Spinal cord injury and development of pressure injury during acute rehabilitation in Norway: a national retrospective cross-sectional study

Abstract

Study design

A national, retrospective, cross-sectional study.

Objectives

To analyze the prevalence of pressure injury (PI), and characteristics associated with PI development in the hospitalized population of persons with a newly acquired spinal cord injury (SCI) between 2004 and 2014.

Setting

All three specialized Spinal Cord Units in Norway.

Methods

Demographic data related to prevalence and potential risk factors were retrieved from the electronic medical record (EMR). Statistical analyses were performed, using IBM SPSS Statistics, version 23.

Results

We identified 1012 individuals with a new SCI. Mean age at injury was 48 years (SD 19). The period prevalence of PI was 16% (95% CI = 0.14–0.19), and identified PI associations were complete SCI (OR = 0.1), being injured abroad (OR = 2.4), bowel (OR = 13), and bladder (OR = 9.2) dysfunction; comorbidities like diabetes mellitus 1 (OR = 7.9), diagnosed depression (OR = 3.8), ventilator support (OR = 3.0), drug abuse (OR = 3.0), and concurrent traumatic brain injury (OR = 1.7). Individuals in the age group of 15–29 years had higher odds of PI compared with middle-aged individuals (45–59 years).

Conclusion

PI is a serious complication after SCI. The association between depression or comorbidity and PI occurrence should be investigated more thoroughly. We recommend implementation of a simple follow-up program regarding observation and prevention of PI. Increased awareness of factors that could contribute to PI will help to focus on better prevention and early recognition of PI. This will contribute to more optimal rehabilitation.

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Fig. 1: Location and frequency of the PIs in the studied population.
Fig. 2: The trend between the AIS grade and the PI risk in the studied population.
Fig. 3: Suggested action plan for prevention of PI.

Data availability

The data set is stored in a locked and fireproof research cabinet at the research department, Sunnaas Rehabilitation Hospital, Norway, and can be made available on request, according to the Norwegian Data and Telecommunications Authority’s requirements for safe information flow [14].

References

  1. 1.

    The National Pressure Ulcer Advisory Panel (NPUAP). http://www.epuap.org/. Downloaded July 22, 2019.

  2. 2.

    Coleman S, Gorecki C, Nelson AE, Closs JS, Defloor T, Halfens R, et al. Patient risk factors for pressure ulcer development: systematic review. Int J Nurs Stud. 2013;50:974–1003.

    PubMed  Article  Google Scholar 

  3. 3.

    Eslami V, Saadat S, Habibi Arejan R, Vaccaro AR, Ghodsi SM, Rahimi-Movaghar V. Factors associated with the development of pressure ulcers after spinal cord injury. Spinal Cord. 2012;50:899–903.

    CAS  PubMed  Article  Google Scholar 

  4. 4.

    Hagen EM, Eide GE, Rekand T, Gilhus NE, Gronning M. A 50-year follow-up of the incidence of traumatic cord injuries in Western Norway. Spinal Cord. 2010;48:313–8.

    CAS  PubMed  Article  Google Scholar 

  5. 5.

    Smith Bridget M, Marylou Guihan, LaVela Sherri L, Garber Susan L. Factors predicting pressure ulcers in veterans with spinal cord injuries. Am J Phys Med Rehabilit. 2008;87:750–7.

    CAS  Article  Google Scholar 

  6. 6.

    van der Wielen H, Post MWM, Lay V, Gläsche K, Scheel-Sailer A. Hospital acquired pressure ulcer in spinal cord injured patients: time to occur, time until closure and risk factors. Spinal Cord. 2016;54:726–31.

    PubMed  Article  Google Scholar 

  7. 7.

    Verschueren JHM, Post MWM, de Groot S, van der Woude LHV, van Asbeck FWA, Rol M. Occurrence and predictors of pressure ulcer during primary in—patient spinal cord injury rehabilitation. Spinal Cord. 2011;49:106–12.

    CAS  PubMed  Article  Google Scholar 

  8. 8.

    Saunders LL, Krause JS, Acuna J. Association of race, socioeconomic status, and health care access with pressure ulcers after spinal cord injury. Arch Phys Med Rehabilit. 2012;93:972–7.

    Article  Google Scholar 

  9. 9.

    Baumgarten M, Margolis DJ, Localio AR, Kagan SH, Lowe RA, Kinosian B. Pressure ulcers among elderly patients in the hospital stay. J Gerontol A Biol Sci Med Sci. 2006;61:749–54.

    PubMed  Article  Google Scholar 

  10. 10.

    Grigorian A, Sugimoto M, Joe V, Schubl S, Lekawa M, Dolich M, et al. Pressure ulcer in trauma patients: a higher spinal cord injury level leads to higher risk. J Am Coll Clin Wound Spec. 2018;9:24–31.e1. 19

    PubMed  PubMed Central  Article  Google Scholar 

  11. 11.

    Irgens I, Hoff JM, Sørli H, Haugland H, Stanghelle JK, Rekand T. Hospital based care at home; study protocol for a mixed epidemiological and randomized controlled trial. Trials. 2019;20:77 https://doi.org/10.1186/s13063-019-3185-y

    PubMed  PubMed Central  Article  Google Scholar 

  12. 12.

    Strom V, Manum G, Leiulfsrud A, Wedege P, Rekand T, Halvorsen A, et al. People with spinal cord injury in Norway. Am J Phys Med Rehabilit. 2017;96:S99–101.

    Article  Google Scholar 

  13. 13.

    NY. https://helsenorge.no/pasientjournal/andres-innsyn-i-din-pasientjournal. Downloaded December 9, 2019.

  14. 14.

    eHelse. https://www.ehelse.no/personvern-og-informasjonssikkerhet/relevante-lover-og-forskrifter. Downloaded July 21, 2019.

  15. 15.

    The National Regional Ethical Committee (REC) 2014/684/REK-Nord. https://helseforskning.etikkom.no/. Downloaded July 21, 2019.

  16. 16.

    Ethical Committee Guidelines. www.etikkom.no/RETNINGSLINJER/ Downloaded May 1, 2019.

  17. 17.

    Biering-Sorensen F, DeVivo MJ, Charlifue S, Chen Y, New PW, Noonan V, et al. International Spinal Cord Injury Core Data Set (version 2.0)—including standardization of reporting. Spinal Cord. 2017;55:759–64.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  18. 18.

    Halvorsen A, Pettersen AL. The Norwegian SCI registry. Trondheim: St Olavs Hospital; 2018. https://stolav.no/fag-og-forskning/medisinske-kvalitetsregistre/norskryggmargsskaderegisternorscir#rapporter.

  19. 19.

    Kirshblum SC, Burns SP, Biering-Sorensen F, Donovan W, Graves DE, Jha A, et al. International standards for neurological classification of spinal cord injury (revised 2011). J Spinal Cord Med. 2011;34:535–46.

    PubMed  PubMed Central  Article  Google Scholar 

  20. 20.

    Halvorsen A, Pettersen AL, Nilsen SM, Halle KK, Schaanning EE, Rekand T. Epidemiology of traumatic spinal cord injury in Norway in 2012–6: a registry-based cross-sectional. Spinal Cord. 2019;57:331–8.

    CAS  PubMed  Article  Google Scholar 

  21. 21.

    Halvorsen A, Pettersen AL, Nilsen SM, Halle KK, Schaanning EE, Rekand T. Non-traumatic spinal cord injury in Norway 2012–6: analysis from a national registry and comparison with traumatic spinal cord injury. Spinal Cord. 2019;57:324–30.

    CAS  PubMed  Article  Google Scholar 

  22. 22.

    Bhattacharya S, Mishra RK. Pressure ulcers: current understanding and newer modalities of treatment. Indian J Plast Surg. 2015;48:4–16.

    PubMed  PubMed Central  Article  Google Scholar 

  23. 23.

    Salzberg CA, Byrne DW, Kabier R, von Niewerburg P, Cayton CG. Predicting pressure ulcers during initial hospitalization for acute spinal cord injury. Wounds. 1999;11:45–57.

    Google Scholar 

  24. 24.

    Ash D. An exploration of the occurrence of pressure ulcers in a British Spinal Injuries Unit. J Clin Nurs. 2002;11:470–78. https://doi.org/10.1046/j.1365-2702.2002.00603.x.

    PubMed  Article  Google Scholar 

  25. 25.

    Curry K, Casady L. The relationship between extended periods of immobility and decubitus ulcer formation in the acutely spinal cord-injured individual. J Neurosci Nurs. 1992;24:185–9.

    CAS  PubMed  Article  Google Scholar 

  26. 26.

    Mawson AR, Biundo JJ Jr, Neville P, Linares HA, Winchester Y, Lopes A. Risk factors for early occuring pressure ulcer following spinal cord injury. Am J Phys Med Rehabilit. 1988;67:123–7.

    CAS  Article  Google Scholar 

  27. 27.

    Brienza D, Krishnan S, Karg P, Sowa G, Allegretti AL. Predictors of pressure ulcer incidence following traumatic spinal cord injury: a secondary analysis of a prospective longitudinal study. Spinal Cord. 2018;56:28–34.

    CAS  PubMed  Article  Google Scholar 

  28. 28.

    Regan MA, Teasell RW, Keast D, Aubut J-AL, Foulon B, Mehta S. Pressure ulcers following spinal cord injury. Spinal Cord Injury Rehabilitation Evidence (SCIRE). 2014. Version 3.0. www.scireproject.com. Downloaded May 1, 2019.

  29. 29.

    Chen D, Apple DF, Hudson MF, Bode R. Medical complications during acute rehabilitation following spinal cord injury. Arch Phys Med Rehabilitation. 1999;80:1397–401.

    CAS  Article  Google Scholar 

  30. 30.

    Bredesen IM, Bjøro K, Gunningberg L, Hofoss D. The prevalence, prevention and multilevel variance of pressure ulcers in Norwegian hospitals: a cross-sectional study. Int J Nurs Stud. 2015;52:149–56.

    PubMed  Article  Google Scholar 

  31. 31.

    Multiresistant bacterias and hospitalization in Norway. https://forskning.no/land-og-regioner-sykdommer-bakterier/i-disse-ferielandene-er-det-mest-resistente-bakterier/335688. Downloaded July 21, 2019.

  32. 32.

    Scovil CY, Delparte JJ, Walia S, Flett HM, Guy SD, Wallace M, et al. Implementation of pressure injury prevention best practices across 6 Canadian rehabilitation sites: results from the spinal cord injury knowledge mobilization network. Arch Phys Med Rehabilit. 2019;100:327–35.

    Article  Google Scholar 

  33. 33.

    Sheerin F, Gillick A, Doyle B. Pressure ulcers and spinal cord injury: incidence among admissions to the Irish national specialist unit. J Wound Care. 2005;14:112–5.

    CAS  PubMed  Article  Google Scholar 

  34. 34.

    Kottner J, Gefen A, Lahmann N. Weight and pressure ulcer occurrence: a secondary data analysis. Int J Nurs Stud. 2011;48:1339–48.

    PubMed  Article  Google Scholar 

  35. 35.

    Your right to medical care. https://helsenorge.no/other-languages/english/rights/health-care-rights?redirect=false. Downloaded July 21, 2019.

  36. 36.

    Beeckman D. A decade of research on incontinence-associated dermatitis (IAD): evidence, knowledge gaps and next steps. J Tissue Viabil. 2017;26:47–56.

    Article  Google Scholar 

  37. 37.

    Apostolopoulou E, Tselebis A, Terzis K, Kamarinou E, Lambropoulos I, Kalliakmanis A. Pressure ulcer incidence and risk factors in ventilated intensive care patients. Health Sci J. 2014;8:333–42.

    Google Scholar 

  38. 38.

    Greenhalgh DG. Wound healing and diabetes mellitus. Clin Plast Surg. 2003;30:37–45.

    PubMed  Article  Google Scholar 

  39. 39.

    Frankel H, Sperry J, Kaplan L. Risk factors for pressure ulcer development in a best practice Surgical Intensive Care Unit. Am Surg. 2007;73:1215–7.

    PubMed  Google Scholar 

  40. 40.

    2015 National Kidney Foundation. Diabetes—a major risk factor for kidney disease. https://www.kidney.org/atoz/content/diabetes. Downloaded August 16, 2019.

  41. 41.

    Tate DG, Forchheimer MB, Krause JS, Meade MA, Bombardier CH. Patterns of alcohol and substance use and abuse in persons with spinal cord injury: risk factors and correlates. Arch Phys Med Rehabilit. 2004;85:1837–47.

    Article  Google Scholar 

  42. 42.

    Kang H. The prevention and handling of the missing data. Korean J Anesthesiol. 2013;64:402–6.

    PubMed  PubMed Central  Article  Google Scholar 

  43. 43.

    Taylor C. The difference between type I and type II errors in hypothesis testing; 2019. https://www.thoughtco.com/difference-between-type-i-and-type-ii-errors-3126414. Downloaded August 19, 2019.

  44. 44.

    The Declaration of Helsinki (DoH), 1964, amended last time at the General Assembly, October 2013. www.wma.net/what-we-do/medical-ethics/declaration-of-Helsinki/. Downloaded July 22, 2019.

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Acknowledgements

Thanks to Toril Stensrud at Sunnaas Rehabilitation Hospital, Tori Lunde, and Hege Storlid at the Spinal Cord Unit at Haukeland University Hospital, and to Tom Tørhaug and Ellen Marie Hatlen at the Spinal Cord Unit at St. Olavs Hospital for all the help with the data collection. Thanks to Annette Halvorsen for guiding in Spinal Cord Injury Core Data Set questions.

Funding

The first author is funded by the DAM Foundation. Name and contact information for the trial founder: Linda Åsheim, e-mail; linda.aasheim@nhf.no. The DAM foundation has no influence on the trial protocol or the results.

Author information

Affiliations

Authors

Contributions

II is a medical doctor (MD) at Sunnaas Rehabilitation Hospital, and a PhD fellow at the University of Oslo. She is the main investigator of the study, and the only investigator with access to the complete data set collected in the study. She is also the main contributor in the writing of the paper. TR is the main supervisor. TR and II were responsible for the design of the study. JKS is the research director at Sunnaas Rehabilitation Hospital, and the project manager. JMH and RJ are co-supervisors in the project. MA is a collaborator in the project. MT is a statistician, guiding in the statistical design of the study and analyses of the results. JKS, TR, JMH, RJ, MA, and MT all contributed to the draft of this paper. All authors read and approved the final paper before submission.

Corresponding author

Correspondence to Ingebjørg Irgens.

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Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

The research project was carried out in accordance with current ethical guidelines and privacy rights for health services in Norway [14], based on the Code of Ethics of the World Medical Association (Declaration of Helsinki) [44] for experiments involving humans. The research project was approved by the Norwegian Regional Ethical Committee (REC) on January 9th 2015 (2014/684 REK-Nord) [15], and registered in Clinical Trials.gov in May 2016 (NCT02800915).

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Irgens, I., Hoff, J.M., Jelnes, R. et al. Spinal cord injury and development of pressure injury during acute rehabilitation in Norway: a national retrospective cross-sectional study. Spinal Cord (2020). https://doi.org/10.1038/s41393-020-0465-z

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