Providers' Perceptions of Spinal Cord Injury Pressure Ulcer Guidelines

Abstract

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 ¼ 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.

Developing a Model of Care for Healing Pressure Ulcers With Electrical Stimulation Therapy for Persons With Spinal Cord Injury

“…These have been confirmed as necessary factors by other SCI-related implementation studies. 48,49 By classifying these items within the implementation drivers outlined by the NIRN model, we were able to visualize that changes are required not only at the individual and patient levels, but also at the organizational and system levels in order to successfully implement and sustain a practice change. 41,42 This is noteworthy, as these implementation drivers are part of a structured (ideally facilitated) process to inform implementation action planning as part of the NIRN framework.…”

A Multisite Quality Improvement Project to Standardize the Assessment of Pressure Ulcer Healing in Veterans with Spinal Cord Injuries/Disorders

“…6,7 Providers of patients with SCI/D have been skeptical of CPG based on expert opinion and are more likely to implement CPG recommendations based on research evidence specific to the SCI/D population. 8 …”

Validity and reliability of a pressure ulcer monitoring tool for persons with spinal cord impairment

“…4 Previously, our study team conducted focus groups with experienced SCI care providers regarding acceptance and clinical application of the CSCM CPG recommendations; several barriers to implementing these CPG recommendations were identified. 5 Specifically, SCI providers were not convinced that existing PrU monitoring tools were generalizable to persons with SCI. 5 Persons with SCI are typically younger than most populations with PrU and are characterized by paralysis, lack of sensation, spasms, autonomic dysfunction, collagen degradation, and other factors below the level of injury that result in impaired healing compared with persons without SCI.…”

“…5 Specifically, SCI providers were not convinced that existing PrU monitoring tools were generalizable to persons with SCI. 5 Persons with SCI are typically younger than most populations with PrU and are characterized by paralysis, lack of sensation, spasms, autonomic dysfunction, collagen degradation, and other factors below the level of injury that result in impaired healing compared with persons without SCI. 1 Specifically, the following limitations were identified in existing tools to monitor PrU healing: (1) lack of established validity, reliability, and sensitivity for persons with SCI; (2) designed predominantly for use with older adult populations; (3) applicable to acute rather than chronic wounds; (4) long length of assessment limiting clinical utility; and (5) omission of important clinical characteristics unique to PrU in persons with SCI.…”