A Prospective Evaluation of a Pressure Ulcer Prevention and Management E-Learning Program for Adults with Spinal Cord Injury

Transcription

1 A Prospective Evaluation of a Pressure Ulcer Prevention and Management E-Learning Program for Adults with Spinal Cord Injury Jacalyn A. Brace, PhD, RN, BC, CWOCN, APRN; and Jane R. Schubart PhD, MS, MBA Abstract Pressure ulcers are a common complication of spinal cord injury (SCI). Pressure ulcer education programs for spinal cord injured individuals have been found to have a positive effect on care protocol adherence. A prospective study was conducted among hospitalized spinal cord-injured men and women to determine if viewing the Pressure Ulcer Prevention and Management Education for Adults with Spinal Cord Injury: E-Learning Program affects their knowledge scores. A -question multiple-choice pre-/post learning test was developed and validated by rehabilitation nurses. Twenty () patients ( men, seven women; mean age 49 years, [SD: 8.6] with injuries to the cervical [seven], thoracic [six], and lumbar [six] regions) volunteered. Most (4%) had completed high school and time since SCI ranged from weeks to 7 years. Eighteen (8) participants completed both the pre- and post test. Of those, 6 showed improvement in pressure ulcer knowledge scores. The median scores improved from 6 (range to ) pre-program to 9. (range 7 to ) post-program. Descriptive statistics, Student s t-test, and analysis of variance (ANOVA) were used to analyze the data. The results suggest that a single viewing of this e-learning program could improve pressure ulcer knowledge of hospitalized adults with SCI. Research to ascertain the effects of this and other educational programs on pressure ulcer rates is needed. Key Words: prospective study, patient education, spinal cord injury, pressure ulcers, pre-test/post test Index: Ostomy Wound Management ;6(8):xx xx Potential Conflicts of Interest: The authors provided no relevant disclosures. The development of the web-based program was supported by Grant #8 (PI: Jane Schubart) from the Paralyzed Veterans Association Education and Training Foun- Pressure ulcer development continues to be a common complication, second only to respiratory illness, among spinal cord-injured persons., Approximately 8% of spinal cord-injured persons will develop a pressure ulcer during their lifetime despite available evidence-based prevention programs.,4 To be effective, an education program must be individualized for spinal cord-injured persons,-7 (most are designed for inpatients in rehabilitation facilities, not for patients in acute care) and should include an assessment of the person s learning abilities and a test of the knowledge and skills retained. 6,8 Yet methods to satisfactorily appraise the information retained by the spinal cord-injured person are rare. A prospective study was conducted to determine if viewing the Pressure Ulcer Prevention and Management Education for Adults with Spinal Cord Injury: E-Learning Program affected spinal cord-injured patient knowledge about the identification, prevention, and early detection of pressure ulcers. Identical tests were administered before and after viewing the program and results assessed. This is the first study of the E- Learning Program. Spinal Cord-Injured Population A recent report by the Christopher and Dana Reeve Foundation 9 shows that approximately.4% of the US population (~,7, people) report being paralyzed due to a SCI, which is five times more people living with SCI than previ- Dr. Brace is a CWOCN/CRNP Clinical Consultant, Roxborough Memorial Hospital, Philadelphia, PA; and an Associate Professor, Widener University, Chester, PA. Dr. Schubart is an Assistant Professor of Surgery, Medicine, and Public Health Sciences, Penn State College of Medicine, State College, PA. Please direct correspondence to: Jacalyn A. Brace, PhD, RN, BC, CWOCN, APRN, BC; jb@hotmail.com. 4 OSTOMY WOUND MANAGEMENT AUGUST

2 ously estimated. This study 9 was led by the University of New Mexico s Center for Development and Disability (CDD) from 6 to 8 and included experts from the US Centers for Disease Control and Prevention (CDC) and universities and medical centers. The main causes of SCI were found to be work-related accidents (8%), vehicle accidents (4%), and sporting/recreational accidents (7%). The average length of time since the SCI occurred among participants was 4 years (SD: years). Of persons who reported being paralyzed due to a SCI, 6% were men (9% women) men were nearly twice as likely as women to incur a SCI; approximately 7% were Caucasian,.6% were Black/African American, 7.% were Native American/Alaskan, and % were Hispanic. Fifty percent (%) of admissions to hospitals specializing in the spinal cord-injured population are related to pressure ulcers. The primary causes of death in spinal cord-injured persons are pneumonia, pulmonary embolism, and septicemia. Considerably higher mortality rates are reported in the first year after injury as compared to subsequent years after injury. Pressure Ulcer Prevalence and Incidence Pressure ulcer rates are highest among the elderly and spinal cord-injured patients ; the latter have a life-long risk for developing a pressure ulcer. -4 Approximately 9% of all pressure ulcers reported in the US are located below the waist,6 ; approximately 6% of these pressure ulcers occur on the ischial tuberosities, sacrum, coccyx, and trochanters and are attributed to wheelchair use among spinal cord-injured persons. 7 Among spinal cord-injured persons, reported annual pressure ulcer prevalence rates range from.% to % and annual incidence rates range from % to %. A review of the literature by the National Pressure Ulcer Advisory Panel 8 (NPUAP) reported that % of pressure ulcers were associated with the spinal cord-injured population. Of the % reported pressure ulcers among spinal cord-injured persons,.% to % were determined to be Stage I to Stage IV, and of these 7.4% were identified as Stage II to Stage IV. 8 Pressure Ulcer Costs and Complications Regan et al estimated the annual cost of treating pressure ulcers among the spinal cord-injured population to be $. billion to $. billion. Pressure ulcers increase the length of hospital stays and, in spinal cord-injured persons, they are one of the foremost reasons for rehospitalization. 9, These expenditures for pressure ulcer treatment are more costly than the treatment of all other health conditions. 9 Data regarding pressure ulcer complications, as well as prevalence and incidence rates, may be underestimated for numerous reasons, including; ) hospitals, long-term care facilities, and home care may not report pressure ulcers or may report a lesser stage of the pressure ulcer to avoid monetary penalties; ) in some facilities, spinal cord-injured persons with pressure ulcers may not be reported separately from all IMPROVING PRESSURE ULCER KNOWLEDGE Ostomy Wound Management ;6(8):xx-xx Key Points Effective programs are needed to help persons with spinal cord injuries (SCI) reduce their risk of developing pressure ulcers. Education may be the first step to achieving this goal because it has been shown to improve adherence to care protocols. The results of this study show that hospitalized SCI patient pressure ulcer knowledge scores improved after patients viewed an Internet-based educational program. Research to evaluate the effects of educational efforts on pressure ulcer rates is needed to help clinicians provide evidence-based care. Figure. Pre-/post test scores. other persons with pressure ulcers; ) individuals who are not experts may not designate the correct pressure ulcer stage; 4) not all persons with pressure ulcers are in a healthcare setting or followed by a home care agency, and ) national databases are not always equipped to track pressure ulcers over a period of time the literature indicates that prevalence and incidence data collected in some studies differ from national database data. 8 Pressure ulcers cause detrimental physical and emotional alterations that affect body image, self-esteem, - social relations, and loss of income and support systems., These are considered hidden costs for healthcare but may drastically impact outcomes for patients. High rates of medical complications and mortality have AUGUST OSTOMY WOUND MANAGEMENT

3 Table.Pressure Ulcer Prevention and Management E-Learning Program Multiple-Choice Pre- and Post test Questions. What is a pressure ulcer?. What is a Stage I pressure ulcer?. What is a Stage II pressure ulcer? 4. What is a Stage III pressure ulcer? Answers A. Damage from excessive moisture B. Damage from a shearing injury C. Damage from unrelieved pressure D. Damage from a friction injury been reported with spinal cord-injured patients with pressure ulcers., Even though this population is living longer due to medical advancements, death occurs at ages younger than the A. Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling B. Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. C. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue D. Partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister A. Partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister B. Full-thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling C. Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed D. Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area A. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue B. Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed C. Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling D. Partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister Continued on next page. general population. 4 Cardenas et al 9 conducted a cross-sectional analysis of data (n = 8,668 persons with SCI) and Chen et al 4 performed a multicenter cohort study design (n =,6 6 OSTOMY WOUND MANAGEMENT AUGUST

4 IMPROVING PRESSURE ULCER KNOWLEDGE Table.Pressure Ulcer Prevention and Management E-Learning Program Multiple-Choice Pre- and Post test cont Questions. What is a Stage IV pressure ulcer? 6. What is an unstageable pressure ulcer? 7. What is a deep tissue injury pressure ulcer? 8. All of the following can cause a pressure ulcer except: Answers A. Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area B. Full-thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling C. Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed D. Partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister A. Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area B. Partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister C. Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling D. Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed A. Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling B. Full-thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling C. Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed D. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue A. Not turning and repositioning B. Performing weight shifts C. Poor nutrition D. Improper equipment Continued on next page. spinal cord-injured persons) both studies found the risk of developing a pressure ulcer increases as the spinal cord-injured patient ages. Complications such as anemia, osteomyelitis, and sepsis from a pressure ulcer can be life-threatening; in addition, patients with injuries of the cervical spine (ie, the neck and upper back region from C to C8) tend to have respiratory complications and patients with injuries of the thoracic and sacral spine (ie, middle to lower back region from T to S) are more likely to have pressure ulcer complications. 9 AUGUST OSTOMY WOUND MANAGEMENT 7

5 Table.Pressure Ulcer Prevention and Management E-Learning Program Multiple- Choice Pre- and Post test cont Questions 9. What stage pressure ulcer do I seek help from a healthcare provider?. All of the following risk factors can be controlled except:. All of the following risk factors cannot be controlled except:. Which of the following should be avoided?. Which of the following should I avoid eating? Answers A. Any stage pressure ulcer B. A Stage IV pressure ulcer C. A Stage II pressure ulcer D. An unstageable pressure ulcer A. Nutrition B. Age C. Skin moisture D. Exercise and activity A. Age B. Severity of my spinal cord injury C. Other health problems D. Nutrition A. Eating a well-balanced meal B. Drinking plenty of fluids C. Alcohol and smoking D. Adherence to recommendations and directions A. Fruits and vegetables B. Soda and caffeine C. Foods high in protein D. Foods high in fiber The patients must know what to do to reduce the risk of occurrence and be able to recognize and manage a pressure ulcer when one occurs. Adherence to the pressure ulcer prevention program is vital. According to the Spinal Cord Medicine s Guidelines,,,6 spinal cord-injured persons who participate in rehabilitation and an educational program have greater protocol adherence than those who do not participate. Increased adherence with prevention programs has been associated with educational strategies that include detailed knowledge and practice techniques. 7 However, few studies have been designed to test knowledge retention and occurrence/reoccurrence rates after initial pressure ulcer prevention education.,6,7 4. All of the following are times A. Before dressing in the morning According to the literature, 6,7 pressure ulcer educa- when I need to perform a skin B. Each time I get up and down from the wheelchair check except: C. Every hour tion is typically offered D. After undressing for bed at night during the hospital and rehabilitation period when. What areas do I need to perform A. All areas with bony prominences the newly injured person is a skin check? B. Only heels adjusting to many life C. Only sacrum changes and may not be receptive to education about D. Only hips pressure ulcers. Additional 6. How often do I need to perform a A. No need to perform a weight shift factors that may influence weight shift? B. Every hour the effectiveness of education include cognitive im- C. Every minutes D. Every hours pairments, psychological distress, unwillingness to 7. How often do I need to turn and A. No need to turn and reposition accept and learn about the reposition in bed? B. Every hour disability, lack of available C. Every 6 hours programs, and timing of D. Every to 4 hours Continued on next page. delivery that may be too soon after injury.,6 Hospital and rehabilitation length of stay have decreased The Role of Educational Programs over the years, further limiting opportunities for effective education. According to the National Spinal Cord Injury Sta- Educational programs providing instruction on the risk, prevention, and early detection of pressure ulcers are important for the overall well being of spinal cord-injured persons. inpatient rehabilitation stays of patients with SCI in 974 tistical Center (NSCISC) database, the average length of was 8 OSTOMY WOUND MANAGEMENT AUGUST

6

7 The E-Learning Table. Pressure Ulcer Prevention and Management E-Learning Program Multiple- Choice Pre- and Post Test cont Program A Pressure Ulcer Prevention Questions Answers and Manage- 8. How do I know what equipment A. Equipment needs depend on your activity level and ment Education for is needed? 9. What is a support surface? your rehabilitation team will make recommendations B. Equipment you receive at time of discharge that will never need to be re-evaluated C. No equipment is needed D. Equipment that is the lowest cost A. A regular mattress B. A surface that reduces pressure to vulnerable areas C. A regular chair cushion Adults with Spinal Cord Injury: E-Learning Program (E-Learning Program) was developed by Jane Schubart, PhD, and Michelle Hilgart, MEd, at the University of Virginia (Pressure Ulcer Prevention E-Learning Program: D. A kitchen chair (University of. All of the following are ways to take charge of my care except: A. Ask for help B. Empower yourself C. Follow up with your primary care physician regularly Virginia Patent Foundation, Copyright Registration No. TXu-7-776, J. Schubart and M. Hilgart). D. Wait for a pressure ulcer to develop 7 Development of the E-Learning Program *Questions and answers for pre- and post test questions to 7 were created from the National Pressure Ulcer Advisory Panel 7 Pressure Ulcer Staging Definitions was funded by a grant from the Paralyzed Veterans of America Education approximately 7. days. Over the next years, NSCISC recorded a steady decline; by 994, the length of inpatient rehabilitation stay was, on average, 4.6 days. 8 The NSCISC data collected from to 8 showed that the average length of stay in acute care and rehabilitation facilities decreased to days and 7 days, respectively. Although evidence-based guidelines for preventing pressure ulcers have been developed, a mail survey study by Krause and Broderick 9 of 86 spinal cord-injured persons who were at least years since injury showed that current prevention programs for this population have had limited success in reducing pressure ulcer occurrence and reoccurrence and that the risk of recurrent pressure ulcer development is related to overall activities such as healthy behavior, not just to health maintenance activities such as weight shifts and skin checks. Garber et al 6 conducted a randomized, controlled study of 4 patients 9 were spinal cord-injured and two had multiple sclerosis. The treatment group (n = ) received four -hour educational sessions on the prevention and management of pressure ulcers and the control group received standard education, which was not specified. The Pressure Ulcer Knowledge Test, which was developed by Garber et al, administered after instruction, showed a significant difference (P <.) between the study and control groups in knowledge gained. A -year follow up showed that the two groups retained the knowledge; however, the treatment group scored higher than the control group on the Pressure Ulcer Knowledge Test (7.86% versus 64.%). Foundation. The content is organized into three sections, Learning, Living, and Looking. The Learning section covers pressure ulcer basics, pressure ulcer risk factors, equipment and environment, healthy skin strategies, and focus on caregivers. The Living section is an interactive case ( Martha s story ) designed to reinforce the material. The Looking section contains a glossary of common terms and images related to the prevention and treatment of pressure ulcers. The E-Learning Program is highly interactive (self testing, risk assessment, and glossary) and includes audio narration of the text. Because the program was designed so the user could stop and start at the same point at a future time, it may be completed in one or multiple sessions, either in a linear fashion or by maneuvering throughout to view or review topics of interest. Positive attributes of the E-Learning program are its ease of use and the narration that guides users throughout the program. Audio instructions/questions, as well videos and images, are provided for those whose reading skills may be limited. Another positive quality is that the E-Learning program is comprehensive and includes various aspects of prevention and early detection of pressure ulcers. The E-Learning program includes standard content and is intended to reduce the amount of time a skilled nurse educator needs to be available to provide instruction and answer questions. The developers can easily update content as pressure ulcer prevention and treatment guidelines change. On the negative side, spinal cord-injured persons without access to the Internet, persons with a lack of computer experience, and persons with cervical injuries would not be able OSTOMY WOUND MANAGEMENT AUGUST

8 Access to the patient population was approved by Table. Participant characteristics Thomas Jefferson University Hospital s administration as well as the SCI program director. This study Age (years) Mean 48.8 was approved by the Institutional Review Boards Median (IRB) of the University of Virginia and Thomas Jefferson University Hospital and determined to be ex- Minimum empt from full IRB review. Weeks since injury Mean 47 Inclusion criteria comprised all of the following: Median spinal cord-injured patients ) with spinal cord injury at any level; ) age 8 years and older; ) men Minimum Frequency (%) and women from all ethnic groups; 4) with or without a current pressure ulcer; ) with or without a his- Gender Male (6.%) Female 7 (6.8 %) tory of pressure ulcer; 6) medically stable on a medical or surgical unit; and 8) who had been transferred to an acute rehabilitation facility. Patients were Ethnicity African American 8 (4.%) Caucasian (.6 %) excluded from consideration if they were: ) non- Other (. %) English speaking (the E-Learning Program is in English) or ) spinal cord-injured, but who were Highest level of education Elementary school (. %) medically unstable in an intensive care unit. High school 8 (4. %) Demographic information was collected and included gender, race, age, highest level of education, College, year 4 (%) College, 4 year 4 (%) level of injury, years since spinal cord injury, prior Graduate school (. %) pressure ulcer, and current pressure ulcer status. Instrument. The investigator (JB) developed the Level of injury Cervical 7 (6.8 %) paper and pencil pre-/post test because no existing Thoracic 6 (.6 %) test was associated with the E-Learning Program. Ten Lumbar 6 (.6 %) major concepts from the E-Learning Program were used to create the pre-/post test questions. These concepts included: ) pressure ulcer definition (one Current pressure ulcer No 8 (4. %) Yes (7.9 %) question); ) NPUAP staging definitions (six questions); ) causes of pressure ulcers (one question); 4) Prior pressure ulcer No (.6 %) seeking professional help (one question); ) common Yes 9 (47.4 %) risk factors (three questions); 6) nutrition (one question); 7) performing skin checks (two questions); 7) to use the E-Learning Program without assistance. repositioning in a bed and weight shifts in a wheelchair (two This is the first study to test the program with hospitalized questions); 9) equipment and support surfaces (two questions); and ) taking charge of their own care (one question) SCI patients for knowledge regarding pressure ulcers. The program can be used wherever there is Internet access. (For access (see Table ). Each correct response was worth points; the to the program, please contact the corresponding author.) possible scores for the knowledge test ranged from to, with being a perfect score. The investigator used the publication Writing Multiple-Choice Items from the University of Methods Study design/sample/setting. A prospective, multiplechoice (options A through D) -question pre-/post test deline to create the multiple-choice test questions. John Sander- Minnesota The Office of Measurement Services as a guidesign was used. The test was given before and after the son, PhD, Professor of Education Curry School of Education, participant viewed the E-Learning Program Learning section. University of Virginia, an expert in educational testing, reviewed the final instrument. Use of the Living and Looking sections was optional due to concerns about program length. Pre-/post test instrument validation. Nurses who worked Patients were invited to participate between August 8 on an acute rehabilitation unit were asked to assist with validation of the test questions. All of the rehabilitation nurses and March 9. Two study sites were selected for this study Thomas Jefferson University Hospital, a level-one trauma had prior education for the prevention and treatment of pressure ulcers. Nurse participation was voluntary and permission center that specializes in SCI, and Thomas Jefferson University Hospital s acute care rehabilitation center, a Delaware Valley was received from the nurse manager, clinical nurse specialist, Regional Spinal Cord Injury Center that received federal designation as a Model System Spinal Cord Injury Center in 978. Internet access was available and nurses were invited to and charge nurse. During a -week time frame, a laptop with view IMPROVING PRESSURE ULCER KNOWLEDGE AUGUST OSTOMY WOUND MANAGEMENT

9 participant was shown how to access the E-Learning Program. Nursing staff provided assistance for Table. Participant pre- and post test scores and years of spinal cord injury participants who were unable to use the keyboard Participant # Pre-test score Post test score Time since injury due to their level of injury or lack of experience 9 7 years with computers. 6 8 years The pretest was administered and the form collected by the researcher before the participant 8 years years viewed the E-Learning Program. The participant 4 9 weeks could opt to view the program in one, two, or three weeks different time periods. After viewing the E-Learning Program, the participant completed the post 7 8. weeks weeks test. The researcher was available to answer questions during the study and reviewed the tests with weeks 7 8 years the participant at the end of the study to ensure years the participant understood the information provided in the E-Learning Program. 7 years 9 8 years Data analysis. Data analysis was completed by 4 6. years the authors using the Statistical Analysis System 9 weeks (SAS) version 9. (Cary, NC). Descriptive statistics years were employed to analyze the participant s demographic information. The primary endpoint was weeks 8 Patient refused Patient refused to years to examine the changes in the participant s preand post test scores. This was accomplished using to take pretest take post test years Student s t-test and analysis of variance (ANOVA). Patient discharged weeks before completing Results Twenty-seven patients met the inclusion criteria. However, six spinal cord-injured patients declined to meet with the researcher and were offered Possible score range: to ; points for each correct answer to view the E-Learning program only. No reason the E-Learning Program Learning section and complete the was given for their decision to decline. Three spinal cord-injured patients agreed to meet with the researcher but they multiple-choice question test. Twelve nurses participated in the test validation. Nurses were discharged from the hospital the same day; however, two test scores included four %, five 9%, two 9%, and one were readmitted to the hospital and accepted the invitation to 8%. Because only % of the nursing staff answered question participate in the study, yielding a total of participants. The number 4 correctly, the question was rewritten more clearly. study was conducted over 8 months but due to a computer Four different nurses answered four questions incorrectly, problem no data were collected for months while the computer was repaired. thus indicating that there were no correlations between the incorrectly answered test questions. Patient information. Of the enrolled participants ( Procedure. A nurse extern who was trained by the investigator provided each potential patient participant a brief de- the pre- and post test assessments. Two participants (one men, seven women; mean age 49 years), 8 completed both scription of the study. The potential participant was asked if woman and one man) withdrew from the study: one used the he/she would be interested in speaking to the researcher to program but chose not to take the pretest and post test and learn more about the study and informed that if he/she declined to meet with the researcher he/she could still view the the post test. Of the participants who completed the program, the other was discharged from the hospital before completing E-Learning Program and the care that he/she would receive eight were African American, nine were Caucasian, and one would not be affected. recorded race as other. Level of injuries included the cervical The nurse extern notified the researcher of potentially eligible participants. If the potential participant met the inclu- levels included elementary school (two), high school (eight), (seven), thoracic (six), and lumbar (six) regions. Educational sion criteria, the purpose of the study was explained, questions and college (nine). Time since spinal cord injury ranged from were answered, and the patient was invited to participate in weeks to 7 years (see Table ). the study. An information sheet was provided and reviewed Test scores. Overall, 6 of the 8 participants completing with the participant because this was an IRB-exempt study. both pre- and post tests had improved pressure ulcer knowledge scores. The median score pre-program was 6, Using a laptop computer and wireless Internet access, each ranging OSTOMY WOUND MANAGEMENT AUGUST

10 Table 4. Change in test score by years since injury Discussion Introducing a pressure ulcer prevention and management program early in Number of Years since Maximum Minimum Median score participants injury score increase score increase increase the rehabilitation process is important 6 Less than year 6 because it might be the only education a years 8 spinal cord-injured person receives. For years. some people, the only opportunity they years 6.67 may have to learn more about pressure ulcer prevention and management is Table. Number of incorrect answers for each question when they are being treated for a pressure ulcer. Test Question Number Years since injury Pressure ulcer definition Pressure ulcer Stage I Pressure ulcer Stage II Pressure ulcer Stage III Pressure ulcer Stage IV Pressure ulcer unstageable Pressure ulcer deep tissue Pressure ulcer causes Seeking professional help Risk factors Risk factors Nutrition Nutrition Skin checks Skin checks Repositioning wheel chair Repositioning bed Equipment Support surfaces Taking charge Pre-test Post test 4 Often, patients do not know their education needs when they are in the hospital and their education and information needs may change over time. A challenge that nurses face with patient education is that the patient is discharged quickly. Therefore, the use of the E-Learning program could enhance nurse s programs because of the narrow window for patient education. This study reported that this type of education could be provided in an acute care setting. Few studies have been conducted to test knowledge retention after initial pressure ulcer prevention education. Therefore, the authors were unable to compare these results with other studies. As evidenced by the difference between pre- and post test scores, spinal cord-injured patients enhanced their knowledge in relation to pressure ulcer prevention strategies and early detection of pressure ulcers. The spinal cord s years of injury were not a factor in this study. This fact is largely attributable to the use of the 7 National Pressure Ulcer Advisory Panel modified pressure ulcer stages and the fact that the newly injured had no previous education with pressure ulcer staging. There was no explanation for the person whose score decreased. These results suggest that from a low of to a perfect score of. The median post program score was 9. (range 7 to ) (see Figure and Table ). Regardless of how many years since injury (see Table a single use of this E-Learning prevention program can improve pressure ulcer knowledge for hospitalized adults with SCI. 4) and level of injury, almost all participants scores improved after completing the E-Learning program. One participant had a decrease (rather than improvement) of points in pre-/post test scores. This participant had a SCI of < year. Another participant with a SCI < year was discharged before completing the post test. One participant with a SCI of years scored in both the pre- and post tests. No other demographic variables affected or changed pretest and post-test scores. Test question responses. The pressure ulcer staging questions (items through 7) were most frequently answered incorrectly in the pretest and in the post test. The Limitations This study is limited by its small sample size. Further studies to assess the effectiveness of this type of educational program on pressure ulcer assessment and prevention should include a larger sample size. A follow-up study with the participants would be helpful to assess if ) they have re-reviewed the information in the E-Learning Program after discharge from the hospital or the acute rehabilitation facility, ) any of the participants developed pressure ulcers, and ) how long they retained and/or acted on the information provided. repositioning questions (items 6 and 7) had 4 incorrect answers and the seeking help question (item 9) had incorrect answers in the pretest compared to and in the post test, respectively, indicating a lack of pressure ulcer prevention education before the E-Learning program (see Table ). Conclusion A small prospective pre-/post test study found that viewing an internet-based education program improved SCI patient knowledge of pressure ulcer assessment and IMPROVING PRESSURE ULCER KNOWLEDGE AUGUST OSTOMY WOUND MANAGEMENT

11 prevention, regardless of age, educational level, or length of time with an SCI. Introducing the E-Learning Program to hospitalized spinal cord-injured patients may have substantial benefits. The program can be used in conjunction with or replace currently available pressure ulcer prevention programs, it can be used throughout spinal cord-injured person s life, and the content s modular format allows easy access to the specific information at the time it is needed. (For access to the program, please contact the corresponding author.) Additional studies are needed to assess the effects of education and outcomes for pressure ulcer prevention and development among spinal cord-injured patients. Acknowledgment The authors thank Michelle Hilgart, MEd, for her technical assistance using the E-Learning Program. They also thank the nursing staff at Thomas Jefferson University Hospital s acute rehabilitation unit for assistance with the pre/post test validation and Katelyn Johnston, a nurse extern at Thomas Jefferson University Hospital and nursing student from Drexel University, for her assistance. References. King RB, Porter SL, Vertiz KB. Preventive skin care beliefs of people with spinal cord injury. Rehabil Nurs. 8;(4):4 6.. Regan MA, Teasell R, Wolfe DL, Keast D, Mortenson WB, Aubut JL. A systematic review of therapeutic interventions for pressure ulcers after spinal cord injury. Arch Phys Med Rehabil. 9;9:.. Rathore FA, Waheed A. Pressure ulcers in spinal cord injury: an unusual site and etiology. Am J Phys Med Rehabil. 9;88(): Vohra R, McCollum C. Fortnightly review: pressure sores. Br Med J. 994;9(698): Consortium for Spinal Cord Medicine. Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. Washington, DC: Paralyzed Veterans of America;. 6. Garber SL, Rintala DH, Holmes SA, Rodriguez GP, Friedman J. A structured educational model to improve pressure ulcer prevention knowledge in veterans with spinal cord dysfunction. J Rehabil Res Develop. ;9(): Schubart JR, Hilgart M, Lyder C. Pressure ulcer prevention and management in spinal cord injured adults: analysis of educational needs. Adv Skin Wound Care. 8;(7): Maklebust J, Magnan MA. Approaches to patient and family education for pressure ulcer management. Decubitus. 99;(4): Christopher and Dana Reeve Foundation. One Degree of Separation: Paralysis and Spinal Cord Injury in the United States. Available at: Prevalence_of_Paralysis.htm. Accessed March,.. Thomas DR. Prevention and treatment of pressure ulcers: What works? What doesn't? Cleve Clin J Med. ;68(8): Spinal Cord Injury Information Network. Spinal Cord Injury Facts and Figures at a Glance 9. Birmingham, AL: National Spinal Cord Injury Statistical Center; 9. Available at: Accessed March,.. Langemo D, Brown G. Skin fails too: acute, chronic, and end-stage skin failure. Adv Skin Wound Care. 6;9(4):6.. Phillips L. Pressure ulcers prevention and treatment guidelines. Nurs Stand. 999;4(): Witkowski J, Parish L. The decubitus ulcer: skin failure and destructive behavior. Int J Dermatol. ;9(): Baldwin KM. Damage control: preventing and treating pressure ulcers. Nursing Made Incredibly Easy! 6;4(): Whittington K, Patrick M, Roberts JL. A national study of pressure ulcer prevalence and incidence in acute care hospitals. J WOCN. ;7(4):9. 7. Gefen A. The biomechanics of sitting-acquired pressure ulcers in patients with spinal cord injury or lesions. Int Wound J. 7;4():. 8. Pressure ulcers in America: prevalence, incidence, and implications for the future. An executive summary of the National Pressure Ulcer Advisory Panel monograph. Adv Skin Wound Care. ;4(4):8. 9. Cardenas DD, Hoffman JM, Kirshblum S, McKinley W. Etiology and incidence of rehospitalization after traumatic spinal cord injury: a multicenter analysis. Arch Phys Med Rehabil. 4;8(): Mawson AR, Biundo JJ, Neville P, Linares HA, Winchester Y, Lopez A. Risk factors for early occurring pressure ulcers following spinal cord injury. Am J Phys Med Rehabil. 988;67(): 7.. Berry C, Kennedy P, Hindson LM. Internal consistency and responsiveness of the skin management needs assessment checklist post-spinal cord injury. J Spinal Cord Med. 4;7():6 7.. Jones ML, Mathewson CS, Adkins VK, Ayllon T. Use of behavioral contingencies to promote prevention of recurrent pressure ulcers. Arch Phys Med Rehabil. ;84(6): Niezgoda JA, Mendez-Eastman S. The effective management of pressure ulcers. Adv Skin Wound Care. 6;9(suppl ):. 4. Chen Y, Devivo MJ, Jackson AB. Pressure ulcer prevalence in people with spinal cord injury: age-period-duration effects. Arch Phys Med Rehabil. ;86(6):8.. Andberg MM, Rudolph A, Anderson T. Improving skin care through patient and family training. Top Clin Nurs. 98;: Chapman K, McGinnis-Rake C, O Halloran W, et al. Convincing the noncompliant patient to change his behavior. Ostomy Wound Manage. 99;:4. 7. Dai YT, Catanzaro M. Health beliefs and compliance with a skin care regimen. Rehabil Nurs. 987;: Fiedler IG, Laud PW, Maiman DJ, Apple DF. Economics of managed care in spinal cord injury. Arch Phys Med Rehabil. 999;8(): Krause JS, Broderick L. Patterns of recurrent pressure ulcers after spinal cord injury: Identification of risk and protective factors or more years after onset. Arch Phys Med Rehabil. 4;8(8): Black JM, Baharestani MM, Cuddigan J, et al. National Pressure Ulcer Advisory Panel s updated pressure ulcer staging system. Adv Skin Wound Care. 7;(): University of Minnesota The Office of Measurement Services. Writing Multiple-Choice Items. Available at: _write/multiplechoice.php). Accessed November, 8. 4 OSTOMY WOUND MANAGEMENT AUGUST