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

Abstract

Objectives: To implement pressure ulcer (PU) prevention best practices in spinal cord injury (SCI) rehabilitation using implementation science frameworks. Design: Quality improvement. Setting: SCI Rehabilitation Center. Participants: Inpatients admitted January 2012 to July 2013. Interventions: Implementation 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 Measures: Implementation processes (e.g. staff training) and BPI outcomes (completion rates). Results: Following 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). Conclusion: Implementation 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.

Development of Tissue Integrity indicators to advance the quality of spinal cord injury rehabilitation: SCI-High Project

“…43 Provision of prevention education has also been shown to reduce PI recurrence. 21 Other drivers 21,38 of tissue integrity such as PI risk assessment have previously been implemented through other initiatives 26 and are often required to be monitored organizationally. 20 We acknowledge that daily skin checks are a beneficial and necessary first step, but are not to sufficient to guarantee the absence of PIs, and that several other practices contribute to maintenance of tissue integrity in individuals with SCI/D.…”

“…[19][20][21][22] Priority areas include: prevention and effective management of PIs through best practice guidelines, 23 care pathways, and patient and caregiver resources. 4,24,25 PI risk factors after SCI/D include: increasing age, male, increasing time post-injury, motor complete injury, severity of muscle atrophy, presence of urinary or fecal incontinence, renal impairment, anemia, underweight, increased tissue temperature, 24 difficulties with level transfers 26 or deep tissue injury on ultrasound. 27,28 With greater focus on patient safety in healthcare settings, organizations like the Agency for Healthcare Research and Quality and the Institute for Healthcare Improvement have identified the need for quality indicators related to PI to measure the effectiveness of quality improvement interventions.…”

Intra-hospital complications in acute traumatic spinal cord injury

“…Effectively repositioning patients at every 2 hours would require more manpower in a public health system stricken by chronic budget issues. Use of a prediction score such as the SCI Pressure Ulcer Scale (SCIPUS) could be beneficial for identifying patients with higher risk of PUs 17,18 and could result in better resource allocation. Pneumonia rates in our population were similar to other studies.…”

Leveraging Electronic Health Care Record Information to Measure Pressure Ulcer Risk in Veterans With Spinal Cord Injury: A Longitudinal Study Protocol

“…Reliability and sensitivity have not been fully established for existing tools in persons with SCI [ 7 ] despite the unique characteristics of this population (eg, lack of sensation and muscle wasting) [ 3 ]. Salzberg and colleagues devised a risk assessment scale specific to the SCI population; although used in a few SCI/D Centers [ 8 ], the psychometrics of this tool are limited [ 9 , 10 ].…”