Annually, 1.7 million people in the US develop pressure ulcers (PUs), with a total prevalence of PU in as much as 17% of the general population.1–4 Stage 1 PUs are potentially reversible, and involve only the epidermal layers of skin; in stage 2, partial-thickness injuries/wounds involve epidermal and dermal layers; in stage 3, full-thickness injuries/wounds involve epidermal/dermal and subcutaneous tissues but not fascia, muscle, tendon, or bone; and in stage 4, full-thickness injuries/wounds involve deep tissue structures (muscle, tendon, bone). Unstageable PUs are at least full-thickness wounds, but the wound’s depth cannot be distinguished between stages 3 and 4 because of nonviable tissue covering all or part of the wound. A deep-tissue injury PU typically manifests as intact skin with deep-tissue damage evidenced by deep purple discoloration and palpable skin changes that may or may not eventually open to a full-thickness wound.5,6
The development of a PU is a significant problem, especially in persons with paralysis or spinal cord injury (SCI).7–10 To reduce the numbers of PUs, clinicians need to address those at highest risk and accurately characterize risk among specific populations such as individuals with different levels of paralysis.11–29 In this study, researchers sought to characterize and identify risk factors for PU among long-term care (LTC) residents, particularly in relation to individuals with paralysis.
Immobility/paralysis is one of the strongest known risk factors for developing a PU.5,30 Typical levels of paralysis include hemiplegia (paralysis on one side of the body typically caused by stroke or brain lesion on the opposite side of the brain), paraplegia (paralysis of lower half of the body and/or both legs, typically attributable to SCI or disease), and quadriplegia (also called tetraplegia, which involves paralysis of all four limbs, typically because of spinal injury at neck level or disease). Besides SCI, diseases commonly associated with paralysis include but are not limited to multiple sclerosis, amyotrophic lateral sclerosis, and muscular dystrophy.
Statistics from various sources suggest the number of Americans in the US currently living with some form of paralysis (including SCI) ranges from 247,000 to as high as 4.3 million.31–36 Individuals with SCI exhibit impaired sensory, motor, and autonomic control, which combine to greatly increase PU risk. In the adult SCI population, more than 95% will develop one or more PUs within their lifetime, making PUs the most common secondary medical complication associated with SCI.30,34,37,38 Historically, the risk of PU has been reported to increase as mobility decreases.39 It is widely accepted that with a higher level of paralysis (greater functional impairment), the greater the risk of PU.40,41 However, specific levels of paralysis, apart from a neurodegenerative diagnosis, have never been closely examined in the LTC population.42,43
Evidence-based guidelines have been developed to provide standards of care to help prevent PUs in adults.5,44–49 Several studies have attempted to identify risk factors7,19,30,50–57 and to develop prevention strategies for PUs, but PUs remain a significant problem among individuals with SCI.30,37,38 Risk factors such as loss of sensation and immobility increase the likelihood of PU development in people with SCI.58–60 Studies identified older age61 and incontinence as significant risk factors for PU.56 In SCI, PUs usually occur in persons who have motor/sensory-complete injuries (ie, complete interruption of the nerve signals through a section of the spinal cord).55,61–66 One study of PU prevalence in community residents with SCI demonstrated that those with higher-level SCI lesions (cervical) carry a greater risk of developing PU than those with lower-level (lumbar) lesions.63
A preliminary analysis of the 2012 Minimum Data Set (MDS) led to this current “level of paralysis” inquiry.67 The initial investigation involving the MDS 3.0,67 which contains information from 2,936,146 LTC residents, demonstrated that 27.5% of persons with quadriplegia, 41.2% of those with paraplegia, and 10.3% of those with hemiplegia had a PU. Also reported in the initial MDS analysis, patients with quadriplegia were 3.4 times (odds ratio [OR], 3.37; 95% confidence interval [CI], 3.24–3.50) more likely to have a PU than other LTC residents; patients with paraplegia were 6.3 times (OR, 6.3; 95% CI, 6.12–6.50) more likely; and patients with hemiplegia were not any more likely to have a PU. Some of these findings were expected (such as the slightly increased risk for residents with hip fracture), but the increased PU risk in patients with paraplegia compared with patients with quadriplegia was surprising because patients with quadriplegia, who require more care and are less mobile, were expected to have a greater prevalence of PUs.
These results prompted the secondary analysis reported in this article, which sought to more closely compare these groups by levels of paralysis (quadriplegic vs paraplegic vs hemiplegic) to see if level of paralysis significantly predicted occurrence of PU after adjusting for other PU risk factors. The aims were to (1) compare paralysis groups by PU risk factors, (2) identify factors most predictive of PU within each paralysis group, and (3) test for the effect of level of paralysis (quadriplegic vs paraplegic) on PU occurrence after controlling for other PU risk factors. For the third aim, study authors chose to exclude the hemiplegic group because the prevalence of PU in this group was similar to the LTC population as a whole.
After obtaining institutional review board approval (University of Florida #IRB201300234), study authors analyzed the national 2012 MDS 3.0. The MDS is a comprehensive data set containing thousands of data points describing the clinical, behavioral, and social status of LTC residents from more than 15,000 skilled nursing and LTC facilities in the US.68–71 The MDS data bank is publicly reported and available for all to see on the CMS website, with data on individual states as well as national rates. These data are obtained from a standardized MDS assessment tool developed in response to recommendations from the 1986 Institute of Medicine report on improving care in LTC and skilled nursing facilities.72 The MDS assessment tool was implemented in 1991 as standard assessment documentation and has been required since then in all LTC facilities participating in Medicare or Medicaid federal reimbursement programs. The number of items on the MDS assessment tool indicates data are now available for more than 400 variables.68–72
The Care Area Assessments are part of the MDS comprehensive assessments and provide the foundation upon which a resident’s individual care plan is formulated. They are performed by registered nurses every 90 days for stable patients and whenever there is a significant change in health status. The MDS 3.0 assessment records the number of PUs by each stage (stages 1–4, unstageable, and suspected deep-tissue injury) at the time of an assessment.
National testing of the MDS 3.0 comprehensive assessment tool (third iteration) was accomplished in the Department of Veterans Affairs at 71 community and 19 LTC facilities in 2008. Interrater reliability of most of the original MDS items has been described as “good.” MDS 1.0 items were demonstrated to have an intraclass correlation of 0.7 or higher in key areas of functional status, such as cognition, activities of daily living, continence, and diagnoses:69 63% had reliability coefficients of 0.6 or higher, and 89% had reliability coefficients of 0.4 or higher. Subsequent iterations of the MDS comprehensive assessment tool were revealed to have improved reliability/validity. Evaluations of items on the MDS 3.0 showed either excellent or very good reliability. There were no categorical differences between the community reliabilities and the independent Veterans Affairs comparisons of research nurse to facility-staff agreement on the MDS 3.0 items. The reliabilities for research nurses in the collection of the criterion measures for the validation sample were in the excellent range.69–72
A total of 2,936,146 nursing home or LTC residents 18 years or older were included in the 2012 MDS 3.0 and received comprehensive assessments from Medicare/Medicaid-certified LTC facilities in the US. The inclusion and exclusion criteria for this study were the same as the parent study (ie, exclusion criteria were age <18 years, missing age data, missing data on PU status, stage 1 PU) with the additional exclusion of neurodegenerative disease (n = 685,893), coma (n = 1,925), or hip fracture (n = 26,182) within the previous 180 days. The final subsample available for analysis included 51,664 residents who met study criteria and had some diagnosis of paralysis (hemiplegia, paraplegia, or quadriplegia).
The outcome variable of interest (dependent variable) was the presence of a PU (yes/no). Risk factors were selected from the strongest PU risk factors identified in the extant literature and confirmed in the larger initial MDS data set analysis conducted by the authors.67 In addition to level of paralysis (hemiplegia, paraplegia, quadriplegia), the PU risk factors validated in the initial MDS analysis67 included age, gender, ethnicity, activities of daily living impairment, cognition, sensory alterations, anemia, body mass index, diabetes, hydration, malnutrition, chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease, deep vein thrombosis, peripheral vascular disease, heart failure, use of anticoagulants, multidrug-resistant organisms, pneumonia, respiratory failure, septicemia, bowel incontinence, neurogenic bladder, urinary incontinence, or urinary tract infection.
SAS version 9.4 (SAS Institute, Cary, North Carolina) was used for all analyses. To ascertain differences among the three paralysis groups (quadriplegic, paraplegic, and hemiplegic), they were first compared on risk factors with χ 2 testing. Within each paralysis group, logistic regression was used to compute the adjusted OR and associated 95% CI of the risk of “any PU” (stage 2, stage 3, stage 4, unstageable, or suspected deep-tissue injury) compared with “no PU” for each risk factor, adjusting for other factors in the model.
To compare the level of paralysis (paraplegia vs quadriplegia) after adjusting for all other PU risk factors, researchers used a logistic regression specifying the outcome variable as PU (yes/no) and including PU risk factors and level of paralysis as predictors. Because researchers found significant differences in PU risk factors (eg, septicemia, pneumonia, diabetes, use of anticoagulants, malnutrition, and incontinence), a propensity score-matching analysis was conducted, which entailed forming comparable groups (with regard to risk profile) to better isolate the investigation of the effect of paralysis type on PU prevalence.
There were 51,664 residents in the MDS data set who had hemiplegia, paraplegia, or quadriplegia and met the inclusion criteria. The mean age was 67.1 (SD, 16.5) years. The majority were male (51.8%) and white (67%). Overall, LTC facilities reported a 10% PU prevalence (excluding stage 1) among all residents. Those with paraplegia had the highest prevalence of PU (almost half), and a little over 30% of those with quadriplegia had PUs (Figure).
Paralysis level groups significantly differed on every PU risk factor that was examined (Table 1). More residents with paraplegia and quadriplegia were males and white, and more residents with hemiplegia were older, overweight/obese, and/or cognitively impaired. The quadriplegic group had the highest rates of respiratory failure, pneumonia, and urinary and bowel incontinence. The paraplegic group had higher rates of anemia, malnutrition, deep vein thrombosis, multidrug-resistant infections, and urinary tract infections. The hemiplegic group had higher rates of heart failure, diabetes, and severe cognitive impairment.
The strongest predictors of PU (ie, ORs >1.5) in the quadriplegic group were being male or underweight or having anemia, diabetes, septicemia, multidrug-resistant infections, urinary tract infection, or bowel incontinence. The strongest predictors of PU in the paraplegic group were being male, black, or underweight or having malnutrition, septicemia, anemia, diabetes, septicemia, multidrug-resistant infections, or urinary tract infection. The strongest predictors of PU in the hemiplegic group were being underweight or having malnutrition, septicemia, pneumonia, multidrug-resistant infections, or urinary tract infection. Adjusted ORs and 95% CIs for each PU risk factor were calculated for each paralysis level group (Table 2).
A full logistic regression model was used to examine the effect of level of paralysis (paraplegia vs quadriplegia) after adjusting for all other PU risks (Table 3). In this model, the strongest predictors (ie, OR >1.5) of PU are paralysis level, being male or underweight, or having malnutrition, pneumonia, multidrug-resistant infections, or urinary tract infection. Those in the paraplegic group had an OR twice that of the quadriplegic group after adjusting for all other variables in the model (OR, 2.03; 95% CI, 1.76–2.35).
In the propensity score-matching analysis, there were 484 in the paraplegic group and 615 in the quadriplegic group with matching risk profiles. In comparing these groups, the odds of having a PU were 80% higher in the paraplegic group compared with the quadriplegic group (OR, 1.80; 95% CI, 1.55–2.09). The OR of 1.80 calculated using the more conservative propensity score-matching analysis is comparable to the OR of 2.03 computed using the entire sample.
The secondary analysis study reported in this article came about after an initial analysis of the MDS related to deep-tissue injury PU risk factors in LTC, which indicated that paraplegia may be a greater risk factor for PUs than quadriplegia. This warranted further investigation. The results of this current analysis demonstrate that indeed there is an increased PU prevalence among patients with paraplegia in LTC than patients with quadriplegia in LTC. This was surprising because patients with quadriplegia are less mobile. However, there are a few potential reasons why this may occur and accompanying lessons LTC facilities may glean from this work.
The scientific literature indicates PUs develop in as many as 95% of persons with an SCI at some time in their lives,34 with 30% experiencing recurrent PU. High mortality is associated with PU and SCI. Numerous studies have reported mortality as high as 60% for adults with PU within 1 year of hospital discharge.7,8 Usually, PU contributes to a decline in health status of patients with SCI and indirectly contributes to their death in 7% to 8% of cases.33,34 Further, PUs are the leading cause of unplanned rehospitalizations of persons with SCI and result in prolonged acute care hospital stays and more expensive treatment than other medical complications.5,11 In particular, PU-related injuries are a significant health problem for residents in LTC facilities, with incidence rates ranging from 2.2% to 23.9%.41
The costs of care for persons with SCI are extremely high, at an estimated $9.7 billion per year.1–3 Healthcare Cost and Utilization Project data report an average cost of $38,000 per PU.31 It has been estimated that the cost of treating a PU is 2.5 times the cost of preventing them.9 However, prevention efforts may not be optimal in certain settings, including LTC facilities.
Prevention efforts are typically targeted at the strongest PU risk factors, some of which have been known for hundreds of years.12–29,67 More than 45 of the strongest PU risk factors were identified by Fogerty et al29 in a sample of 6,610,787 patients hospitalized in acute care settings. Immobility has been identified as a critical risk factor for persons with paralysis but chronic illnesses, obesity, and depressive symptoms may also impact PU development, particularly in persons with varying degrees of paralysis and SCI.65,66,73–75
The mobility literature suggests increasing PU risk with increasing levels of paralysis. Results from this analysis demonstrated a higher prevalence of PU in patients with paraplegia than quadriplegia in LTC facilities. The authors wish to make it clear this research is about observed PU risk in US LTC facilities under current practices. Although the authors are cautious about not suggesting patients with quadriplegia are at less risk of PU development in the absence of any medical intervention, these findings may indicate that LTC facilities have been less successful at PU prevention interventions for patients with paraplegia than they have for individuals with quadriplegia (who rely on LTC staff for total care). These findings provide strong evidence for the need to improve PU preventive interventions in LTC residents who are wheelchair- or chair-bound, especially individuals with paraplegic paralysis. That said, there is absolutely no evidence in favor of decreasing current LTC PU preventive interventions to individuals with quadriplegia.
These findings demonstrated that LTC patients with paraplegia may need more aggressive preventive interventions than are presently used in these facilities. Patients with paraplegia may need more attention, assistive technology, education, motivational approaches, and reminders with regard to PU prevention.
Some reasons posited by the authors for the observed higher prevalence of PU in paraplegics in LTC include: sitting pressure on bony prominences may increase interface pressure to 200 mm Hg, versus 18 mm Hg of surface interface pressures in a supine individual with weight distributed over greater surface areas and the head of bed elevated less than 30 degrees. Other potential reasons for pressure-related injury in chair-bound individuals may be related to more frequent transfers or shearing activities.12,39,66,74,75 More patients with paraplegia may be smokers than patients with quadriplegia, and smoking has been listed as a PU risk factor and impediment to wound healing in the past. Patients with paraplegia are also typically given more responsibility for their own care and changing their own body position in LTC facilities versus patients with quadriplegia, who may rely solely on staff for total care and regular turning.
In addition, data from this analysis showed a higher risk of malnutrition in patients with paraplegia than patients with quadriplegia, possibly because of a higher calorie expenditure among patients with paraplegia, who are capable of greater mobility of the upper body. It is also possible that the quadriplegic group may be receiving enteral nutrition or supplementation to assist their nutritional equilibrium, whereas the paraplegic group self-feeds, possibly with more difficulty. All of these potential explanations warrant further investigation.
The authors acknowledge several study limitations. First, this is a retrospective secondary data analysis examining data collected from LTC documentation, and therefore, causal relationship cannot be established but may be inferred. Second, findings from this study are not intended to be generalized to populations in settings outside LTC.
This study has important clinical implications for providers working in LTC. Healthcare providers should attentively look for and address PU risk factors among all patients with limited mobility, especially those with paraplegia. Ways to improve PU preventive interventions in this group are needed, and further research is warranted.
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