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IMPLEMENTING EVIDENCE-BASED CLINICAL PRACTICE GUIDELINES WITHIN AN 5-YEAR INTERNATIONAL

COHORT STUDY OF THE RISK FACTORS FOR SITTING-ACQUIRED PRESSURE ULCERS (AUSCAN RISK)

Karen E Campbell, Jillian Swaine,, Keith Hayes, Michael Stacey & The AusCAN Pressure Ulcer Risk Scale Study*

The AusCAN Pressure Ulcer Risk Scale Study*◦ Jillian M Swaine, Dan Bader, Michael C. Stacey, James

Middleton, James Olver, Keith Hayes, Susan Garber, Delia Hendrie, Karol Miller, Barbara Braden, Richard Parsons, Amit Gefen, Timothy Geraghty, John Ker, and Karen Campbell.◦ This research was supported by the National Health and Medical

Research Council (Australia(grant number 634388)), Ontario Neurotrauma Foundation (Canada), and the Rick Hansen Institute (Canada)

Objectives◦ To provide a brief overview

AusCAN Risk study◦ To identify key recommendations

from the Canadian BPG Pressure Ulcers (Injuries)

◦ To demonstrate an example of how they were integrated into the study design

BACKGROUND◦Pressure Ulcers and SCI• 35% point prevalence of SIII, SIV pressure ulcers• 80-90% people with spinal cord injury (SCI) will have PU sometime in lifetime

• most prevalent >20years post SCI (age adjusted)

• 15% SCI population have recurrent pressure ulcers - spent a total of 8 of past 20 years with Pus (40% of time)

• PU location• Acute care: sacrum , heels• Whole population (maj community) ischial tuberosity -

SAPUs,

AusCAN◦AusCAN Risk Assessment for Sitting Acquired Pressure Ulcers (AusCAN Risk) study is a cohort study ◦Aim to determine the risk factors associated with the development of sitting acquired pressure ulcers following spinal cord injury (SCI) ◦6 sites across Australia and Canada

CANADIAN BEST PRACTICE GUIDELINES FOR THEPREVENTION, ASSESSMENT, AND TREATMENT OFPRESSURE ULCERS IN PEOPLE WITH SCI ◦ Co-Leads Pamela Houghton & Karen Campbell◦ David Keast, Laura Titus, Chris Fraser

◦ and 8 interdisciplinary BPG Panel Members

Ontario Neurotrauma Foundation in collaboration with Rick Hansen Institute

Levels of evidence

3 8 12 25 75

Recommendation level = Ia

◦Components of nutritional assessment◦ Nutrition- hydration- related blood work

◦Daily protein intake

◦Electrical stimulation to speed closure◦ of pressure ulcers

3.3: Components of nutritional assessment ◦ Assess nutritional status of all spinal cord-injured

individuals who are at risk of developing, or present with, a pressure ulcer, on admission, with each change in condition, and when the pressure ulcer is not healing at the expected rate. ◦ This assessment should include the following: Level• Dietary intake and losses IIb• Nutrition- and hydration-related blood work Ia

Daily protein intake

◦ Provide 1.0 to 2.0 g/kg protein daily for people at risk of developing pressure ulcers. ◦ Provide a daily protein intake at the higher end of the range for

people with severe pressure ulcers

◦ Recommendation level Ia

24-hour approach to pressure ulcer risk management

◦ Perform a comprehensive assessment of posture and positioning to evaluate pressure ulcer risk. Consider all surfaces in both recumbent and sitting positions that a person uses to participate in daily activities over the entire 24-hour period.

◦ Recommendation level IV

Principles of sitting posture and positioning for pressure management ◦Address pelvic asymmetry, postural instability, kyphosis, and spasticity using postural management and support surfaces.

◦ Evaluate the effects of posture, deformity, and movement on interface pressure distribution

Principles of sitting posture and positioning for pressure management ◦ Evaluate the influence of sub-dermal tissue loads on sitting support surfaces.

◦Consider the effects of clothing, shoes, and additional layers on the surface’s microclimate, friction, shear and pressure-redistributing properties.

Interprofessional team for pressure ulcer treatment

◦ Ensure timely referral to the interprofessional spinal cord injury team in treating pressure ulcers in this population.

Spinal cord injury interprofessional team ◦ Develop an interprofessional spinal cord injury team that

includes, at a minimum, ◦ a physiatrist (or physician with spinal cord injury

training), ◦ occupational therapist, ◦ physiotherapist, ◦ wound-care clinician, ◦ nurse, ◦ psychologist, social worker, ◦ dietitian.

◦ Ensure that all team members have knowledge of spinal cord injury and pressure ulcer prevention and care.

Electrical stimulation to speed closure of pressure ulcers◦ Use electrical stimulation combined with

standard wound care interventions to promote closure of stage III or IV pressure injuries

◦ Recommendation level Ia

Other adjunctive therapies for nonsurgical treatment of pressure injuries ◦ Consider adding the following adjunctive therapies to a standard

wound care program to speed healing of stage II, III or IV pressure injuries

◦ Recommendation level ◦ Electromagnetic energy Ib◦ Ultraviolet-C light Ib◦ Noncontact nonthermal acoustic therapy III◦ Topical oxygen III◦ Maggot therapy III◦ Topical recombinant growth factors III◦ Recombinant erythropoietin III◦ Anabolic steroids III◦ Activated factor XIII III◦ Tension therapy IV◦ Hyperbaric oxygen IV

Aims◦To develop an evidence-based method to identify signs of a pressure injury for both the research assistants in an international cohort study who are not HCP, OTs and PTs and participants with Spinal Cord Injuries

Methods◦Review Clinical Practice Guidelines◦ Literature review to identify clinical guidelines for the

assessment of pressure injuries ◦ Assess clinical guidelines based on inclusion/exclusion criteria

◦ Translate Interventions◦ Two wound care experts independently review the guidelines

for specific signs and symptoms ◦ Identify key criteria and ancillary criteria for each pressure injury type◦ Identify any criteria that is overlapping between pressure injury types

Methods◦ Translate Interventions◦ Literature review for valid and reliable methods for assessing

specific pressure injuries or signs/symptoms

◦Design interventions◦ Translate the CPG into a clinical tool for participants in Australia

and Canada in the study to identify signs of a pressure injury ◦ Create a training video, handout and a script for the face-to-

face skin assessment and biweekly telephone surveillance

Results◦Part A: Review Clinical Practice Guidelines The CPG has 6 distinct pressure injury: 5 stages and a suspected deep tissue injury ◦ Definitions for pressure ulcers from international CPG

◦Each pressure injury type have a description that includes: key clinical sign and numerous “may have” additional signs/conditions

Results◦Part B: Translating Clinical Practice Guidelines usingBehaviour Change Theory

◦ We integrated the new Clinical Practice Guidelines with the BehaviourChange Theory [4] which is a systematic methodology for identifying thetarget behaviour and designing the intervention specific to that targetbehaviour

Results◦ Part C: Intervention Design Figure: ◦ “Check Your Cheeks” training video ◦ Telephone surveillance script ◦ Handout: Behaviour change techniques (BCTs) and Motivational

Interviewing techniques have been embedded in each of these interventions

Results

VideoTelephone script

BCT

Conclusions• Clinical Practice Guidelines need to be translated using a theoretical model

that provides a systematic approach that includes a Behavioural Analysis and Intervention Design

• Intervention Design includes defining the target behaviour, modes, and behaviour change techniques (BCTs) and Motivational Interviewing

• The skin checking behaviour intervention design is ‘Check Your Cheeks’ video, handout and telephone surveillance script

• It is being used in AusCAN Pressure Ulcer Risk Scale Study every 2 weeks and it has high acceptability with 108 participants, 6 sites in Canada and Australia

References 1.Clay-Williams, R., Hounsgaard, J., & Hollnagel, E. (2015). Where the rubber meets

the road: using FRAM to align work-as-imagined with work-as-done whenimplementing clinical guidelines. Implementation Science, 10(125).

2.Cramm, H., & White, C. (2011). KT and OT: A context for knowledge translation foroccupational therapy. 13(6), 24-26.

3.European Pressure Ulcer Advisory Panel (EPUAP), & National Pressure UlcerAdvisory Panel (NPUAP). (2009). Prevention and treatment of pressure ulcers:quick reference guide. Washington, DC: National Pressure Ulcer Advisory Panel.

4.Michie, S., van Stralen, M., & West, R. (2011). The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation Science, 6,42.