- Email: [email protected]
Psychometric Properties of the Spinal Cord Injury Pressure Ulcer Scale (SCIPUS) for Pressure Ulcer Risk Assessment During Inpatient Rehabilitation
Accepted Manuscript Psychometric properties of the spinal cord injury pressure ulcer scale (SCIPUS) for pressure ulcer risk assessment during inpatient rehabilitation Jude J. Delparte, MSc, Carol Y. Scovil, PhD, Heather M. Flett, BScPT, MSc, Johanne Higgins, PhD, Marie-Thérèse Laramée, PT, MSc, Anthony S. Burns, MD MSc PII:
S0003-9993(15)00563-8
DOI:
10.1016/j.apmr.2015.06.020
Reference:
YAPMR 56249
To appear in:
ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION
Received Date: 22 April 2015 Revised Date:
29 June 2015
Accepted Date: 30 June 2015
Please cite this article as: Delparte JJ, Scovil CY, Flett HM, Higgins J, Laramée M-T, Burns AS, Psychometric properties of the spinal cord injury pressure ulcer scale (SCIPUS) for pressure ulcer risk assessment during inpatient rehabilitation, ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION (2015), doi: 10.1016/j.apmr.2015.06.020. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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TITLE Psychometric properties of the spinal cord injury pressure ulcer scale (SCIPUS) for pressure ulcer risk assessment during inpatient rehabilitation
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Running Head SCIPUS Psychometrics
Authors
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Jude J. Delparte, MSc1 Carol Y. Scovil, PhD1, 2
Johanne Higgins, PhD 4,5,6 Marie-Thérèse Laramée, PT, MSc5,6,7 Anthony S. Burns, MD MSc1,8
1
M AN U
Heather M. Flett, BScPT, MSc1, 3
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Brain and Spinal Cord Rehabilitation Program, Lyndhurst Centre, University Health Network -
Toronto Rehabilitation Institute (Toronto, ON) 2
Department of Occupational Science and Occupational Therapy, University of Toronto
(Toronto, ON) 3 4
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Department of Physical Therapy, University of Toronto (Toronto, ON) Recherche, Institut de réadaptation Gingras-Lindsay-de-Montréal du CIUSSS Centre-est-de-
5
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l'Île-de-Montréal (Montreal, QC)
École de réadaptation, Faculté de médecine, Université de Montréal (Montreal, QC)
6
Centre de recherche interdisciplinaire en réadaptation du Montréal métropolitain, (Montreal,
QC) 7
Programme lésions médullaires, Institut de réadaptation Gingras-Lindsay-de-Montréal du
CIUSSS Centre-est-de-l'Île-de-Montréal (Montreal, QC) 8
Division of Physical Medicine and Rehabilitation, Department of Medicine, University of
Toronto (Toronto, ON)
ACCEPTED MANUSCRIPT
Acknowledgement of Previous Presentation: Preliminary results have been previously presented in poster format: Delparte JJ, Burns AS, Flett H, Scovil C, Leber D, Higgins J, Laramée MT, Patenaude C, Joly C, Casimir M. Psychometric properties of the Spinal Cord Injury Pressure Ulcer Scale
RI PT
(SCIPUS) for pressure ulcer risk assessment. American Spinal Injury Association Annual Meeting. May 14-17 2014. San Antonio, Texas, United States.
Burns AS, Delparte JJ, Flett HM, Leber DJ, Scovil CY. Inter-rater reliability and concurrent
SC
validity of the SCIPUS during inpatient spinal cord injury rehabilitation. 52nd Annual Scientific Meeting of International Spinal Cord Society (ISCoS). Oct 27-30 2013. Istanbul,
M AN U
TR. Poster
Acknowledgements
The authors would like to acknowledge the involvement of Diane Leber and Trisha Domingo who assisted with data collection and Lan McMillan who assisted with training nurses to
Financial Support:
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complete the SCIPUS.
Ontario Ministry of Health and Long-Term Care Academic Health Sciences Centre Alternative Funding Plan Innovation Fund, Rick Hansen Institute, and Ontario Neurotrauma Foundation
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(2010-RHI-ONF-BPI-832).
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Corresponding Author: Jude J. Delparte
Lyndhurst Centre (Research) 206-520 Sutherland Dr.
Toronto, ON M4G 3V9 Canada Phone: 416-597-3422 x6359 Fax: (416) 425-9923 Email: [email protected]
Reprints not available.
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Abbreviations IRGLM: Institut de Réadaptation Gingras-Lindsay-de-Montréal UHN-TRI: University Health Network – Toronto Rehabilitation Institute
Abstract
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University Health Network – Toronto Rehabilitation Institute (Toronto, ON) and Institut de Réadaptation Gingras-Lindsay-de-Montréal (Montréal, QC).
Methods
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SCI Knowledge Mobilization Network (SCI-KMN)21 University Health Network – Toronto Rehabilitation Institute (UHN-TRI) and Institut de Réadaptation Gingras-Lindsay-de-Montréal (IRGLM)
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Results IRGLM UHN-TRI
References
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21 Scovil CY, Flett HM, McMillan LT, et al. The application of implementation science for pressure ulcer prevention best practices in an inpatient spinal cord injury rehabilitation program. The journal of spinal cord medicine. 2014;37(5):589-597.
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TITLE
2
Psychometric properties of the spinal cord injury pressure ulcer scale (SCIPUS) for pressure
3
ulcer risk assessment during inpatient rehabilitation
4
Running Head
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SCIPUS Psychometrics
6
Authors
7
Jude J. Delparte, MSc1
8
Carol Y. Scovil, PhD1, 2
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Heather M. Flett, BScPT, MSc1, 3 Johanne Higgins, PhD 4,5,6
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Marie-Thérèse Laramée, PT, MSc5,6,7
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Anthony S. Burns, MD MSc1,8
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1
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1
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Toronto Rehabilitation Institute (Toronto, ON)
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2
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(Toronto, ON)
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3
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4
20
l'Île-de-Montréal (Montreal, QC)
21
5
22
6
23
QC)
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7
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CIUSSS Centre-est-de-l'Île-de-Montréal (Montreal, QC)
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Brain and Spinal Cord Rehabilitation Program, Lyndhurst Centre, University Health Network -
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Department of Occupational Science and Occupational Therapy, University of Toronto
Department of Physical Therapy, University of Toronto (Toronto, ON)
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Recherche, Institut de réadaptation Gingras-Lindsay-de-Montréal du CIUSSS Centre-est-de-
École de réadaptation, Faculté de médecine, Université de Montréal (Montreal, QC) Centre de recherche interdisciplinaire en réadaptation du Montréal métropolitain, (Montreal,
Programme lésions médullaires, Institut de réadaptation Gingras-Lindsay-de-Montréal du
1
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26
8
27
Toronto (Toronto, ON)
28
Acknowledgement of Previous Presentation:
29
Preliminary results have been previously presented in poster format:
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30
Division of Physical Medicine and Rehabilitation, Department of Medicine, University of
Delparte JJ, Burns AS, Flett H, Scovil C, Leber D, Higgins J, Laramée MT, Patenaude C, Joly C, Casimir M. Psychometric properties of the Spinal Cord Injury Pressure Ulcer Scale
32
(SCIPUS) for pressure ulcer risk assessment. American Spinal Injury Association Annual
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Meeting. May 14-17 2014. San Antonio, Texas, United States.
34
SC
31
Burns AS, Delparte JJ, Flett HM, Leber DJ, Scovil CY. Inter-rater reliability and concurrent validity of the SCIPUS during inpatient spinal cord injury rehabilitation. 52nd Annual
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Scientific Meeting of International Spinal Cord Society (ISCoS). Oct 27-30 2013. Istanbul,
37
TR. Poster
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Corresponding Author:
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Jude J. Delparte
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Lyndhurst Centre (Research)
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206-520 Sutherland Dr.
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Toronto, ON M4G 3V9 Canada
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Phone: 416-597-3422 x6359 Fax: (416) 425-9923
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Email: [email protected]
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Reprints not available.
46
Figure Legend
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Figure 1. SCIPUS items. Risk Levels: Low 0-2, Moderate 3-5, High 6-8, Very high 9-25. * Item was pre-circled yes; ** Local lab norms were used.
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Figure 2. Receiver Operator Curve for PU Incidence. Diagonal line represents 50% area under
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the curve.
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Abstract
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OBJECTIVE: To assess the psychometric properties of the Spinal Cord Injury Pressure Ulcer Scale
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(SCIPUS) for pressure ulcer (PU) risk assessment during inpatient rehabilitation.
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DESIGN: Prospective cohort.
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SETTING: Tertiary rehabilitation centres: University Health Network – Toronto Rehabilitation
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Institute (Toronto, ON) and Institut de Réadaptation Gingras-Lindsay-de-Montréal (Montréal,
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QC).
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PARTICIPANTS: Individuals (n=759) participating in inpatient spinal cord injury (SCI)
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rehabilitation between January 3, 2012 and April 23, 2014.
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MAIN OUTCOME MEASURES: Admission SCIPUS scores and corresponding risk stratification, PU
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incidence, intraclass correlation coefficient (ICC) for inter-rater reliability, sensitivity, specificity,
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and likelihood ratios (LR). Receiver operating characteristic (ROC) and area under the curve
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(AUC) analysis were also performed.
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RESULTS: Mean SCIPUS scores were higher for individuals who developed PU vs. those who did
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not (9.8 ± 2.5 vs. 8.5 ± 2.6). Inter-rater reliability was excellent for SCIPUS composite scores
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(ICC=0.91) and very good for risk stratification (ICC=0.86). Using the existing cutoff value of ≥ 6
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for ‘high risk’, sensitivity and specificity were 0.97 and 0.12 respectively (LR=1.1). A cutoff value
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of ≥ 8 yielded a better balance between sensitivity and specificity; sensitivity and specificity of
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0.85 and 0.38 respectively. AUC equaled 0.64 with a LR=1.4. Results were similar when analysis
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was confined to PUs of stage II or greater.
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CONCLUSION: The psychometric properties of the SCIPUS do not currently support its routine
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use as a measure of PU risk in individuals with SCI undergoing inpatient rehabilitation. LRs < 2
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indicate that stratification as high risk or greater does not substantially increase the likelihood
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of identifying individuals who develop PUs beyond chance alone. AUCs were also below the
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desired cutoff of 0.7.
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77 KEYWORDS: spinal cord injuries; pressure ulcers; risk assessment; sensitivity and specificity;
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reliability and validity
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List of Abbreviations
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ANOVA: analysis of variance
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AUC: area under the curve
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ICC: intraclass correlation coefficients
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IRGLM: Institut de Réadaptation Gingras-Lindsay-de-Montréal
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IRR: inter-rater reliability
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LR: likelihood ratios
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PU: pressure ulcer
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REB: research ethics board
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ROC: receiver operating characteristic
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SCI: spinal cord injury
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SCIPUS: spinal cord injury pressure ulcer scale
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UHN-TRI: University Health Network – Toronto Rehabilitation Institute
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Pressure ulcers (PUs) are common and costly complications following traumatic and non-
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traumatic spinal cord injury (SCI). Approximately 85% of individuals with SCI will develop a PU
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during their lifetime.1 PUs have important economic2-5 and quality of life impacts,6-8 and can
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even be fatal.9 Individuals who develop PUs during SCI rehabilitation have poorer rehabilitation
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outcomes and longer lengths of stay.10 Given that hospitalization costs make up 62% of total
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PU-associated costs in Canada,3 hospitals have a financial impetus to reduce the incidence of
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PUs. Despite the scale and importance of the problem, PUs are still a common occurrence
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following a SCI, including rehabilitation.
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Compared to other conditions, individuals with SCI have one of the highest PU prevalence
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rates (10-20%) at the time of admission to rehabilitation programs.10,11 Studies have observed
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incidence rates ranging between 10% and 48% during inpatient SCI rehabilitation.10-15 Salzberg
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observed a 38% incidence of PUs within 30 days of the injury with 26% being ≥ stage II.15 In
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another study, 32% of people had a PU at the time of admission to an SCI unit and 56%
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experienced one by the time of discharge.13
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Clinical practice guidelines have recommended the performance of risk assessment as a
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PU prevention strategy.16,17 Previously recommended scales for SCI17,18 include the Braden,19
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Waterlow, SCI Pressure Ulcer Scale (SCIPUS),20 and acute SCIPUS (SCIPUS-A);15 however all
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require further validation for the SCI population.18 The SCIPUS is the only risk assessment
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measure developed specifically for people with SCI; however,,its psychometric properties have
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yet to be elucidated. The SCIPUS is a 15 item scaled developed by Salzberg and colleagues20 to
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address the lack of SCI-specific risk factors in existing tools for PU risk assessment. The purpose
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of this study was therefore to assess the psychometric properties of the SCIPUS (inter-rater
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reliability, sensitivity, specificity) for individuals with SCI participating in inpatient rehabilitation.
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Methods
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Study Cohort
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As part of the SCI Knowledge Mobilization Network (SCI-KMN)21 the SCIPUS was implemented in
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SCI rehabilitation programs at University Health Network – Toronto Rehabilitation Institute
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(UHN-TRI) and Institut de Réadaptation Gingras-Lindsay-de-Montréal (IRGLM). The SCIPUS was
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chosen for implementation and evaluation based on the fact that it is the only measure
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developed specifically for individuals with SCI. At both sites, inpatient nurses received training
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on how to complete the SCIPUS and were instructed to complete it within 72hrs of inpatient
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admission. Data were abstracted from patient records of 759 admissions between January 3,
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2012 and April 23, 2014. The majority of patients were admitted for the first time to
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rehabilitation; however some patients were readmissions with longer durations of injury.
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Data Collection
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As the current study was performed as part of ongoing quality improvement and best practice
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implementation, a Research Ethics Board (REB) exemption was granted by the UHN-TRI REB.
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The study was approved by the IRGLM REB. Collected variables included admission SCIPUS
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scores; demographics; and PU incidence, prevalence, and severity. PUs were classified
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according to the National Pressure Ulcer Advisory Panel staging guidelines.22 Prevalence was
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the number of people documented to have a PU at any time point during rehabilitation.
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Incidence was the number of people who developed new PUs during rehabilitation whether or
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not they already had a PU at admission. PUs initially classified as unstageable were re-classified
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if the stage became apparent at a later date. SCIPUS scores and corresponding risk stratification
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were calculated if all items were complete. SCIPUS data were included in the analysis regardless
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of whether the SCIPUS was completed within 72hrs. To assess inter-rater reliability (IRR), a
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second blinded nurse completed the SCIPUS for 150 patients.
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Outcome Measures
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The SCIPUS is a 15-item SCI-specific PU risk assessment scale originally developed using a cohort
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of community dwelling individuals with SCI (Figure 1).20 Items requiring laboratory values were
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scored using local laboratory norms.
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[Insert Figure 1 here]
Statistical Analyses
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Analysis of variance (ANOVA) and Mann-Whitney (non-parametric) were used to analyze
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differences. IRR was determined using raw agreement and by calculating the two-way mixed
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intraclass correlation coefficients (ICC). Sensitivity, specificity, and likelihood ratios (LR) were
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calculated for the SCIPUS using PU incidence.23 An optimal SCIPUS cutoff value was identified
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using sensitivity/specificity in a manner previously reported.24 Ideally this was achieved by
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searching for the SCIPUS cutoff value for which sensitivity and specificity were both ≥ 0.7; while
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at the same time maximizing sensitivity. If it were not possible for both values to be ≥ 0.7, the
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SCIPUS cutoff was assigned to the SCIPUS score with a sensitivity ≥ 0.7 while maximizing
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specificity. Receiver Operating Characteristic (ROC) analysis was conducted to calculate areas
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under the curve (AUC). Tests with AUC values of 0.5 to 0.7 were considered poorly accurate, 0.7
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to 0.9 somewhat accurate, and >0.9 highly accurate.25 Analyses were conducted using the SAS
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9.2 and SPSS v21 statistical packages.
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Results
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Cohort demographics are summarized in Table 1. Of the patients included in the analysis, 142
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were from IRGLM and 617 were from UHN-TRI. Targeted variables were compared across sites.
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There were no differences in age or length of stay between the two study sites. Composite
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SCIPUS scores were slightly higher at IRGLM (9.4) compared to UHN-TRI (8.5) [F(1,572)=10.38;
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p<.05]. The duration of injury (rehabilitation admission) also differed slightly between the sites
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with TRI having a median of 22 days, and IRGLM having a median of 27.5 days.
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[Insert Table 1 here]
Pressure Ulcer Incidence and Prevalence
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PU data for the 759 admissions is summarized in Table 2. Four hundred twenty four PUs were
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documented in 244 patients (32%). Seventy patients had more than one PU. One hundred sixty
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three patients (21 %) had PUs at rehabilitation admission; while 136 patients (18%) developed
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PUs during inpatient rehabilitation. The incidence of stage II or greater PUs during rehabilitation
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was 10% (n=77). Including patients admitted with PUs, 24% of patients had at least one stage II
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or greater PU at some point during rehabilitation. The anatomical distribution of observed PUs
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was sacrum (42%), heels (17%), ischial tuberosities (18%), and other (23%).
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[Insert Table 2 here]
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Relationship between SCIPUS Scores and Pressure Ulcer Incidence
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As expected, ANOVA revealed significantly higher SCIPUS scores for individuals who developed
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PUs versus those who did not (mean ± SD SCIPUS score 9.8 ± 2.5 vs. 8.5 ± 2.6) [t(571) = -4.72;
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p<.0001]. There was no difference in mean SCIPUS scores between those who developed Stage
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I versus stage II or greater PUs (mean ± SD SCIPUS score 9.8 ± 2.4 vs. 9.8 ± 2.6).
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SCIPUS Completion & Inter-Rater Reliability
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SCIPUS completion rates are summarized in Table 2. Of the 696 SCIPUSs initiated, 573 (82%)
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were completed. SCIPUS items most often missing included serum tests (5.0 - 8.8%) and
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completeness of injury (2.9%). The SCIPUS composite score had an ICC of 0.91 indicating
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excellent inter-rater reliability. Agreement for risk stratification was lower (ICC=0.86) but still
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very good. For individual SCIPUS items, the level of disagreement was > 10% for the majority
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(Table 3). Only age, renal disease, and laboratory measures had discrepancies < 10%. Raw
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agreement between the two raters was 78% for risk stratification and 29% for composite
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scores.
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[Insert Table 3 here]
Sensitivity and Specificity
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Using PU incidence and the previously reported SCIPUS cutoff of ≥ 6 for ‘high risk’
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categorization, sensitivity and specificity were 0.97 and 0.12 respectively; while the LR was 1.1.
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Using a cutoff of ≥ 8, sensitivity and specificity were 0.85 and 0.38 respectively, with a LR of 1.4
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and AUC of 0.64 (95% CI 0.59-0.70) (Figure 2). Sensitivity and specificity were similar when
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analysis was confined to PUs of stage II or greater. With a cutoff of ≥6, sensitivity and specificity
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were 0.95 and 0.11 respectively; whereas a cutoff of ≥8 yielded 0.88 and 0.36 respectively.
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AUC and LR were unchanged (using a cutoff of ≥ 8) when only PUs of stage II or greater were
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considered. In all analyzed scenarios LRs were < 2. This indicates that stratification as high risk
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or greater does not substantially increase the likelihood of identifying individuals who develop
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PUs beyond chance alone. Furthermore, all SCIPUS AUCs were below 0.7 indicating poor
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accuracy.25
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208 209
[Insert Figure 2 here]
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Discussion
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Study findings demonstrate that the SCIPUS as currently constructed has limited utility for
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identifying individuals at risk for developing PUs while participating in inpatient SCI
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rehabilitation. Using the existing cutoff value for high or very high risk in a cohort of individuals
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participating in inpatient SCI rehabilitation, the balance between sensitivity and specificity is
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less than ideal (0.97/0.12). While the sensitivity is excellent and the majority of individuals who
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develop a PU are appropriately identified as high or very high risk, the specificity in contrast is
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quite low. This is due to the fact that in an inpatient setting almost all individuals (89%) were
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stratified as high or very high risk; suggesting the cutoff for high risk is too low. LRs help
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clinicians assess the utility of diagnostic tests by determining whether a test result changes the
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probability that a condition is present. When a LR is close to 1 there is little practical
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significance as the post-test probability (odds) is similar to the pre-test probability. With a LR of
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less than 2.0, completion of the SCIPUS fails to double the odds of accurately identifying at-risk
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individuals compared to chance alone.
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Given the inherent tradeoff between sensitivity and specificity, a new cutoff value might yield a better balance between the two performance metrics. Sensitivity/specificity and ROC
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analysis were performed for all PUs as well as PUs ≥ stage 2. A cutoff value ≥ 8 demonstrates
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the best tradeoff between sensitivity and specificity. Unfortunately, even with a cutoff value of
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≥ 8 the SCIPUS fails to demonstrate acceptable LRs and AUCs fell below 0.7.25
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Inter-rater reliability is excellent for composite SCIPUS scores (ICCs = 0.91) and very good for risk stratification (ICC = 0.86). Levels of agreement, however, are less robust for
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individual items of the SCIPUS. The majority of individual items had > 10% disagreement, which
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limits their utility in isolation. Items with lower levels of agreement tended to require subjective
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judgment or were dependent on very specific knowledge of the patient (e.g. cardiac disease OR
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abnormal EKG, autonomic dysreflexia OR severe spasticity, urine incontinence OR constantly
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moist). In comparison, objective items (e.g. age, serum values) scored better across raters.
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Improving and clarifying the scoring instructions placed directly on the scoring sheet could
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possibly improve scoring consistency for individual items.
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Study findings confirmed that PUs are a common occurrence even in the relatively early phases following a SCI. When one combines PUs present at admission and PUs that developed
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during rehabilitation, 32% of the study sample had a PU at some point during inpatient
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rehabilitation, with 9% having more than one PU. Ten percent developed stage II or greater PUs
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during their rehabilitation admission. Previous studies have reported similar findings in acute
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and rehabilitation settings.12,13,15 The observed prevalence of PUs reinforces the importance of
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screening and identifying high risk individuals for preventative strategies.
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It is important to note that the initial development of the SCIPUS utilized a cohort of
community dwelling individuals.20 In this context, using a cutoff value of ≥ 6, the SCIPUS was
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found to have very good sensitivity (0.76) and specificity (0.74), and a LR of 2.9. Modifications
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to the SCIPUS might improve its predictive validity in a rehabilitation setting, similar to what has
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been done in the acute care setting with the SCIPUS-A.15 Individual items should demonstrate a
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reasonable variance in scores among tested individuals. Item endorsement ranging from 20-
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80% has been recommended as reasonable variance.26 SCIPUS items with very low rates of
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endorsement included renal disease, cognitive impairment, and autonomic
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dysreflexia/spasticity (5-11%). The use of items not correlated with risk has been cited as one of
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the major weaknesses of PU risk assessments and brings into question their general utility.27 A
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refinement of the SCIPUS including both a re-assessment and re-weighting of contributing
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items could possibly improve PU risk assessment for inpatient rehabilitation. This work is
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ongoing and will be reported in a future publication.
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The Canadian Best Practice Guidelines for the Prevention and Management of PUs in People with SCI indicated that there was level IIa (moderate) evidence for the use of risk
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assessment.17 Others have argued that current PU risk assessment measures do not have the
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right items, are not properly scaled, and may be no more effective than clinical judgment.27,28
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Given that SCIPUS has LRs < 2 for candidate cutoff values and has an AUC < 0.7, it cannot
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currently be recommended for routine PU risk assessment in an inpatient SCI rehabilitation
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setting. A tool with better psychometric properties and lower administrative burden might be a
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more effective tool for this context.
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Individuals with SCI are known to be at high risk of PU development and universal
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precautions should always be in place. The clinical utility of a risk assessment lies in its ability to
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prospectively identify individuals at high risk of PU development in order to proactively
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implement more rigorous prevention strategies. As an example, certain individuals might
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warrant the proactive use of specialized surfaces (e.g., mattresses) or more frequent turning
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schedules. Conversely, the identification of individuals who are not at risk of PU development
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could result in a more focused use of clinical resources. Using a four point scale to categorize
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risk from low to very high is questionable without explicit guidelines informing how clinical
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practice should be altered for each risk level; although there might be some implicit value in
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heightening awareness and sensitivity among clinicians. A binary risk level (high risk or low risk)
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may be sufficient for a PU screening tool. This is an issue that could be assessed in future
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studies.
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Study Limitations
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The sample used to develop the SCIPUS was quite different than the sample in this study, and
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our study results underscore the need to validate PU risk assessment scales in specific
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populations.29 The SCIPUS was developed from a dataset of community-dwelling individuals
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and demonstrated good sensitivity and specificity.20 In that dataset, 80% of individuals had a
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history of PU development and the average duration of injury was 15 years. In the current
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study, 18% of cases developed a new PU during rehabilitation and 32% were documented as
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having a PU at some point during their rehabilitation (including admission). Individuals in this
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study had a median duration of injury of 27 days and were assessed over a median length of
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stay of 68 days. When using the current SCIPUS cutoff for high risk or greater (≥ 6), 89% of
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inpatients were classified as high or very high risk (close to the lifetime risk of 85% previously
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reported).1 It is possible that the SCIPUS functions better as a tool to predict lifetime risk of PU
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development as opposed to the comparatively short stays in rehabilitation centres.
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Subsequently, a different risk assessment scale may be needed to identify individuals at risk for
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developing a PU during rehabilitation (e.g. SCIPUS-A).15
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Our study also incorporated more than one participating site which introduces the possibility of differences between the clinical settings. In fact this is likely. It is the opinion of
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the authors that this is more analogous to the real world and the different contexts within
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which clinicians practice. The intent of the study was to assess the performance of the SCIPUS
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in applicable clinical settings and maximize generalizability. Participation of more than one
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study site therefore increased the number of study subjects and enhanced the generalizability
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of study results. Overall, the advantages were felt to out-weigh the value of limiting the study
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to one site.
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Conclusion
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The SCIPUS had acceptable inter-rater reliability but failed to perform adequately as a measure
305
of PU risk assessment in a rehabilitation setting due to limited specificity. Modifications to the
306
current measure could possibly improve its performance. Future work should focus on
307
identifying high impact items and optimized weighting schemes to maximize the utility of a risk
308
assessment measure for individuals with SCI participating in inpatient rehabilitation. The new
309
tool should be constructed to minimize interpretation, have low administrative burden and
310
include clear, practical recommendations on how to interpret risk levels and accordingly adjust
311
clinical practice.
312
Acknowledgements
313
The authors would like to acknowledge the involvement of Diane Leber and Trisha Domingo
314
who assisted with data collection and Lan McMillan who assisted with training nurses to
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complete the SCIPUS.
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References
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1.
Gunnewicht BR. Pressure sores in patients with acute spinal cord injury. Journal of wound care. 1995;4(10):452-454.
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8. 9. 10.
11.
12.
13. 14.
15.
16.
17.
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Bennett G, Dealey C, Posnett J. The cost of pressure ulcers in the UK. Age and ageing. 2004;33(3):230-235. Chan BC, Nanwa N, Mittmann N, Bryant D, Coyte PC, Houghton PE. The average cost of pressure ulcer management in a community dwelling spinal cord injury population. International wound journal. 2013;10(4):431-440. Mittmann N, Chan BC, Craven BC, Isogai PK, Houghton P. Evaluation of the costeffectiveness of electrical stimulation therapy for pressure ulcers in spinal cord injury. Archives of physical medicine and rehabilitation. 2011;92(6):866-872. Pancorbo-Hidalgo PL, Garcia-Fernandez FP, Lopez-Medina IM, Alvarez-Nieto C. Risk assessment scales for pressure ulcer prevention: a systematic review. Journal of advanced nursing. 2006;54(1):94-110. Jackson J, Carlson M, Rubayi S, et al. Qualitative study of principles pertaining to lifestyle and pressure ulcer risk in adults with spinal cord injury. Disability and rehabilitation. 2010;32(7):567-578. Langemo DK, Melland H, Hanson D, Olson B, Hunter S. The lived experience of having a pressure ulcer: a qualitative analysis. Advances in skin & wound care. 2000;13(5):225-235. Hopkins A, Dealey C, Bale S, Defloor T, Worboys F. Patient stories of living with a pressure ulcer. Journal of advanced nursing. 2006;56(4):345-353. Redelings MD, Lee NE, Sorvillo F. Pressure ulcers: more lethal than we thought? Advances in skin & wound care. 2005;18(7):367-372. Wang H, Niewczyk P, Divita M, et al. Impact of pressure ulcers on outcomes in inpatient rehabilitation facilities. American journal of physical medicine & rehabilitation / Association of Academic Physiatrists. 2014;93(3):207-216. Iyun AO, Malomo AO, Oluwatosin OM, Ademola SA, Shokunbi MT. Pattern of presentation of pressure ulcers in traumatic spinal cord injured patients in University College Hospital, Ibadan. International wound journal. 2012;9(2):206213. Chen D, Apple DF, Jr., Hudson LM, Bode R. Medical complications during acute rehabilitation following spinal cord injury--current experience of the Model Systems. Archives of physical medicine and rehabilitation. 1999;80(11):1397-1401. Ash D. An exploration of the occurrence of pressure ulcers in a British spinal injuries unit. Journal of clinical nursing. 2002;11(4):470-478. DeJong G, Hsieh CH, Brown P, et al. Factors Associated with Pressure Ulcer Risk in Spinal Cord Injury Rehabilitation. American journal of physical medicine & rehabilitation / Association of Academic Physiatrists. 2014. Salzberg CA, Byrne DW, Kabir R, van Niewerburg P, Cayten CG. Predicting pressure ulcers during initial hospitalization for acute spinal cord injury. Wounds. 1999;11:45-57. Consortium for Spinal Cord Medicine Clinical Practice Guidelines. Pressure ulcer prevention and treatment following spinal cord injury: a clinical practice guideline for health-care professionals. The journal of spinal cord medicine. 2001;24 Suppl 1:S40-101. Houghton PE, Campbell KE, CPG Panel. Canadian Best Practice Guidelines for the Prevention and Management of Pressure Ulcers in People with Spinal Cord Injury. 2013; www.onf.org. Accessed November 14, 2014.
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320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365
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23. 24.
25. 26. 27. 28.
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Mortenson WB, Miller WC. A review of scales for assessing the risk of developing a pressure ulcer in individuals with SCI. Spinal cord. 2008;46(3):168-175. Bergstrom N, Braden BJ, Laguzza A, Holman V. The Braden Scale for Predicting Pressure Sore Risk. Nursing research. 1987;36(4):205-210. Salzberg CA, Byrne DW, Cayten CG, van Niewerburgh P, Murphy JG, Viehbeck M. A new pressure ulcer risk assessment scale for individuals with spinal cord injury. American journal of physical medicine & rehabilitation / Association of Academic Physiatrists. 1996;75(2):96-104. Scovil CY, Flett HM, McMillan LT, et al. The application of implementation science for pressure ulcer prevention best practices in an inpatient spinal cord injury rehabilitation program. The journal of spinal cord medicine. 2014;37(5):589-597. Black J, Baharestani M, Cuddigan J, et al. National Pressure Ulcer Advisory Panel's updated pressure ulcer staging system. Dermatology nursing / Dermatology Nurses' Association. 2007;19(4):343-349; quiz 350. Lalkhen AG, McCluskey A. Clinical tests: sensitivity and specificity. Continuing Education in Anaesthesia, Critical Care & Pain. 2008;8(6):221-223. Tannen A, Balzer K, Kottner J, Dassen T, Halfens R, Mertens E. Diagnostic accuracy of two pressure ulcer risk scales and a generic nursing assessment tool. A psychometric comparison. Journal of clinical nursing. 2010;19(11-12):1510-1518. McDowell I, Newell C. Measuring Health. A Guide to Rating Scales and Questionnaires. New York, NY: Oxford University Press; 2006. Streiner DL, Norman GR. Health Measurement Scales: A practical guide to their development and use. Fourth ed. New York, NY: Oxford University Press; 2008. Anthony D, Papanikolaou P, Parboteeah S, Saleh M. Do risk assessment scales for pressure ulcers work? Journal of tissue viability. 2010;19(4):132-136. Anthony D, Parboteeah S, Saleh M, Papanikolaou P. Norton, Waterlow and Braden scores: a review of the literature and a comparison between the scores and clinical judgement. Journal of clinical nursing. 2008;17(5):646-653. Atkinson G, Nevill AM. Statistical methods for assessing measurement error (reliability) in variables relevant to sports medicine. Sports medicine (Auckland, N.Z.). 1998;26(4):217-238.
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Table 1. Cohort demographics (n=759). *one patient was admitted and discharged same day. **calculated only for traumatic cases. Values are means ± standard deviation; ns: not significant No PU (n = 623)
PU Incidence (n = 136)
8.7 (2.7) 53.9 (18.5) 68 (41.2) 84.9 (379.7) 67%
8.5 (2.6) 53.9 (18.5) 62.3 (39.2) 91 (432.8) 79%
9.8 (2.5) 53.8 (18.6) 94.6 (39.9) 65.7 (90.5) 21%
Females
33%
89%
11%
Paraplegia
53%
81%
19%
Quadriplegia
47%
81%
Traumatic
40%
76%
Non-Traumatic
60%
86%
Complete
16%
Incomplete
84%
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<.0001 ns <.0001 ns -
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63%
37%
84%
16%
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Admission SCIPUS Age (yrs) Length of stay (days)* Duration of injury (days)** Males
p
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All
-
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Table 2. Summary of PU Incidence and Prevalence. The percentages represent individuals who were documented with at least one PU of a given stage. Some individuals had more than one PU. *PUs were categorized according to highest observed stage during rehabilitation. DTI: Deep
6.6 12 2.9 1.4 1.6 21 16
91 87 11 1 7 197 99
9.2 9.2 1.2 0.13 0.79 18 10
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Overall* Prevalence # PUs %
146 202 37 20 19 424 258
14 20 4.3 2.4 2.2 32 24
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63 118 23 11 12 227 152
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Stage I Stage II Stage III Stage IV DTI Total Stage ≥ II
Rehabilitation Incidence # PUs %
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tissue injury.
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Table 3. Completeness, Endorsement and Disagreement of SCIPUS Items. Values represent percentages of incomplete fields (missing), items endorsed, and disagreement between two
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IRR Dataset (n=150) Disagreement (%) 4 16.4 24.2 12.8 19.7 12.2 14.7 10.7 16.2 7.4 17.3 0 5.8 7.4 9.4
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Age Complete SCI Mobility Level of activity Incontinence/moisture AD/spasticity Tobacco use Pulmonary disease Cardiac disease/EKG Renal disease Cognitive impairments Hospitalization Diabetes/high glucose Low albumin Low hematocrit
SCIPUS Dataset (n=696) Missing Endorsed (%) (%) 0.0 81 2.9 19 0.3 87 0.4 82 1.3 26 1.6 11 0.9 45 1.0 14 0.9 27 2.2 5 1.3 7 0.0 100 5.0 17 8.8 69 6.2 71
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raters in the inter-rater reliability database (IRR).
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S0003-9993(15)00563-8
DOI:
10.1016/j.apmr.2015.06.020
Reference:
YAPMR 56249
To appear in:
ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION
Received Date: 22 April 2015 Revised Date:
29 June 2015
Accepted Date: 30 June 2015
Please cite this article as: Delparte JJ, Scovil CY, Flett HM, Higgins J, Laramée M-T, Burns AS, Psychometric properties of the spinal cord injury pressure ulcer scale (SCIPUS) for pressure ulcer risk assessment during inpatient rehabilitation, ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION (2015), doi: 10.1016/j.apmr.2015.06.020. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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TITLE Psychometric properties of the spinal cord injury pressure ulcer scale (SCIPUS) for pressure ulcer risk assessment during inpatient rehabilitation
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Running Head SCIPUS Psychometrics
Authors
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Jude J. Delparte, MSc1 Carol Y. Scovil, PhD1, 2
Johanne Higgins, PhD 4,5,6 Marie-Thérèse Laramée, PT, MSc5,6,7 Anthony S. Burns, MD MSc1,8
1
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Heather M. Flett, BScPT, MSc1, 3
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Brain and Spinal Cord Rehabilitation Program, Lyndhurst Centre, University Health Network -
Toronto Rehabilitation Institute (Toronto, ON) 2
Department of Occupational Science and Occupational Therapy, University of Toronto
(Toronto, ON) 3 4
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Department of Physical Therapy, University of Toronto (Toronto, ON) Recherche, Institut de réadaptation Gingras-Lindsay-de-Montréal du CIUSSS Centre-est-de-
5
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l'Île-de-Montréal (Montreal, QC)
École de réadaptation, Faculté de médecine, Université de Montréal (Montreal, QC)
6
Centre de recherche interdisciplinaire en réadaptation du Montréal métropolitain, (Montreal,
QC) 7
Programme lésions médullaires, Institut de réadaptation Gingras-Lindsay-de-Montréal du
CIUSSS Centre-est-de-l'Île-de-Montréal (Montreal, QC) 8
Division of Physical Medicine and Rehabilitation, Department of Medicine, University of
Toronto (Toronto, ON)
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Acknowledgement of Previous Presentation: Preliminary results have been previously presented in poster format: Delparte JJ, Burns AS, Flett H, Scovil C, Leber D, Higgins J, Laramée MT, Patenaude C, Joly C, Casimir M. Psychometric properties of the Spinal Cord Injury Pressure Ulcer Scale
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(SCIPUS) for pressure ulcer risk assessment. American Spinal Injury Association Annual Meeting. May 14-17 2014. San Antonio, Texas, United States.
Burns AS, Delparte JJ, Flett HM, Leber DJ, Scovil CY. Inter-rater reliability and concurrent
SC
validity of the SCIPUS during inpatient spinal cord injury rehabilitation. 52nd Annual Scientific Meeting of International Spinal Cord Society (ISCoS). Oct 27-30 2013. Istanbul,
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TR. Poster
Acknowledgements
The authors would like to acknowledge the involvement of Diane Leber and Trisha Domingo who assisted with data collection and Lan McMillan who assisted with training nurses to
Financial Support:
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complete the SCIPUS.
Ontario Ministry of Health and Long-Term Care Academic Health Sciences Centre Alternative Funding Plan Innovation Fund, Rick Hansen Institute, and Ontario Neurotrauma Foundation
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(2010-RHI-ONF-BPI-832).
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Corresponding Author: Jude J. Delparte
Lyndhurst Centre (Research) 206-520 Sutherland Dr.
Toronto, ON M4G 3V9 Canada Phone: 416-597-3422 x6359 Fax: (416) 425-9923 Email: [email protected]
Reprints not available.
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Abbreviations IRGLM: Institut de Réadaptation Gingras-Lindsay-de-Montréal UHN-TRI: University Health Network – Toronto Rehabilitation Institute
Abstract
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University Health Network – Toronto Rehabilitation Institute (Toronto, ON) and Institut de Réadaptation Gingras-Lindsay-de-Montréal (Montréal, QC).
Methods
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SCI Knowledge Mobilization Network (SCI-KMN)21 University Health Network – Toronto Rehabilitation Institute (UHN-TRI) and Institut de Réadaptation Gingras-Lindsay-de-Montréal (IRGLM)
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Results IRGLM UHN-TRI
References
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21 Scovil CY, Flett HM, McMillan LT, et al. The application of implementation science for pressure ulcer prevention best practices in an inpatient spinal cord injury rehabilitation program. The journal of spinal cord medicine. 2014;37(5):589-597.
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TITLE
2
Psychometric properties of the spinal cord injury pressure ulcer scale (SCIPUS) for pressure
3
ulcer risk assessment during inpatient rehabilitation
4
Running Head
5
SCIPUS Psychometrics
6
Authors
7
Jude J. Delparte, MSc1
8
Carol Y. Scovil, PhD1, 2
9
Heather M. Flett, BScPT, MSc1, 3 Johanne Higgins, PhD 4,5,6
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Marie-Thérèse Laramée, PT, MSc5,6,7
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Anthony S. Burns, MD MSc1,8
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SC
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1
14
1
15
Toronto Rehabilitation Institute (Toronto, ON)
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2
17
(Toronto, ON)
18
3
19
4
20
l'Île-de-Montréal (Montreal, QC)
21
5
22
6
23
QC)
24
7
25
CIUSSS Centre-est-de-l'Île-de-Montréal (Montreal, QC)
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Brain and Spinal Cord Rehabilitation Program, Lyndhurst Centre, University Health Network -
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Department of Occupational Science and Occupational Therapy, University of Toronto
Department of Physical Therapy, University of Toronto (Toronto, ON)
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Recherche, Institut de réadaptation Gingras-Lindsay-de-Montréal du CIUSSS Centre-est-de-
École de réadaptation, Faculté de médecine, Université de Montréal (Montreal, QC) Centre de recherche interdisciplinaire en réadaptation du Montréal métropolitain, (Montreal,
Programme lésions médullaires, Institut de réadaptation Gingras-Lindsay-de-Montréal du
1
ACCEPTED MANUSCRIPT SCIPUS Psychometrics
26
8
27
Toronto (Toronto, ON)
28
Acknowledgement of Previous Presentation:
29
Preliminary results have been previously presented in poster format:
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30
Division of Physical Medicine and Rehabilitation, Department of Medicine, University of
Delparte JJ, Burns AS, Flett H, Scovil C, Leber D, Higgins J, Laramée MT, Patenaude C, Joly C, Casimir M. Psychometric properties of the Spinal Cord Injury Pressure Ulcer Scale
32
(SCIPUS) for pressure ulcer risk assessment. American Spinal Injury Association Annual
33
Meeting. May 14-17 2014. San Antonio, Texas, United States.
34
SC
31
Burns AS, Delparte JJ, Flett HM, Leber DJ, Scovil CY. Inter-rater reliability and concurrent validity of the SCIPUS during inpatient spinal cord injury rehabilitation. 52nd Annual
36
Scientific Meeting of International Spinal Cord Society (ISCoS). Oct 27-30 2013. Istanbul,
37
TR. Poster
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35
Corresponding Author:
39
Jude J. Delparte
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Lyndhurst Centre (Research)
41
206-520 Sutherland Dr.
42
Toronto, ON M4G 3V9 Canada
43
Phone: 416-597-3422 x6359 Fax: (416) 425-9923
44
Email: [email protected]
45
Reprints not available.
46
Figure Legend
47 48
Figure 1. SCIPUS items. Risk Levels: Low 0-2, Moderate 3-5, High 6-8, Very high 9-25. * Item was pre-circled yes; ** Local lab norms were used.
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Figure 2. Receiver Operator Curve for PU Incidence. Diagonal line represents 50% area under
50
the curve.
51
Abstract
53
OBJECTIVE: To assess the psychometric properties of the Spinal Cord Injury Pressure Ulcer Scale
54
(SCIPUS) for pressure ulcer (PU) risk assessment during inpatient rehabilitation.
55
DESIGN: Prospective cohort.
56
SETTING: Tertiary rehabilitation centres: University Health Network – Toronto Rehabilitation
57
Institute (Toronto, ON) and Institut de Réadaptation Gingras-Lindsay-de-Montréal (Montréal,
58
QC).
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PARTICIPANTS: Individuals (n=759) participating in inpatient spinal cord injury (SCI)
60
rehabilitation between January 3, 2012 and April 23, 2014.
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MAIN OUTCOME MEASURES: Admission SCIPUS scores and corresponding risk stratification, PU
62
incidence, intraclass correlation coefficient (ICC) for inter-rater reliability, sensitivity, specificity,
63
and likelihood ratios (LR). Receiver operating characteristic (ROC) and area under the curve
64
(AUC) analysis were also performed.
65
RESULTS: Mean SCIPUS scores were higher for individuals who developed PU vs. those who did
66
not (9.8 ± 2.5 vs. 8.5 ± 2.6). Inter-rater reliability was excellent for SCIPUS composite scores
67
(ICC=0.91) and very good for risk stratification (ICC=0.86). Using the existing cutoff value of ≥ 6
68
for ‘high risk’, sensitivity and specificity were 0.97 and 0.12 respectively (LR=1.1). A cutoff value
69
of ≥ 8 yielded a better balance between sensitivity and specificity; sensitivity and specificity of
70
0.85 and 0.38 respectively. AUC equaled 0.64 with a LR=1.4. Results were similar when analysis
71
was confined to PUs of stage II or greater.
72
CONCLUSION: The psychometric properties of the SCIPUS do not currently support its routine
73
use as a measure of PU risk in individuals with SCI undergoing inpatient rehabilitation. LRs < 2
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indicate that stratification as high risk or greater does not substantially increase the likelihood
75
of identifying individuals who develop PUs beyond chance alone. AUCs were also below the
76
desired cutoff of 0.7.
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77 KEYWORDS: spinal cord injuries; pressure ulcers; risk assessment; sensitivity and specificity;
79
reliability and validity
80
List of Abbreviations
81
ANOVA: analysis of variance
82
AUC: area under the curve
83
ICC: intraclass correlation coefficients
84
IRGLM: Institut de Réadaptation Gingras-Lindsay-de-Montréal
85
IRR: inter-rater reliability
86
LR: likelihood ratios
87
PU: pressure ulcer
88
REB: research ethics board
89
ROC: receiver operating characteristic
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SCI: spinal cord injury
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SCIPUS: spinal cord injury pressure ulcer scale
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UHN-TRI: University Health Network – Toronto Rehabilitation Institute
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Pressure ulcers (PUs) are common and costly complications following traumatic and non-
96
traumatic spinal cord injury (SCI). Approximately 85% of individuals with SCI will develop a PU
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during their lifetime.1 PUs have important economic2-5 and quality of life impacts,6-8 and can
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even be fatal.9 Individuals who develop PUs during SCI rehabilitation have poorer rehabilitation
99
outcomes and longer lengths of stay.10 Given that hospitalization costs make up 62% of total
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PU-associated costs in Canada,3 hospitals have a financial impetus to reduce the incidence of
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PUs. Despite the scale and importance of the problem, PUs are still a common occurrence
102
following a SCI, including rehabilitation.
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Compared to other conditions, individuals with SCI have one of the highest PU prevalence
104
rates (10-20%) at the time of admission to rehabilitation programs.10,11 Studies have observed
105
incidence rates ranging between 10% and 48% during inpatient SCI rehabilitation.10-15 Salzberg
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observed a 38% incidence of PUs within 30 days of the injury with 26% being ≥ stage II.15 In
107
another study, 32% of people had a PU at the time of admission to an SCI unit and 56%
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experienced one by the time of discharge.13
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Clinical practice guidelines have recommended the performance of risk assessment as a
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PU prevention strategy.16,17 Previously recommended scales for SCI17,18 include the Braden,19
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Waterlow, SCI Pressure Ulcer Scale (SCIPUS),20 and acute SCIPUS (SCIPUS-A);15 however all
112
require further validation for the SCI population.18 The SCIPUS is the only risk assessment
113
measure developed specifically for people with SCI; however,,its psychometric properties have
114
yet to be elucidated. The SCIPUS is a 15 item scaled developed by Salzberg and colleagues20 to
115
address the lack of SCI-specific risk factors in existing tools for PU risk assessment. The purpose
116
of this study was therefore to assess the psychometric properties of the SCIPUS (inter-rater
117
reliability, sensitivity, specificity) for individuals with SCI participating in inpatient rehabilitation.
118
Methods
119
Study Cohort
120
As part of the SCI Knowledge Mobilization Network (SCI-KMN)21 the SCIPUS was implemented in
121
SCI rehabilitation programs at University Health Network – Toronto Rehabilitation Institute
122
(UHN-TRI) and Institut de Réadaptation Gingras-Lindsay-de-Montréal (IRGLM). The SCIPUS was
123
chosen for implementation and evaluation based on the fact that it is the only measure
124
developed specifically for individuals with SCI. At both sites, inpatient nurses received training
125
on how to complete the SCIPUS and were instructed to complete it within 72hrs of inpatient
126
admission. Data were abstracted from patient records of 759 admissions between January 3,
127
2012 and April 23, 2014. The majority of patients were admitted for the first time to
128
rehabilitation; however some patients were readmissions with longer durations of injury.
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Data Collection
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As the current study was performed as part of ongoing quality improvement and best practice
131
implementation, a Research Ethics Board (REB) exemption was granted by the UHN-TRI REB.
132
The study was approved by the IRGLM REB. Collected variables included admission SCIPUS
133
scores; demographics; and PU incidence, prevalence, and severity. PUs were classified
134
according to the National Pressure Ulcer Advisory Panel staging guidelines.22 Prevalence was
135
the number of people documented to have a PU at any time point during rehabilitation.
136
Incidence was the number of people who developed new PUs during rehabilitation whether or
137
not they already had a PU at admission. PUs initially classified as unstageable were re-classified
138
if the stage became apparent at a later date. SCIPUS scores and corresponding risk stratification
139
were calculated if all items were complete. SCIPUS data were included in the analysis regardless
140
of whether the SCIPUS was completed within 72hrs. To assess inter-rater reliability (IRR), a
141
second blinded nurse completed the SCIPUS for 150 patients.
142
Outcome Measures
143
The SCIPUS is a 15-item SCI-specific PU risk assessment scale originally developed using a cohort
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of community dwelling individuals with SCI (Figure 1).20 Items requiring laboratory values were
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scored using local laboratory norms.
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[Insert Figure 1 here]
Statistical Analyses
149
Analysis of variance (ANOVA) and Mann-Whitney (non-parametric) were used to analyze
150
differences. IRR was determined using raw agreement and by calculating the two-way mixed
151
intraclass correlation coefficients (ICC). Sensitivity, specificity, and likelihood ratios (LR) were
152
calculated for the SCIPUS using PU incidence.23 An optimal SCIPUS cutoff value was identified
153
using sensitivity/specificity in a manner previously reported.24 Ideally this was achieved by
154
searching for the SCIPUS cutoff value for which sensitivity and specificity were both ≥ 0.7; while
155
at the same time maximizing sensitivity. If it were not possible for both values to be ≥ 0.7, the
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SCIPUS cutoff was assigned to the SCIPUS score with a sensitivity ≥ 0.7 while maximizing
157
specificity. Receiver Operating Characteristic (ROC) analysis was conducted to calculate areas
158
under the curve (AUC). Tests with AUC values of 0.5 to 0.7 were considered poorly accurate, 0.7
159
to 0.9 somewhat accurate, and >0.9 highly accurate.25 Analyses were conducted using the SAS
160
9.2 and SPSS v21 statistical packages.
161
Results
162
Cohort demographics are summarized in Table 1. Of the patients included in the analysis, 142
163
were from IRGLM and 617 were from UHN-TRI. Targeted variables were compared across sites.
164
There were no differences in age or length of stay between the two study sites. Composite
165
SCIPUS scores were slightly higher at IRGLM (9.4) compared to UHN-TRI (8.5) [F(1,572)=10.38;
166
p<.05]. The duration of injury (rehabilitation admission) also differed slightly between the sites
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with TRI having a median of 22 days, and IRGLM having a median of 27.5 days.
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168 169
[Insert Table 1 here]
Pressure Ulcer Incidence and Prevalence
171
PU data for the 759 admissions is summarized in Table 2. Four hundred twenty four PUs were
172
documented in 244 patients (32%). Seventy patients had more than one PU. One hundred sixty
173
three patients (21 %) had PUs at rehabilitation admission; while 136 patients (18%) developed
174
PUs during inpatient rehabilitation. The incidence of stage II or greater PUs during rehabilitation
175
was 10% (n=77). Including patients admitted with PUs, 24% of patients had at least one stage II
176
or greater PU at some point during rehabilitation. The anatomical distribution of observed PUs
177
was sacrum (42%), heels (17%), ischial tuberosities (18%), and other (23%).
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[Insert Table 2 here]
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Relationship between SCIPUS Scores and Pressure Ulcer Incidence
181
As expected, ANOVA revealed significantly higher SCIPUS scores for individuals who developed
182
PUs versus those who did not (mean ± SD SCIPUS score 9.8 ± 2.5 vs. 8.5 ± 2.6) [t(571) = -4.72;
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p<.0001]. There was no difference in mean SCIPUS scores between those who developed Stage
184
I versus stage II or greater PUs (mean ± SD SCIPUS score 9.8 ± 2.4 vs. 9.8 ± 2.6).
185
SCIPUS Completion & Inter-Rater Reliability
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SCIPUS completion rates are summarized in Table 2. Of the 696 SCIPUSs initiated, 573 (82%)
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were completed. SCIPUS items most often missing included serum tests (5.0 - 8.8%) and
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completeness of injury (2.9%). The SCIPUS composite score had an ICC of 0.91 indicating
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excellent inter-rater reliability. Agreement for risk stratification was lower (ICC=0.86) but still
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very good. For individual SCIPUS items, the level of disagreement was > 10% for the majority
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(Table 3). Only age, renal disease, and laboratory measures had discrepancies < 10%. Raw
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agreement between the two raters was 78% for risk stratification and 29% for composite
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scores.
194 195
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[Insert Table 3 here]
Sensitivity and Specificity
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Using PU incidence and the previously reported SCIPUS cutoff of ≥ 6 for ‘high risk’
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categorization, sensitivity and specificity were 0.97 and 0.12 respectively; while the LR was 1.1.
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Using a cutoff of ≥ 8, sensitivity and specificity were 0.85 and 0.38 respectively, with a LR of 1.4
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and AUC of 0.64 (95% CI 0.59-0.70) (Figure 2). Sensitivity and specificity were similar when
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analysis was confined to PUs of stage II or greater. With a cutoff of ≥6, sensitivity and specificity
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were 0.95 and 0.11 respectively; whereas a cutoff of ≥8 yielded 0.88 and 0.36 respectively.
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AUC and LR were unchanged (using a cutoff of ≥ 8) when only PUs of stage II or greater were
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considered. In all analyzed scenarios LRs were < 2. This indicates that stratification as high risk
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or greater does not substantially increase the likelihood of identifying individuals who develop
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PUs beyond chance alone. Furthermore, all SCIPUS AUCs were below 0.7 indicating poor
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accuracy.25
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208 209
[Insert Figure 2 here]
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Discussion
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Study findings demonstrate that the SCIPUS as currently constructed has limited utility for
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identifying individuals at risk for developing PUs while participating in inpatient SCI
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rehabilitation. Using the existing cutoff value for high or very high risk in a cohort of individuals
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participating in inpatient SCI rehabilitation, the balance between sensitivity and specificity is
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less than ideal (0.97/0.12). While the sensitivity is excellent and the majority of individuals who
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develop a PU are appropriately identified as high or very high risk, the specificity in contrast is
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quite low. This is due to the fact that in an inpatient setting almost all individuals (89%) were
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stratified as high or very high risk; suggesting the cutoff for high risk is too low. LRs help
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clinicians assess the utility of diagnostic tests by determining whether a test result changes the
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probability that a condition is present. When a LR is close to 1 there is little practical
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significance as the post-test probability (odds) is similar to the pre-test probability. With a LR of
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less than 2.0, completion of the SCIPUS fails to double the odds of accurately identifying at-risk
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individuals compared to chance alone.
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Given the inherent tradeoff between sensitivity and specificity, a new cutoff value might yield a better balance between the two performance metrics. Sensitivity/specificity and ROC
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analysis were performed for all PUs as well as PUs ≥ stage 2. A cutoff value ≥ 8 demonstrates
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the best tradeoff between sensitivity and specificity. Unfortunately, even with a cutoff value of
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≥ 8 the SCIPUS fails to demonstrate acceptable LRs and AUCs fell below 0.7.25
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Inter-rater reliability is excellent for composite SCIPUS scores (ICCs = 0.91) and very good for risk stratification (ICC = 0.86). Levels of agreement, however, are less robust for
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individual items of the SCIPUS. The majority of individual items had > 10% disagreement, which
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limits their utility in isolation. Items with lower levels of agreement tended to require subjective
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judgment or were dependent on very specific knowledge of the patient (e.g. cardiac disease OR
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abnormal EKG, autonomic dysreflexia OR severe spasticity, urine incontinence OR constantly
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moist). In comparison, objective items (e.g. age, serum values) scored better across raters.
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Improving and clarifying the scoring instructions placed directly on the scoring sheet could
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possibly improve scoring consistency for individual items.
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Study findings confirmed that PUs are a common occurrence even in the relatively early phases following a SCI. When one combines PUs present at admission and PUs that developed
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during rehabilitation, 32% of the study sample had a PU at some point during inpatient
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rehabilitation, with 9% having more than one PU. Ten percent developed stage II or greater PUs
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during their rehabilitation admission. Previous studies have reported similar findings in acute
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and rehabilitation settings.12,13,15 The observed prevalence of PUs reinforces the importance of
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screening and identifying high risk individuals for preventative strategies.
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It is important to note that the initial development of the SCIPUS utilized a cohort of
community dwelling individuals.20 In this context, using a cutoff value of ≥ 6, the SCIPUS was
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found to have very good sensitivity (0.76) and specificity (0.74), and a LR of 2.9. Modifications
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to the SCIPUS might improve its predictive validity in a rehabilitation setting, similar to what has
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been done in the acute care setting with the SCIPUS-A.15 Individual items should demonstrate a
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reasonable variance in scores among tested individuals. Item endorsement ranging from 20-
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80% has been recommended as reasonable variance.26 SCIPUS items with very low rates of
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endorsement included renal disease, cognitive impairment, and autonomic
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dysreflexia/spasticity (5-11%). The use of items not correlated with risk has been cited as one of
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the major weaknesses of PU risk assessments and brings into question their general utility.27 A
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refinement of the SCIPUS including both a re-assessment and re-weighting of contributing
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items could possibly improve PU risk assessment for inpatient rehabilitation. This work is
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ongoing and will be reported in a future publication.
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The Canadian Best Practice Guidelines for the Prevention and Management of PUs in People with SCI indicated that there was level IIa (moderate) evidence for the use of risk
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assessment.17 Others have argued that current PU risk assessment measures do not have the
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right items, are not properly scaled, and may be no more effective than clinical judgment.27,28
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Given that SCIPUS has LRs < 2 for candidate cutoff values and has an AUC < 0.7, it cannot
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currently be recommended for routine PU risk assessment in an inpatient SCI rehabilitation
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setting. A tool with better psychometric properties and lower administrative burden might be a
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more effective tool for this context.
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Individuals with SCI are known to be at high risk of PU development and universal
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precautions should always be in place. The clinical utility of a risk assessment lies in its ability to
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prospectively identify individuals at high risk of PU development in order to proactively
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implement more rigorous prevention strategies. As an example, certain individuals might
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warrant the proactive use of specialized surfaces (e.g., mattresses) or more frequent turning
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schedules. Conversely, the identification of individuals who are not at risk of PU development
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could result in a more focused use of clinical resources. Using a four point scale to categorize
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risk from low to very high is questionable without explicit guidelines informing how clinical
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practice should be altered for each risk level; although there might be some implicit value in
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heightening awareness and sensitivity among clinicians. A binary risk level (high risk or low risk)
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may be sufficient for a PU screening tool. This is an issue that could be assessed in future
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studies.
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Study Limitations
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The sample used to develop the SCIPUS was quite different than the sample in this study, and
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our study results underscore the need to validate PU risk assessment scales in specific
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populations.29 The SCIPUS was developed from a dataset of community-dwelling individuals
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and demonstrated good sensitivity and specificity.20 In that dataset, 80% of individuals had a
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history of PU development and the average duration of injury was 15 years. In the current
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study, 18% of cases developed a new PU during rehabilitation and 32% were documented as
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having a PU at some point during their rehabilitation (including admission). Individuals in this
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study had a median duration of injury of 27 days and were assessed over a median length of
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stay of 68 days. When using the current SCIPUS cutoff for high risk or greater (≥ 6), 89% of
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inpatients were classified as high or very high risk (close to the lifetime risk of 85% previously
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reported).1 It is possible that the SCIPUS functions better as a tool to predict lifetime risk of PU
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development as opposed to the comparatively short stays in rehabilitation centres.
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Subsequently, a different risk assessment scale may be needed to identify individuals at risk for
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developing a PU during rehabilitation (e.g. SCIPUS-A).15
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Our study also incorporated more than one participating site which introduces the possibility of differences between the clinical settings. In fact this is likely. It is the opinion of
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the authors that this is more analogous to the real world and the different contexts within
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which clinicians practice. The intent of the study was to assess the performance of the SCIPUS
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in applicable clinical settings and maximize generalizability. Participation of more than one
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study site therefore increased the number of study subjects and enhanced the generalizability
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of study results. Overall, the advantages were felt to out-weigh the value of limiting the study
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to one site.
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Conclusion
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The SCIPUS had acceptable inter-rater reliability but failed to perform adequately as a measure
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of PU risk assessment in a rehabilitation setting due to limited specificity. Modifications to the
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current measure could possibly improve its performance. Future work should focus on
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identifying high impact items and optimized weighting schemes to maximize the utility of a risk
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assessment measure for individuals with SCI participating in inpatient rehabilitation. The new
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tool should be constructed to minimize interpretation, have low administrative burden and
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include clear, practical recommendations on how to interpret risk levels and accordingly adjust
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clinical practice.
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Acknowledgements
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The authors would like to acknowledge the involvement of Diane Leber and Trisha Domingo
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who assisted with data collection and Lan McMillan who assisted with training nurses to
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complete the SCIPUS.
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References
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1.
Gunnewicht BR. Pressure sores in patients with acute spinal cord injury. Journal of wound care. 1995;4(10):452-454.
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7.
8. 9. 10.
11.
12.
13. 14.
15.
16.
17.
RI PT
6.
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5.
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4.
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3.
Bennett G, Dealey C, Posnett J. The cost of pressure ulcers in the UK. Age and ageing. 2004;33(3):230-235. Chan BC, Nanwa N, Mittmann N, Bryant D, Coyte PC, Houghton PE. The average cost of pressure ulcer management in a community dwelling spinal cord injury population. International wound journal. 2013;10(4):431-440. Mittmann N, Chan BC, Craven BC, Isogai PK, Houghton P. Evaluation of the costeffectiveness of electrical stimulation therapy for pressure ulcers in spinal cord injury. Archives of physical medicine and rehabilitation. 2011;92(6):866-872. Pancorbo-Hidalgo PL, Garcia-Fernandez FP, Lopez-Medina IM, Alvarez-Nieto C. Risk assessment scales for pressure ulcer prevention: a systematic review. Journal of advanced nursing. 2006;54(1):94-110. Jackson J, Carlson M, Rubayi S, et al. Qualitative study of principles pertaining to lifestyle and pressure ulcer risk in adults with spinal cord injury. Disability and rehabilitation. 2010;32(7):567-578. Langemo DK, Melland H, Hanson D, Olson B, Hunter S. The lived experience of having a pressure ulcer: a qualitative analysis. Advances in skin & wound care. 2000;13(5):225-235. Hopkins A, Dealey C, Bale S, Defloor T, Worboys F. Patient stories of living with a pressure ulcer. Journal of advanced nursing. 2006;56(4):345-353. Redelings MD, Lee NE, Sorvillo F. Pressure ulcers: more lethal than we thought? Advances in skin & wound care. 2005;18(7):367-372. Wang H, Niewczyk P, Divita M, et al. Impact of pressure ulcers on outcomes in inpatient rehabilitation facilities. American journal of physical medicine & rehabilitation / Association of Academic Physiatrists. 2014;93(3):207-216. Iyun AO, Malomo AO, Oluwatosin OM, Ademola SA, Shokunbi MT. Pattern of presentation of pressure ulcers in traumatic spinal cord injured patients in University College Hospital, Ibadan. International wound journal. 2012;9(2):206213. Chen D, Apple DF, Jr., Hudson LM, Bode R. Medical complications during acute rehabilitation following spinal cord injury--current experience of the Model Systems. Archives of physical medicine and rehabilitation. 1999;80(11):1397-1401. Ash D. An exploration of the occurrence of pressure ulcers in a British spinal injuries unit. Journal of clinical nursing. 2002;11(4):470-478. DeJong G, Hsieh CH, Brown P, et al. Factors Associated with Pressure Ulcer Risk in Spinal Cord Injury Rehabilitation. American journal of physical medicine & rehabilitation / Association of Academic Physiatrists. 2014. Salzberg CA, Byrne DW, Kabir R, van Niewerburg P, Cayten CG. Predicting pressure ulcers during initial hospitalization for acute spinal cord injury. Wounds. 1999;11:45-57. Consortium for Spinal Cord Medicine Clinical Practice Guidelines. Pressure ulcer prevention and treatment following spinal cord injury: a clinical practice guideline for health-care professionals. The journal of spinal cord medicine. 2001;24 Suppl 1:S40-101. Houghton PE, Campbell KE, CPG Panel. Canadian Best Practice Guidelines for the Prevention and Management of Pressure Ulcers in People with Spinal Cord Injury. 2013; www.onf.org. Accessed November 14, 2014.
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320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365
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23. 24.
25. 26. 27. 28.
29.
RI PT
22.
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21.
M AN U
20.
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19.
Mortenson WB, Miller WC. A review of scales for assessing the risk of developing a pressure ulcer in individuals with SCI. Spinal cord. 2008;46(3):168-175. Bergstrom N, Braden BJ, Laguzza A, Holman V. The Braden Scale for Predicting Pressure Sore Risk. Nursing research. 1987;36(4):205-210. Salzberg CA, Byrne DW, Cayten CG, van Niewerburgh P, Murphy JG, Viehbeck M. A new pressure ulcer risk assessment scale for individuals with spinal cord injury. American journal of physical medicine & rehabilitation / Association of Academic Physiatrists. 1996;75(2):96-104. Scovil CY, Flett HM, McMillan LT, et al. The application of implementation science for pressure ulcer prevention best practices in an inpatient spinal cord injury rehabilitation program. The journal of spinal cord medicine. 2014;37(5):589-597. Black J, Baharestani M, Cuddigan J, et al. National Pressure Ulcer Advisory Panel's updated pressure ulcer staging system. Dermatology nursing / Dermatology Nurses' Association. 2007;19(4):343-349; quiz 350. Lalkhen AG, McCluskey A. Clinical tests: sensitivity and specificity. Continuing Education in Anaesthesia, Critical Care & Pain. 2008;8(6):221-223. Tannen A, Balzer K, Kottner J, Dassen T, Halfens R, Mertens E. Diagnostic accuracy of two pressure ulcer risk scales and a generic nursing assessment tool. A psychometric comparison. Journal of clinical nursing. 2010;19(11-12):1510-1518. McDowell I, Newell C. Measuring Health. A Guide to Rating Scales and Questionnaires. New York, NY: Oxford University Press; 2006. Streiner DL, Norman GR. Health Measurement Scales: A practical guide to their development and use. Fourth ed. New York, NY: Oxford University Press; 2008. Anthony D, Papanikolaou P, Parboteeah S, Saleh M. Do risk assessment scales for pressure ulcers work? Journal of tissue viability. 2010;19(4):132-136. Anthony D, Parboteeah S, Saleh M, Papanikolaou P. Norton, Waterlow and Braden scores: a review of the literature and a comparison between the scores and clinical judgement. Journal of clinical nursing. 2008;17(5):646-653. Atkinson G, Nevill AM. Statistical methods for assessing measurement error (reliability) in variables relevant to sports medicine. Sports medicine (Auckland, N.Z.). 1998;26(4):217-238.
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Table 1. Cohort demographics (n=759). *one patient was admitted and discharged same day. **calculated only for traumatic cases. Values are means ± standard deviation; ns: not significant No PU (n = 623)
PU Incidence (n = 136)
8.7 (2.7) 53.9 (18.5) 68 (41.2) 84.9 (379.7) 67%
8.5 (2.6) 53.9 (18.5) 62.3 (39.2) 91 (432.8) 79%
9.8 (2.5) 53.8 (18.6) 94.6 (39.9) 65.7 (90.5) 21%
Females
33%
89%
11%
Paraplegia
53%
81%
19%
Quadriplegia
47%
81%
Traumatic
40%
76%
Non-Traumatic
60%
86%
Complete
16%
Incomplete
84%
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<.0001 ns <.0001 ns -
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Admission SCIPUS Age (yrs) Length of stay (days)* Duration of injury (days)** Males
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Table 2. Summary of PU Incidence and Prevalence. The percentages represent individuals who were documented with at least one PU of a given stage. Some individuals had more than one PU. *PUs were categorized according to highest observed stage during rehabilitation. DTI: Deep
6.6 12 2.9 1.4 1.6 21 16
91 87 11 1 7 197 99
9.2 9.2 1.2 0.13 0.79 18 10
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Overall* Prevalence # PUs %
146 202 37 20 19 424 258
14 20 4.3 2.4 2.2 32 24
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Rehabilitation Incidence # PUs %
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Table 3. Completeness, Endorsement and Disagreement of SCIPUS Items. Values represent percentages of incomplete fields (missing), items endorsed, and disagreement between two
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IRR Dataset (n=150) Disagreement (%) 4 16.4 24.2 12.8 19.7 12.2 14.7 10.7 16.2 7.4 17.3 0 5.8 7.4 9.4
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Age Complete SCI Mobility Level of activity Incontinence/moisture AD/spasticity Tobacco use Pulmonary disease Cardiac disease/EKG Renal disease Cognitive impairments Hospitalization Diabetes/high glucose Low albumin Low hematocrit
SCIPUS Dataset (n=696) Missing Endorsed (%) (%) 0.0 81 2.9 19 0.3 87 0.4 82 1.3 26 1.6 11 0.9 45 1.0 14 0.9 27 2.2 5 1.3 7 0.0 100 5.0 17 8.8 69 6.2 71
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raters in the inter-rater reliability database (IRR).
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