Evaluation of a pilot Pressure Ulcer Prevention Initiative (PUPI) for patients with traumatic spinal cord injury admitted to an acute care setting John Cobb, Occupational Therapist II Acute Spine Unit, Vancouver General Hospital 2015 Quality Forum, Creating Connections

Context Vancouver General Hospital Acute Spine Unit Full compliment of medical and allied health professionals Approximately 120 newly spinal cord injured admissions per year Length of stay varies from weeks to months 15% of traumatic spinal cord injured patients develop at least one pressure ulcer during their acute care admission (Street, J., Thorogood, N.P., Cheung, A. et al. 2013)

Problem/Issue Pressure ulcer incidence, severity, timing and recurrence were unknown Practice review demonstrated that ‘general’ skin care was provided, but no ‘rigorous and standardized process’ Determine whether or not implementation of a Pressure Ulcer Prevention Initiative (PUPI) changed the assessment and treatment of patients and improved patient outcomes. SDTI* Stage 1 Stage 2 Stage 3 Stage 4 Unstageable

Intervention 1 - Identify All new traumatic spinal cord injured patients 2 - Assess OT Skin Care Chart Template Braden Risk for Pressure Ulcer Assessment 3 - Intervene Prescribe and provide a therapeutic support surface Alert other team members 4 - Follow-Up Monitor patients until discharge Direct therapeutic support surface upgrades and downgrades 5 - Document OT Skin Care Chart Template Photos if/as necessary

Measurement Success of PUPI implementation was evaluated by: – Examining the percentage of patients with completed: i) occupational therapist skin care assessments ii) prescriptions for therapeutic support surfaces (ie. mattress) Effect on patient outcomes was evaluated by: – Examining changes in: i) pressure ulcer incidence, severity, timing and recurrence in acute care ii) pressure ulcer prevalence and life satisfaction in the community Tests used: Wilcoxon-T-test, Fisher’s exact test, Chi-square test, Mann-Whitney test, p-value <0.05

Results Effect of PUPI on OT Practice Change: Sample Size: 70 in cohort 1, 73 in cohort 2 Pressure ulcer screening increased significantly – 31% to 60% Completed Braden assessment increased significantly – 13% to 55% Screenings with pressure ulcer severity data remained low – 50% and 46% (no significant difference) TSS upgrades doubled from 23% to 45% (not significantly different) TSS upgrades accompanied by an OT skin care assessment and Braden assessment increased significantly – 13% to 48% *** * Percent Completed

Results Effect of PUPI on Patient Outcome: PU incidence - significantly increased from 14% to 33% PU recurrence - increased from 10% to 38% (but was not significantly different) PU timing - ulcers occurring after admission increased significantly from 50% to 88% PU severity – Stage 1: 25% to 18%, Stage 2: 12% to 16% (no significant difference was found; no Stage 3 or 4 pressure ulcers observed) Percent Completed * *

Conclusions PUPI was successful in changing clinical practice in pressure ulcer prevention but no statistically significant improvement in pressure ulcer - related patient outcomes was demonstrated. No effect of the PUPI was seen on immediate or long-term patient outcomes during the study period.

Challenges Implementation: Implementation alongside day-to-day operations OT’s lack of pressure ulcer knowledge and comfort to stage Data collection: Lack of OT follow-up documentation Lack of data required for study analysis

Lessons Learned Implementation: Use of an implementation model (National Implementation Research Network) Providing formal training and testing of the OT’s pressure ulcer knowledge Data collection: Trialing the skin care charting template to a greater degree Performing documentation audits after implementation

Next Steps 1.Maintain PUPI and refine 2.Obtain focus group feedback 3.Reintroduce using a formal implementation model 4.Increase OT knowledge and confidence 5.Simplify OT documentation tool 6.Maintain the Braden Scale for Predicting Pressure Ulcer Risk © (Braden, B.J., Makleburst, J.) 7.Introduce the Therapeutic Surface Selection Tool © (Norton, L., Coutts, P., Sibbald, R.G.) 8.Explore regular access to high-specification therapeutic support surfaces 9.Present findings to the VGH Quality Council 10.Determine if the PUPI should become a required organizational practise

Thank you! John Cobb, BScOT, Occupational Therapist II VGH Acute Spine Program, Centennial Pavilion Vancouver General Hospital, 855 W. 12 th Ave. Vancouver, BC, V5Z 1M9 (604) This project has been published: Journal of Wound Care, May 2014 Volume 23, Number 5 Pages