Functional electrical stimulation cycling exercise after spinal cord injury: a systematic review of health and fitness-related outcomes.

OBJECTIVES: The objective of this review was to summarize and appraise evidence on functional electrical stimulation (FES) cycling exercise after spinal cord injury (SCI), in order to inform the development of evidence-based clinical practice guidelines. METHODS: PubMed, the Cochrane Central Register of Controlled Trials, EMBASE, SPORTDiscus, and CINAHL were searched up to April 2021 to identify FES cycling exercise intervention studies including adults with SCI. In order to capture the widest array of evidence available, any outcome measure employed in such studies was considered eligible. Two independent reviewers conducted study eligibility screening, data extraction, and quality appraisal using Cochranes' Risk of Bias or Downs and Black tools. Each study was designated as a Level 1, 2, 3 or 4 study, dependent on study design and quality appraisal scores. The certainty of the evidence for each outcome was assessed using GRADE ratings ('High', 'Moderate', 'Low', or 'Very low'). RESULTS: Ninety-two studies met the eligibility criteria, comprising 999 adults with SCI representing all age, sex, time since injury, lesion level and lesion completeness strata. For muscle health (e.g., muscle mass, fiber type composition), significant improvements were found in 3 out of 4 Level 1-2 studies, and 27 out of 32 Level 3-4 studies (GRADE rating: 'High'). Although lacking Level 1-2 studies, significant improvements were also found in nearly all of 35 Level 3-4 studies on power output and aerobic fitness (e.g., peak power and oxygen uptake during an FES cycling test) (GRADE ratings: 'Low'). CONCLUSION: Current evidence indicates that FES cycling exercise improves lower-body muscle health of adults with SCI, and may increase power output and aerobic fitness. The evidence summarized and appraised in this review can inform the development of the first international, evidence-based clinical practice guidelines for the use of FES cycling exercise in clinical and community settings of adults with SCI. Registration review protocol: CRD42018108940 (PROSPERO).

Economic Evaluations of Strategies to Prevent Hospital-Acquired Pressure Injuries.

GENERAL PURPOSE: To provide information from a review of literature about economic evaluations of preventive strategies for pressure injuries (PIs). TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant should be better able to:1. Identify the purpose and methods used for this study.2. Compare costs and effectiveness related to preventative strategies for PIs. ABSTRACT: BACKGROUND: Pressure injuries (PIs) are a common and resource-intensive challenge for acute care hospitals worldwide. While a number of preventive strategies have the potential to reduce the cost of hospital-acquired PIs, it is unclear what approach is the most effective. OBJECTIVE: The authors performed a narrative review of the literature on economic evaluations of preventive strategies to survey current findings and identify important factors in economic assessments. DATA SOURCES: Ovid, MEDLINE, NHS Economic Evaluation Databases, and the Cochrane Database of Systematic ReviewsSELECTION CRITERIA: Potentially relevant original research articles and systematic reviews were considered. DATA EXTRACTION: Selection criteria included articles that were written in English, provided data on cost or economic evaluations of preventive strategies of PIs in acute care, and published between January 2004 and September 2015. Data were abstracted from the articles using a standardized approach to evaluate how the items on the Consolidated Health Economic Evaluation Reporting Standards checklist were addressed. DATA SYNTHESIS: The searches identified 192 references. Thirty-three original articles were chosen for full-text reviews. Nineteen of these articles provided clear descriptions of interventions, study methods, and outcomes considered. CONCLUSIONS: Limitations in the available literature prevent firm conclusions from being reached about the relative economic merits of the various approaches to the prevention of PIs. The authors' review revealed a need for additional high-quality studies that adhere to commonly used standards of both currently utilized and emerging ways to prevent hospital-acquired PIs.

Medication self-management toolkits for adults with multiple sclerosis: A scoping review.

Background: Multiple sclerosis (MS) is an autoimmune disease that is often treated with multiple medications. Managing multiple medications, also known as polypharmacy, can be challenging for persons with MS. Toolkits are instructional resources designed to promote behaviour change. Toolkits may support medication self-management for adults with MS, as they have been useful in other populations with chronic conditions. Objective: The main purpose of this review was to identify and summarize medication self-management toolkits for MS, as related to the design, delivery, components, and measures used to evaluate implementation and/or outcomes. Methods: A scoping review was conducted following guidelines by JBI. Articles were included if they focused on adults (18 years or older) with MS. Results: Six articles reporting on four unique toolkits were included. Most toolkits were technology-based, including mobile or online applications, with only one toolkit being paper-based. The toolkits varied in type, frequency, and duration of medication management support. Varying outcomes were also identified, but there were improvements reported in symptom management, medication adherence, decision-making, and quality of life. The six studies were quantitative in design, with no studies exploring the user experience from a qualitative or mixed-methods design. Conclusions: There is limited research on medication self-management toolkits among adults with MS. Future development, implementation, and evaluation mixed-methods research are needed to explore user experiences and overall design of toolkits.

Medication self-management interventions for persons with stroke: A scoping review.

The use of multiple medications is common following a stroke for secondary prevention and management of co-occurring chronic conditions. Given the use of multiple medications post-stroke, optimizing medication self-management for this population is important. The objective of this scoping review was to identify and summarize what has been reported in the literature on interventions related to medication self-management for adults (aged 18+) with stroke. Electronic databases (Ovid Medline, Ovid Embase, EBSCO CINAHL, Ovid PsycINFO, Web of Science) and grey literature were searched to identify relevant articles. For inclusion, articles were required to include an adult population with stroke undergoing an intervention aimed at modifying or improving medication management that incorporated a component of self-management. Two independent reviewers screened the articles for inclusion. Data were extracted and summarized using descriptive content analysis. Of the 56 articles that met the inclusion criteria, the focus of most interventions was on improvement of secondary stroke prevention through risk factor management and lifestyle modifications. The majority of studies included medication self-management as a component of a broader intervention. Most interventions used both face-to-face interactions and technology for delivery. Behavioural outcomes, specifically medication adherence, were the most commonly targeted outcomes across the interventions. However, the majority of interventions did not specifically or holistically target medication self-management. There is an opportunity to better support medication self-management post-stroke by ensuring interventions are delivered across sectors or in the community, developing an understanding of the optimal frequency and duration of delivery, and qualitatively exploring experiences with the interventions to ensure ongoing improvement.

A scoping review of medication self-management intervention tools to support persons with traumatic spinal cord injury.

BACKGROUND: Persons with traumatic spinal cord injury (SCI) use multiple medications (polypharmacy) to manage the high number of secondary complications and concurrent conditions. Despite the prevalence of polypharmacy and challenges associated with managing medications, there are few tools to support medication self-management for persons with SCI. OBJECTIVE: The purpose of this scoping review was to identify and summarize what is reported in the literature on medication self-management interventions for adults with traumatic SCI. METHODS: Electronic databases and grey literature were searched for articles that included an adult population with a traumatic SCI and an intervention targeting medication management. The intervention was required to incorporate a component of self-management. Articles were double screened and data were extracted and synthesized using descriptive approaches. RESULTS: Three studies were included in this review, all of which were quantitative. A mobile app and two education-based interventions to address self-management of SCI, medication management, and pain management, respectively, were included. Only one of the interventions was co-developed with patients, caregivers, and clinicians. There was minimal overlap in the outcomes measured across the studies, but learning outcomes (e.g., perceived knowledge and confidence), behavioural outcomes (e.g., management strategies, data entry), and clinical outcomes (e.g., number of medications, pain scores, functional outcomes) were evaluated. Results of the interventions varied, but some positive outcomes were noted. CONCLUSIONS: There is an opportunity to better support medication self-management for persons with SCI by co-designing an intervention with end-users that comprehensively addresses self-management. This will aid in understanding why interventions work, for whom, in what setting, and under what circumstances.

Physiological measurements of tissue health; implications for clinical practice.

Pressure mapping alone insufficiently describes tissue health. Comprehensive, quantitative non invasive assessment is crucial. Interface pressures (IPs) and transcutaneous blood gas levels [transcutaneous tissue oxygen (T(c) PO(2) )] were simultaneously assessed over both ischia and the sacrum to investigate the hypotheses: (i) tissue oxygenation decreases with sustained applied pressure; (ii) tissue oxygen and IP are inversely correlated in loaded soft tissues; (iii) multisite assessments are unnecessary because healthy individuals are symmetrical. Measurements were taken at 5-minute intervals for 20 minutes in both sitting and supine lying for a cohort of 20 able-bodied adults. There were no statistically significant changes over time for either variable in 96% of timepoint comparisons. Specifically, no significant differences were seen between 10 and 20 minutes in either position. These findings imply that a 10-minute assessment can reliably indicate tissue health and that tissue may adapt to applied load over time. No statistically significant correlations between T(c) PO(2) and IP were observed. However, the left and right ischia were significantly different for both variables in supine lying (P < 0.001) and for sitting IP (P < 0.010). Thus, even in this healthy cohort, postural symmetry was not observed and should not be assumed for other populations with restricted mobility. If a multisite technique cannot be used, repeated tissue health assessments must use the same anatomic location.

Empowerment, Communication, and Navigating Care: The Experience of Persons With Spinal Cord Injury From Acute Hospitalization to Inpatient Rehabilitation.

Background: Spinal cord injury (SCI) results in long-term functional impairments that significantly impact participation and role in the community. Newly injured persons are often reintroduced to the community with significant deficits in knowledge, including how to access and navigate community resources and supports. This warrants a better understanding of the patient experience of in-hospital care and discharge planning to ensure individuals with SCI are best supported during transitions in care and while living in the community. Objective: To explore the lived experience of persons with acute SCI and their perceptions of care, focusing on the initial hospital experiences to inpatient rehabilitation. Methods: A phenomenological research study was conducted using semi-structured interviews. Eligible participants had differing etiologies of SCI (including non-traumatic and traumatic SCI), were over the age of 18 at the time of initial care, and experienced acute hospital and inpatient rehabilitation at an Alberta-based institution within the last 10 years. One-on-one interviews took place between March and June 2021 over telephone or virtual platforms (Zoom). Interview transcripts, and field notes developed the text, which underwent hermeneutic analysis to develop central themes. Results: The present study included 10 participants living with an SCI in Alberta, Canada. Most participants (80%) were male. Participants' age ranged from 24 to 69 years. The median years since initial SCI was 3 years. Interviews lasted 45-75 min. Seven participants identified as having a traumatic SCI injury and three identified as having a non-traumatic SCI. The interplay between empowerment and disempowerment emerged as the core theme, permeating participants' meanings and perceptions. Three main themes emerged from the interviews regarding the perceptions of the SCI patient experience. Each theme represents a perception central to their inpatient experience: desire to enhance functional independence to empower confidence and self-management; need for effective communication with healthcare providers to support recovery; and navigating appropriate care supports to enhance preparedness for discharge and returning home. Conclusion: This study demonstrates the significant need to enhance education of person/family-centered SCI care, foster positive communication between care recipients and care providers, and facilitate better in-hospital access to appropriate navigation and wayfinding supports.

Vitamin B(12) deficiency as a cause of delirium in a patient with spinal cord injury.

A man with spinal cord injury (SCI) and multiple medical comorbidities had new-onset delirium during his 14th month of hospitalization. Diagnostic workup did not elicit an obvious etiology for mental status changes. Delirium persisted despite psychiatry intervention, and he was unable to be weaned from the ventilator because of prolonged agitation. Routine anemia workup revealed a possible untreated vitamin B(12) deficiency, although laboratory values were inconclusive. Empiric treatment with cyanocobalamin injections was initiated, and his delirium remarkably resolved after 3 weeks of treatment. We provide a concise review of the etiologies and varied clinical presentations of vitamin B(12) deficiency. As illustrated in this case, classic laboratory findings may not appear, and neurologic impairments from SCI can obscure the physical signs of deficiency, making diagnosis difficult. Empiric treatment may be indicated in cases of neuropsychiatric abnormalities not explained by other causes.

What's happening now! Telehealth management of spinal cord injury/disorders.

CONTEXT: Spinal cord injury and/or disorders (SCI/D) is a costly chronic condition. Impaired mobility, and lengthy travel distances to access specialty providers are barriers that can have adverse impact on expenses and quality of care. Although ample opportunities for use of telehealth technologies exist between medical facilities, and from clinical to home settings, field experience has largely been focused on home telehealth services to promote better patient self-management skills and improve clinical outcomes. FINDINGS: This paper provides an overview of published literature on use of telehealth technologies with the SCI/D population. Presentation of case studies describe telehealth as a potential strategy for addressing disparities in providing quality care, and explore comprehensive management of multiple health issues in individuals with SCI/D. Experiences of providers in both private sector health-care systems and VHA medical facilities are described. Development of telehealth clinical protocols and adaptive devices that can be integrated with equipment to accommodate for the functional limitations in the SCI/D population are discussed as necessary for expansion of use of telehealth services. Rigorous research studies are lacking. As use of this technology spreads and issues surrounding implementation are addressed, we look forward to increased research to assess and evaluate its efficacy in the SCI/D population. CONCLUSION/CLINICAL RELEVANCE: Telehealth in the home setting appears to be able to help persons with SCI/D remain in the community. As the use of telehealth increases, research will be necessary in both clinical and home settings to assess its efficacy in improving outcomes in the SCI/D population.

Poor nutrition is a relative contraindication to negative pressure wound therapy for pressure ulcers: preliminary observations in patients with spinal cord injury.

OBJECTIVE: To assess the efficacy of negative-pressure wound therapy (NPWT) for healing of pressure ulcers (PrUs) in individuals with spinal-cord injury (SCI). DESIGN: Multicenter, 28-day observational study. SETTING: Ten Veterans Affairs Medical Center SCI centers. PATIENTS: Eighty-six SCI inpatients with Stage III/IV pelvic PrUs. INTERVENTIONS: Standard wound care with NPWT versus standard wound care alone (NoNPWT). MAIN OUTCOME MEASURES: Change in wound surface area (WSA) using the Verg Videometer Measurement Documentation software. MAIN RESULTS: The proportion of patients demonstrating a decrease in WSA (healing subgroup) was not significantly different between the NPWT (n = 33) and NoNPWT (n = 53) groups (67% vs 70%, respectively). In the healing subgroup, there was no significant difference between the NPWT versus NoNPWT groups in WSA decrease (-43 ± 22% vs -50% ± 26%, not statistically significant). Similarly, in the nonhealing subgroup, there was no significant difference between NPWT and NoNPWT groups (31% ± 26% vs 32% ± 34%). In the NPWT group, the nonhealing subgroup (11/33) had significantly lower serum albumin levels than the healing subgroup (22/33) (2.9 ± 0.4 vs 3.3 ± 0.5 mg/dL, P < .05). In the NoNPWT group, there was no significant difference in serum albumin levels between the healing versus nonhealing subgroups (3.2 ± 0.3 vs 3.2 ± 0.3 mg/dL). CONCLUSION: In SCI patients with Stage III/IV pelvic PrUs, NPWT did not significantly influence the rate of healing. Additionally, in malnourished individuals (albumin <3.0 mg/dL), NPWT was not efficacious. Healing outcomes in the NPWT group were significantly influenced by albumin levels, whereas no such disparity was noted between the healing and nonhealing PrUs for the NoNPWT group. Nutritional status appears to be important in the effectiveness of NPWT.

Is the use of low-pressure pulsatile lavage for pressure ulcer management associated with environmental contamination with Acinetobacter baumannii?

UNLABELLED: Ho CH, Johnson T, Miklacic J, Donskey CJ. Is the use of low-pressure pulsatile lavage for pressure ulcer management associated with environmental contamination with Acinetobacter baumannii? OBJECTIVE: To determine the extent of environmental contamination associated with low-pressure pulsatile lavage of stage III or IV pressure ulcers in patients with spinal cord injury (SCI) when routine infection control precautions are used for wounds colonized or infected with Acinetobacter baumannii. DESIGN: Prospective investigation in which pressure ulcer cultures and environmental cultures were obtained before and after low-pressure pulsatile lavage treatment, and before and after regular dressing changes. Environmental cultures included the patient's bedrail and settle plates placed 0.6, 1.5, and 2.4m from the wound to assess airborne spread of A. baumannii. SETTING: SCI inpatient unit in a Department of Veterans Affairs Medical Center. PARTICIPANTS: Inpatients (N=15) with SCI receiving daily low-pressure pulsatile lavage treatment for stage III or IV pressure ulcers with standard dressing change, as well as regular dressing changes without low-pressure pulsatile lavage at other times of the day. INTERVENTIONS: Standard, regular dressing changes and dressing changes with low-pressure pulsatile lavage. MAIN OUTCOME MEASURES: Comparison of frequency of environmental contamination with A. baumannii associated with low-pressure pulsatile lavage versus regular dressing changes. RESULTS: Of the 15 SCI inpatients meeting inclusion criteria, 9 (60%) grew A. baumannii from their wounds. Of the 9 patients with wound cultures positive for A. baumannii, only 1 (11%) had environmental contamination with this organism after performance of low-pressure pulsatile lavage, and the same patient had environmental contamination after a standard dressing change. The antibiotic susceptibility patterns of the wound and environmental A. baumannii isolates were identical. CONCLUSIONS: Low-pressure pulsatile lavage using the infection control methods described is not associated with an increased rate of environmental contamination of A. baumannii in comparison with standard dressing changes.

A novel topical oxygen treatment for chronic and difficult-to-heal wounds: case studies.

BACKGROUND: Pressure ulcers are one of the most prevalent causes of morbidity in patients with spinal cord injury (SCI). For those requiring hospital-based management, conventional wound management may necessitate a prolonged institutional stay. This may subsequently increase the likelihood of comorbidities and increase the social, psychological, and financial burdens associated with wound management. Therefore, novel adjunct treatments that potentiate improved healing rates should be seriously considered. STUDY DESIGN: Case reports. OBJECTIVE: To observe the efficacy of the EpiFLO device as an adjunct treatment modality in chronic wound management. SETTING: An SCI unit at a Veterans Affairs Medical Center. METHODS: Three men with SCI, who each presented with a stage IV pressure ulcer in the pelvic region, were treated with the EpiFLO device as an adjunct therapy. In Case 1, the patient was monitored for 9 weeks, whereas in Cases 2 and 3, the patients were monitored for 5 weeks. Healing was determined on a weekly basis by wound dimensions and volume, which were compared before and after the intervention. RESULTS: Comparison of pre- and posttreatment outcome measurements showed significant improvement with EpiFLO in each case. CONCLUSION: EpiFLO seems to have had a positive effect on the healing rate of chronic pressure ulcers in individuals with SCI.

Survey of use of the insufflator-exsufflator in patients with spinal cord injury.

BACKGROUND/OBJECTIVE: The insufflator-exsufflator has been shown to be effective in assisting cough in individuals with spinal cord injury. However, many institutions do not use this device. The study was performed to assess use of the device and attitudes among health care providers. METHODS: We developed a questionnaire with 4 categories of questions: knowledge of the device, type of facility, clinical practice with the device, and patient and provider satisfaction. The questionnaire was mailed to members of the American Paraplegia Society. RESULTS: Eighty-six questionnaires (16%) were returned. The device was being used in 49% of the institutions. The device was most commonly used with a tracheostomy; use did not correlate with size or type of facility. Patient and provider satisfaction with the insufflator-exsufflator was high. CONCLUSIONS: The insufflator-exsufflator is used as a means of removal of secretions in approximately one half of institutions polled. Satisfaction with the device is high.

The prevention and treatment of pressure ulcers.

Pressure ulcers remain a significant secondary complication for many individuals with spinal cord injury (SCI). Technological advances have the potential to affect both the prevention and treatment of pressure ulcers. The focus of this article is hi-tech devices and methodologies. The current state-of-the-art methods are discussed and conceptual approaches are presented.

Integrating wound care research into clinical practice.

The process of integrating wound care research into clinical practice incorporates research methodology--i.e., the standardized practices, procedures, and rules by which research is performed--and an evidence-based approach. Using examples from the literature and clinician experience treating pressure ulcers in a 32-bed regional spinal cord injury unit in a tertiary referral center in Cleveland, Ohio, the authors describe this process and review the challenges faced by an interdisciplinary skin care team tasked with implementing evidence-based care. Additional considerations include determining the amount of current wound care that is evidence-based and whether wound prevention and care outcomes are improved through the use of evidence-based medicine. Five years after establishing the skin care team and implementing evidence-based care, improvements in care processes and short-term outcomes--specifically, pressure ulcer prevention and treatment protocols including documentation--have been realized. Studies to ascertain the effects of these changes on long-term outcomes are planned.

Multidisciplinary approaches to the pressure ulcer problem.

Multiple factors affect the specific condition and overall clinical profile of individuals at risk for chronic wounds. The complexity of the pressure ulcer problem lends itself to the application of the National Institute of Health Roadmap Initiative that encourages interdisciplinary research and new organizational models. An overview of research studies relevant to telemedicine and neuromuscular electrical stimulation in the care and prevention of pressure ulcers as well as preliminary results of an innovative multidisciplinary skin care team approach to the primary and tertiary prevention of pressure ulcers are encouraging. The team's pilot study results indicate that patients are satisfied with telehealth provision of care; however, literature and experience also suggest that discrepancies in the inter-rater assessment of wounds using digital photography remain, particularly with regard to wound dimension variables assessed (P<0.01). In another endeavor, the skin care team developed a Longitudinal Analysis with Self-Registration statistical algorithm to assess the effects of electrical stimulation; in a preliminary study, this tool documented improvement in gluteus maximus health and resultant ability to withstand pressure. As the number of groups pursuing multidisciplinary research and care increases, so, too, will the evidence base required to address these common, and complex, chronic wounds.

Normal ranges of variability for urodynamic studies of neurogenic bladders in spinal cord injury.

BACKGROUND/OBJECTIVE: Urodynamic studies are conducted on a regular basis to evaluate changes in bladder function after spinal cord injury. Often, differences in urodynamic parameters exist from one study or one year to the next. The objective of this study was to provide reference ranges for "normal" variability in urodynamic parameters that can be considered as "no real change" from one study to the next. DESIGN: Retrospective chart review. METHODS: Fifty consecutive individuals with spinal cord injury had 2 trials (trial 1 and trial 2) of urodynamic studies done 5 minutes apart, and the following data were collected: maximum cystometric capacity, opening pressure, maximum detrusor pressure, volume voided, and postvoid residual. The corresponding data were compared, and the frequency distribution for the change between consecutive studies was plotted. Because there is no standard, variability ranges for 5th to 95th, 10th to 90th, and 25th to 75th percentiles were calculated to give health care providers more choices. RESULTS: Ranges of variability are as follows in the following format (urodynamic parameter; mean value; +, maximum increase; -, maximum decrease)--5th to 95th percentile: cystometric capacity (234.63 mL, +213.50 mL, -158.05 mL); opening pressure (54.56 cmH2O, +30 cmH2O, -18.00 cmH2O); maximum detrusor pressure (60.82 cmH2O, +17.35 cmH2O, -27.80 cmH2O); volume voided (122.20 mL, +177.25 mL, -176.00 mL); postvoid residual (176.06 mL, +197.25 mL, -118.00 mL); 10th to 90th percentile: cystometric capacity (234.63 mL, +126.40 mL, -74.60 mL); opening pressure (54.56 cmH2O, +13.70 cmH2O, -12.00 cmH2O); maximum detrusor pressure (60.82 cmH2O, +10.00 cmH2O, -20.00 cmH2O); volume voided (122.20 mL, +105.60 mL, -82.00 mL); postvoid residual (176.06 mL, +131.00 mL, -86.00 mL); 25th to 75th percentile: cystometric capacity (234.63 mL, +72.00 mL, -27.00 mL); opening pressure (54.56 cmH2O, +4.00 cmH2O, -9.50 cmH2O; maximum detrusor pressure (60.82 cmH2O, +4.00 cmH2O, -10.00 cmH2O); volume voided (122.20 mL, +50.00 mL, -30.00 mL); postvoid residual (176.06 mL, +50.00 mL, -30.00 mL). CONCLUSIONS: Urodynamic studies have variability. Knowing these ranges of variability can be helpful in determining whether differences between filling trial 1 and filling trial 2 in a single study or year-to-year changes in urodynamic studies are significant or simply the normal variability of the urodynamic study.

Primary care for persons with spinal cord injury - not a novel idea but still under-developed.

Primary care for persons with spinal cord injury (SCI) has long been recognized as an important issue. Over the last two decades, there has not been any consensus on its contents, pathway or delivery model. Despite the lack of attention on this issue, various health care organizations and settings have successfully developed their own version of primary care for persons with SCI. On the other hand, persons with SCI have also found different ways to obtain primary care through Family Physicians and specialists, often depending on the health care structure of their country. This has blurred the line between what is traditionally seen as primary vs. specialist care. The "medical home" model may be ideal for SCI primary care, and it may be establishsed in different care settings. In order to create this model, health care funding structure, appropriate access to physical facility and SCI knowledge, interdisciplinary provider availability and collaboration, as well as active engagement with persons with SCI are necessary. The SCI community should endorse SCI primary care with effective advocacy and implementation.

A Mixed-methods Study to Assess Interrater Reliability and Nurse Perception of the Braden Scale in a Tertiary Acute Care Setting.

Research regarding the reliability of the Braden Scale and nurses' perspectives on the instrument for predicting pressure ulcer (PU) risk in acute care settings is limited. A mixed-methods study was conducted in a tertiary acute care facility to examine interrater reliability (IRR) of the Braden Scale and its subscales, and a qualitative survey using semi-structured interviews was conducted among nurses caring for patients in acute care units to gain nurse perspective regarding scale usability. Data were extracted from a previous retrospective, randomized, controlled trial involving adult patients with compromised mobility receiving care in a tertiary acute care hospital in Canada. One-way, intraclass correlation coefficients (ICCs) were calculated on item and total scores, and kappa statistics were used to determine reliability of categorizing patients on their risk. Interview results were categorized by common themes. Reliability was assessed on 64 patients, where nurses and research staff independently assessed enrolled participants at baseline and after 72 hours using the Braden Scale as it appeared on an electronic medical record. IRR for the total score was high (ICC = 0.807). The friction and shear item had the lowest reliability (ICC = 0.266). Reliability of categorizing patients' level of risk had moderate agreement (κ = 0.408). Three (3) major and 12 subthemes emerged from the 14 nurse interviews; nurses were aware of the scale's purpose but were uncertain of its effectiveness, some items were difficult to rate, and questions were raised as to whether using the scale enhanced patient care. Aspects identified by nurses to enhance usability included: 1) changes to the electronic version (incorporating the scale into daily assessment documents with readily available item descriptions), 2) additional training, and 3) easily available resource material to improve reliability and usability of scale. These findings need to be considered when using the Braden Scale in clinical practice. Further study of the value of the total Braden Scale and its subscales is warranted.

Efficacy of a pressure-sensing mattress cover system for reducing interface pressure: study protocol for a randomized controlled trial.

BACKGROUND: Interface pressure is a key risk factor in the development of pressure ulcers. Visual feedback of continuous interface pressure between the body and support surface could inform clinicians on repositioning strategies and play a key role in an overall strategy for the prevention and management of pressure ulcers. METHODS/DESIGN: A parallel two-group randomized controlled clinical trial will be conducted to study the effect of continuous pressure imaging on reducing interface pressure and on the incidence of pressure ulcers in vulnerable hospital patients. A total of 678 eligible consenting inpatients at risk of pressure ulcer development in a tertiary acute care institution will be randomly allocated to either having the ForeSite PT™ system with the liquid-crystal display monitor turned on to provide visual feedback to the clinicians while also collecting continuous interface pressure data (intervention group) or to having the ForeSite PT™ system with monitor turned off (that is, not providing visual feedback) but still collecting continuous interface pressure data (control group), in a ratio of 1:1. Continuous interface pressure data will be collected in both groups for 3 days (72 h). Data collection will continue until discharge for a subset of approximately 60 patients. The primary outcome will be the differences in the two groups' interface pressure analysis. Interface pressure readings will be collected through hourly samplings of continuous interface pressure recordings. Secondary outcomes will be the differences between the two groups in pressure-related skin and soft tissue changes in areas at risk of pressure ulcer (obtained at baseline within 24 h of admission) and on the third day of the trial or at discharge and perceptions of the intervention by patients and clinicians (obtained on the third day or at discharge). DISCUSSION: This will be the first randomized controlled trial to investigate the effect of visual feedback with continuous interface pressure of vulnerable hospital patients across different care settings, and the association between interface pressure and development of pressure-related skin and soft tissue changes. The results could provide important information to guide clinical practice in the prevention and management of pressure ulcers. TRIALS REGISTRATION: ClinicalTrials.gov NCT02325388 (date of registration: 24 December 2014).