Amy S. Chin

Characteristics of recurrent pressure ulcers in veterans with spinal cord injury.

Abstract Background/Objective: To describe characteristics of recurrent pressure ulcers (PrUs) in veterans with spinal cord injury (SCI). Design: Descriptive, cohort study. Settings and Participants: Twenty-four veterans with SCI from 6 SCI centers in the Department of Veterans Affairs. Methods: Data from a prospective study evaluating PrUs were analyzed for 24 veterans with 29 recurrent PrUs during 9 months. Additional retrospective medical record data were analyzed for 15 veterans who received inpatient treatment. Results: Participants were male, 50% non-Hispanic white, with paraplegia (63%), complete SCI (83%), a mean age of 56 years, and mean time since SCI of 21 years. Most PrUs recurred (63%, n = 15 patients) in the same location as the most recent ulcer and at the ischial tuberosities (63%). Mean time to recurrence was 16.6 weeks. PrUs were stage III (28%, n = 8) or IV (45%, n = 13) with undermining (48%), necrotic slough (50%), and minimal exudate. One third were (n = 9) larger than 16 cm2. Mean Bates-Jensen Wound Assessment Tool Score was 33.63. Inpatient medical record data (n = 15) showed 73% with documentation indicating infection treated with antibiotics (53%, n = 8 patients), osteomyelitis (47%, n = 7), and/or cellulitis (1 3%, n = 2) noted. Plastic surgery consultation was obtained for 67% with surgery as an option for 73% (1 without consultation). Scheduled repositioning was documented for 21%. Conclusions: Most PrUs were severe, located at the same anatomic site, and recurred within 4 months, suggesting that the recurrent ulcers were more likely incomplete healing of the initial PrUs. This sample of veterans with SCI provides early data on recurrent PrU characteristics.

Assessing the feasibility of subepidermal moisture to predict erythema and stage 1 pressure ulcers in persons with spinal cord injury: A pilot study

Abstract Background Persons with spinal cord injury (SCI) are at high risk for pressure ulcers (PrUs) throughout their lifetime due to decreased mobility, lack of sensation, and other physiological changes. The high prevalence and recurrence rates, and costs associated with PrUs in veterans with SCI indicate the need for a reliable and practical method of detecting early PrUs. Objective To assess the feasibility of obtaining biophysical measures of sub-epidermal moisture (SEM) using a handheld dermal phase meter to predict PrUs. Design/methods Prospective observational design. Thirty-four veterans at two VA SCI centers (Hines, Long Beach) received daily (n = 12) or weekly (n = 22) SEM and concurrent visual skin assessment (VSA) across nine anatomic locations for up to 6 weeks. Outcome measures SEM, visual skin assessment (VSA), and stage I PrUs. Findings/results SEM was lowest for normal skin (39.3 dermal phase units (DPU), SD = 12.6) and higher for erythema/stage 1 PrUs (40.8 DPU, SD = 10.4) across all anatomic sites. Buttocks SEM were different between normal skin (40.5 DPU, SD = 10.3) and erythema/stage1 PrUs (43.8, SD = 9.5). SEM taken at heels were lower across all skin conditions (normal skin 28.2 DPU; erythema/stage 1 PrUs 34.7 DPU). SEM was taken when generalized edema present was lower than without generalized edema. Conclusions Preliminary results of using SEM to detect early PrU damage may translate from nursing home (NH) residents to persons with SCI. This study provides a foundation for a larger study to implement and assess SEM use as a method of prevention of PrUs.

The association of opioid use with incident lower extremity fractures in spinal cord injury

Abstract Objective To determine the association between opioid use and lower extremity fracture risk in men with spinal cord injury (SCI). Design Retrospective cohort study. Setting Veterans Affairs Healthcare System. Participants In total, 7447 male Veterans with a history of a traumatic SCI identified from the Veterans Affairs (VA) Spinal Cord Dysfunction Registry (SCD) from September 2002 through October 2007 and followed through October 2010. Outcome measures Incident lower extremity fractures by use of opioids. Results In individuals identified from the VA SCD Registry 2002–2007, opioid use was quite common, with approximately 70% of the cohort having received a prescription for an opioid. Overall, there were 892 incident lower extremity fractures over the time period of this study (597 fractures in the opioid users and 295 fractures in the non-opioid users). After adjusting for covariates, there was a statistically significant relationship between opioid use and increased risk for lower extremity fractures (hazard ratio 1.82 (95% confidence interval 1.59–2.09)). Shorter duration of use (<6 months) and higher doses were positively related to fracture risk (P < 0.0001). Conclusions Opioid use is quite common in SCI and is associated with an increased risk for lower extremity fractures. Careful attention to fracture prevention is warranted in patients with SCI, particularly upon initiation of an opioid prescription and when higher doses are used.

A retrospective review of lower extremity fracture care in patients with spinal cord injury

Abstract Context/Objective To identify circumstances surrounding incident lower extremity fractures (ILEFs) in patients with spinal cord injury (SCI) and to describe the impact of these fractures on service needs and provision of pharmacological therapies for osteoporosis. Design Retrospective medical record review. Setting Four Veterans Affairs Medical Centers in the USA. Participants One hundred and forty patients with traumatic SCI who sustained an ILEF from 2002 to 2007. Outcome measures Fracture circumstances and use of assistive devices were described using percentages, means, and standard deviations. Fishers exact test was used to determine the relationship between fracture site, and patient age and duration of SCI. Differences in pharmacological provision of therapies for osteoporosis pre- and post-fracture were examined using exact McNemars test. Results One hundred and fifty-five ILEFs were identified in 140 patients. Tibia/fibula and femur fractures were the most common fractures. Fracture site was not related to patients age or duration of SCI. Almost one-third of all fractures occurred during transfers to and from wheelchairs. Post-fracture, the provision of new or modified assistive devices, primarily wheelchairs, was frequent, occurring in 83% of patients in the year post-fracture. Few patients transferred residence to a nursing home following the fracture. There was a significant difference in the use of pharmacological therapies for osteoporosis in the first year post-fracture compared with the year prior to the fracture (P < 0.01), with significant differences in the volume of prescriptions for calcium supplements (P < 0.01) and bisphosphonates (P = 0.02). Overall, the amount of prescriptions for osteoporosis increased the year post-fracture (56%) from the year pre-fracture (39%); this increase was secondary to increases in prescriptions for calcium supplements (pre = 13%; post = 30%) and bisphosphonates (pre = 2%; post = 7%). Conclusions We have identified that wheelchair and other transfer activities are a key area that could be a focus of fracture prevention in SCI. The need for new or modified assistive devices and/or wheelchair skills retraining post-fracture should be anticipated. Examination of whether treatments for osteoporosis following a fracture can prevent future osteoporotic fractures is warranted.

Bloodstream infections and setting of onset in persons with spinal cord injury and disorder

Study Design:A retrospective cohort study.Objective:Health-care-associated (HCA) bloodstream infection (BSI) has been shown to be a distinct epidemiologic category in the general adult population, but few studies have examined specific patient populations. The objective of this study was to assess characteristics associated with BSI that occurred in the hospital (hospital-acquired, HA BSI), from health-care contact outside the hospital (HCA BSI) or in the community (community-acquired, CA BSI) in veterans with spinal cord injury and disorder (SCI&D).Setting:Two United States Department of Veterans Affairs hospitals.Methods:All patients with SCI&D with a positive blood culture admitted to study hospitals over a 7-year period (1 October 1997 to 30 September 2004). Demographics, medical characteristics and causative organisms were collected.Results:Four hundred and thirteen episodes of BSI occurred in 226 patients, with a rate of 7.2 BSI episodes per 100 admissions: 267 (64.7%) were HA BSI, 110 (26.6%) were HCA BSI and 36 (8.7%) were CA BSI. Antibiotic resistance was more common in those with HA BSI (65.5%) compared with that in those with HCA (49.1%, P=0.001) and CA BSI (22.2%, P<0.0001). Methicillin resistance in Staphylococcus aureus was highly prevalent; HA BSI (84.5%), HCA BSI (60.6%) and CA BSI (33.3%).Conclusion:HCA BSI comprises one-quarter of all BSIs in hospitalized patients with SCI&D. Although those with HCA and CA BSI share similarities, several differences in medical characteristics and causal microorganism are noted. Treatment and management strategies for HCA and CA infections need to vary.

The association of anticonvulsant use with fractures in spinal cord injury.

ObjectiveThe aim of this study was to determine whether anticonvulsants, including the benzodiazepine subclass, are associated with an increased risk for lower extremity fractures in male patients with spinal cord injury. DesignAll male patients with a history of a traumatic spinal cord injury of 2 yrs’ duration or longer in the Veterans Affairs Spinal Cord Disease Registry from 2002 to 2007 were included. Incident lower extremity fractures during this period and anticonvulsant use were identified. The association of anticonvulsant use, overall, by type (enzyme inducing, non–enzyme inducing), by number (monotherapy vs. polytherapy), by benzodiazepine subclass, and by individual medication used was determined. ResultsIn this cohort, 892 veterans sustained a fracture, and 6555 did not. Compared with nonusers of anticonvulsants, there was a significant positive relationship with fractures by overall use of anticonvulsants (HR, 1.17 [95% CI, 1.01–1.36]), by users of the benzodiazepine subclass (HR, 1.28 [95% CI, 1.11–1.47]), and by polytherapy compared with monotherapy (HR, 1.20 [95% CI, 1.00–1.42]) but not by anticonvulsant type (HR, 0.92 [95% CI, 0.58–1.47]). Temazepam (HR, 1.28 [95% CI, 1.01–1.62]), alprazolam (HR, 1.54 [95% CI, 1.04–2.29]), and diazepam (HR, 1.23 [95% CI, 1.06–1.41]) were significantly positively associated with fractures. ConclusionsAttention to fracture prevention is important when anticonvulsants are prescribed in spinal cord injury, particularly when more than one anticonvulsant is used.

Predictors and outcomes of antibiotic adequacy for bloodstream infections in veterans with spinal cord injury.

OBJECTIVE To identify predictors and outcomes associated with receiving inadequate empirical antimicrobial treatment for bloodstream infections (BSIs) in persons with spinal cord injury (SCI). DESIGN Retrospective cohort study from October 1, 1997, through September 30, 2004. SETTING A Department of Veterans Affairs SCI center that serves approximately 700 patients a year. PARTICIPANTS Hospitalized patients with SCI (N=123) who had 1 or more BSIs during the study period. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Adequacy of antimicrobial treatment (inadequate treatment was defined as the absence of antimicrobial agents for a particular organism within 2 days after the collection of blood cultures and/or the microorganisms resistance to the antimicrobial administered), hospital length of stay (LOS) post-BSI infection, and in-hospital and 30-day mortality. Cluster-adjusted multivariable models were assessed. RESULTS Over one third (88; 37.4%) of the 235 episodes of BSI identified received inadequate empirical antibiotic treatment. Having a polymicrobial BSI was associated with inadequate treatment (odds ratio [OR]=3.28; 95% confidence interval [CI]=1.62-6.65; P=.001). Factors protective against inadequate therapy included having a comorbid pressure ulcer (OR=0.37; 95% CI=0.21-0.68; P=.001) or a BSI that was not primary (OR=0.30; 95% CI=0.15-0.58; P<.0001). Mortality did not differ between the inadequate and adequate treatment groups (11.4% vs 10.9%; P=.92). Similarly LOS postinfection was not affected by treatment status (inadequate treatment median=22d vs adequate treatment median=27d; P=.98). CONCLUSIONS Over one third of patients received inadequate empirical treatment, which was associated with having a polymicrobial BSI. However, inadequate treatment was not associated with increased mortality or LOS postinfection.

Thiazide Use Is Associated With Reduced Risk for Incident Lower Extremity Fractures in Men With Spinal Cord Injury

OBJECTIVE To determine the association between thiazide use and lower extremity fractures in patients who are men with a spinal cord injury (SCI). DESIGN Cohort study from fiscal years 2002 to 2007. SETTING Medical centers. PARTICIPANTS Men (N=6969) with an SCI from the Veterans Affairs (VA) Spinal Cord Dysfunction (SCD) Registry, including 1433 users of thiazides and 5536 nonusers of thiazides. INTERVENTION Thiazide use versus nonuse. MAIN OUTCOME MEASURE Incident lower extremity fractures. RESULTS Among the men, 21% in the VA SCD Registry (fiscal years 2002-2007) included in these analyses used thiazide diuretics. There were 832 incident lower extremity fractures over the time period of this study: 110 fractures (7.7%) in 1433 thiazide users and 722 fractures (13%) in 5536 nonusers of thiazides. In unadjusted and adjusted models alike, thiazide use was associated with at least a one-quarter risk reduction in lower extremity fracture at any given point in time (unadjusted: hazard ratio (HR)=.75; 95% confidence interval (CI), .59-.94; adjusted: HR=.74; 95% CI, .58-.95). CONCLUSIONS Thiazide use is common in men with SCI and is associated with a decreased likelihood for lower extremity fractures.

Antibiotic prescribing trends in the emergency department for veterans with spinal cord injury and disorder 2002-2007

Abstract Objective Clinical guidelines exist to promote antibiotic stewardship, particularly in ambulatory care settings such as the emergency department (ED). However, there is limited evidence on prescribing practice for persons with spinal cord injury and disorder (SCI/D). The goal of this study was to assess trends in antibiotic prescribing in the ED setting for persons with SCI/D. Design A retrospective dynamic cohort study design. Setting ED visits that did not result in same day hospitalization over 6 years (fiscal year (FY) 2002-FY2007) in Department of Veterans Affairs (VA) facilities Participants Veterans with SCI/D. Outcome measures VA clinical and administrative databases were used to identify the cohort and to obtain demographics, diagnoses, and medications. The rate of antibiotic prescribing for ED visits was defined as the number of antibiotics/total ED visits. Results Veterans with SCI/D had 21 934 ED visits and 5887 antibiotics prescribed over the study period (rate of 268.4 prescriptions/1000 visits). The antibiotic prescribing rate increased from 238.8/1000 visits in FY2002 to 310.8/1000 visits in FY2007 (P < 0.0001). This increase in the rate of prescribing was seen across all patient demographics and factors assessed. Conclusion Although clinical guidelines for judicious use of antibiotics in persons with SCI/D have been disseminated to providers, antibiotic prescribing in an ED setting is high and continuing to rise in this population.

Implementing a patient education intervention about Methicillin-resistant Staphylococcus aureus prevention and effect on knowledge and behavior in veterans with spinal cord injuries and disorders: A pilot randomized controlled trial

Abstract Objectives To assess the feasibility and effect of a nurse-administered patient educational intervention about Methicillin-resistant Staphylococcus aureus (MRSA) prevention on knowledge and behavior of Veterans with spinal cord injuries and disorders (SCI/D). Design Blinded, block-randomized controlled pilot trial. Setting Two Department of Veterans Affairs (VA) SCI Centers. Participants Veterans were recruited March–September 2010 through referral by a healthcare provider from inpatient, outpatient, and residential care settings. Intervention Thirty participants were randomized to the nurse-administered intervention and 31 to the usual care group. The intervention included a brochure and tools to assist nurses in conducting the education. Outcome measures Pre- and post-intervention measurement of knowledge and behaviors related to MRSA and prevention strategies and feasibility measures related to implementation. Results Participants were primarily male (95.1%), white (63.9%), with tetraplegia (63.9%) and mean age and duration of injury of 64.3 and 20.5 years, respectively. The intervention groups mean knowledge score significantly increased between pre- and post-test (mean change score = 1.70, 95% confidence interval, CI 0.25–3.15) while the usual care groups score did not significantly change (mean change score = 1.45, 95% CI −0.08–2.98). However, the mean knowledge change between intervention and usual care groups was not significantly different (P = 0.81). Overall behavior scores did not significantly differ between treatment groups; however, the intervention group was more likely to report intentions to clean hands (90.0% vs. 64.5%, P = 0.03) and asking providers about MRSA status (46.7% vs. 16.1%, P = 0.01). Nurse educators reported that the quality of the intervention was high and could be implemented in clinical care. Conclusions A targeted educational strategy is feasible to implement in SCI/D clinical practices and may improve some participants’ knowledge about MRSA and increase intentions to improve hand hygiene and engagement with providers about their MRSA status.