Machine learning to develop a predictive model of pressure injury in persons with spinal cord injury.

STUDY DESIGN: A 5-year longitudinal, retrospective, cohort study. OBJECTIVES: Develop a prediction model based on electronic health record (EHR) data to identify veterans with spinal cord injury/diseases (SCI/D) at highest risk for new pressure injuries (PIs). SETTING: Structured (coded) and text EHR data, for veterans with SCI/D treated in a VHA SCI/D Center between October 1, 2008, and September 30, 2013. METHODS: A total of 4709 veterans were available for analysis after randomly selecting 175 to act as a validation (gold standard) sample. Machine learning models were created using ten-fold cross validation and three techniques: (1) two-step logistic regression; (2) regression model employing adaptive LASSO; (3) and gradient boosting. Models based on each method were compared using area under the receiver-operating curve (AUC) analysis. RESULTS: The AUC value for the gradient boosting model was 0.62 (95% CI = 0.54-0.70), for the logistic regression model it was 0.67 (95% CI = 0.59-0.75), and for the adaptive LASSO model it was 0.72 (95% CI = 0.65-80). Based on these results, the adaptive LASSO model was chosen for interpretation. The strongest predictors of new PI cases were having fewer total days in the hospital in the year before the annual exam, higher vs. lower weight and most severe vs. less severe grade of injury based on the American Spinal Cord Injury Association (ASIA) Impairment Scale. CONCLUSIONS: While the analyses resulted in a potentially useful predictive model, clinical implications were limited because modifiable risk factors were absent in the models.

Preventing Falls and Fall-Related Injuries at Home: Teaching family caregivers about home modification and what to do if a fall occurs.

This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's health care at home. The articles in this new installment of the series explain principles for promoting safe mobility that nurses should reinforce with family caregivers. Each article also includes an informational tear sheet-Information for Family Caregivers-that contains links to instructional videos. To use this series, nurses should read the article first, so they understand how best to help family caregivers, and then encourage the caregivers to watch the videos and ask questions. For additional information, see Resources for Nurses.

Preventing Falls and Fall-Related Injuries at Home.

: This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's health care at home.The articles in this new installment of the series explain principles for promoting safe mobility that nurses should reinforce with family caregivers. Each article also includes an informational tear sheet-Information for Family Caregivers-that contains links to instructional videos. To use this series, nurses should read the article first, so they understand how best to help family caregivers, and then encourage the caregivers to watch the videos and ask questions. For additional information, see Resources for Nurses.

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

BACKGROUND: Pressure ulcers (PrUs) are a frequent, serious, and costly complication for veterans with spinal cord injury (SCI). The health care team should periodically identify PrU risk, although there is no tool in the literature that has been found to be reliable, valid, and sensitive enough to assess risk in this vulnerable population. OBJECTIVE: The immediate goal is to develop a risk assessment model that validly estimates the probability of developing a PrU. The long-term goal is to assist veterans with SCI and their providers in preventing PrUs through an automated system of risk assessment integrated into the veteran's electronic health record (EHR). METHODS: This 5-year longitudinal, retrospective, cohort study targets 12,344 veterans with SCI who were cared for in the Veterans Health Administration (VHA) in fiscal year (FY) 2009 and had no record of a PrU in the prior 12 months. Potential risk factors identified in the literature were reviewed by an expert panel that prioritized factors and determined if these were found in structured data or unstructured form in narrative clinical notes for FY 2009-2013. These data are from the VHA enterprise Corporate Data Warehouse that is derived from the EHR structured (ie, coded in database/table) or narrative (ie, text in clinical notes) data for FY 2009-2013. RESULTS: This study is ongoing and final results are expected in 2017. Thus far, the expert panel reviewed the initial list of risk factors extracted from the literature; the panel recommended additions and omissions and provided insights about the format in which the documentation of the risk factors might exist in the EHR. This list was then iteratively refined through review and discussed with individual experts in the field. The cohort for the study was then identified, and all structured, unstructured, and semistructured data were extracted. Annotation schemas were developed, samples of documents were extracted, and annotations are ongoing. Operational definitions of structured data elements have been created and steps to create an analytic dataset are underway. CONCLUSIONS: To our knowledge, this is the largest cohort employed to identify PrU risk factors in the United States. It also represents the first time natural language processing and statistical text mining will be used to expand the number of variables available for analysis. A major strength of this quantitative study is that all VHA SCI centers were included in the analysis, reducing potential for selection bias and providing increased power for complex statistical analyses. This longitudinal study will eventually result in a risk prediction tool to assess PrU risk that is reliable and valid, and that is sensitive to this vulnerable population.

Difficulty in Identifying Factors Responsible for Pressure Ulcer Healing in Veterans With Spinal Cord Injury.

OBJECTIVE: To identify characteristics associated with pressure ulcer (PrU) healing for individuals with spinal cord injury (SCI). DESIGN: Secondary analysis of a large clinical trial's data for healing PrUs in individuals with SCI; prospective Delphi process was conducted with SCI and/or PrU experts. SETTING: Spinal cord injury centers. PARTICIPANTS: There were 629 screening and 162 treatment participants (N=791); 185 SCI clinicians/national PrU/wound care experts participated in the Delphi process. INTERVENTIONS: None. MAIN OUTCOME MEASURE: PrU healing of 50% and 100% at weeks 4 and 12. RESULTS: Poisson regression models using the top Delphi-recommended factors found that only ulcer stage consistently predicted 50% and 100% healing at weeks 4 and 12. Additionally, ischial/perineal location was associated with 33% higher likelihood of 50% healing at week 4. Patient noncompliance with treatment recommendations, the top-ranked Delphi factor, did not predict healing at week 4 or 12. Expanded models found that at week 4, baseline PrU size, PrU stage IV, PrU pain, and American Spinal Injury Association grade A significantly predicted 100% healing, while at week 12, only PrU stage (IV) significantly predicted 100% healing. Significant predictors of 50% healing at week 4 included baseline PrU size, stage, ischial/perianal location body mass index >30kg/m2, foul odor, and signs of infection. At week 12, PrU duration, paraplegia predicted 50% healing. SCI center identifiers consistently showed 2- to 5-fold variation in predicting 50% PrU healing at weeks 4 and 12. CONCLUSIONS: Delphi panel-recommended factors (eg, patient compliance) did not predict PrU healing. Reducing center-level variability in wound healing by learning from best practices should be a health system goal. PrU healing in SCI is still poorly understood, and future studies should focus on as yet unidentified or underappreciated factors.

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.

Perceptions of practice guidelines for people with spinal cord injury.

PURPOSE: The Consortium for Spinal Cord Medicine published clinical practice guidelines (CPG) related to upper limb (UL) preservation in people with spinal cord injury (SCI) in 2005. The purpose of this qualitative research was to identify stakeholder agreement with recommendations, performance gaps, and barriers and facilitators to CPG implementation. DESIGN: This 6-month study focused on the perspectives of healthcare providers, veterans, and key informants. The Promoting Action on Research Implementation in Health Services (PARiHS) was used to frame the interview questions, analyze data from focus groups and interviews, and develop conclusions and recommendations. METHOD: SCI Centers at the Tampa, Seattle, and Hines Veterans' hospitals participated. The purposeful sample for the focus groups included 32 healthcare providers, 21 veterans with SCI, and 3 key informants. Analysis of qualitative data netted the percent of agreement with recommendations, performance gaps, and strategies for CPG implementation. FINDINGS: Content analysis of focus group data revealed that healthcare providers agreed or partially agreed with 20 (57%) of the 35 CSCM CPG on UL preservation of function. Agreement ranged from 100% for assessment to 28% for equipment use. Barriers for implementation related to administrative and system issues. CONCLUSION: Consideration of gaps, barriers, and facilitators to implementation will assist clinicians to target interventions to preserve UL function.

A pilot study to evaluate the role of the Spinal Cord Impairment Pressure Ulcer Monitoring Tool (SCI-PUMT) in clinical decisions for pressure ulcer treatment.

The Spinal Cord Impairment Pressure Ulcer Monitoring Tool (SCI-PUMT) was designed to assess pressure ulcer (PrU) healing in the spinal cord impaired (SCI) population. The tool contains 7 variables: wound surface area, depth, edges, tunneling, undermining, exudate type, and necrotic tissue amount. A 2-phased, quantitative pilot study based on the Theory of Reasoned Action and Theory of Planned Behavior was conducted at a large SCI/Disorders Center in the Department of Veterans Affairs (VA). In the first phase of the study, a convenience sample of 5 physicians, 3 advanced practice registered nurses, and 3 certified wound care nurses (CWCN) was surveyed using a 2-part questionnaire to assess use of the SCI-PUMT instrument, its anticipated improvement in PrU assessment, and intent to use the SCI-PUMT in clinical practice. Attitudes, subjective norms, perceived behavioral controls, and barriers related to the intent to use the SCI-PUMT were evaluated using a 5-point Likert scale (range: 1= extremely likely, 5 = extremely unlikely). In the second phase of the study, the electronic health records (EHR) of 24 veterans (with 30 PrUs) who had at least 2 completed SCI-PUMT scores during a 4-week period were used to evaluate whether an association existed between magnitudes of change of total SCI-PUMT scores and ordered changes in PrU treatment. The overall mean score for intent to use SCI-PUMT was 1.80 (SD 0.75). The least favorable scores were for convenience and motivation to use the SCI-PUMT. Analysis of EHR data showed no significant difference in magnitudes of change in the SCI-PUMT score and changes in PrU treatment recommendations made by the CWCNs. The significance was not affected regardless of an increase or no change in the score (χ2 with 1 degree of freedom = 1.158, P = 0.282) or for a decrease in the score (χ2 with 1 degree of freedom = 0.5, P = 0.478). In this pilot study, the expressed intent to use the SCI-PUMT in making clinical decisions was generally positive but reservations remain. Additional research is being conducted to determine the barriers and facilitators to SCI-PUMT implementation. The SCI-PUMT was the first tool found to be valid, reliable, and sensitive to assess PrU healing in persons with SCI, and studies to examine the prospective validity of using this instrument on ulcer treatment decisions and outcomes are warranted.

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

OBJECTIVE: The purpose was to provide support for validity and reliability of the spinal cord impairment pressure ulcer monitoring tool (SCI-PUMT) to assess pressure ulcer (PrU) healing. DESIGN: Expert panels developed a 30-item pool, including new items and items from two established PrU healing tools, to represent potential variables for monitoring PrU healing. Subjects were prospectively assessed weekly for each variable over a 12-week period. SETTING: Data collection was conducted on a cohort of inpatients and outpatients in one Spinal Cord Injury/Disorders Center in the Veterans' Health Administration. SUBJECTS: A convenience sample of Veterans (n = 66) with spinal cord impairment (SCI) was recruited. Eligible subjects had at least one PrU (n = 167) and a history of SCI for longer than 1 year. Interventions Not applicable. OUTCOME MEASURE: A change in PrU volume was calculated using VeV Measurement Documentation software and a digital imaging camera. RESULTS: Content validity was established for a pool of items designed to gauge PrU healing. Exploratory factor analysis (construct validity) identified a parsimonious set of seven items for inclusion in the SCI-PUMT to assess PrU healing. The SCI-PUMT was found to explain 59% of the variance of the volume across the study. Inter-rater reliability was 0.79 and intra-rater reliability ranged from 0.81 to 0.99 among research assistants. Similar levels of reliability were subsequently established among registered nurses, who used the SCI-PUMT in the clinical setting. CONCLUSIONS: The final version of the SCI-PUMT was determined to be valid, reliable, and sensitive in detecting PrU healing over time in Veterans with SCI.

Providers' perceptions of spinal cord injury pressure ulcer guidelines.

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 = 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.

Monitoring pressure ulcer healing in persons with disabilities.

Pressure ulcers are a high-risk, high-volume, and high-cost problem for persons with disabilities. This article describes four tools published in the literature and reports the validity, reliability, strengths, and limitations of each. These tools include the Pressure Ulcer Scale for Healing (PUSH), the Pressure Sore Status Tool (PSST), the Sussman Wound Healing Tool (SWHT), and the Sessing Scale. Rehabilitation nurses should use a consistent framework with accurate quantification to assess, document, and monitor changes in pressure ulcers over time. Such a measurement tool must prove valid for the disabled population in which the tool is used. This will enable healthcare providers to communicate more effectively and evaluate the therapeutic plan of care.

Aging: a new opportunity to publish in SCI nursing.

Publishing in SCI Nursing is a rewarding experience in terms of professional growth and contributing to the body of knowledge of SCI nurses. "Guidelines for Contributors" are on the back, inside cover of each issue of SCI Nursing and on the AASCIN Web site. Collaborate with nursing colleagues, or interdisciplinary team members, to begin your manuscript today.