A patient from Audie Murphy VAMC is transported onto a C-130 aircraft last summer at Joint Base San Antonio-Kelly Airfield, Texas. South Texas Veterans Health Care System successfully transferred Spinal Cord Injury Unit patients to the VA North Texas Health Care System in Dallas to make room for more COVID-19 patients in the San Antonio area. U.S. Air Force photo by Sarayuth Pinthong
CLEVELAND — During the peak of the conflicts in Iraq and Afghanistan, servicemembers sustained spinal cord injuries at eight times the rate of their civilian counterparts. The DoD estimates that approximately 300,000 individuals in the United States have a spinal cord injury (SCI) and the VA cares for 10% to 20% of those patients.
Up to 30% of patients with spinal cord injury experience pressure injuries, also known as pressure ulcers or bedsores. Because SCI disrupts communication between the brain and body, patients do not receive the signals that one part of the body is experiencing excess pressure which typically leads people to move or rotate even when lying down. The SCI also means that they are generally less capable of moving parts of their body independently, while the loss of sensation prevents awareness that a sore is forming, something they could communicate to the care team.
To meet the needs of the thousands of veterans with spinal cord injuries, the VA created two complementary care systems. The Spinal Cord Injuries and Disorders System of Care is a hub and spoke system that radiates from 25 centers around the country to small facilities to provide the specialized care veterans with SCI often need, including measures to prevent pressure injuries. As the TeleWound Practice rolls out, it will also support patients with pressure injuries in rural and highly rural areas.
Predicting Pressure Injuries
A team led by Kath Bogie, D.Phil., a senior research scientist at the Advanced Platform Technology Center at the Louis Stokes Cleveland VAMC and associate professor at Case Western Reserve University, has enlisted the VA’s massive database to help veterans with SCI. Motivated by an understanding that preventing pressure injuries (PrI) is far more economical and vastly better for the veteran’s quality of life than treating those wounds, they created the SCI pressure injury resource (SCI-PIR). SCI-PIR provides a foundation for a system that will offer weighted insight in the risk of pressure injury in veterans with SCI.
A system that brought together the myriad clinical practice guidelines addressing this area was urgently needed. “Indicative of the complex holistic nature of PrI, over 200 PrI risk factors have been reported for individuals with SCI,” the researchers wrote in a study published in Military Medicine. “The 2014 Pressure Ulcer Prevention and Treatment Following SCI from the Consortium for Spinal Cord Medicine contained over 400 evidence-based recommendations, with a summary of over 25 recommendations to be followed by the care provider.” Further, the guidelines are constantly updated based on new studies and emerging treatment options.1
Implementing all the recommendations “continues to be overwhelming and impractical,” they noted. Even with scores of identified risk factors, the guidelines frequently fail to consider issues common to veterans such as difficulty getting to a care center because of travel restrictions or distance. Other individuals with SCI may have unique factors that increase their risk of pressure injuries.
Prioritization of recommendations for interventions also poses a challenge, particularly without a method to weigh risk factors. To overcome these issues, the team employed a bioinformatics approach which also allowed them to manipulate the vast amount of data involved.
Personalized Management
The total study cohort included 36,626 veterans with SCI, which represented between 10% and 14% of the total number of individuals with SCI in the U.S. in 2019, the authors said. The team input the relevant electronic health record data from those veterans for a five-year period. The researchers queried patient data tables to create more than 18 million records. Extracted datasets included diagnostics, demographics, comorbidities, rurality, medications, and laboratory tests for a total of 70 variables of interest for each patient. “This large cohort enhances the robustness and power of our multivariate analysis and model development,” the authors said.
The team also developed the Spinal Cord Injury Pressure Ulcer and Deep Tissue Injury Ontology (SCIPUDO) from free text clinical notes in the cohort’s records to collect important information that had not been coded in the medical record. Information gathered and standardized covered five primary domains: personal, environmental, clinical, social, and tissue health. SCIPUDO continues to be used to extract data from more than six million text integration utility notes each year. SCIPUDO can be queried directly about specific patients.
The researchers created a tissue health subgroup of 40 veterans with medically stable SCI for more than 12 months. The team gathered a history of pressure injuries, then monitored the group monthly for up to three years to determine when a pressure injury occurred. They used principal component analysis of tissue health measurements to identify the factors most responsible for variations in tissue health.
“The multifactorial nature of PrI strongly implies that a universal standard approach will fail many patients,” the authors wrote. Yet, “a standardized process to create and implement a PrI prevention and care program tailored to each individual” is of the highest priority for VHA.
The team successfully created a beta version of a holistic and systemic approach that draws on existing tools to provide one point for access to unidentified pressure injury risk data through the SCI-PIR. In addition, the system evaluates each veteran’s specific characteristics to develop a plan for primary and secondary pressure wound prevention.
“Effective personalized PrI management provides a foundation to maximize active quality of life for military service members and veterans with SCI,” the authors concluded. Personalized interactive programs can enhance best practices in SCI care by providing adaptive personalized predictive PrI prevention care planning for veterans with SCI based on CPG prioritization.”
- Kath M Bogie, D.Phil., Steven K Roggenkamp, MS, Ningzhou Zeng, BS, Jacinta M Seton, DPN, RN, ACNS-BC, Katelyn R Schwartz, MPH, RN, M Kristi Henzel, MD, PhD, Mary Ann Richmond, MD, Jiayang Sun, PhD, Guo-Qiang Zhang, PhD, Development of Predictive Informatics Tool Using Electronic Health Records to Inform Personalized Evidence-Based Pressure Injury Management for Veterans with Spinal Cord Injury, Mil Med. 2021 Jan 25;186(suppl1): 651–658. doi.org/10.1093/milmed/usaa469
