Microclimate evaluation of strap-based wheelchair seating systems for persons with spinal cord injury: A pilot study.

STUDY PURPOSE: The purpose of this pilot study was to assess microclimate characteristics of two versions of a strap-based wheelchair seating system (perforated and solid straps) and to conduct preliminary microclimate comparisons of subjects' current wheelchair seating systems. MATERIALS AND METHODS: In this pilot study, the microclimate properties of two variations (solid and perforated) of a strap-based seating system were compared with two commonly used seating systems. Six subjects sat on three different seating systems each for 100-min test periods, while temperature and relative humidity were measured with a single sensor adjacent to the skin-seat interface. Additionally, thermal images of the seat interface were collected before and after each test period. RESULTS: The thermal images revealed that the maximum surface temperature of the solid-strap-based seating system was significantly lower than the other seating systems, -1.21 °C. (95% CI -2.11 to -0.30, p = 0.02), immediately following transfer out of the seat. Five minutes after transferring out of the seat, the perforated-strap seat was significantly cooler than the other seats -0.94 °C. (95% CI -1.59 to -0.30), p = 0.01, as was the solid-strap-based seat, -1.66 °C. (95% CI -2.69 to -0.63), p = 0.01. There were no significant differences in interface temperature or relative humidity measured with the single sensor near the skin-seat interface. CONCLUSION: This pilot study offers preliminary evidence regarding the microclimate of the strap-based seating systems compared with other common seating systems. Clinically, the strap-based seating system may offer another option for those who struggle with microclimate management.

Recruitment strategies and challenges in a large intervention trial: Systolic Blood Pressure Intervention Trial.

BACKGROUND: The Systolic Blood Pressure Intervention Trial is a multicenter, randomized clinical trial of 9361 participants with hypertension who are ≥50 years old. The trial is designed to evaluate the effect of intensive systolic blood pressure control (systolic blood pressure goal <120 mm Hg) compared to standard control (systolic blood pressure goal <140 mm Hg) on cardiovascular events using commonly prescribed antihypertensive medications and lifestyle modification. OBJECTIVE: To describe the recruitment strategies and lessons learned during recruitment of the Systolic Blood Pressure Intervention Trial cohort and five targeted participant subgroups: pre-existing cardiovascular disease, pre-existing chronic kidney disease, age ≥75 years, women, and minorities. METHODS: In collaboration with the National Institutes of Health Project Office and Systolic Blood Pressure Intervention Trial Coordinating Center, five Clinical Center Networks oversaw clinical site selection, recruitment, and trial activities. Recruitment began on 8 November 2010 and ended on 15 March 2013 (about 28 months). Various recruitment strategies were used, including mass mailing, brochures, referrals from healthcare providers or friends, posters, newspaper ads, radio ads, and electronic medical record searches. RESULTS: Recruitment was scheduled to last 24 months to enroll a target of 9250 participants; in just over 28 months, the trial enrolled 9361 participants. The trial screened 14,692 volunteers, with 33% of initial screens originating from the use of mass mailing lists. Screening results show that participants also responded to recruitment efforts through referral by Systolic Blood Pressure Intervention Trial staff, healthcare providers, or friends (45%); brochures or posters placed in clinic waiting areas (15%); and television, radio, newspaper, Internet ads, or toll-free numbers (8%). The overall recruitment yield (number randomized/number screened) was 64% (9361 randomized/14,692 screened), 77% for those with cardiovascular disease, 79% for those with chronic kidney disease, 70% for those aged ≥75 years, 55% for women, and 61% for minorities. As recruitment was observed to lag behind expectations, additional clinics were included and inclusion criteria were broadened, keeping event rates and trial power in mind. As overall recruitment improved, a greater focus on subgroup recruitment was implemented. CONCLUSION: Systolic Blood Pressure Intervention Trial met its overall projected recruitment goal using diverse, locally adapted enrollment strategies to specifically target persons with cardiovascular disease, chronic kidney disease, ≥75 years old, women, and minority subgroups. The trial exceeded its recruitment goal for minorities but found it a challenge to meet the competing demands of the targeted goals for recruiting into the remaining four subgroups. Important lessons include the imperative to monitor the recruitment process carefully, decide early to add new clinics or modify inclusion and exclusion criteria if recruitment lags, and consider limiting enrollment to subgroups only. We found benefit in using multiple recruitment sources simultaneously; mass mailing produced the largest number of participants, but referrals resulted in the greater randomization yield.

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

OBJECTIVE: The objective was to implement the evidence-based Spinal Cord Impairment Pressure Ulcer Monitoring Tool (SCI-PUMT) in 23 Spinal Cord Injury/Disorders Centers (SCI/D) in the Veterans Health Administration (VHA). SETTING: A collaborative was held in Minnesota that was attended by key personnel from SCI/D Centers in the VHA. METHODS: This initiative was based on a 3-year longitudinal study that established the validity and reliability of a novel pressure ulcer monitoring tool for persons with spinal cord impairment. A multifaceted evidence-based strategy was used to implement the Institute for Healthcare Improvement's framework of Plan-Do-Study-Act. The plan was executed by clinical champions who implemented the tool in their respective SCI/D Centers following a conference that used both didactic and practicum approaches. OUTCOMES: A 15-item toolkit was developed to educate clinicians and patients regarding use of the SCI-PUMT. Toolkit elements were frequently accessed over the VA intranet (n = 3254). The 1.5-day national conference rolled out the new tool to the SCI/D Centers. Pre/post SCI-PUMT knowledge of the SCI-PUMT improved by 78% during the conference. Following the conference, periodic conference calls cemented the implementation efforts of the SCI-PUMT clinical champions and barriers were mitigated.

Supine arm cycling during the post-flap recovery period for persons with spinal cord injuries: The multi-purpose arm cycle ergometer (M-PACE) safety and pilot testing.

OBJECTIVE: To describe how using a supine arm cycle ergometer can safely reduce deconditioning experienced by patients with spinal cord injury or disorder (SCI/D) during their four to six weeks of complete bed rest after surgery to close a stage 4 pressure injury. DESIGN: This pilot project used a newly designed arm cycle ergometer (known as the M-PACE) that extends over the bed, allowing a patient to lie completely supine while exercising. SETTING: The M-PACE was designed and built at the Minneapolis Veterans Affairs Health Care System (MVAHCS) and pilot tested at the MVAHCS SCI/D Center. PARTICIPANTS: Patients with SCI/D, recovering from flap surgery and deemed appropriate to use the arm cycle ergometer were enrolled in the pilot study (n = 47). OUTCOME MEASURES: A pre-post six-minute arm test (6MAT), a proxy for conditioning, was conducted on a subset (n = 15) of participants before and after the supine cycling exercise training program. Participants' rating of perceived exertion (RPE) scores were collected at cessation of each 6MAT. Participants gave feedback on their perception of using the M-PACE. RESULTS/CONCLUSIONS: The 6MAT RPE was significantly reduced after training with the M-PACE while on bed rest (P = 0.003). Also, significantly more rotations were performed after completing the training program (P = 0.02). Further, study participants who accessed the M-PACE found using it helped offset the tedium of laying supine during flap surgery recovery. The differences in the 6MAT pre- to post measures indicate the M-PACE should be further studied for offsetting the normal deconditioning that occurs with extended bedrest.

Veteran Perspectives on Phantom Limb Pain and Non-Drug Interventions.

Background: Phantom limb pain (PLP) commonly occurs post-amputation and can negatively affect the daily functioning of persons with amputation. Best practices for medication and non-drug management remain unclear. Objective: To better understand the PLP experience and patients' familiarity with treatments, phone interviews were conducted at the Minneapolis Veterans Affairs Regional Amputation Center in Veterans with amputations. Methods: Fifty Veteran participants (average age 66, 96% male) with lower limb amputation were recruited for phone-based data collection of patient-reported outcomes (ie, demographics using the Trinity Amputation and Prosthesis Experience Scales-Revised (TAPES-R) and pain experience using the Phantom Phenomena Questionnaire) to characterize the population and a semi-structured interview. Notes taken during interviews were analyzed using the Krueger and Casey constant comparison analysis method. Results: Participants had an average of 15 years since amputation, and 80% reported PLP as identified with the Phantom Phenomena Questionnaire. Investigators identified several core themes from the qualitative interviews including 1) high variability in the experience of PLP, 2) acceptance and resilience, and 3) PLP treatment perceptions. The majority of participants reported trying common non-drug treatments with none endorsed consistently as highly effective. Conclusion: More research is needed to inform identification and implementation of clinical best practices for non-drug interventions for PLP and understand the factors that influence engagement in non-drug interventions. The participants in this study were largely male, so these results may not be generalizable to females.

Clinician perspectives on postamputation pain assessment and rehabilitation interventions.

OBJECTIVE: The purpose of this study was to explore self-reported Veterans Affairs (VA) amputation clinician perspectives and clinical practices regarding the measurement and treatment for amputation-related pain. STUDY DESIGN: Cross-sectional survey with 73 VA rehabilitation clinicians within the VA Health Care System. RESULTS: The most frequent clinical backgrounds of respondents included physical therapists (36%), prosthetists (32%), and physical medicine and rehabilitation specialist (21%). Forty-one clinicians (56%) reported using pain outcome measures with a preference for average pain intensity numeric rating scale (generic) (97%), average phantom limb pain intensity numeric rating scale (80%), or Patient-Reported Outcomes Measurement Information System pain interference (12%) measures. Clinicians' most frequently recommended interventions were compression garments, desensitization, and physical therapy. Clinicians identified mindset, cognition, and motivation as factors that facilitate a patient's response to treatments. Conversely, clinicians identified poor adherence, lack of belief in interventions, and preference for traditional pain interventions (e.g., medications) as common barriers to improvement. We asked about the frequently used treatment of graded motor imagery. Although graded motor imagery was originally developed with 3 phases (limb laterality, explicit motor imagery, mirror therapy), clinicians reported primarily using explicit motor imagery and mirror therapy. RESULTS: Most clinicians who use standardized pain measures prefer intensity ratings. Clinicians select pain interventions based on the patient's presentation. This work contributes to the understanding of factors influencing clinicians' treatment selection for nondrug interventions. Future work that includes qualitative components could further discern implementation barriers to amputation pain rehabilitation interventions for greater consistency in practice.

Impact of Antihypertensive Drug Class on Outcomes in SPRINT.

BACKGROUND: The primary objective of this analysis is to assess if greater exposure to any major antihypertensive drug class was associated with reduced primary composite outcome events in SPRINT (Systolic Blood Pressure Intervention Trial). METHODS: This is a secondary analysis of the SPRINT trial evaluating whether longitudinal, time varying exposure to any major antihypertensive drug class had any impact on primary outcome events, after adjusting for effects of randomization arm, time varying achieved systolic blood pressure, other drug class exposure, and baseline characteristics. RESULTS: Nine thousand two hundred fifty-two participants were included. After adjustments, exposure of one year or greater to thiazide-type diuretics or renin-angiotensin system blockers was associated with significantly fewer primary events than exposure of less than one year (hazard ratio, 0.78 [95% CI, 0.64-0.94]). There was no significant difference with longer versus shorter exposure to calcium channel blockers. Greater exposure to beta-blockers was associated with an increase in primary events compared with exposure of <1 year (hazard ratio, 1.35 [95% CI, 1.13-1.62]). Furthermore, thiazide-type diuretics were associated with a reduction in heart failure events and renin-angiotensin system blockers with reduced myocardial infarction. Both were associated with less cardiovascular deaths. CONCLUSIONS: The SPRINT trial demonstrated a lower target blood pressure led to reductions in adverse cardiovascular events. This analysis suggests greater exposure to thiazide-type diuretics and renin-angiotensin system blockers also contributed to reduced adverse cardiovascular events. Greater exposure to beta-blockers was associated with increased cardiovascular events.

Visualization of user interactions with a pressure mapping mobile application for wheelchair users at risk for pressure injuries.

Pressure injuries for individuals with spinal cord injuries (SCI) are correlated with mortality and are a leading cause for rehospitalizations. The Assisted Weight Shift (AW-Shift©) is a mobile pressure mapping application designed to provide users with a live map view and reminders to perform weight shifts. Novel visualization techniques were used to understand daily distributions of user interaction wit h AW-Shift©. The date and time of system interactions were recorded for six participants with SCI over 7 days (five males/one female, five manual users/one power user, 55.3 ± 17.3 years old, 10.6 ± 6.5 years since injury). Circular frequency plots were created to visualize the time and frequency participants brought the app to the foreground of their phone and received alerts and reminders to complete weight shifts. While some participants used the system regularly throughout the day, others primarily used it before 8am; highlighting the system's importance for regular spot checks and morning wheelchair setup. Participant adherence to weight shift reminders was low suggesting the live pressure map may be more useful. Circular frequency plots can be used by clinicians to more easily review large amounts of patient data. Future work will investigate raw pressure mat data and create a closed-loop weight shift detection algorithm.

Impact of Intensive Blood Pressure Therapy on Concern about Falling: Longitudinal Results from the Systolic Blood Pressure Intervention Trial (SPRINT).

OBJECTIVES: Concern about falling is common among older hypertension patients and could impact decisions to intensify blood pressure therapy. Our aim was to determine whether intensive therapy targeting a systolic blood pressure (SBP) of 120 mm Hg is associated with greater changes in concern about falling when compared with standard therapy targeting an SBP of 140 mm Hg. DESIGN: Subsample analysis of participants randomized to either intensive or standard therapy in the Systolic Blood Pressure Intervention Trial (SPRINT). SETTING: Approximately 100 outpatient sites. PARTICIPANTS: A total of 2313 enrollees in SPRINT; participants were all age 50 or older (mean = 69 y) and diagnosed with hypertension. MEASUREMENTS: Concern about falling was described by the shortened version of the Falls Efficacy Scale International as measured at baseline, 6 months, 1 year, and annually thereafter. RESULTS: Concern about falling showed a small but significant increase over time among all hypertension patients. No differences were noted, however, among those randomized to intensive vs standard therapy (P = .95). Among participants younger than 75 years, no increase in concern about falling over time was noted, but among participants aged 75 years and older, the mean falls self-efficacy score increased by .3 points per year (P < .0001). No differences were observed between the intensive and standard treatment groups when stratified by age (P = .55). CONCLUSION: Intensive blood pressure therapy is not associated with increased concern about falling among older hypertension patients healthy enough to participate in SPRINT. J Am Geriatr Soc 68:614-618, 2020.

Automated clinical documentation: does it allow nurses more time for patient care?

When a west central Florida hospital prepared to move to an electronic health record with a clinical documentation system, the nursing staff and administration were concerned about the effects that the technology change would have on nursing work behavior. Specifically, would the move toward automation increase the time at the bedside, decrease the time nurses spent on documentation, and decrease time spent on administrative tasks? A time-in-motion study was conducted to specifically measure six categories of nurse work behavior on a progressive cardiac unit. The nurses were observed by data collectors prior to the implementation of the electronic health record and then again a year after the implementation. Results showed a significant increase (P=.000) in the amount of time nurses devoted to direct care. Furthermore, there was a significant increase (P=.000) in the time nurses spent documenting after the implementation of the electronic system. Much of the increased time available for direct care and documentation came from a 12% decrease in the time nurses spent on administrative tasks after implementing the automated documentation system. For this progressive cardiac unit, the move to automated documentation seems to be a positive step in developing a fully interactive computerized system.

Connected care: reducing errors through automated vital signs data upload.

Vital signs are a fundamental component of patient care. Omitted or inaccurately transcribed vital sign data could result in inappropriate, delayed, or missed treatment. A previous baseline study determined that error rates for vital signs captured on plain paper then entered into a paper chart or EMR were 10% and 4.4%, respectively. This study evaluated the impact of automated vital signs captured using a PDA with bar-code technology for patient identification. The PDA enabled the wireless capture and transmission of data directly from the vital sign monitor into the EMR. Researchers reviewed 1514 sets of vital signs collected electronically for accuracy and compared the error rate with data from the previous paper and EMR systems. Automated upload of vital signs directly into an EMR reduced the documentation error rate to less than 1%. This represented a significant reduction in vital sign documentation errors with the use of mobile technology when compared with traditional charting methods (P < .001). The automated vital sign data upload system helped promote a culture of patient safety by greatly reducing documentation error rates. Additional safety benefits may include improved timeliness to vital sign data and clinical work-flow processes.

Development of a comprehensive mobile assessment of pressure (CMAP) system for pressure injury prevention for veterans with spinal cord injury.

Objective: This paper reports the iterative redesign, feasibility and usability of the Comprehensive Mobile Assessment of Pressure (CMAP) system's mobile app used by Veterans with SCI.Design: This three-year, multi-staged study used a mixed-methods approach.Setting: Minneapolis VA Health Care System, Minneapolis, Minnesota.Participants: Veterans with spinal cord injury (N = 18).Interventions: Veterans with spinal cord injury engaged in iterative focus groups and personal interviews, sharing their needs and desires for the CMAP app redesign. App developers used these data for the redesign. The redesigned CMAP app was tested for six-weeks in users' homes.Outcome Measures: Quantitative (surveys) and qualitative (interviews) methods measured feasibility for self-management of seating pressure. Qualitative data were audio recorded, transcribed, anonymized, and coded. Survey data were analyzed using summary statistics.Results: After the CMAP system's redesign, the in-home use interview found: (1) any tool that can assist in prevention and monitoring of skin ulcers is important; (2) the desired key features are present in the app; (3) the main barrier to CMAP use was inconsistent functionality; (4) when functioning as expected, the live pressure map was the central feature, with reminders to weight shift also of high importance. The survey found: power wheelchair users tended to score closer than manual wheelchair users to the positive response end ranges on two separate surveys.Conclusions: Overall both the power and manual wheelchair users reported that they wanted to use the system, felt confident using the system, and that the functions of the system were well integrated.

Enhancing patient safety through electronic medical record documentation of vital signs.

As technology becomes more sophisticated in healthcare, there is increasing need to measure its impact on key quality indicators, such as error reduction, patient safety, and cost-benefit ratios. When a product is designed to decrease medical errors, the baseline error rate must be determined before implementation to accurately measure the impact. Given the opportunity to adopt a technology that would eliminate the need to manually document vital signs, a large Florida hospital decided to measure the current process and error rate of vital signs documentation. University Community Hospital in Tampa, Fla., designed a two-phase study to evaluate this process. Phase I of the study evaluated errors in the electronic medical record and traditional manual documentation. The results demonstrate that use of an EMR can reduce vital sign documentation errors by more than half compared with traditional manual documentation in paper charts. Researchers found the error rate for electronic vital signs documentation to be less than 5 percent, compared with the paper chart error rate of 10 percent.

The effect of therapeutic back massage in hypertensive persons: a preliminary study.

Hypertension, one of the most pervasive disease processes in the United States, can lead to target organ damage. Although there is no one cause of primary hypertension, the theory of an unchecked long-term stress response continues to be a valid argument. Conversely, eliciting the relaxation response may alter the course of the unchecked stress response. Massage therapists have suggested that their therapy elicits the relaxation response and therefore can decrease blood pressure (BP) and hypertension. This preliminary study tested the effects of a regularly applied back massage on the BP of patients with clinically diagnosed hypertension. In this experimental, pretest-posttest study, a 10-min back massage was given to the experimental group (n = 8), three times a week for 10 sessions. The control group (n = 6) relaxed in the same environment for 10 min, three times a week for 10 sessions. Analysis of variance determined systolic BP changed significantly, F(1, 12) = 17.90, p = .001, between groups over time as did the diastolic BP, F(1, 12) = 8.34, p = .014. Effect size was 2.25 for systolic pressure and 1.56 for diastolic pressure (alpha of .05 and power at .80). This preliminary study suggests that regular massage may lower BP in hypertensive persons.

Spinal Cord Injury survey to determine pressure ulcer vulnerability in the outpatient population.

Pressure ulcers are one of the most common causes of morbidity, mortality and rehospitalization for those living with Spinal Cord Injury (SCI). Literature examining risk and recurrence of pressure ulcers (PrUs) has primarily focused on the nursing home elderly who do not have SCI. More than 200 factors that increase PrU risk have been identified. Yet unlike the elderly who incur pressure ulcers in nursing homes or when hospitalized, most persons with SCI develop their pressure ulcers as outpatients, while residing in the community. The Veterans Health Administration (VHA) provides medical care for a large number of persons with chronic SCI. Included in the VHA SCI model of chronic disease management is the provision of an annual Comprehensive Preventive Health Evaluation, a tool that has potential to identify individuals at high risk for PrUs. This research was motivated by the clinical observation that some individuals appear to be protected from developing PrUs despite apparently 'risky' behaviors while others develop PrUs despite vigilant use of the currently known preventative measures. There is limited literature regarding protective factors and specific risk factors that reduce PrU occurrence in the community dwelling person with chronic SCI have not been delineated. The purpose of this study is to examine the preliminary hypothesis that there are biological and/or psychosocial factors that increase or reduce vulnerability to PrUs among persons with SCI. A limited number of refined hypotheses will be generated for testing in a prospective fashion. A retrospective cross-sectional survey of 119 randomly selected Veterans with SCI undergoing the Comprehensive Health Prevention Evaluation during the year 2009 was performed. Factors that differed between patients with 0, 1 or ⩾2 PrUs were identified and stratified, with an emphasis on modifiable risk factors. Three hypotheses generated from this study warrant further investigation: (1) cumulative smoking history increases the risk of PrUs independent of co-morbidities, (2) being moderately overweight, BMI>25, with or without spasticity, is a modifiable factor that may be protective and (3) increased use of a caregiver does not reduce PrU risk. Prospective studies that focus on these hypotheses will lead to evidence-based risk assessment tools and customized interventions to prevent PrUs in persons with SCI in the outpatient setting.