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Poster 21: Telemetric Wound Monitoring and its Clinical Applications: A Review of the Literature
Abstracts / PM R 9 (2017) S131-S290 Poster 19: Evaluating Amputee Mobility with AMPPRO and PEQMS: A 4.5-Year Retrospective Chart Review Brian Kaluf (Ability Prosthetics and Orthotics, Inc., Exton, PA, USA) Disclosures: Brian Kaluf: Research Grants - Freedom Innovations, LLC Objective: A 4.5-year retrospective chart review of outcome measure data from patients with amputation investigated the relationship of patient perceived mobility and functional ability, as well as the effect of age, amputation level and cause of amputation. The effects of proposed Medicare policy changes relating to lower limb amputees were then evaluated through projections against retrospective data. The subjective nature of the Medicare Functional Classification Level (MFCL) for amputees, poses frequently cited limitations. Recently, Medicare proposed changes to the MFCL guidelines without investigating potential implications. Outcome measure data allows projection of how proposed Medicare policy changes would affect access to care for patients in different MFCL. Design: Retrospective chart review. Setting: Outpatient prosthetic clinic. Participants: 109 lower limb amputees across 11 clinics. Interventions: Lower limb prostheses. Main Outcome Measures: The Prosthetic Evaluation Questionnaire Mobility Subscale (PEQ-MS) rates difficulty performing 12 ambulatory tasks. The Amputee Mobility Predictor (AMPPRO) assesses mobility and function of amputees. These tools produce quantitative data on mobility and functional outcome. Results: There was a positive correlation between PEQ-MS and AMPPRO scores. Average AMPPRO decreased with age. PEQ-MS scores did not follow the same trend. Little difference was seen across amputation level, but traumatic/tumor amputation cause had higher AMPPRO and PEQ-MS scores than dysvascular/infection. If proposed Medicare policy was enacted, 44% of patients would lose access to their current prosthetic technology due to falling into a lower MFCL category. By looking at AMPPRO scores, even patients with high functional mobility would be affected by proposed policy change. Conclusions: Patients with higher functional mobility (AMPPRO) had higher perceived mobility (PEQ-MS). Age and amputation cause influenced mobility. Using retrospective outcome measure data to project effects of a proposed Medicare policy change, showed how patients at all levels of functional mobility could lose access to their current prosthetic technology with the proposed policy change. Level of Evidence: Level III Poster 20: Preliminary Study of Vitamin D Level in Adult Patients with Severe Burn Yuemeng Dai, MD (Univ of TX Southwestern Med Ctr), Karen J. Kowalske, MD, Cindy A. Dolezal, PT, DPT Disclosures: Yuemeng Dai: I Have No Relevant Financial Relationships To Disclose Objective: To measure and trend vitamin D (25-(OH)D) level in hospitalized adult patients with severe burn (>20% total body surface area (TBSA)). Design: Prospective cohort study. Setting: Burn unit and inpatient rehabilitation unit of level one trauma hospital. Participants: Adult patients with severe burn. Interventions: Not applicable. Main Outcome Measures: Serum vitamin D (25-(OH)D) level weekly. Results: Four patients (three males, one female, age 19-56) with severe burn injury (45%-75% total body surface area) have been enrolled, none of whom received vitamin D supplementation during the study. All patients had very low level of vitamin D (25-(OH)D) on admission
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(i.e. Patient 1: 22.2 ng/mL; patient 2: <13 ng/mL; patient 3: 14.9 ng/ mL, patient 4 <13 ng/mL). To trend the vitamin D level during the hospital stay, the vitamin D (25-(OH)D) level was measured every week for up to 8 weeks or until patient was discharged home. Patient 1 was followed for 4 weeks and the vitamin D (25-(OH)D) level was 26.9 ng/ mL upon discharge, which was the highest level during the hospital stay. Patient 2 was followed for 8 weeks and the vitamin D (25-(OH)D) level was slightly increased to 20.8 ng/mL on week 8. Patient 3 was followed for 2 weeks and the vitamin D (25-(OH)D) level was 19 ng/mL in the second week. Patient 4 was followed for 4 weeks and the vitamin D (25-(OH)D) level continued to be <13 ng/mL (undetectable level) every week. Conclusions: This preliminary study shows that all four adult patients with severe burns had vitamin D deficiency (<30 ng/mL), which was not significantly improved during hospital stay without vitamin D supplement treatment. This suggests that the vitamin D level in the patients with severe burn should be measured on admission and the early vitamin D supplementation might be necessary for those with vitamin D deficiency. This study is currently ongoing and the results will be confirmed as enrollment continues. Level of Evidence: Level IV Poster 21: Telemetric Wound Monitoring and its Clinical Applications: A Review of the Literature Vinicius Tieppo Francio, MD/PhD(c) (USAT College of Medicine, Oklahoma City, OK, United States), Robert Dima, none, Mark A. Young, MD, MBA, FACP Disclosures: Vinicius Tieppo Francio: I Have No Relevant Financial Relationships To Disclose Objective: Chronic wounds present a significant financial burden to the U.S. healthcare system, and current methods in wound monitoring are often ineffective. The cost for wound treatment is nearly $25 billion annually. To improve economical and clinical efficiency, it is imperative to explore novel technological wound monitoring methods that avoid wound aggravation. The purpose of this review is to investigate the current state of the research in telemetric wound monitoring and its potential benefits and impact to care delivery. Design: Review of the literature. Setting: N/A. Participants: N/A. Interventions: N/A. Main Outcome Measures: N/A. Results: Current methods in wound monitoring tend to disturb the healing process. Moisture, pressure, temperature and pH under dressings are difficult to monitor, yet significantly impact healing rates and the likelihood of infection. In response to the need for more effective wound monitoring, recent studies exploring the efficacy of remote wound monitoring using telemetric devices coupled with specialized sensors have been published. Based on our review, different telemetry systems that can accurately measure changes in moisture, temperature, pH and pressure under dressings have been developed. They feature flexible pad materials adaptable to human skin contour. These systems are low energy for patient safety yet capable of effective transmission (typically 4-5 meter range). Few human studies assessing their performance have been published, but those reviewed suggest that this technology may be of potential benefit in clinical practice to monitor physiological variables, which are difficult to observe with manual methods yet relevant to the healing process. Conclusions: The utilization of telemetry sensing technology could be considered a useful strategy to improve wound monitoring, thus potentially improving clinical outcomes, decreasing infection rates and hospitalization length of stay. Current barriers to the use of these systems are the lack of human studies and the limitations of the
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technology itself in terms of cost and implementation to health care facilities. Level of Evidence: Level III Poster 22: Lack of Vitamin D Replacement in Low Vitamin D Individuals with Spinal Cord Injury is Associated with an Increased Risk of Venous Thrombotic Events During Acute Inpatient and Rehabilitation Hospitalization Reza Ehsanian, MD, PhD (Santa Clara Valley Medical Center, San Jose, CA, USA), Molly A. Timmerman, DO, Kazuko L. Shem, MD, Jerry Wright, MS, Stephen McKenna, MD, James Crew, MD Disclosures: Reza Ehsanian: I Have No Relevant Financial Relationships To Disclose Objective: To determine if lack of vitamin D replacement in persons with acute spinal cord injury (SCI) and low vitamin D levels is associated with an increased risk of venous thrombotic events (VTE). Design: Retrospective cohort study. Setting: Academic Medical Center. Participants: Two hundred eighty two persons admitted consecutively to acute inpatient rehabilitation at Santa Clara Valley Medical Center (SCVMC) with a diagnosis of SCI from December 2009 to January 2013. Interventions: Not applicable. Main Outcome Measures: We investigated the incidence of low vitamin D in our patient population and determined significant associations with regard to demographic variables, injury characteristics, low vitamin D and replacement status. Specific to our hypothesis, we looked at whether low vitamin D levels and status of vitamin D replacement correlated with VTE incidence. Results: The risk of VTE is clinically relevant but not statistically significant among SCI patients who have low vitamin D levels (43/228 ¼ 18.8%) vs. normal vitamin D levels (6/54 ¼ 11.1%) (Fisher’s exact test, p ¼ .23). Individuals with low vitamin D who did not have vitamin D replaced had a VTE rate of 24 % (42/178) vs. 2% (1/50) amongst those with low vitamin D who did not receive replacement (p ¼ .0002); Odds ratio 15.13; 95% CI 2.03-113. In contrast, there was no statistically significant difference of VTE rates (p ¼ 1.0) in persons with normal vitamin D levels who were not taking vitamin D supplementation vs. those who were taking vitamin D supplementation (10.8% (5/46) vs. 12.5% (1/8). Conclusions: This study is the first to demonstrate an association between lack of vitamin D replacement and VTE occurrence in person with acute SCI and low vitamin D. Level of Evidence: Level III Poster 23: Measuring the Effect of Patient and Caregiver Education on Preventing UTI and the Inappropriate Treatment of Catheter-Associated Bacteriuria in the Outpatient Spinal Cord Injury Population Peter D. Torberntsson, MD (Denver VA Med Cntr), Kathleen BertoneKellogg, APRN, CRRN Disclosures: Peter Torberntsson: I Have No Relevant Financial Relationships To Disclose Objective: To test the hypothesis that patients and their caregivers in an outpatient spinal cord injury clinic setting who use chronic indwelling or intermittent catheters and are provided information on symptoms of true UTI, appropriate catheter hygiene and indications for antibiotic treatment would result in less of an incidence of antibiotic treatment, culture confirmed UTI, and utilization of urinalyses. Design: Retrospective chart review study collecting UTI treatment data after educational intervention during clinic including a patient handout on identifying symptoms of true UTI, appropriate catheter hygiene, and education on the indications for antibiotic treatment.
Setting: Outpatient Spinal Cord injury clinic. Participants: A cohort of 11 patients with identified recurrent UTI (greater than 2 UTIs or antibiotic treatments for suspected UTIs) over the course of one year prior to the intervention were identified and given education information during their clinic visits and a patient hand out. Interventions: Education provided in clinical setting and patient handout regarding UTI symptoms, catheter hygiene and indications for antibiotic use. Main Outcome Measures: Reduction in the number of antibiotic treatments for suspected UTI, the number of urinalyses performed and the number of culture positive UTIs and sensitivities in the year after education intervention was provided. Results: Education intervention was associated with a 75% reduction in antibiotic treatment for UTIs. Furthermore, there was a 56% reduction in the number of urinalyses that were performed and 62% reduction in culture positive UTIs (p¼.1.05). Conclusions: Educational intervention appeared to trend towards statistical significance in reducing the number of antibiotic treatments for UTI, the number of UAs performed and the number of culture confirmed UTIs. The number of study participants should be increased to determine if statistical significance can be determined. Level of Evidence: Level IV Poster 24: Burn and Amputations: A Retrospective Analysis 379 Amputation out of 19,958 Burns in 10-year Ki Un Jang (Gangnam Sacred Heart Hosp., Hallym University Medical College, Seoul, South Korea, Korea, Republic Of), Jee Hee Jo, MD, Cheonghoon Seo, MD Disclosures: Ki Un Jang: I Have No Relevant Financial Relationships To Disclose Objective: This study set the goal to afford a baseline for practical programming in prevention, management and rehabilitation in burned amputation. Several special suggestions could be recommended based on these findings. Our work looks for reducing incidence of burned amputation and to promote the rehabilitation program. Design: Retrospective cohort study. Setting: University hospital burn center and rehabilitation unit. Participants: Data were collected from 19,958 burn patients during the period 2001e2010, and amputation occurred in 379 burn patients in the same period. Interventions: Not applicable. Main Outcome Measures: Demographics, etiology, a kind of burn, extent of burn, administrative data, hospital stay, and data of amputations. Amputations not due to burns were excluded. The kind of burns was classified into flame, scald, electrical, contact, spark, radiation and chemical burns. Total burn body surface area (%TBSA) was collected. Results: The most common kind of burn was scald burn in 42.1%, followed by flame burn 33.6%, contact burn 10.8%, and electrical burn 5.9%. Children under the age of 15 constituted about 29.1% (n¼5818). Average hospital stay was 28.80.9 days (P<.05), the longest stayed in electrical burns in 72.6 days. The amputation occurred in 379 out of total 19,958. The amputation rate was 1.9%, which slowly decreased in the last ten years, changing from 2.3-2.6% to 1.2-1.4%. The amputation rate was highest in the electrical burn in 19.2%; the most common level of amputation was finger amputation in 168 as 42.0%. Major amputation was 158 cases in 38.9%; minor amputation was 248 cases in 61.1%. Conclusions: This information thus obtained in this investigation would be expected to be helpful to support prevention program, management protocol, and rehabilitation program for burned amputees for their welfare. Level of Evidence: Level II
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(i.e. Patient 1: 22.2 ng/mL; patient 2: <13 ng/mL; patient 3: 14.9 ng/ mL, patient 4 <13 ng/mL). To trend the vitamin D level during the hospital stay, the vitamin D (25-(OH)D) level was measured every week for up to 8 weeks or until patient was discharged home. Patient 1 was followed for 4 weeks and the vitamin D (25-(OH)D) level was 26.9 ng/ mL upon discharge, which was the highest level during the hospital stay. Patient 2 was followed for 8 weeks and the vitamin D (25-(OH)D) level was slightly increased to 20.8 ng/mL on week 8. Patient 3 was followed for 2 weeks and the vitamin D (25-(OH)D) level was 19 ng/mL in the second week. Patient 4 was followed for 4 weeks and the vitamin D (25-(OH)D) level continued to be <13 ng/mL (undetectable level) every week. Conclusions: This preliminary study shows that all four adult patients with severe burns had vitamin D deficiency (<30 ng/mL), which was not significantly improved during hospital stay without vitamin D supplement treatment. This suggests that the vitamin D level in the patients with severe burn should be measured on admission and the early vitamin D supplementation might be necessary for those with vitamin D deficiency. This study is currently ongoing and the results will be confirmed as enrollment continues. Level of Evidence: Level IV Poster 21: Telemetric Wound Monitoring and its Clinical Applications: A Review of the Literature Vinicius Tieppo Francio, MD/PhD(c) (USAT College of Medicine, Oklahoma City, OK, United States), Robert Dima, none, Mark A. Young, MD, MBA, FACP Disclosures: Vinicius Tieppo Francio: I Have No Relevant Financial Relationships To Disclose Objective: Chronic wounds present a significant financial burden to the U.S. healthcare system, and current methods in wound monitoring are often ineffective. The cost for wound treatment is nearly $25 billion annually. To improve economical and clinical efficiency, it is imperative to explore novel technological wound monitoring methods that avoid wound aggravation. The purpose of this review is to investigate the current state of the research in telemetric wound monitoring and its potential benefits and impact to care delivery. Design: Review of the literature. Setting: N/A. Participants: N/A. Interventions: N/A. Main Outcome Measures: N/A. Results: Current methods in wound monitoring tend to disturb the healing process. Moisture, pressure, temperature and pH under dressings are difficult to monitor, yet significantly impact healing rates and the likelihood of infection. In response to the need for more effective wound monitoring, recent studies exploring the efficacy of remote wound monitoring using telemetric devices coupled with specialized sensors have been published. Based on our review, different telemetry systems that can accurately measure changes in moisture, temperature, pH and pressure under dressings have been developed. They feature flexible pad materials adaptable to human skin contour. These systems are low energy for patient safety yet capable of effective transmission (typically 4-5 meter range). Few human studies assessing their performance have been published, but those reviewed suggest that this technology may be of potential benefit in clinical practice to monitor physiological variables, which are difficult to observe with manual methods yet relevant to the healing process. Conclusions: The utilization of telemetry sensing technology could be considered a useful strategy to improve wound monitoring, thus potentially improving clinical outcomes, decreasing infection rates and hospitalization length of stay. Current barriers to the use of these systems are the lack of human studies and the limitations of the
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technology itself in terms of cost and implementation to health care facilities. Level of Evidence: Level III Poster 22: Lack of Vitamin D Replacement in Low Vitamin D Individuals with Spinal Cord Injury is Associated with an Increased Risk of Venous Thrombotic Events During Acute Inpatient and Rehabilitation Hospitalization Reza Ehsanian, MD, PhD (Santa Clara Valley Medical Center, San Jose, CA, USA), Molly A. Timmerman, DO, Kazuko L. Shem, MD, Jerry Wright, MS, Stephen McKenna, MD, James Crew, MD Disclosures: Reza Ehsanian: I Have No Relevant Financial Relationships To Disclose Objective: To determine if lack of vitamin D replacement in persons with acute spinal cord injury (SCI) and low vitamin D levels is associated with an increased risk of venous thrombotic events (VTE). Design: Retrospective cohort study. Setting: Academic Medical Center. Participants: Two hundred eighty two persons admitted consecutively to acute inpatient rehabilitation at Santa Clara Valley Medical Center (SCVMC) with a diagnosis of SCI from December 2009 to January 2013. Interventions: Not applicable. Main Outcome Measures: We investigated the incidence of low vitamin D in our patient population and determined significant associations with regard to demographic variables, injury characteristics, low vitamin D and replacement status. Specific to our hypothesis, we looked at whether low vitamin D levels and status of vitamin D replacement correlated with VTE incidence. Results: The risk of VTE is clinically relevant but not statistically significant among SCI patients who have low vitamin D levels (43/228 ¼ 18.8%) vs. normal vitamin D levels (6/54 ¼ 11.1%) (Fisher’s exact test, p ¼ .23). Individuals with low vitamin D who did not have vitamin D replaced had a VTE rate of 24 % (42/178) vs. 2% (1/50) amongst those with low vitamin D who did not receive replacement (p ¼ .0002); Odds ratio 15.13; 95% CI 2.03-113. In contrast, there was no statistically significant difference of VTE rates (p ¼ 1.0) in persons with normal vitamin D levels who were not taking vitamin D supplementation vs. those who were taking vitamin D supplementation (10.8% (5/46) vs. 12.5% (1/8). Conclusions: This study is the first to demonstrate an association between lack of vitamin D replacement and VTE occurrence in person with acute SCI and low vitamin D. Level of Evidence: Level III Poster 23: Measuring the Effect of Patient and Caregiver Education on Preventing UTI and the Inappropriate Treatment of Catheter-Associated Bacteriuria in the Outpatient Spinal Cord Injury Population Peter D. Torberntsson, MD (Denver VA Med Cntr), Kathleen BertoneKellogg, APRN, CRRN Disclosures: Peter Torberntsson: I Have No Relevant Financial Relationships To Disclose Objective: To test the hypothesis that patients and their caregivers in an outpatient spinal cord injury clinic setting who use chronic indwelling or intermittent catheters and are provided information on symptoms of true UTI, appropriate catheter hygiene and indications for antibiotic treatment would result in less of an incidence of antibiotic treatment, culture confirmed UTI, and utilization of urinalyses. Design: Retrospective chart review study collecting UTI treatment data after educational intervention during clinic including a patient handout on identifying symptoms of true UTI, appropriate catheter hygiene, and education on the indications for antibiotic treatment.
Setting: Outpatient Spinal Cord injury clinic. Participants: A cohort of 11 patients with identified recurrent UTI (greater than 2 UTIs or antibiotic treatments for suspected UTIs) over the course of one year prior to the intervention were identified and given education information during their clinic visits and a patient hand out. Interventions: Education provided in clinical setting and patient handout regarding UTI symptoms, catheter hygiene and indications for antibiotic use. Main Outcome Measures: Reduction in the number of antibiotic treatments for suspected UTI, the number of urinalyses performed and the number of culture positive UTIs and sensitivities in the year after education intervention was provided. Results: Education intervention was associated with a 75% reduction in antibiotic treatment for UTIs. Furthermore, there was a 56% reduction in the number of urinalyses that were performed and 62% reduction in culture positive UTIs (p¼.1.05). Conclusions: Educational intervention appeared to trend towards statistical significance in reducing the number of antibiotic treatments for UTI, the number of UAs performed and the number of culture confirmed UTIs. The number of study participants should be increased to determine if statistical significance can be determined. Level of Evidence: Level IV Poster 24: Burn and Amputations: A Retrospective Analysis 379 Amputation out of 19,958 Burns in 10-year Ki Un Jang (Gangnam Sacred Heart Hosp., Hallym University Medical College, Seoul, South Korea, Korea, Republic Of), Jee Hee Jo, MD, Cheonghoon Seo, MD Disclosures: Ki Un Jang: I Have No Relevant Financial Relationships To Disclose Objective: This study set the goal to afford a baseline for practical programming in prevention, management and rehabilitation in burned amputation. Several special suggestions could be recommended based on these findings. Our work looks for reducing incidence of burned amputation and to promote the rehabilitation program. Design: Retrospective cohort study. Setting: University hospital burn center and rehabilitation unit. Participants: Data were collected from 19,958 burn patients during the period 2001e2010, and amputation occurred in 379 burn patients in the same period. Interventions: Not applicable. Main Outcome Measures: Demographics, etiology, a kind of burn, extent of burn, administrative data, hospital stay, and data of amputations. Amputations not due to burns were excluded. The kind of burns was classified into flame, scald, electrical, contact, spark, radiation and chemical burns. Total burn body surface area (%TBSA) was collected. Results: The most common kind of burn was scald burn in 42.1%, followed by flame burn 33.6%, contact burn 10.8%, and electrical burn 5.9%. Children under the age of 15 constituted about 29.1% (n¼5818). Average hospital stay was 28.80.9 days (P<.05), the longest stayed in electrical burns in 72.6 days. The amputation occurred in 379 out of total 19,958. The amputation rate was 1.9%, which slowly decreased in the last ten years, changing from 2.3-2.6% to 1.2-1.4%. The amputation rate was highest in the electrical burn in 19.2%; the most common level of amputation was finger amputation in 168 as 42.0%. Major amputation was 158 cases in 38.9%; minor amputation was 248 cases in 61.1%. Conclusions: This information thus obtained in this investigation would be expected to be helpful to support prevention program, management protocol, and rehabilitation program for burned amputees for their welfare. Level of Evidence: Level II