer Clinical Practice Guidelines (held in 2009) was the apparent disconnect between these early-stage research efforts and their implementation as routine clinical practice, as documented in current clinical practice guidelines (CPGs). EBP and expert opinion are frequently combined during the formulation of CPGs. The balance of expert opinion and EBP in a given CPG depends on the maturity and depth of the research base. Currently, there are multiple CPGs for ulcer prevention and treatment, including the Consortium for Spinal Cord Medicine Clinical Practice Guidelines on Pressure Ulcer Prevention and Treatment (SCICPG) [4]. The common goal of these CPGs is to reduce the incidence and prevalence of PUs. Unfortunately, Thomason et al. found that although SCI physicians and nurses generally agreed with the SCICPG recommendations as written, they did not believe that these recommendations were fully implemented in their respective clinical settings. Furthermore, clinical personnel identified lack of knowledge and organizational factors--such as communication difficulties across teams, shifts, and hospital departments--as the biggest barriers to implementing CPGs [5]. The effective selection and implementation of evidence-based guidelines for PU are critically important to improving rehabilitative and lifetime outcomes for people at risk for PU development. Education in the use and implementation of CPGs is an ongoing need. Additionally, a critical need exists to identify the remaining research gaps and pathways to effective implementation of research efforts in clinical practice. An invited expert panel met in Cleveland, Ohio, on June 4, 2009, in conjunction with the 2nd International Conference on Evidence Based Practice in Wound Care, to develop a research agenda based on critical knowledge gaps regarding PUs in individuals with SCI and on implementation of advanced clinical practice. We report a literature-based discussion of the consensus panel conclusions. The meeting was sponsored by the Department of Veterans Affairs (VA) SCI Quality Enhancement Research Initiative (SCI QUERI). The SCI QUERI works closely with the VA's SCI/D Strategic Health Group to identify the critical, time-sensitive issues important for Veterans Health Administration operations as part of the SCI QUERI mission: promotion of patient health, functioning, and quality of life through the implementation of evidence-based methods for enhancing patient self-management and disease prevention in the context of multidisciplinary care. …