practice

Factors in rehospitalisation for severe pressure ulcer care in spinal cord injury/disorders  Objective: 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. l Method: 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. l Results: 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. Suboptimally managed neurogenic bowel (SMNB) at admission was significantly associated with reduced RHA. l Conclusion: 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. l Declaration of interest: There were no external sources of funding for this study. The authors have no conflicts of interests to declare. l

spinal cord injuries; severe pressure ulcers; repeat admission

J O U R N A L O F WO U N D C A R E V O L 2 3 , N O 4 , A P R I L 2 0 1 4

prevalence for those living in the community.6 People with SCI/D remain at risk for PUs throughout their lifetime. Once a person with SCI/D has had a PU, he/she is at increased risk of developing recurrent ulcers.1 PUs are among the leading causes for unplanned rehospitalisation of people with SCI/D.6 Although detailed information on the costs of PU in the SCI/D population is not known, the overall burden of costs on the US healthcare system from chronic wound treatment is high, recently estimated at $6–$15 billion per year.7,8 In the UK, the total annual cost is estimated to be £1.4–£2.1 billion, comprising 4% of total NHS expenditure.9 External applied pressure and duration of loading are recognised as primary extrinsic risk factors, although tissue breakdown leading to PU development is known to involve many other factors.10 Known patient-centred risk factors for individuals with SCI/D include clinical variables such as level and extent of injury, comorbidities, prior history of PUs, advanced age, smoking, fitness level, and difficulty performing skin care procedures.11 Limited research has indicated that psychological factors, such as life satisfaction and high self-esteem, as well as positive behavioural factors, such as good diet or weight shifting, may be protective against PU devel-

B.L. Goodman,1,2 MPH; A. Schindler,3 BA; M. Washington,1 RN, MS; K.M. Bogie,1,4 PhD; C.H. Ho,1,5 MD; 1 Louis Stokes Cleveland Department of Veterans Affairs Medical Center (LSCDVAMC), Cleveland, Ohio, US; 2 Department of Epidemiology & Biostatistics, Case Western Reserve University, Cleveland, Ohio, US; 3 The Ohio College of Podiatric Medicine, Cleveland, Ohio, US; 4 Department of Orthopaedics, Case Western Reserve University, Cleveland, Ohio, US; 5 Division of Physical Medicine & Rehabilitation, University of Calgary, Calgary, Canada. Email: [email protected]

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P

ressure ulcers are one of the most common comorbidities in individuals with spinal cord injuries/disorders (SCI/D), and frequently require recurrent hospital admissions with long periods of stay.1,2 A survey of self-reported risk factors by Krause and Broderick identified a healthy lifestyle as being associated with reduced PU recurrence, but the authors did not appear to correlate participant reports with medical records.3 Personalised pressure ulcer (PU) education following surgery appeared to decrease the rate of recurrenc;4 however, even with a structured educational monthly follow-up, 33% of study participants exhibited PU recurrence. A recent case study reported that the cost of conservative management followed by minimally invasive surgical intervention for 1 severe Grade IV PU may be in excess of $200,000.5 The systemic costs of treating PUs requiring rehospitalisation have not been investigated in depth, but we suspect they are high. Loss or impairment of mobility and sensation increases the risk of PU development in people with SCI/D. The rate of PUs in the SCI/D population is consequently high, with reports of 33–40% incidence during acute rehabilitation and a similar

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practice

166

RHA

repeated hospital admissions

PU

pressure ulcer

SCI/D

spinal cord injuries/disorders

LSCDVAMC

Louis Stokes Cleveland Department of Veterans Affairs Medical Centre

SCIPUD

Spinal cord injury pressure ulcer database

WCT

wound care team

SMS

sub-optimally managed spasticity

SMNB

sub-optimally managed neurogenic bowel

SMNU

sub-optimally managed neurogenic bladder

CPRS

computerised patient record system

Method A retrospective chart review of people with SCI/D admitted to the Louis Stokes Cleveland Department of Veterans Affairs Medical Center (LSCDVAMC), for the clinical management of severe PUs, was carried out. The facility is a tertiary referral SCI/D Center for a 4-state catchment area which includes 32 inpatient beds for acute and chronic SCI/D management. Multiple factors known to be associated with PU development were assessed at the admission timepoint and analysed. The Spinal Cord Injury Pressure Ulcer Database (SCIPUD) was created by a diverse team of SCI/D employees including the wound care team defined below, biomedical engineers, biostatisticians and a public health specialist. The long-term goal of SCIPUD is to create a database with the relevant intrinsic and extrinsic factors that may be associated with PU prevention and healing in SCI/D. A literature review,3 together with consultations with clinical experts was conducted to determine variables related to PU development to be included in the database. Multiple factors under the categories of basic demographic information, SCI/D history, equipment, medications, comorbidities and environment were selected, and data collection forms created. All data collection forms were pilot-tested to ensure accuracy, as described in detail below.

Participants The SCIPUD sampling frame included all patients admitted to the LSCDVAMC SCI/D unit for PU management and evaluated by the wound care team (WCT) from 2006 to 2009. The SCI/D service at our facility provides care for individuals with SCI and associated diseases. Individuals with multiple sclerosis are seen by the service once they develop an extensive level of disability, as indicated by a Kurtzke Expanded Disability Severity Score greater than six.20 All patients with amyotrophic lateral sclerosis included in this study had functional tetraplegia. The LSCDVAMC WCT is a multidisciplinary team consisting of a wound care nurse, physician, staff nurses, physical and occupational therapists, and a dietician. Approximately 75 to 100 patients (patient admissions) were evaluated by the LSCDVAMC WCT annually over the sampling period. Data obtained through the VA Informatics and Computing Infrastructure from the corporate data warehouse indicated that ICD9 codes were infrequently used to define PU as a reason for admission. A search based on all ICD9 codes for PUs found that over the 3-year data collection period of SCIPUD, only 93 individuals were admitted to the SCI/D service with an initial

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Glossary

increased risk of an adverse condition,19 specifically PU development. Identifying risk factors that are correctable may ultimately decrease RHA.

© 2014 MA Healthcare

opment. Employment and education have also been shown to be protective against PU development.12 Although the associations between various factors and initial PU development have been studied, there is a limited amount of information and research on factors related to rehospitalisation for PU management in the individual with SCI/D. A PubMed search for the term ‘pressure ulcer hospitalisation’ found over 650 papers; however, a search for ‘pressure ulcer rehospitalisation’ detected only 10 papers, the majority of which were focused on acute SCI.13,14 Over a decade ago, Cardenas et al. found that repeated hospital admissions (RHA) due to PU were more likely for individuals with paraplegia than for those with tetraplegia.15 Paker et al. also reported that PUs were one of the top three reasons for re-admission.16 More recently, the first article in the SCIRehab series reported that patient characteristics were strong predictors of RHA, including for PU.17 These papers addressed reasons for RHA in general, amongst which PU development was a frequent reason. However, information on specific factors which influenced RHA for PU is limited. In order to provide the information needed for continuous improvement in the lifetime clinical management of this patient population, it is essential to investigate the potential contributory roles of the multiple intrinsic and extrinsic factors leading to both PU development and recurrence. The goal of this retrospective, observational study was to examine associations between known risk factors for initial PU development and the potential for RHA in the management of Category III and IV PUs. As defined by the National Pressure Ulcer Advisory Panel, a Category III PU has full-thickness skin loss involving damage of subcutaneous tissue and a Category IV PU has full thickness skins loss with extensive destruction; tissue necrosis; or damage to muscle, bone, or supporting structures.18 The underlying hypothesis was that risk factors for initial PU development will also be indicative of increased RHA. In this study, a risk factor was defined as a characteristic associated with an

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practice for treatment of one or more Category III or IV PU during the study time fame. Individuals with a single admission were defined as the control group for this study of RHA. Sample size was selected to allow differences between groups to be determined with a moderate effect size (0.50) and power of 0.08. The study received IRB approval and HIPAA consent waivers, and therefore informed consent was not required.

Enrollment

Assessed for eligibility (n=399 patients)

Randomly sampled for model development (n=150 patients) Excluded - Not meeting inclusion criteria (n=45) All Category I/II Unstageable

Allocation

Allocated detailed review (n=105 patients)

Analysis

Analysed (n=105 patients) Excluded from analysis (n=0)

admission code indicating a PU was present. Therefore, the use of an administrative database to identify the presence of PU on admission through the use of ICD9 codes would have underestimated the number of patients with PU. Over the study duration, 70% of admissions to the LSCDVAMC SCI/D unit coded for PU management had Category III or IV wounds. Patients were admitted under the VA Directive 1176 for SCI which mandates that patients with SCI and Category III and IV PUs should be admitted to a specialised SCI/D unit such as ours and remain hospitalised until their PU healed. All patients admitted for inpatient PU management and care are seen by the WCT. In order to obtain detailed information from as many patients with PU as possible, a chart review of baseline data collected at admission was therefore conducted using manual text-mining based on keywords. Within the study time frame, 399 individuals with SCI were consecutively admitted for PU management and included in SCIPUD. Within the database population, the number of individual admissions for the treatment of Category III or IV wounds for each patient varied from one to six admissions. The primary reason for multiple admissions for a single patient is that it may or may not have been for the same Category III or IV PU. In the current study, a two-stage process, as outlined in Fig 1, was applied to identify a stratified random sample of the SCIPUD population treated for a severe PU from groups of those who had single or repeat hospital admissions for PU management. Individuals admitted with a severe PU (n=150) were selected for model development. Stratified random sampling with oversampling to account for missing data resulted in a study population of 105 individuals admitted 168

Study procedures Data were obtained through retrospective chart reviews of people with SCI/D admitted to the LSCDVAMC for PU care. The data were extracted from the electronic health record system, known as the Computerised Patient Record System (CPRS). SCIPUD contains longitudinal data including all admission time points during the study timeframe. All data were collected using standardised data collection forms, and entered into SCIPUD. Data collection forms were reviewed by SCI/D clinical experts and pilot tested for accuracy and completeness of data. A data-collection manual was also developed to ensure inter- and intra-rater reliability of data collection. The manual was used to train study personnel on the data collection form and chart review methods. Three data collectors were trained prior to data collection to prevent misclassification of data in the clinical record. Data collection forms were completed independently by three study staff using the same patient for chart review. Data obtained by chart review were then compared between staff, and all data collected were equivalent and accurate compared to the chart record. Oversight was provided by a content expert knowledgeable on CPRS and SCI/D to further ensure reliability of data.

Selection and definition of risk factors for review Factors evaluated included those that were identified as being possibly related to PU development or healing in the SCI Clinical Practice Guidelines together with expert clinical opinion and reviews of cross-sectional and observational studies.21,22 They included demographic information (age, race, education level, marital status), SCI-factors (ASIA Impairment Scale), level of injury, duration of injury), wheelchair type, medication use (polypharmacy [use of ≥9 prescribed medications] and use of medications with somnolence side-effects), comorbidities (diagnosis of diabetes mellitus and depression; tobacco use), environmental factors (living status and distance to health-care centre), and SCI/D-Medical Conditions (SMNB, SMNU, SMS, and diagnosis of chronic pain) that are specifically related to having SCI/D and the Charlson Comorbidity Index.23 Sub-optimally managed medical conditions (SMNB, SMNU, and SMS) were defined on the basis of provider documentation,

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(Modified CONSORT 2010 Flow diagram)

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Fig 1. Study recruitment flow diagram

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practice Table 1. Summary study cohort demographics Demographics

n

%

Age

Age (range 19–85)

Mean= 58 yrs

Race

White

57

63%

Non-white

34

37%

Less than high school

12

14%

High school or higher

75

86%

Married

34

37%

Non-married

57

63%

Complete (AIS= A)

45

49%

Incomplete (AIS= B, C, D)

27

30%

N/A

19

21%

Paraplegia

43

47%

Tetraplegia

30

33%

MS/ALS

18

20%

Years (range 0.2 -53)

Mean = 16 yrs

Data analysis

SCI Factors AIS

Type of Injury

Length of Injury

Owing to the longitudinal nature of this study, some demographic variables are subject to change over time. All demographic variables are derived from the first admission entered in SCIPUD

Table 2. High-risk factors significantly associated with RHA (Tukey’s HSD applied) Variable

Group 1

Group 2

Group 3

Total

p-value

24 yrs. (27)

17 yrs. (104)

.004

.021

SCI factors: Duration of Injury 12 yrs. (37)

18 yrs. (40)

Equipment use: Wheelchair Type Power

11 (26%)

14 (33%)

17 (41%)

42 (100%)

Manual

10 (42%)

12 (50%)

2 (8%)

24 (100%)

SCI Medical factors SMNB Yes

10 (63%)

6 (38%)

0 (0%)

16 (100%)

No

21 (26%)

34 (42%)

26 (32%)

81 (100%)

Yes

13 (21%)

26 (42%)

23 (37%)

62 (100%)

No

23 (54%)

15 (35%)

5 (12%)

43 (100%)

.005

Spasticity .001*

Table Key: Group 1 = 1 admission Group 2 = 2 admissions Group 3 = ≥ 3 admissions

extracted by text-mining from the admission note. Text-mining that is based on defined keywords is a rapidly developing field shown to be reliable and highly specific in predictive model development and clinical-trial recruitment.24,25 In the current study, sub-optimal management of medical conditions was determined by review of the admission note for clinical indicator keywords. Thus, keywords for sub-optimal bowel (SMNB) or bladder 170

All analysis was performed using PASW® Statistics 18 for Windows. Descriptive statistics, including prevalence within our study population and 95% confidence intervals (CI) as appropriate, were calculated for all study variables. RHA was employed as the dependent outcome variable. Chi-square and ANOVA statistics were used to assess associations between risk factors and RHA. An initial significance value of p