Jeffrey J. Harrow

Wheelchair-related falls: current evidence and directions for improved quality care

While much of the research on falls has focused on the ambulatory elderly, little is known about wheelchair-related falls that occur in persons with disabilities. A thorough understanding of wheelchair-related falls would include the demographics, the mechanism and nature of the fall event, and the nature of any resultant injury, including the cost of treatment and long-term sequelae. The purpose of this article is to provide an overview of the current data on wheelchair-related falls and to make recommendations for avenues for improved quality of care and future research to promote patient safety.

Implementation of clinical practice guidelines for prevention of thromboembolism in spinal cord injury.

Abstract Background/Objectives: The purpose of this study was to determine whether publication of the “Prevention of Thromboembolism in Spinal Cord Injury” clinical practice guideline (CPG) changed patient management and whether adherence to CPG recommendations improved after a targeted implementation strategy. Methods: Data were abstracted from medical records of 1 34 and 520 patients with acute and chronic spinal cord injury (SCI), respectively, from 6 Veterans Affairs medical centers over 3 time periods: prepublication (T1 ), pre implementation (T2), and postimplementation (T3) of the CPG. Targeted interventions were developed to address provider-perceived barriers to guideline adherence, based on findings from focus groups conducted at each site. The interventions incorporated two implementation strategies: standardized documentation templates/standing orders and social marketing /outreach visits. Results: Use of the specified duration for pharmacologic prophylaxis increased from 60% to 65% to 75% of patients with acute SCI in T1, T2, and T3, respectively (P = 0.060 and 0.041 for T1 vs T2 and T2 vs T3, respectively). Rates of use for individual pharmacologic prophylaxis agents changed significantly over the course of the study, with use of low-molecular-weight heparin increasing from 7% in T1 to 42% in T3. Physical assessments for thrombosis on hospitalization days 1 and 30 improved between T2 and T3. Use of prophylaxis in chronically injured patients with new risk factors for thromboembolism increased from 16% to 31% to 34% during T1, T2, and T3 (P = 0.001 and 0.87, respectively). Conclusions: The CPG publication had only a modest effect on practice. Use of structured implementation further increased the adherence to some CPG recommendations for thromboembolism prophylaxis. Similar implementation strategies should be considered for CPG recommendations with low adherence and high potential for morbidity and mortality.

A comparison of patient outcomes and quality of life in persons with neurogenic bowel: standard bowel care program vs colostomy.

Abstract Background/Objective: The purpose of this study was to compare patient outcomes and quality of life for people with neurogenic bowel using either a standard bowel care program or colostomy. Methods: We analyzed survey data from a national sample, comparing outcomes between veterans with spinal cord injury (SCI) who perform bowel care programs vs individuals with colostomies. This study is part of a larger study to evaluate clinical practice guideline implementation in SCI. The sample included 1,503 veterans with SCI. The response rate was 58.4%. For comparison, we matched the respondents with colostomies to matched controls from the remainder of the survey cohort. A total of 74 veterans with SCI and colostomies were matched with 296 controls, using propensity scores. Seven items were designed to elicit information about the respondents satisfaction with their bowel care program, whereas 7 other items were designed to measure bowel-related quality of life. Results: No statistically significant differences in satisfaction or quality of life were found between the responses from veterans with colostomies and those with traditional bowel care programs. Both respondents with colostomies and those without colostomies indicated that they had received training for their bowel care program, that they experienced relatively few complications, such as falls as a result of their bowel care program, and that their quality of life related to bowel care was generally good. However, large numbers of respondents with colostomies (n = 39; 55.7%) and without colostomies (n = 113; 41.7%) reported that they were very unsatisfied with their bowel care program. Conclusion: Satisfaction with bowel care is a major problem for veterans with SCI.

Pressure Ulcers and Occipital Alopecia in Operation Iraqi Freedom Polytrauma Casualties

OBJECTIVE Several of the casualties from Operation Iraqi Freedom arriving at one Veterans Administration (VA) polytrauma rehabilitation center (PRC) were noted to have occipital pressure ulcers or hair loss. The objective of this study was to determine the prevalence and severity of pressure-related injuries in VA PRC admissions. METHODS A retrospective review of admissions from active duty from 2004 to 2006 was performed. RESULTS Thirty-eight percent of admissions to this VA PRC had pressure-related injuries on the day of admission. Casualties from Iraq had a higher rate of pressure ulcers (53%) than did those from elsewhere (22%). Occipital lesions constituted 50% of non-stage I pressure ulcers and were more severe than those of the sacrum or extremities. CONCLUSIONS Further epidemiological research should be performed to identify risk factors for pressure injury in the military continuum of care, by linking specific military medical evacuation and treatment processes and characteristics of casualties with outcomes.

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

Abstract 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.

Design and Evaluation of a Stand-Up Motorized Prone Cart

Abstract Background/Objective: Prone carts are used for mobility by individuals with spinal cord injury in whom seated mobility (wheelchair) is contraindicated due to ischial or sacral pressure ulcers. Currently available prone carts are uncomfortable, subjecting the user to neck and shoulder strain, and make social interaction and performing activities of daily living difficult. A better design of prone carts is needed. In addition, standing devices have shown some medical benefits. The objective was to design and evaluate an improved prone cart that facilitates standing. Design: Engineering development project with user feedback through questionnaire. Users selected by convenience sampling. Methods: A marketing survey was performed of nurse managers of spinal cord injury units. Then 2 prototype carts were designed and built. These carts are able to tilt up to 45° and have a joystick-controlled motor for propulsion and other design features, including a workspace storage shelf and rearview mirrors. The carts were evaluated by both patients and caregivers at 2 Veterans Administration hospitals. Outcome Measures: Questionnaire of subjects, both patients and caregivers, who used the cart. Findings: Both patients and caregivers liked the carts and the ability to assume a nonhorizontal body angle. The major complaint about the cart was that it seemed too long when it came to making turns. Conclusion: This prone cart design is an improvement over the standard, flat variety. However, further design changes will be necessary. This study provided valuable information that will be useful in the next- generation prone cart design project.

Diagnostic Pitfalls: Case Report Of Scurvy In A Man With Spinal Cord Injury

Abstract Background: A 49-year-old man with spinal cord injury (SCI) developed a progressive purpuric rash and painful swelling of the lower extremities, in addition to chronic purpura over the ischial tuberosities. Design: Case report Findings: Following an extensive workup for presumed vasculitis, a skin biopsy showed evidence of scurvy. Risk facto rs for scurvy included limited means of transportation, living alone, and alcohol abuse. Conclusions: Scurvy can be confused with disorders common among SCI patients, such as vasculitis, venous thrombosis, occult trauma, and pressure injury. Scurvy should be considered in the differential diagnosis of skin lesions, especially in individuals who abuse alcohol and live alone.

Secondary adrenal insufficiency after glucocorticosteroid administration in acute spinal cord injury: A case report

Abstract Context/background A 61-year-old female with cervical stenosis underwent an elective cervical laminectomy with post-op worsening upper extremity weakness. Over the first 3 weeks post-op, she received two separate courses of intravenous steroids. Two days after cessation of steroids, she presented with non-specific symptoms of adrenal insufficiency (AI). Initial formal diagnostic tests of random cortisol level and 250 µg cosyntropin challenge were non-diagnostic; however, symptoms resolved with the initiation of empiric treatment with hydrocortisone. Ten days later, repeat cosyntropin (adrenocortocotropic hormone stimulation) test confirmed the diagnosis of AI. Findings AI is a potentially life-threatening complication of acute spinal cord injury (ASCI), especially in those receiving steroids acutely. Only three cases have been reported to date of AI occurring in ASCI after steroid treatment. The presenting symptoms can be non-specific (as in this patient) and easily confused with other common sequelae of ASCI such as orthostasis and diffuse weakness. The 250 µg cosyntropin simulation test may not the most sensitive test to diagnose AI in ASCI. Conclusion The non-specific presentations and variability of diagnosis criteria make diagnosis more difficult. One microgram cosyntropin simulation test may be more sensitive than higher dose. Clinicians should be aware that AI can be a potential life-threatening complication of ASCI post-steroid treatment. Prompt diagnosis and treatment can reverse symptoms and minimize mortality.