Spinal Cord Injury Pressure Ulcer Research Articles

Neuropeptide Substance P Enhances Skin Wound Healing In Vitro and In Vivo under Hypoxia.

Pressure ulcers (PUs) or sores are a secondary complication of diabetic neuropathy and traumatic spinal cord injury (SCI). PUs tend to occur in soft tissues located around bony prominences and may heal slowly or not at all. A common mechanism underlying impaired healing of PUs may be dysfunction of the local neurovascular system including deficiency of essential neuropeptides, such as substance P (SP). Previous studies indicate that disturbance in cutaneous sensory innervation leads to a defect in all stages of wound healing, as is the case after SCI. It is hypothesized that nerve fibers enhance wound healing by promoting initial inflammation via the releasing of neuropeptides such as SP. Therefore, we investigated whether exogenous SP improves skin wound healing using in vitro and in vivo models. For in vitro studies, the effects of SP on keratinocyte proliferation and wound closure after a scratch injury were studied under normoxia (pO2 ~21%) or hypoxia (pO2 ~1%) and in presence of normal serum (10% v/v) or low serum (1% v/v) concentrations. Hypoxia and low serum both significantly slowed cell proliferation and wound closure. Under combined low serum and hypoxia, used to mimic the nutrient- and oxygen-poor environment of chronic wounds, SP (10−7 M) significantly enhanced cell proliferation and wound closure rate. For in vivo studies, two full-thickness excisional wounds were created with a 5 mm biopsy punch on the dorsum on either side of the midline of 15-week-old C57BL/6J male and female mice. Immediately, wounds were treated topically with one dose of 0.5 μg SP or PBS vehicle. The data suggest a beneficial role in wound closure and reepithelization, and thus enhanced wound healing, in male and female mice. Taken together, exogenously applied neuropeptide SP enhanced wound healing via cell proliferation and migration in vitro and in vivo. Thus, exogenous SP may be a useful strategy to explore further for treating PUs in SCI and diabetic patients.

Development of Predictive Informatics Tool Using Electronic Health Records to Inform Personalized Evidence-Based Pressure Injury Management for Veterans with Spinal Cord Injury

Pressure injuries (PrI) are serious complications for many with spinal cord injury (SCI), significantly burdening health care systems, in particular the Veterans Health Administration. Clinical practice guidelines (CPG) provide recommendations. However, many risk factors span multiple domains. Effective prioritization of CPG recommendations has been identified as a need. Bioinformatics facilitates clinical decision support for complex challenges. The Veteran's Administration Informatics and Computing Infrastructure provides access to electronic health record (EHR) data for all Veterans Health Administration health care encounters. The overall study objective was to expand our prototype structural model of environmental, social, and clinical factors and develop the foundation for resource which will provide weighted systemic insight into PrI risk in veterans with SCI. The SCI PrI Resource (SCI-PIR) includes three integrated modules: (1) the SCIPUDSphere multidomain database of veterans' EHR data extracted from October 2010 to September 2015 for ICD-9-CM coding consistency together with tissue health profiles, (2) the Spinal Cord Injury Pressure Ulcer and Deep Tissue Injury Ontology (SCIPUDO) developed from the cohort's free text clinical note (Text Integration Utility) notes, and (3) the clinical user interface for direct SCI-PIR query. The SCI-PIR contains relevant EHR data for a study cohort of 36,626 veterans with SCI, representing 10% to 14% of the U.S. population with SCI. Extracted datasets include SCI diagnostics, demographics, comorbidities, rurality, medications, and laboratory tests. Many terminology variations for non-coded input data were found. SCIPUDO facilitates robust information extraction from over six million Text Integration Utility notes annually for the study cohort. Visual widgets in the clinical user interface can be directly populated with SCIPUDO terms, allowing patient-specific query construction. The SCI-PIR contains valuable clinical data based on CPG-identified risk factors, providing a basis for personalized PrI risk management following SCI. Understanding the relative impact of risk factors supports PrI management for veterans with SCI. Personalized interactive programs can enhance best practices by decreasing both initial PrI formation and readmission rates due to PrI recurrence for veterans with SCI.

Assessment of pressure ulcers in physically handicapped patients

AbstractPurposeAssessment of pressure ulcers is an indicator of nursing care quality. In physically handicapped patients, the risk is elevated, due to the neuropathy and incontinence that frequently accompany paresis and paralysis. We conducted a systematic review of 4 assessment scales to assess their use and usefulness for these patients.Materials/methodsWe searched 5 databases for articles published between 2016 and 2018 that included terms related to the risk of pressure ulcers in physically handicapped patients, including the names of 4 assessment scales (Norton, Braden, Waterlow and Spinal Cord Injury Pressure Ulcer Scale). One hundred and three sources were returned, from which we selected 10. We also selected an earlier source, for a total of 11.ResultsThe Braden and Waterlow scales are popular in clinical practice. The Norton scale is used for scientific comparisons and in clinical practice only sporadically. Expert opinion suggests that acceptance of the Spinal Cord Injury Pressure Ulcer Scale could reduce the incidence of pressure ulcers in physically handicapped patients.ConclusionsIntroduction of a scale designed for handicapped patients, combined with better preventive measures, could result in the bedsore reduction of pressure ulcers. Research testing the effectiveness of the Spinal Cord Injury Pressure Ulcer Scale in the Czech population is needed to validate its use in clinical practice.

The Spinal Cord Injury Pressure Ulcer Scale (SCIPUS): an assessment of validity using Rasch analysis.

Secondary analysis of retrospective data. The aim of this study was to further validate the Spinal Cord Injury Pressure Ulcer Scale (SCIPUS) using Rasch analysis. Two rehabilitation centers in Canada. Data were collected as part of the Spinal Cord Injury Knowledge Mobilization Network (SCI KMN) initiative. The SCIPUS was completed within 72 h of inpatient admission. Persons admitted for initial rehabilitation in two inpatient spinal cord rehabilitation programs were included in the project. Data from 886 participants were analyzed, approximately 60% of whom were males. Rasch analyses demonstrated that the SCIPUS, in its current format did not meet criteria required for true measurement. A transformed version of the SCIPUS obtained by deletion of misfitting items and modification of the response scales improved fit to the model and showed preliminary evidence of unidimensionality. The person separation index, however indicated that the scale requires further adjustments of its scoring options. In its original form, the SCIPUS does not meet the requirements of the Rasch model and its total score should be used cautiously. However, following some adjustments to the items such as addressing DIF between sites to insure a standardized assessment across sites and adding response options to some of the items, interval-scale measurement should be possible.

Determining Pressure Injury Risk on Admission to Inpatient Spinal Cord Injury Rehabilitation: A Comparison of the FIM, Spinal Cord Injury Pressure Ulcer Scale, and Braden Scale

ObjectiveAssess the utility of the admission Spinal Cord Injury Pressure Ulcer Scale (SCIPUS), Braden Scale, and the FIM for identifying individuals at risk for developing pressure injury during inpatient spinal cord injury (SCI) rehabilitation. DesignRetrospective cohort. SettingTwo tertiary rehabilitation centers. ParticipantsIndividuals (N=754) participating in inpatient SCI rehabilitation. InterventionsNot applicable. Main Outcome MeasuresLogistic regression analysis was performed to determine the utility of the SCIPUS, Braden Scale, and FIM for identifying individuals at risk for developing pressure injury (PI) during inpatient SCI rehabilitation. Sensitivity, specificity, positive predictive value, negative predictive value, false negative rate, odds ratio, likelihood ratio, and area under the curve (AUC) are reported. ResultsThe SCIPUS total score and its individual items did not demonstrate acceptable accuracy (AUC≥0.7) whereas the Braden Scale (0.73) and the FIM score (0.74) did. Once items were dichotomized into high and low risk categories, 1 Braden item (friction and shear), 5 FIM items (bathing, toileting, bed/chair transfer, tub/shower transfer, toilet transfer), the FIM transfers subscale, FIM Motor subscale, and the FIM instrument as a whole, maintained AUCs ≥0.7 and negative predictive values ≥0.95. The FIM bed/chair transfer score demonstrated the highest likelihood ratio (2.62) and overall was the most promising measure for determining PI risk. ConclusionStudy findings suggest that a simple measure of mobility, admission FIM bed/chair transfer score of 1 (total assist), can identify at-risk individuals with greater accuracy than both an SCI specific instrument (SCIPUS) and a PI specific instrument (Braden). The FIM bed/chair transfer score can be readily determined at rehabilitation admission with minimal administrative and clinical burden.

Individualized Clinical Practice Guidelines for Pressure Injury Management: Development of an Integrated Multi-Modal Biomedical Information Resource.

BackgroundPressure ulcers (PU) and deep tissue injuries (DTI), collectively known as pressure injuries are serious complications causing staggering costs and human suffering with over 200 reported risk factors from many domains. Primary pressure injury prevention seeks to prevent the first incidence, while secondary PU/DTI prevention aims to decrease chronic recurrence. Clinical practice guidelines (CPG) combine evidence-based practice and expert opinion to aid clinicians in the goal of achieving best practices for primary and secondary prevention. The correction of all risk factors can be both overwhelming and impractical to implement in clinical practice. There is a need to develop practical clinical tools to prioritize the multiple recommendations of CPG, but there is limited guidance on how to prioritize based on individual cases. Bioinformatics platforms enable data management to support clinical decision support and user-interface development for complex clinical challenges such as pressure injury prevention care planning.ObjectiveThe central hypothesis of the study is that the individual’s risk factor profile can provide the basis for adaptive, personalized care planning for PU prevention based on CPG prioritization. The study objective is to develop the Spinal Cord Injury Pressure Ulcer and Deep Tissue Injury (SCIPUD+) Resource to support personalized care planning for primary and secondary PU/DTI prevention.MethodsThe study is employing a retrospective electronic health record (EHR) chart review of over 75 factors known to be relevant for pressure injury risk in individuals with a spinal cord injury (SCI) and routinely recorded in the EHR. We also perform tissue health assessments of a selected sub-group. A systems approach is being used to develop and validate the SCIPUD+ Resource incorporating the many risk factor domains associated with PU/DTI primary and secondary prevention, ranging from the individual’s environment to local tissue health. Our multiscale approach will leverage the strength of bioinformatics applied to an established national EHR system. A comprehensive model is being used to relate the primary outcome of interest (PU/DTI development) with over 75 PU/DTI risk factors using a retrospective chart review of 5000 individuals selected from the study cohort of more than 36,000 persons with SCI. A Spinal Cord Injury Pressure Ulcer and Deep Tissue Injury Ontology (SCIPUDO) is being developed to enable robust text-mining for data extraction from free-form notes.ResultsThe results from this study are pending.ConclusionsPU/DTI remains a highly significant source of morbidity for individuals with SCI. Personalized interactive care plans may decrease both initial PU formation and readmission rates for high-risk individuals. The project is using established EHR data to build a comprehensive, structured model of environmental, social and clinical pressure injury risk factors. The comprehensive SCIPUD+ health care tool will be used to relate the primary outcome of interest (pressure injury development) with covariates including environmental, social, clinical, personal and tissue health profiles as well as possible interactions among some of these covariates. The study will result in a validated tool for personalized implementation of CPG recommendations and has great potential to change the standard of care for PrI clinical practice by enabling clinicians to provide personalized application of CPG priorities tailored to the needs of each at-risk individual with SCI.Registered Report IdentifierRR1-10.2196/10871

Spinal cord injury rehabilitation and pressure ulcer prevention after the 2005 South Asian Earthquake: a CBR case study from Pakistan

Background: The 2005 South Asian earthquake led to large-scale injuries and disabilities in northern Pakistan, which were dealt with using various approaches. In this regard, a community-based rehabilitation approach was initiated in the Muzaffarabad district of Pakistan in early 2006, focused on preventing complications among persons with Spinal Cord Injury. This case study briefly describes its development, aims and service provision components, in addition to the distribution of injuries from the disaster. Pressure ulcer prevention education, its recall and decrease in prevalence over a year are presented as key outcomes and illuminate the process of implementing rehabilitation in this context.Methods: This case study presents findings from a larger internal program evaluation in 2010–11. The study design was cross-sectional, to elicit recall of education components and the resulting prevalence of pressure ulcers over the year, in 33 randomly selected persons with Spinal Cord Injury. Outcomes included retention of knowledge about pressure ulcer prevention, practices and reduction in the prevalence of pressure ulcers over the last year. We also conducted a narrative literature review on the types of injuries and complications in the Spinal Cord population from Northern Pakistan.Results: Hospital cohort studies reported “spine” injuries at 5%, while persons with spinal cord injury were identified as the most underserved needing rehabilitation services after the quake. Results from the evaluation of prevention education revealed that all 33 respondents were trained in detection of pressure ulcers, while 32 recalled “danger signs” for which they would seek immediate help. All correctly recalled postural change timings, however, their actual practices differed. Twenty-seven respondents (82%) reported no pressure ulcers over the last year.Conclusion: The decrease in pressure ulcer prevalence over the last year in persons with spinal cord injury highlights the strengths of the community-based rehabilitation approach, particularly preventive education in geographically challenging and highly resource constrained settings. The research also begins to fill a critical gap in the present literature as most research is limited to hospital based interventions from the first year of the 2005 earthquake.Implications for RehabilitationPrevention education for targeting pressure ulcers can be effective in reducing incidence of this important complication in persons with spinal cord injury.Community-based rehabilitation approaches can prove beneficial in post-disaster settings, especially in resource constrained settings and difficult hilly terrain.Rehabilitation programs should consider nutrition interventions to reduce multiple pressure ulcers, especially in lower middle income countries.

Predictive validity of the Spinal Cord Injury Pressure Ulcer Scale (SCIPUS) in acute care and inpatient rehabilitation in individuals with traumatic spinal cord injury.

To evaluate the validity of the Spinal Cord Injury Pressure Ulcer Scale (SCIPUS) during acute care and inpatient rehabilitation following spinal cord injury (SCI) by determining critical cutoff points and assessing the ability to predict risk for pressure ulceration (PrU). Retrospective. Sensitivity, specificity, and area under the curve (AUC) for the receiver operating characteristic were determined for the scale's ability to predict PrU 2-3 and 5-7 days after administrating the SCIPUS during acute care, and 5-7 and 14-21 days after administrating the SCIPUS during inpatient rehabilitation. During acute hospitalization, SCIPUS's ability to assess risk for PrUs within 2-3 days was determined at cutoff score of 15 with 100% sensitivity and 75% specificity, AUC = 0.85. The scale was unable to assess PrU risk at 5-7 days, AUC < 0.6 at cutoff score of 13. During inpatient rehabilitation, the scale was unable to assess PrU risk at 5-7 and 14-21 days, AUC < 0.6 at cutoff score of 9. The SCIPUS could predict PrU occurring within 2-3 days following administration during acute, but unable to predict over a longer term within acute or inpatient rehabilitation. Improved PrU risk assessment following SCI may be possible with modification to the SCIPUS.

Psychometric Properties of the Spinal Cord Injury Pressure Ulcer Scale (SCIPUS) for Pressure Ulcer Risk Assessment During Inpatient Rehabilitation

ObjectiveTo assess the psychometric properties of the Spinal Cord Injury Pressure Ulcer Scale (SCIPUS) for pressure ulcer (PU) risk assessment during inpatient rehabilitation. DesignProspective cohort. SettingTertiary rehabilitation centers. ParticipantsIndividuals (N=759) participating in inpatient spinal cord injury rehabilitation between January 3, 2012, and April 23, 2014. InterventionsNot applicable. Main Outcome MeasuresAdmission SCIPUS scores and the corresponding risk stratification, PU incidence, intraclass correlation coefficient (ICC) for interrater reliability, sensitivity, specificity, and likelihood ratios (LRs). Receiver operating characteristic analysis was performed to calculate the area under the curve (AUC). ResultsMean SCIPUS scores were higher for individuals who developed PUs than for those who did not (mean SCIPUS score, 9.8±2.5 vs 8.5±2.6). Interrater reliability was excellent for SCIPUS composite scores (ICC=.91) and very good for risk stratification (ICC=.86). Using the existing cutoff value of ≥6 for “high risk” category, sensitivity and specificity were estimated to be .97 and .12, respectively, with an LR of 1.1. A cutoff value of ≥8 yielded a better balance between sensitivity and specificity (.85 and .38, respectively). The AUC equaled .64 with an LR of 1.4. Results were similar when the analysis was confined to PUs of stage II or greater. ConclusionsThe psychometric properties of the SCIPUS do not currently support its routine use as a measure of PU risk in individuals with spinal cord injury undergoing inpatient rehabilitation. LRs of <2 indicate that stratification as high risk or very high risk does not substantially increase the likelihood of identifying individuals who develop PUs beyond chance alone. AUCs were also below the desired cutoff value of 0.7.

Prevention of Pressure Ulcers Among People With Spinal Cord Injury: A Systematic Review

ObjectivesTo evaluate the literature on the effectiveness of bed and wheelchair positioning and repositioning in the prevention of pressure ulcers (PUs) in both the spinal cord injury (SCI) and non-SCI populations. DesignSystematic review. MethodsPubMed, CINAHL, PsycINFO, and EMBASE were queried with the subject heading terms “pressure sore,” “pressure ulcer,” “position or turn in bed, wheelchair,” “pressure relief,” and “pressure release.” All study design types that assessed the effectiveness of bed and wheelchair positioning and pressure relief maneuvers in any patient group and in any setting were sought. Three independent reviewers extracted and summarized details of eligible trials using a standardized method. Two independent reviewers assessed the methodological quality of each trial using the American Academy of Neurology guidelines. When reviewers were not able to reach consensus, a third independent reviewer served as tiebreaker. ResultsWe identified 2820 publications, of which 49 met inclusion criteria. Of these publications, the subject population was 2834 (923 persons with SCI, 717 persons without SCI, and 1194 healthy control subjects). Among studies examining pressure related to position or repositioning in bed or sitting, procedures for measuring skin pressure and metabolism were highly variable by anatomic location, measurement technique, outcome measure, study site, participant characteristics, and description of position/turning for bed and seated interventions. Numerous factors can influence tissue interface pressures, and no prospective studies had been performed to determine a causal relationship between interface pressure and skin breakdown. Several studies suggest that skin response to pressure differs between subjects with and without SCI. Conflicting results and insufficient evidence for optimal bed and seated positioning and turning and pressure relief maneuvers to prevent PUs in both SCI and non-SCI populations were limiting factors. ConclusionsAlthough there is no clear optimal positioning or turning frequency in bed, the evidence suggests avoiding the 90° lateral position because of high pressures and PU risk over the trochanters. During sitting, pressures are linearly redistributed from the sitting area during recline and tilt; however, reclining carries with it an increased risk of shear forces on this skin. The evidence does not support conclusive guidelines on positioning or repositioning techniques for PU prevention in bed or during sitting. We conclude that PU risk is highly individualized, with the SCI population at a higher risk, which demands flexible PU prevention strategies for bed/seated positioning and pressure relief maneuvers. Education has and will remain our most powerful ally to thwart this pervasive public health problem.

The ‘Minneapolis Score’: a pre-operative scoring system for spinal cord injury pressure ulcer treatment: an outcome analysis

The ‘Minneapolis Score’: a pre-operative scoring system for spinal cord injury pressure ulcer treatment: an outcome analysis

The application of implementation science for pressure ulcer prevention best practices in an inpatient spinal cord injury rehabilitation program

ObjectivesTo implement pressure ulcer (PU) prevention best practices in spinal cord injury (SCI) rehabilitation using implementation science frameworks.DesignQuality improvement.SettingSCI Rehabilitation Center.ParticipantsInpatients admitted January 2012 to July 2013.InterventionsImplementation of two PU best practices were targeted: (1) completing a comprehensive PU risk assessment and individualized interprofessional PU prevention plan (PUPP); and (2) providing patient education for PU prevention; as part of the pan-Canadian SCI Knowledge Mobilization Network. At our center, the SCI Pressure Ulcer Scale replaced the Braden risk assessment scale and an interprofessional PUPP form was implemented. Comprehensive educational programing existed, so efforts focused on improving documentation. Implementation science frameworks provided structure for a systematic approach to best practice implementation (BPI): (1) site implementation team, (2) implementation drivers, (3) stages of implementation, and (4) improvement cycles. Strategies were developed to address key implementation drivers (staff competency, organizational supports, and leadership) through the four stages of implementation: exploration, installation, initial implementation, and full implementation. Improvement cycles were used to address BPI challenges.Outcome MeasuresImplementation processes (e.g. staff training) and BPI outcomes (completion rates).ResultsFollowing BPI, risk assessment completion rates improved from 29 to 82%. The PUPP completion rate was 89%. PU education was documented for 45% of patients (vs. 21% pre-implementation).ConclusionImplementation science provided a framework and effective tools for successful pressure ulcer BPI in SCI rehabilitation. Ongoing improvement cycles will target timeliness of tool completion and documentation of patient education.

Factors in rehospitalisation for severe pressure ulcer care in spinal cord injury/disorders.

Repeated hospital admissions (RHA) for ongoing pressure ulcer (PU) care remains a significant challenge in the clinical management of the spinal cord injury/disorders (SCI/D) population. The current study investigated the significance of risk factors for PU treatment and RHA. A retrospective chart review of veterans admitted to the Louis Stokes Cleveland Department of Veterans Affairs Medical Center (LSCDVAMC) Spinal Cord Injury (SCI) unit for Category III or IV PUs was carried out. A random sample of 105 individuals with SCI/D, evaluated by the Wound Care Team (WCT) from 2006 to 2009 was assessed. Multiple PU development risk factors were extracted from the electronic health record system using standardised data collection forms and entered into the Spinal Cord Injury Pressure Ulcer Database (SCIPUD). Potential associations with RHA were analysed. Twenty variables were initially identified as potentially related to PU development. Descriptive statistics and statistically significant associations between risk factors and RHA were determined. Demographic factors showed no significant association with RHA. Duration of injury, power wheelchair use and sub-optimally managed spasticity (SMS) were significantly associated with higher RHA. Sub-optimally managed neurogenic bowel (SMNB) at admission was significantly associated with reduced RHA. Factors previously found to be predictive of initial PU development may not, in fact, be predictive of RHA. Some protective trends were observed, such as polypharmacy and marital status, but these did not reach statistical significance in this preliminary study of admission characteristics, warranting further research. There were no external sources of funding for this study. The authors have no conflicts of interests to declare.

Model for bridging the translational &amp;quot;valleys of death&amp;quot; in spinal cord injury research

Model for bridging the translational &quot;valleys of death&quot; in spinal cord injury research Bill Barrable,1 Nancy Thorogood,1 Vanessa Noonan,1,2 Jocelyn Tomkinson,1 Phalgun Joshi,1 Ken Stephenson,1 John Barclay,1 Katharina Kovacs Burns3 1Rick Hansen Institute, 2Division of Spine, Department of Orthopaedics, University of British Columbia, Vancouver, BC, 3Health Sciences Council, University of Alberta, Edmonton, AB, Canada Abstract: To improve health care outcomes with cost-effective treatments and prevention initiatives, basic health research must be translated into clinical application and studied during implementation, a process commonly referred to as translational research. It is estimated that only 14% of health-related scientific discoveries enter into medical practice and that it takes an average of 17 years for them to do so. The transition from basic research to clinical knowledge and from clinical knowledge to practice or implementation is so fraught with obstacles that these transitions are often referred to as &ldquo;valleys of death&rdquo;. The Rick Hansen Institute has developed a unique praxis model for translational research in the field of spinal cord injury (SCI). The praxis model involves three components. The first is a coordinated program strategy of cure, care, consumer engagement, and commercialization. The second is a knowledge cycle that consists of four phases, ie, environmental scanning, knowledge generation and synthesis, knowledge validation, and implementation. The third is the provision of relevant resources and infrastructure to overcome obstacles in the &ldquo;valleys of death&rdquo;, ie, funding, clinical research operations, informatics, clinical research and best practice implementation, consumer engagement, collaborative networks, and strategic partnerships. This model, which is to be independently evaluated in 2018 to determine its strengths and limitations, has been used to advance treatments for pressure ulcers in SCI. The Rick Hansen Institute has developed an innovative solution to move knowledge into action by bridging the &ldquo;valleys of death&rdquo; in the research continuum, with the intention of improving health outcomes for people with SCI and decreasing the financial impact on the health care system. This model may be generalizable to other health conditions and the lessons learned in developing the praxis model may assist other organizations dealing with similar translational research challenges. Keywords: spinal cord injuries, clinical outcomes, translational research, implementation, knowledge mobilization, praxis model

Identification of capillary blood pressure levels at which capillary collapse is likely in a tissue subjected to large compressive and shear deformations

Pressure ulcers (PU) are localised damage to skin and underlying tissues, caused by sustained tissue deformations and ischaemia. PU typically appear in insensitive or immobile patients, e.g. those with spinal cord injury (SCI) or geriatric patients. As these patients often experience fluctuations in blood pressure, and are also exposed to high-shear loads in their weight-bearing soft tissues during wheelchair sitting or bed rest, we used an inverse finite element method to determine the effects of capillary blood pressure (CBP) and shear deformations on occurrence of mechanical collapse in capillaries. We studied collapse in straight, U-shaped and bifurcated capillaries. All model configurations were consistent in demonstrating that the level of CBP has a considerable influence on the likelihood of capillary collapse in the physiological CBP range, particularly if shear is present. Our modelling therefore suggests that low CBP is a ‘suspect’ risk factor for PU in SCI and geriatric patients.

Poster 48: Psychometric Properties of the Spinal Cord Injury Pressure Ulcer Knowledge Scale

Objective: Despite all existing pressure ulcer (PU) prevention guidelines and education efforts in spinal cord injury (SCI), what is absent is a validated method to measure patient's knowledge about skin care. The purpose of this pilot study was to explore the validity of a newly developed SCI Pressure Ulcer Knowledge Scale (PRESS). It measures the knowledge of necessary prevention and skin care self-management techniques in individuals newly injured. Design: Repeated measures study. Setting: Inpatient rehabilitation facility.

Providers' Perceptions of Spinal Cord Injury Pressure Ulcer Guidelines

Background/Objective: Pressure ulcers are a serious complication for people with spinal cord injury (SCI). The Consortium for Spinal Cord Medicine (CSCM) published clinical practice guidelines (CPGs) that provided guidance for pressure ulcer prevention and treatment after SCI. The aim of this study was to assess providers' perceptions for each of the 32 CPG recommendations regarding their agreement with CPGs, degree of CPG implementation, and CPG implementation barriers and facilitators. Methods: This descriptive mixed-methods study included both qualitative (focus groups) and quantitative (survey) data collection approaches. The sample (n = 60) included 24 physicians and 36 nurses who attended the 2004 annual national conferences of the American Paraplegia Society or American Association of Spinal Cord Injury Nurses. This sample drew from two sources: a purposive sample from a list of preregistered participants and a convenience sample of conference attendee volunteers. We analyzed quantitative data using descriptive statistics and qualitative data using a coding scheme to capture barriers and facilitators. Results: The focus groups agreed unanimously on the substance of 6 of the 32 recommendations. Nurse and physician focus groups disagreed on the degree of CGP implementation at their sites, with nurses as a group perceiving less progress in implementation of the guideline recommendations. The focus groups identified only one recommendation, complications of surgery, as being fully implemented at their sites. Categories of barriers and facilitators for implementation of CPGs that emerged from the qualitative analysis included (a) characteristics of CPGs: need for research/evidence, (b) characteristics of CPGs: complexity of design and wording, (c) organizational factors, (d) lack of knowledge, and (e) lack of resources. Conclusions: Although generally SCI physicians and nurses agreed with the CPG recommendations as written, they did not feel these recommendations were fully implemented in their respective clinical settings. The focus groups identified multiple barriers to the implementation of the CPGs and suggested several facilitators/solutions to improve implementation of these guidelines in SCI. Participants identified organizational factors and the lack of knowledge as the most substantial systems/issues that created barriers to CPG implementation.