Katherine Orenczuk^1-2

Swati Mehta, BSc-^1-2

Amanda McIntyre, MSc, BSc-^1-2

Maryann Regan, BScN, CNN (C)- ²

Robert W. Teasell, MD FRCPC-^1-3

and the SCIRE Research Team

^1. Aging, Rehabilitation and Geriatric Care Program, Lawson Health Research Institute, London Ontario

^2. St. Joseph’s Healthcare London, Parkwood Hospital, London Ontario

^3. Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, University of Western Ontario, London Ontario.

Reprints available from author.

Corresponding author:

Robert W. Teasell, MD, FRCPC

Department of Physical Medicine and Rehabilitation

Parkwood Hospital

Hobbins Building, Suite 404

801 Commissioners Road E.

London, ON, N6C 5J1 Canada

Robert.Teasell@sjhc.london.on.ca

ABSTRACT

BACKGROUND: Pressure ulcers are a serious problem in the spinal cord injury (SCI) population, and approximately 85% will develop a pressure ulcer in their lifetime. Patient education is an important intervention in preventing and treating pressure ulcers in patients with SCI.

OBJECTIVE: To evaluate the effectiveness of pressure ulcer prevention education to reduce the occurrence of pressure ulcers.

METHODS: A systematic review of the literature was conducted using an extensive database (MEDLINE, CINAHL, EMBASE, PsycInfo) search, using the key terms ‘spinal cord injury’, ‘pressure ulcer’, and ‘education’. Relevant articles were evaluated for their methodological quality using the PEDro and/or Downs and Black assessment tools. Each study was then classified based on a modified version of Sackett’s Levels of Evidence.

RESULTS: Four articles met inclusion criteria including two level 2 randomized control trials, one level 2 prospective controlled trial, and one level 4 pre-post study. Follow-up education via telephone and an E-Learning prevention education program were the most common and successful patient education interventions. . An increased level of knowledge was documented in the majority of people who participated in the intervention groups, along with a decrease in hospital visits and occurrence of pressure ulcers.

CONCLUSION: There was strong evidence that increased SCI patient education regarding prevention and maintenance of pressure ulcers can decrease the incidence of pressure ulcers in patients with a spinal cord injury. This education therefore has significant implications for an individual’s quality of life (QOL). Furthermore, less frequent hospital stays would be expected to lead to a decrease in health care costs.

        Introduction

At present, there are approximately 44,000 people living with spinal cord injury (SCI) in Canada, and on average, there are 1,700 new injuries each year (Ramlo, Berlin, & Baxter, 2009). People with SCI require extensive and costly care, both as inpatients and outpatients. In 2005 the estimated cost of pressure ulcer related health care was three billion dollars (Fogerty et al., 2008). We can logically predict that the cost has increased substantially due to an overall rise in health care costs. Pressure ulcers are a  common secondary complication following  spinal cord injury and are most likely to occur in persons  that are frequently hospitalized,  who have less than a high school education, and/or have a high level of disability and mobility impairment, such as those who reside in a nursing home. Injury etiology does not appear to have a significant effect on development of a pressure ulcer (Chen, DeVivo, DrPH, Jackson, 2005).

Several factors put persons with SCI at a higher risk for developing a pressure ulcer; some of these factors are modifiable (i.e., preventable) and some are not (i.e., non-modifiable). Modifiable risk factors include a history of drug or alcohol abuse, diabetes, smoking, personal behaviours (e.g., poor self-care), and obesity. Identified non-modifiable risk factors include gender, age, race, level of SCI, level of functional status and economic status (Schryvers, Stranc, & Nance 2000). The most reliable predictor for the development of a recurrent pressure ulcer is having had a previous ulcer (Krause, & Broderick 2004). Development of pressure ulcers can also lead to secondary complications such as sepsis, contractures, permanent scarring, osteomyelitis, and deformities (Mathewson, Adkins, Lenyoun, Schmidt, & Jones 1999).

Caring for an individual with a spinal cord injury can be physically and emotionally taxing, especially when the person is highly dependent upon assistance to complete activities of daily living (ADL’s). Preventative skin care is among the most important daily routines for a person with SCI. It has been shown that individuals, who are active in their rehabilitation and are engaged in educational pressure ulcer prevention and management programs, often adhere to skin management protocols more successfully than do individuals who do not participate in such programs (Consortium for Spinal Cord Medicine, 2000). To date, patient education strategies that instruct people with SCI how to effectively care, manage, and prevent pressure ulcers have included online learning modules, telephone and video conferencing and one-on-one education sessions. The purpose of this study was to conduct a systematic review of the efficacy of pressure ulcer education interventions available for individuals with SCI.  

          Methods

Literature Search Strategy

A systematic review of all relevant literature, published from 1980 to June 2011, was conducted using multiple databases (MEDLINE, CINAHL, EMBASE, and PsycINFO). Key words included: spinal cord injuries, pressure ulcer, pressure sore, education, behavior management, and counseling. Retrieved references were scanned for relevant citations

  Study Selection

Studies were selected for analysis if: (i) at least 50% of the subjects had a SCI; (ii) there were at least three SCI subjects; (iii) there was a definable intervention involving education or counseling of individuals on pressure ulcer management.  There was no exclusion of studies passed on study design. Studies were excluded if there was insufficient reporting detail to enable data synthesis or if the study was a non-clinical trial i.e. reviews; epidemiology or basic sciences.

Study Appraisal

A quality assessment was conducted for each study by two reviewers, using the Physiotherapy Evidence Database (PEDro) scoringsystem for randomized controlled trials (RCTs; Moseley, Herbert, Sherrington, & Maher, 2002).  Any disagreements were resolved through consensus. The PEDro tool consists of 11 questions with a maximum score of 10.  In the present methodology, a PEDro score of 5 or lower was used to designate “poor” quality RCTS, which corresponds to a marginally lower score than the approximate mean value over all RCTs in the PEDro database conducted over the latest reported time periods (i.e., 1995-2002), (Foley, Bhogal, Teasell, Bureau, & Speechley, 2006).

Data Synthesis

Studies involving similar interventions were grouped and tabulated. Summary tables were developed indicating the PEDro (for RCTs), the type of study, a brief summary of intervention outcomes, and study results. The strength of the evidence for each intervention was rated using a modified Sackett scale (Straus, 2005).  .  The evaluation of the data led to the conclusion that a meta-analysis would be inappropriate to summarize the evidence due to the heterogeneity of the studies, inconsistency in the use of outcome measures, low methodological quality and insufficient data reporting.

 

         Results

 Study Size and Quality

Of the five studies included for analysis, only Rintala et al (2008) conducted power calculations. Sample sizes of all included studies ranged from 3 to 39, with an average sample size of 23 participants. Three studies qualified as Level 2 evidence; Garber et al. (2002) and Rintala et al. (2008) conducted randomized controls trials and Phillips et al. (1999) conducted a prospective controlled trial. Two studies qualified as Level 4 evidence (Brace et al., 2010; Jones et al., 2003); both studies had a pre-post study design. None of the studies used blind assessors and none of the participants were blinded from the interventions.

 Study Design

Three studies (Garber et al., 2002; Phillips et al., 1999; Rintala et al., 2008) compared one or more intervention groups to a control group. The remaining two studies (Brace et al., 2010; Jones et al., 2003) utilized a pre-post design whereby participants were measured at baseline, took part in an intervention and were measured again post-intervention (Table 1). All five studies incorporated pressure ulcer education on topics such as pressure ulcer definitions, risk factors, nutritional guidelines, skin checking, equipment, and preventative health behaviours, among others. Garber et al. (2002) and Brace et al. (2010) assessed knowledge uptake as a result of an intervention whereas Jones et al. (2003), Phillips et al. (1999), and Rintala et al. (2008) assessed knowledge translation; the ability of participants to change their behaviour after acquiring PU knowledge and reduce wound reoccurrence.

Garber et al. (2002) organized participants into two groups; the intervention group received individualized pressure ulcer prevention and management education sessions (4 hours) with take home information pamphlets and monthly follow-up telephone calls. The control group received only standard care at the hospital. Participants were followed for up to two years; pre-education test scores were compared to the post-education test scores from the pressure ulcer knowledge test, thereby assessing knowledge uptake. Similarly, Brace et al. (2010) had participants complete a pre-education pressure ulcer knowledge test, an e-learning program, and a post-education pressure ulcer knowledge test; pre- and post-test scores were compared to assess for knowledge uptake.

Rintala et al. (2008) organized participants into three groups; the intervention group received individualized pressure ulcer education sessions (4 hours) with take-home information and monthly telephone reminders whereas the other intervention group received monthly telephone reminders. The third group was the control and received only periodic telephone calls to ask about pressure ulcer reoccurrence. Patients were assessed for the reoccurrence and severity of pressure ulcers during baseline, intervention and post-intervention phases.

Jones et al. (2003) conducted two studies to also compare the reoccurrence and severity of pressure ulcers during baseline, intervention, and post-intervention phases. The first study had participants develop a nurse-participant health plan and attend clinic visits (maximum 14 over 2 years). The second study utilized the health plan and clinical visits in addition to a monetary reward system where participants received financial compensation for staying pressure ulcer-free.

Phillips et al. (1999) compared two intervention groups to a control; one intervention group took part in video counseling sessions for 6-8 weeks with an additional 4-6 weeks of telephone counseling sessions. The other intervention group received, on average, ten weeks of only telephone counseling sessions. The control group received only standard hospital education. All participants were surveyed 2-3 months post-discharge for the number of doctor, hospital and emergency department visits, and calls to the pressure ulcer help line.

Table 1: Summary of Reviewed Articles

Study	Participants	Intervention	Outcome Measure	Results
Braceet al., 2010Level 4Pre-Post	N = 18Mean Age = 49 yearsSex = 13M/7F	e-Learning Program(modules on PU definitions, risk factors, nutrition, skin checking, equipment etc.)	PU knowledge pre-test scores compared topost-test scores	89% of participants’ scores increased from pre- to post-testing1 participant’s score decreased from pre- to post-testing
Garberet al., 2002Level 2RCT	N = 39Mean Age =53 yearsSex: 39 M/0 F	Individual, structured PU prevention and management education sessions (4 hours) with take-home information pamphletsANDMonthly telephone call reminders	PU knowledge pre-test scores compared topost-test scores	Intervention group (84%) and control group (80%) improved test scoresIntervention and control group scores increased by 19.7% and 9.24%, respectively (significant difference, p<0.03)
Joneset al., 2003Level 4Pre-Post	N1 = 6N2 = 3Mean Age = 32 yearsSex: 7M/2F	Study 1 – Nurse-participant developed health planANDClinic visits (maximum of 14 over two years)Study 2 – Monetary rewards for PU-free skin	Occurrence and severity (PUSH) of pressure ulcers during baseline, intervention, and post-intervention phases, number of hospitalizations	Study 1 – Mean PUSH scores decreased from baseline by an average of 10.5 points per participant.  No participant needed hospitalization during the intervention phase. Average monthly cost of care decreased from $6262.00/participant to $235.00 (US)Study 2 – Mean PUSH scores decreased from baseline by 8.3 points (visits only) and a further 3.1 points (visits and payment). Total number of hospitalizations decreased from 1.67 (baseline) to 0.33 (intervention and post-intervention phase).
Phillipset al., 1999Level 2Prospective Controlled Trial	N = 35Mean Age = 33 yearsSex = 26M/9F	Educational video (10-12 weeks) + Counseling Session (6-8 weeks)OR Counseling Telephone Call (10 weeks)	Surveyed 2-3 months post-discharge for doctor, hospital and ER visits; calls to a PU help line; ulcer occurrences; and employment status	Annual ulcers: video (1.7), standard (1.6) and telephone (1.3)Annual ER visits: video (0.56), telephone (0.53) and standard (0.44)Annual hospitalizations: telephone (0.96), video (0.95) and standard (0.49)
Rintalaet al., 2008Level 2RCT	N = 39Mean Age = 54 yearsSex: 39M/0F	Individual, structured PU prevention and management education sessions (4 hours) with take-home information pamphletsAND/ORMonthly telephone call reminders	Occurrence and severity of pressure ulcers during baseline, intervention, and post-intervention phases	PU Reoccurrence: Enhanced education (33.3%), monthly telephone calls (60%), and quarterly mail survey (90%)Enhanced education participants had a longer time before recurrence of PU than participants receiving telephone callsIndividuals were ulcer free longer if many years had passed since their last surgery.For those with no previous ulcer surgery, persons receiving enhanced education were ulcer free longer than those receiving only telephone calls

Note.   ER = Emergency Room; F = Females; M = Males; PU = Pressure Ulcer;

PUSH = Pressure Ulcer Scale for Healing; RCT = Randomized Controlled Trial

 

Participant Characteristics

Three of the five studies included statistical information about their participants. Rintala et al. (2008) and Garber et al. (2002) did not find any significant differences between their participants on age, age at SCI, time since SCI, race, ethnicity, education, or etiology. Additionally, Rintala et al. (2008) did not find any differences in marital status, or the number of health problems related or unrelated to SCI between participants. Phillips et al. (1999) found that the only significant difference between treatment groups was that the video group were more likely to be married, less likely to be employed, more likely to be African American and have post-high school education. The two remaining studies (Brace et al., 2010; Jones et al., 2003) did not conduct statistical analyses to determine if participants differed significantly from one another. Jones et al. (2003) did not establish inclusion or exclusion criteria and did not reject participants based on past medical, behavioural or psychosocial history, therefore, a wide variety of participants were included.

 Patient Education Effectiveness

  Knowledge Uptake

To assess how well participants acquired knowledge regarding pressure ulcer prevention, Garber et al. (2002) gave pressure ulcer knowledge tests before and after in-person education/monitoring sessions.  They found that the 84% of the intervention group and 80% of the control group improved from pre-testing (hospital admission) to post-testing (hospital discharge). Scores increased by 19.7% in the intervention group but only 9.2% for the control group, which was statistically significant. The authors re-tested participants 24 months post-discharge to observe how well they retained the PU knowledge and found that the intervention group (68%) retained more knowledge than the control group (60.8%). Using the same testing method, Brace et al. (2010) also found that 89% of participants’ test scores improved after viewing a PU e-learning program.

 Knowledge Translation

To assess how well participants translated pressure ulcer education into preventative behaviors, Jones et al. (2003) offered in-person clinic visits for participants. The authors found that on average, PUSH (Pressure Ulcer Scale for Healing) scores decreased from baseline by 10.5 points per person indicating that the participant’s pressure ulcers reduced in frequency and severity. Additionally, no participant was hospitalized for a PU during the intervention phase which lasted between 9 and 22 months, resulting in a reduction in the monthly health care costs from $6262.00 to $235.00 per person. In Jones et al. (2003) second study it was observed that by incorporating monetary rewards for staying ulcer-free, participants’ average hospitalizations decreased from 1.67 at baseline to 0.33 during intervention and post-intervention phases. Compared to those receiving only clinic visits, participants receiving monetary rewards and clinic visits demonstrated an even further reduction in PUSH scores (8.3 points vs. 3.1 points, respectively). Rintala et al. (2008) also observed pressure ulcer reoccurrence rates among three study groups. Compared to those receiving enhanced education sessions (33%), individuals receiving monthly telephone calls and periodic telephone calls had reoccurrence rates as high as 60% and 90%, respectively. Additionally, enhanced education participants also had a longer time between pressure ulcers compared to those receiving only telephone calls. Phillips et al. (1999) also used telephone sessions, and video counseling sessions to monitor PU prevention behaviour. The authors found that compared to the standard and telephone group, 1.6 and 1.3 respectively, the video group had a greater number of annual ulcers (1.7). The video group (0.56) also had a higher number of annual emergency room visits compared to the telephone (0.53) and standard group. Finally, the highest rate of annual hospitalizations occurred in the telephone group (0.96) as compared to the video (0.95) and standard group (0.49).

 

 Discussion

In this systematic review, five articles met criteria for inclusion. The methods of pressure sore prevention education included e-learning strategies, in-person one-on-one education counseling combined with clinic visits, monthly telephone monitoring/education sessions, video monitoring/education sessions, and a system of monetary rewards. There was moderate evidence that SCI individuals’ knowledge of pressure ulcer prevention increased after in-person education sessions (level 2), and an e-learning program (level 4). There was level 4 evidence that showed following in-person clinic visits, individuals with SCI were able to decrease pressure ulcer severity scores and prevent rehospitalisation for PU for up to 22 months. In addition, there was level 4 evidence indicating that offering monetary rewards to patients, in combination with clinic visits, decreased the overall number of hospitalizations. There was level 2 evidence that enhanced education sessions, along with monthly structured follow-up intervention, was more effective in preventing pressure ulcers and showed a longer time between recurrences than monthly telephone calls or periodic contact.

 Knowledge Uptake

Two studies administered a PU knowledge test to their participants before and after an intervention. Brace et al. (2010) found 89% of participants improved their knowledge score. Following an e-learning program, Garber et al. (2002) had a similar result with 84% of participants’ scores improving after just four hours of individually structured PU prevention and management education sessions. Brace et al. (2010) had a more successful intervention, which could be due to the smaller sample size, a greater number of questions (20 vs. 14), and access to the testable information. The e-learning program was available for review at any time, whereas the individual information sessions in the Garber et al. (2002) study were only one hour long each time. Garber et al. (2002) also indicated that there was occasionally missing data, although what kind of data remains unknown; this lack of data could have altered the results.

The e-learning program provided SCI individuals with information on preventing and identifying pressure ulcer development and can assist in reducing the time a nurse educator is required to spend with a patient. The program was user friendly as it allowed participants to stop, start, and go back to the information whenever needed; it also included audio, videos and images. It also appeared suitable for use by a diverse range of learning levels and needs. Although this e-learning program has many unique advantages, there are some obstacles. These may include the inability of individuals to use the program if they are not familiar with computers or computer testing software; therefore, they might be less inclined to participate. Individuals with a higher level of injury also may not be able to use this program without assistance or specific computer adaptation

One-on-one education sessions are beneficial to patients as they receive individual attention and can have information presented to them in a way that is specifically tailored to their needs. Garber et al. (2002) measured knowledge that was “gained and retained” by veterans with SCI after participating in individualized education sessions on a variety of topics. One of the sessions included family members and care providers which is valuable as they are often providing most of the care. Veterans were also provided with a variety of take-home material which was helpful in reinforcing the material presented during the sessions. One-on-one education is beneficial to the patient because it allows for questions to be asked immediately, and directly to an educator who specializes in pressure ulcer prevention and management. It also gives the educator an opportunity to observe how the information is being understood by the participant.

 Knowledge Translation

There were three studies that examined knowledge uptake that is, transferring what was learned into behaviour. These studies showed a decrease in occurrence and severity of pressure ulcers following an intervention. Two of the studies measured the occurrence and severity of pressure ulcers at pre-intervention and post-intervention phases (Jones et al. 2003; Rintala et al. 2008). The third study, Philips et al. (1999), surveyed participants 2-3 months post-discharge for the number of hospital and ER visits they had, the number of times they called the PU help line, employment status, and the number of pressure ulcer occurrences.

Jones et al. (2003) indicated that mean PUSH scores decreased showing that both pressure ulcer reoccurrence and severity over time decreased. However, this study did not provide rates of PU reoccurrence as the other studies did, which limits our ability to compare between studies. In Jones et al. (2003) first study, the authors found that the average monthly cost of health care for a PU was reduced which can be attributed to the fact that no participant was hospitalized during the 9-22 months of the study. The results of this study are limited due to the fact that there were a small number of participants and only one individual completed the full intervention.  Additionally, the participants chosen for this study were not screened for any medical, behavioural, or psychosocial conditions which may have interfered with their ability for self-care. It was also noted that the participants were described as resistant to authority, and were reluctant to follow direction from physicians and health care professionals. When a monetary reward was introduced to participants in the second study, they had a seemingly stronger interest in performing proper skin care. All participants were in a financial situation where they could have benefitted from the use of the monetary incentives to improve their living conditions. In the second study with monetary rewards, there was an insufficient number of participants (n = 2) to make any firm conclusions regarding efficacy of the intervention and this requires further study regarding the role of financial incentives and self-care. Providing a monetary reward to individuals may also be unrealistic given limited current healthcare resources.

Phillips et al. (1999) measured the reoccurrence of PU’s over a one year span, while Rintala et al. (2008) measured reoccurrence over approximately one and a half years’ time. Compared to the two standard groups in the studies by Phillips et al. and Rintala et al. (2008) the telephone education intervention was more effective in reducing pressure ulcer reoccurrence. The video group in Phillips et al. (1999) had little differentiation in success from the standard group. Due to the fact that the video group had a nurse actually viewing their skin, it was more likely that the nurse who is experienced at recognizing PU’s would diagnose an ulcer at an earlier stage than a patient who may not recognize and report an ulcer until the later stages of an ulcer. This could be the explanation as to why the video group had a higher PU occurrence rate than the telephone or standard group.

The in-person education group in the study by Rintala et al. (2008) was much more successful in preventing reoccurrence of PU’s than the standard group. Only 33.3% (n=20) of participants in the enhanced education group had PU reoccurrence during the study, whereas 90% (n=10) in the standard group had a reoccurrence. The enhanced education group had twice as many participants in it than the telephone group and the standard group. This could potentially be problematic as small sample sizes often report significant findings that are neutralized with more participants. With a larger sample size we could still observe this same trend, but it could also show a statistically significant stronger or weaker relationship.  An obvious limitation to this study is self-assessment of PU’s by participants in the telephone intervention and standard group. Individuals may exclude information or not properly report their skin status; as well, they may not be able to see their skin in some areas and must rely on someone else to report findings, risking that this person may not be able to evaluate a PU properly. Standard group participants may not have mailed back their information which also could have altered results. Finally, due to the broad inclusion criteria of this study, all of the participants had a wide variety of characteristics such as time since last surgery, self-reported health at admission, level of SCI, and PU location. Given the variability of the participants, it is difficult to generalize the results to one type of SCI individual. To a larger extent, all of the studies included in this review involved participants who had never had a pressure ulcer, who had had a pressure ulcer, or included both types of participants.

          Conclusion

The e-learning program presented by Brace et al. (2010) is the most feasible education intervention regarding prevention and management of pressure ulcers in individuals with SCI. E-learning is cost effective because one program could be purchased per institution and used with all patients. It does not require an institution to hire an individual to run the program and it has the potential to be used in the comfort of the participant’s home once they have been discharged. The enhanced education sessions presented by Rintala et al. (2008) provided a multifactorial way of effectively educating participants about the prevention and management of pressure ulcers. Individually structured education sessions with an expert on PU’s are feasible, yet time consuming. It is costly to hire an individual to run these sessions, although it is likely to be much less expensive than the cost of treating PU’s (US Department of Health and Human Services, 1992). Follow-up telephone interviews are also a time consuming intervention, yet worth-while to ensure participants understand and retain the knowledge gained through their individual sessions. Hopefully this review will help SCI practitioners and nurse educators when designing and administering education programs.

 

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EDITOR: June Kaminski