Spinal Cord Injury Provider Knowledge and Attitudes Toward Bacteriuria Management and Antibiotic Stewardship.

INTRODUCTION: Bacteriuria, either asymptomatic or urinary tract infection, is common in persons with spinal cord injury or disorder (SCI/D). In the Veterans Health Administration (VHA), conflicting clinical practice guidelines make appropriate bacteriuria management and antibiotic stewardship challenging. OBJECTIVE: To explore SCI/D provider knowledge, attitudes, and teamwork around bacteriuria management during the VHA SCI/D annual examination. DESIGN: Mixed methods. SETTING: VHA SCI/D centers. PARTICIPANTS: SCI/D staff providers and physical medicine and rehabilitation resident physicians. MAIN OUTCOME MEASUREMENTS: Knowledge, safety, and teamwork scores on bacteriuria management using a validated questionnaire. Themes on barriers and facilitators to bacteriuria management during the SCI/D annual exam, and attitudes toward antibiotic stewardship in general. RESULTS: We received 84 responses from 344 distributed surveys, with a response rate of 24%. Thirty percent of all participants endorsed incorrect triggers for obtaining a urine culture (change in urine color, cloudiness, or odor). The type of organism identified on culture drove unnecessary antibiotic use; 57% would treat asymptomatic bacteriuria if caused by extended spectrum beta-lactamase Escherichia coli. There were no significant differences between the median (interquartile range [IQR]) knowledge score of the staff providers (70.6 [58.8-82.4]) and the resident physicians (64.7 [58.8-82.4]), but the teamwork climate scores (P = .02) and safety climate scores (P < .01) were higher among staff providers than among resident physicians. Interview analysis identified how the limited recall of content among SCI/D providers of the guidelines for bacteriuria was a potential barrier to their use but attitudes toward guidelines and antibiotic stewardship initiatives were positive. CONCLUSION: All participants objectively demonstrated actionable gaps in bacteriuria management and expressed uncertainty in their knowledge during qualitative interviews. Through addressing these gaps, we can develop effective antibiotic stewardship programs for the VHA SCI/D system of care.

Routine Urine Testing at the Spinal Cord Injury Annual Evaluation Leads to Unnecessary Antibiotic Use: A Pilot Study and Future Directions.

OBJECTIVES: To measure the prevalence of asymptomatic bacteriuria (ASB) in persons with spinal cord injury (SCI) at the time of their annual examination and to examine the effect on urine testing during the annual examination on subsequent antibiotic use. DESIGN: Retrospective cohort study. SETTING: A major SCI center. PARTICIPANTS: Veterans (N=393) with SCI seen for an outpatient annual evaluation in 2012 or 2013. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Antibiotic use for bacteriuria within 7 days of the annual evaluation encounter. RESULTS: There were 327 clinic visits that met inclusion criteria; of these 327 veterans, 249 had a urine culture performed. A total of 171 urine cultures (69%) were positive for bacteria, of which 22 (13%) represented urinary tract infection (UTI) cases and 149 (87%) were ASB cases. More than a third of the ASB cases (n=53 [36%]) were treated with antibiotics. None of the 78 visits with negative urine cultures received antibiotics to treat the UTI; thus, a positive urine culture alone was associated with antibiotic use (P<.01). Factors predicting antibiotic use were higher age, nitrite presence on urinalysis, and urease-producing organism on culture media. When comparing bladder management strategies, indwelling catheterization was found to be associated with higher levels of pyuria and hematuria than did spontaneous voiding or intermittent catheterization (P<.01). CONCLUSIONS: Two-thirds of the urine cultures of persons with SCI presenting for their annual examination were positive. Most of the positive cultures represented ASB cases, and more than a third of these were treated with antibiotics. A better understanding of the mandate for urine testing at the annual examination and the outcomes of this practice is an important first step in developing antibiotic stewardship for UTI in persons with SCI.

Individual Placement and Support in Spinal Cord Injury: A Longitudinal Observational Study of Employment Outcomes.

OBJECTIVE: To determine the effects of a 24-month program of Individual Placement and Support (IPS) supported employment (SE) on employment outcomes for veterans with spinal cord injury (SCI). DESIGN: Longitudinal, observational multisite study of a single-arm, nonrandomized cohort. SETTING: SCI centers in the Veterans Health Administration (n=7). PARTICIPANTS: Veterans with SCI (N=213) enrolled during an episode of either inpatient hospital care (24.4%) or outpatient care (75.6%). More than half the sample (59.2%) had a history of traumatic brain injury (TBI). INTERVENTION: IPS SE for 24 months. MAIN OUTCOME MEASURE: Competitive employment. RESULTS: Over the 24-month period, 92 of 213 IPS participants obtained competitive jobs for an overall employment rate of 43.2%. For the subsample of participants without TBI enrolled as outpatients (n=69), 36 obtained competitive jobs for an overall employment rate of 52.2%. Overall, employed participants averaged 38.2±29.7 weeks of employment, with an average time to first employment of 348.3±220.0 days. Nearly 25% of first jobs occurred within 4 to 6 months of beginning the program. Similar employment characteristics were observed in the subsample without TBI history enrolled as outpatients. CONCLUSIONS: Almost half of the veterans with SCI participating in the 24-month IPS program as part of their ongoing SCI care achieved competitive employment, consistent with their expressed preferences at the start of the study. Among a subsample of veterans without TBI history enrolled as outpatients, employment rates were >50%. Time to first employment was highly variable, but quite long in many instances. These findings support offering continued IPS services as part of ongoing SCI care to achieve positive employment outcomes.

Effectiveness of supported employment for veterans with spinal cord injuries: results from a randomized multisite study.

OBJECTIVE: To examine whether supported employment (SE) is more effective than treatment as usual (TAU) in returning veterans to competitive employment after spinal cord injury (SCI). DESIGN: Prospective, randomized, controlled, multisite trial of SE versus TAU for vocational issues with 12 months of follow-up data. SETTING: SCI centers in the Veterans Health Administration. PARTICIPANTS: Subjects (N=201) were enrolled and completed baseline interviews. In interventional sites, subjects were randomly assigned to the SE condition (n=81) or the TAU condition (treatment as usual-interventional site [TAU-IS], n=76). In observational sites where the SE program was not available, 44 subjects were enrolled in a nonrandomized TAU condition (treatment as usual-observational site [TAU-OS]). INTERVENTIONS: The intervention consisted of an SE vocational rehabilitation program called the Spinal Cord Injury Vocational Integration Program, which adhered as closely as possible to principles of SE as developed and described in the individual placement and support model of SE for persons with mental illness. MAIN OUTCOME MEASURES: The primary study outcome measurement was competitive employment in the community. RESULTS: Subjects in the SE group were 2.5 times more likely than the TAU-IS group and 11.4 times more likely than the TAU-OS group to obtain competitive employment. CONCLUSIONS: To the best of our knowledge, this is the first and only controlled study of a specific vocational rehabilitation program to report improved employment outcomes for persons with SCI. SE, a well-prescribed method of integrated vocational care, was superior to usual practices in improving employment outcomes for veterans with SCI.

Efficacy of cranial electrotherapy stimulation for neuropathic pain following spinal cord injury: a multi-site randomized controlled trial with a secondary 6-month open-label phase.

BACKGROUND: Chronic pain is a significant problem for many individuals following spinal cord injury (SCI). Unfortunately, SCI-related neuropathic pain has proven to be largely refractory to analgesic medications and other available treatments. Cranial electrotherapy stimulation (CES) has been effective in managing some types of pain. It involves the application of a small amount of current through the head via ear clip electrodes. OBJECTIVE: Explore the effectiveness of CES for neuropathic pain in persons with SCI and chronic pain. STUDY DESIGN: Multi-site, double-blind, sham-controlled study. PARTICIPANTS: Adults with SCI and chronic neuropathic pain at or below the level of injury were randomized to receive active or sham CES. INTERVENTION: Application of active CES or sham CES 1 hour daily for 21 days. Six-month open-label phase to assess 'as-needed' CES use. OUTCOME MEASURES: Change in pre- to post-session pain ratings as well as change in pain intensity, pain interference, pain quality, pain beliefs and coping strategies, general physical and mental health status, depressive symptomatology, perceived stress, and anxiety pre- to post-treatment. RESULTS: The active group reported a significantly greater average decrease in pain during daily treatments than the sham group (Kruskal-Wallis chi-square = 4.70, P < 0.05). During the 21-day trial, there was a significant group × time interaction for only one outcome variable; the active group showed larger pre- to post-treatment decreases in pain interference than the sham group did (F = 8.50, P < 0.01, d = 0.59). CONCLUSIONS: On average, CES appears to have provided a small but statistically significant improvement in pain intensity and pain interference with few troublesome side effects. Individual results varied from no pain relief to a great deal of relief.

Effect of dronabinol on central neuropathic pain after spinal cord injury: a pilot study.

OBJECTIVE: To test the efficacy and safety of a cannabinoid, dronabinol, compared with an active control, diphenhydramine, in relieving neuropathic pain in persons with spinal cord injury. DESIGN: A randomized, controlled, double-blind, crossover pilot study. RESULTS: Seven adults with spinal cord injury and neuropathic pain below the level of injury participated. Two participants withdrew while receiving dronabinol, their first medication. For the remaining five participants, change in pain on a scale of 0-10 from baseline to the end of the maintenance phase did not differ significantly between the two medications (mean change, dronabinol: 0.20 ± 0.837, range = -1.00 to 1.00; diphenhydramine: -1.80 ± 2.490, range = -6.00 to 0; Wilcoxon Z = 1.63, P = 0.102). Similar results were found when the average of the two ratings during the maintenance phase was used (dronabinol: -0.20 ± 0.671, range = -0.50 to 1.00; diphenhydramine: -1.40 ± 1.245, range = -3.50 to -0.50; Wilcoxon Z = 1.60, P = 0.109). The most common side effects were dry mouth, constipation, fatigue, and drowsiness for both medications. CONCLUSIONS: On average, dronabinol was no more effective than diphenhydramine for relieving chronic neuropathic pain below the level of injury.

Preventing recurrent pressure ulcers in veterans with spinal cord injury: impact of a structured education and follow-up intervention.

OBJECTIVE: To test the hypothesis that enhanced education and structured follow-up after pressure ulcer surgery will result in fewer recurrences. DESIGN: Randomized controlled trial. SETTING: Veterans Affairs medical center. PARTICIPANTS: Forty-nine veteran men with spinal cord injury or dysfunction were approached on admission for pressure ulcer surgery. Five never had surgery, 2 refused to participate, and one withdrew. Forty-one were randomized into 3 groups. Three participants' ulcers did not heal, so follow-up could not begin. INTERVENTIONS: Group 1 received individualized pressure ulcer education and monthly structured telephone follow-up (n=20); group 2 received monthly mail or telephone follow-up without educational content (n=11); and group 3 received quarterly mail or telephone follow-up without educational content (n=10). Follow-up continued until recurrence, death, or 24 months. MAIN OUTCOME MEASURE: Time to pressure ulcer recurrence. RESULTS: Group 1 had a longer average time to ulcer recurrence or end of study than groups 2 and 3 (19.6 mo, 10.1 mo, 10.3 mo; P=.002) and had a smaller rate of recurrence (33%, 60%, 90%; P=.007). Survival analysis confirmed these findings (P=.009). CONCLUSIONS: Individualized education and structured monthly contacts may be effective in reducing the frequency of or delaying pressure ulcer recurrence after surgical repair of an ulcer.

Comparison of the effectiveness of amitriptyline and gabapentin on chronic neuropathic pain in persons with spinal cord injury.

OBJECTIVE: To test the hypotheses that both amitriptyline and gabapentin are more effective in relieving neuropathic pain than an active placebo, diphenhydramine. DESIGN: Randomized, controlled, double blind, triple crossover 8-week trial. SETTING: Veterans Affairs medical center. PARTICIPANTS: Community dwelling adults with spinal cord injury (N=38) were recruited by telephone, letters, and flyers. INTERVENTION: Eight-week trial each of amitriptyline, gabapentin, and diphenhydramine. MAIN OUTCOME MEASURES: Pain intensity measured with a 10-cm visual analog scale (VAS) and an 11-point (0-10) numeric rating scale (NRS) and depressive symptomatology measured with the Center for Epidemiologic Studies Depression Scale-Short Form (CESD-SF). RESULTS: Baseline VAS scores for participants with low (< 10) CESD-SF scores was 4.61 and for those with high scores (> or = 10) it was 7.41. At week 8, in participants with high baseline CESD-SF scores, amitriptyline (mean, 4.21) was more effective than diphenhydramine (mean, 6.67; P=.035), and there was a nonsignificant trend suggesting that amitriptyline may be more effective than gabapentin (mean, 6.68; P=.061). Gabapentin was no more effective than diphenhydramine (P=.97). There was no significant difference among the medications for those with lower CESD-SF scores. Results could not be attributed to dropout rates, order or dose of medications, amount of medication taken for breakthrough pain, or side effects. CONCLUSIONS: Amitriptyline is more efficacious in relieving neuropathic pain than diphenhydramine at or below the level of spinal cord injury in people who have considerable depressive symptomatology.

Lessons learned while conducting research on prevention of pressure ulcers in veterans with spinal cord injury.

OBJECTIVE: To describe the challenges of conducting a large randomized controlled trial (RCT) to assess the effectiveness of an intervention to prevent recurrent pressure ulcers among a high-risk population of subjects with spinal cord injury (SCI). DESIGN: Prospective multisite, randomized design comparing outcomes of patients who received individualized education and structured telephone counseling follow-up with those of patients receiving customary care. This study was stopped early because of unanticipated recruitment problems. SETTING: Six Veterans Affairs SCI specialty centers. PARTICIPANTS: Veterans (N=150) treated for stage III or IV pelvic pressure ulcers. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Recurrence (defined as new skin breakdown in the pelvic area) and time to recurrence. The study was stopped early because of slow recruitment, so the focus of this study is lessons learned, not the main planned outcome measures. RESULTS: Subject recruitment did not meet original expectations because almost 50% of those enrolled left the hospital with the study ulcer unhealed (having a healed ulcer was a requirement for participation). No significant differences were observed between groups on rate of or time to recurrence at the time the study was stopped. Among the 6 sites, variability in ulcer management (eg, length of stay, receipt of medical vs surgical treatment, sitting tolerance before discharge) and time to recurrence (median, 4mo) were observed. CONCLUSIONS: RCTs in real-world settings are the most robust method of assessing the effectiveness of prevention strategies. However, in complex, rapidly changing health care organizations, blinding is infeasible, it may be impractical to control for every variable that influences a study's outcome, and any assumptions that usual care is static are probably mistaken. Investigators must be prepared to use innovative approaches to maintain the integrity of the study design, including flexibility in inclusion and exclusion criteria to support accrual, obtaining a better understanding of the important aspects of usual care that may need to be standardized, continuous improvement within the intervention arm, and anticipation and minimization of risks from organizational changes. With attention to these delivery system issues and the usual design features of randomized trials, we believe real-world care settings can serve as important laboratories to test pressure ulcer prevention strategies in this population.

Prevalence and characteristics of chronic pain in veterans with spinal cord injury.

To assess prevalence and characteristics of individual chronic (>6 mo) pain components in the veteran spinal cord injury (SCI) population, we conducted a telephone survey with 348 (66%) of 530 veterans with SCI who received care from one regional Department of Veterans Affairs SCI center during a 3 yr period. The short-form McGill Pain Questionnaire was used to assess qualitative properties of the pain experience. Other questions were used to assess frequency, duration, intensity, exacerbating factors, and effects on daily activities. Of the participants, 75% reported at least one chronic pain component. The majority (83%) of the chronic pain components occurred daily (mean = 27.4 d/mo) and lasted most of the day (mean = 17.4 h/d). Mean pain intensity in the week before the interview averaged 6.7 (on a 0 to 10 scale), while worst pain intensity averaged 8.6. Two-thirds (67%) of the chronic pain components interfered with daily activities. The most commonly selected pain descriptors were "aching," "sharp," "hot-burning," and "tiring-exhausting." More research is needed to identify better ways to prevent, assess, and treat chronic pain in the veteran SCI population.

Comparison of dalteparin and enoxaparin for deep venous thrombosis prophylaxis in patients with spinal cord injury.

OBJECTIVE: To determine differences between dalteparin and enoxaparin in patients with spinal cord injury. DESIGN: This prospective, randomized, open-label study was performed as a multiple hospital trial in a large urban setting. A total of 100 patients with acute (<3 mo) spinal cord injury were recruited. A total of 95 patients met all inclusion criteria. Fifty received enoxaparin, and 45 received dalteparin. Main outcome measures included deep venous thrombosis, bleeding, compliance, Short Form-12 Health Status Survey, satisfaction, and medication/labor costs. Patients were randomized to receive 30 mg of enoxaparin subcutaneously every 12 hr or 5000 IU of dalteparin subcutaneously once daily. Prophylaxis was continued for 3 mo for motor-complete and 2 mo for motor-incomplete patients. RESULTS: Six percent of the patients developed deep venous thrombosis while receiving enoxaparin and 4% while receiving dalteparin (chi2 = 0.44, df = 1, P = 0.51). Four percent developed bleeding while receiving dalteparin and 2% while receiving enoxaparin (chi2 = 0.13, df = 1, P = 0.72). No differences were noted in compliance, health status, or most of the satisfaction measures. It was, however, noted that after being discharged home, the patients receiving enoxaparin rated the shots significantly more inconvenient (two injections per day) compared with taking three pills per day, than those receiving dalteparin (one injection per day, P < 0.05). The cost of the medication was 1101 US dollars/mo for enoxaparin (two injections per day) and 750 US dollars/mo for dalteparin (one injection per day). CONCLUSION: Similar compliance, health status, deep venous thrombosis, and bleeding rates were found between dalteparin and enoxaparin.

A structured educational model to improve pressure ulcer prevention knowledge in veterans with spinal cord dysfunction.

OBJECTIVE: This paper describes an educational model for increasing and retaining the knowledge of pressure ulcer prevention and management in veterans with spinal cord injury (SCI) or multiple sclerosis (MS) who have had surgical repair of a pressure ulcer. It also describes the correlates of pressure ulcer knowledge at admission and discharge. METHODS: Before pressure ulcer surgery, 41 male veterans with SCI or MS were randomized to either an intervention group or a control group. A pressure ulcer prevention knowledge test was administered before surgery and at discharge from the hospital, as well as at 3, 6, 12, and 24 months after discharge for the intervention group and at the end of participation for the control group. Other measures obtained at admission included health locus of control and health beliefs. Near the end of their hospital stay, participants of the intervention group received 4 hours of structured, individualized education on the prevention of pressure ulcers while participants of the control group received standard education. RESULTS: Results indicated that participants in the intervention group gained more knowledge during hospitalization than did those in the control group. Lower admission knowledge scores were related to the "chance" dimension of locus of control, nonbelief that an ulcer would interfere "a lot" in one's life, and nonbelief that daily skin checks make "a lot" of difference in whether one gets an ulcer. Lower discharge knowledge scores were related to older age, older age at onset, a greater number of previous pressure ulcer surgeries, and nonbelief that daily skin checks make "a lot" of difference in whether one gets an ulcer. Both groups retained most of their discharge knowledge up to 24 months postdischarge or to discontinuation because of recurrence. CONCLUSIONS: Enhanced, individualized education about pressure ulcer prevention and management was effective in improving pressure ulcer knowledge during hospitalization for surgical repair of a pressure ulcer. The effect of the intervention on recurrence of pressure ulcers will be addressed in future reports.