A Pilot Study to Evaluate the Role of the Spinal Cord Impairment Pressure Ulcer Monitoring Tool (SCI-PUMT) in Clinical Decisions for Pressure Ulcer Treatment

The Spinal Cord Impairment Pressure Ulcer Monitoring Tool (SCI-PUMT) was designed to assess pressure ulcer (PrU) healing in the spinal cord impaired (SCI) population. The tool contains 7 variables: wound surface area, depth, edges, tunneling, undermining, exudate type, and necrotic tissue amount.   A 2-phased, quantitative pilot study based on the Theory of Reasoned Action and Theory of Planned Behavior was conducted at a large SCI/Disorders Center in the Department of Veterans Affairs (VA). In the first phase of the study, a convenience sample of 5 physicians, 3 advanced practice registered nurses, and 3 certified wound care nurses (CWCN) was surveyed using a 2-part questionnaire to assess use of the SCI-PUMT instrument, its anticipated improvement in PrU assessment, and intent to use the SCI-PUMT in clinical practice. Attitudes, subjective norms, perceived behavioral controls, and barriers related to the intent to use the SCI-PUMT were evaluated using a 5-point Likert scale (range: 1= extremely likely, 5 = extremely unlikely). In the second phase of the study, the electronic health records (EHR) of 24 veterans (with 30 PrUs) who had at least 2 completed SCI-PUMT scores during a 4-week period were used to evaluate whether an association existed between magnitudes of change of total SCI-PUMT scores and ordered changes in PrU treatment. The overall mean score for intent to use SCI-PUMT was 1.80 (SD 0.75). The least favorable scores were for convenience and motivation to use the SCI-PUMT. Analysis of EHR data showed no significant difference in magnitudes of change in the SCI-PUMT score and changes in PrU treatment recommendations made by the CWCNs. The significance was not affected regardless of an increase or no change in the score (c² with 1 degree of freedom = 1.158, P = 0.282) or for a decrease in the score (c² with 1 degree of freedom = 0.5, P = 0.478). In this pilot study, the expressed intent to use the SCI-PUMT in making clinical decisions was generally positive but reservations remain. Additional research is being conducted to determine the barriers and facilitators to SCI-PUMT implementation. The SCI-PUMT was the first tool found to be valid, reliable, and sensitive to assess PrU healing in persons with SCI, and studies to examine the prospective validity of using this instrument on ulcer treatment decisions and outcomes are warranted.

Persons with spinal cord impairment (SCI) are at high risk for developing pressure ulcers (PrU). This complication can compound the person’s existing disability and severely limit community participation due to extended bed rest and deconditioning.¹ The Consortium for Spinal Cord Medicine (CSCM) published clinical practice guidelines on PrU prevention and management containing 26 recommendations.¹ The Veterans Health Administration (VHA) Quality Enhancement Research Initiative² (QUERI) identified PrUs as a top priority for research in the SCI population based upon the “staggering costs and human suffering.” The SCI QUERI panel advocated the need for more research into the clinical behaviors related to these recommendations. Henzel et al’s² consensus document noted many recommendations of the CSCM were not supported by evidence and all were weighted equally. Thomason et al³ found clinical practice guidelines were more likely to be followed if based on evidence instead of expert consensus.

A review of the literature⁴ revealed that, with the exception of the SCI Pressure Ulcer Monitoring Tool (SCI-PUMT), no instrument was designed specifically to assess PrU healing in the SCI population (see Figure 1). The SCI-PUMT originated as a result of a previous study funded by the Health Services Research and Development, Nursing Research Initiative (NRI 03-245-4). Research objectives for the 3-year longitudinal study were to develop and establish the validity, reliability, and sensitivity of a tool to monitor PrU healing in persons with SCI. The setting was the James A. Haley Veterans’ Hospital in Tampa, FL.

Before implementing the SCI-PUMT, practice among SCI Centers in the VHA ranged from using tools found reliable and valid for the non-SCI population to using locally developed tools that lacked psychometric testing in patients with SCI. The Pressure Ulcer Scale for Healing (PUSH)^5,6 and the Bates-Jensen Wound Assessment Tool (BWAT)^7-9 were the 2 instruments predominately used, although other tools had been validated in the literature.^10,11 Variability in PrU healing assessment in patients with SCI has led to variability in treatment, which in turn has resulted in observed differences in PrU outcomes.¹²

Furthermore, no studies have been found in the literature regarding the use of tools to make clinical decisions regarding PrU assessment in persons with SCI. However, studies were found that addressed knowledge in the SCI population regarding prevention and management of PrU in clinical practice,¹³ roles of interdisciplinary team members,¹⁴ and psychometrics rather than implications for clinical practice.¹²

SCI unique characteristics. A PrU in a person with SCI is often difficult to manage and takes an extended amount of time to heal. In a 3-year, longitudinal study (N = 553), Garber and Rintala¹⁵ reported 251 veterans with SCI (39%) had PrUs and each veteran averaged 4 PrUs. According to data extracted from 102 charts, only 9.8% of Stage IV PrUs (the most prevalent stage) healed; a Stage IV PrU extends into the muscle and may result in morbidities such as osteomyelitis and even death. Furthermore, this investigation revealed only 23 veterans healed versus 54 who did not heal during the study period.

Persons with SCI constitute a unique population.¹ According to statistics and retrospective chart reviews,^1,16,17 compared to persons who do not have SCI, persons with SCI are young when they become disabled (average age 42.6 years old); have decreased collagen that compromises tissue integrity; commonly have multiple PrU surgeries; are insensate, contributing to a delay in seeking treatment; and may have a lowered blood pressure that results in compromised tissue perfusion, adversely influencing PrU development and healing.

SCI-PUMT development. The research and psychometrics related to SCI-PUMT development have been reported⁴; a convenience sample of 66 veterans with 167 PrUs was recruited and assessed weekly for 12 weeks using a 30-item pool of PrU healing variables consisting of elements of the PUSH, BWAT, and study-specific items devised by 2 expert panels. Investigators compared the predictive validity and sensitivity to change over time using items from the PUSH, BWAT, and SCI-PUMT. With regard to predictive validity, the SCI-PUMT was found to explain 59% of the variance of surface area and volume of the ulcers at baseline using the VeV MD Software and Digital Imaging Camera as a gold standard (Vista Medical, Winnipeg, Canada). By contrast, the PUSH and BWAT scores predicted 57% and 24% of PrU volume, respectively. With regard to SCI-PUMT sensitivity, mixed regression analyses found the total score was associated with the measure of area/volume across the 12-week follow-up period of the study (P <0.0001). Cronbach’s alpha for the tool was 0.74, indicating construct validity; interrater reliability was 0.79 and intrarater reliability ranged from 0.81 to 0.99 for 4 trained registered nurse data collectors.

The final SCI-PUMT was developed based on the validity, reliability, and sensitivity of the tool using an iterative process. The instrument consisted of PrU descriptors (site, body side, orientation), patient positioning (upper leg flexion when turned, dependent side), and assessment variables (see Figure 1). A manageable set of 7 items was identified to be included in the final version of the SCI-PUMT. Based on exploratory factor analysis and clinical judgment, the “Geometric Factors” section included surface area (length x width), depth, edges, tunneling, and undermining; “Substance Factors” consisted of exudate type and necrotic tissue amount. Each range of measurement or the presence of a factor had a denoted point value. Subscores were calculated for the geometric and substance factors; a total score could range from 2 (PrU healed) to 26 (PrU severe).³

Upon study completion in 2008, the SCI-PUMT was exported throughout the VHA to 23 SCI Centers in 2011. A SCI-PUMT toolkit comprised of tool guidelines, a healing trajectory graph, mannequins, educational presentations, barrier and facilitator guidelines, and multiple other products was developed and disseminated to all SCI Centers in the VHA. Implementation continues with conference calls every 1 to 3 months involving each participating centers’ SCI-PUMT Champions, Management of Information Outcomes Coordinators, VHA Office of SCI/D Services, and SCI QUERI representatives. The implementation initiative for the SCI-PUMT is described in another publication.¹⁸

Clinical practice guidelines on the prevention and management of PrUs noted PrU assessment set the foundation for an appropriate plan of care, established a basis for subsequent serial measurements to determine intervention effectiveness, and provided a means to communicate PrU status. The CSCM and National Pressure Ulcer Advisory Panel recommended using a valid and reliable tool to assess PrU healing and changing the PrU treatment if a PrU is not healing in 2 to 4 weeks.^1,19 Further, a SCI QUERI expert panel on PrU research implementation in the VHA underscored the need for a standardized assessment methodology based on quantitative benchmarks for PrU healing to enable intervention comparisons.²

With these guidelines in mind, a pilot study was developed, guided by a hypothesis based on noted gaps in the literature regarding reliable and valid healing assessment tools to assist in making clinical decisions regarding PrU healing in persons with SCI.²⁰ The hypothesis was: An association exists between an increase (PrU worsens) or plateau in SCI-PUMT scores and a change in PrU treatment. The goal of the pilot study was to understand the use and impact of the SCI-PUMT in clinical practice. The study was comprised of 2 phases: the first examined clinician intent to use the SCI-PUMT in clinical practice and identify attitudes, subjective norms, perceived behavioral control, and barriers related to the intent to use the SCI-PUMT. The second phase attempted to establish an association between magnitudes of change of total SCI-PUMT scores and changes in PrU treatment.

Conceptual framework. The Theory of Reasoned Action (TRA)²¹ and Theory of Planned Behavior (TPB)²² provided the theoretical foundation for this pilot study. Both theories focus on factors that impact the driving forces leading to the adoption of behaviors related to the use of the SCI-PUMT in clinical decision making. The TRA was developed by Fishbein,²¹ who differentiated between attitudes toward objects and attitudes toward behaviors directed toward those objects. Fishbein and Ajzen²² emphasized the importance of focusing on behavior (eg, using the SCI-PUMT) as the best attitude predictor.

In this pilot study, the perceived likelihood of adopting the behaviors of completing the SCI-PUMT and using this tool to make decisions regarding PrU treatment in veterans with SCI were assessed using statistical analysis. Behavioral intent was integral to performing these dual behaviors. Researchers presumed clinician intent to use the SCI-PUMT would be greater if study participants believed the SCI-PUMT was of value in assessing PrU healing and could assist in guiding PrU treatment. Thus, a positive attitude toward the behavior would translate into more positive use of the SCI-PUMT in clinical practice.²³ The TPB augments the TRA by adding the dimension of perceived behavioral control (overall control of the behavior of using the SCI-PUMT in clinical practice).²⁴ For example, clinicians may have been more likely to use the tool if they believed they had more autonomy in deciding this was the tool of choice for assessing PrU healing.

Setting. The study was conducted at the Michael Bilirakis SCI/D Center in Tampa, FL. The 100-bed center is comprised of 60 beds on 2 inpatient subacute care units, a 30-bed community living center, and a 10-bed unit for veterans who are ventilator-dependent. The Center also has outpatient and home care programs.

Approvals. This pilot study was approved by the University of Alabama’s Institutional Review Board (IRB) (IRB# 13-OR-177-ME) as a research study. It was approved by VHA Research and Development as a quality improvement project.

Data collection and analyses. Data collection forms were constructed for both phases using a TeleForm format (Cardiff TeleForm, Brookline, MA). TeleForm is a software application that automatically captures, classifies, and extracts data from documents by using recognition technologies. The purpose of using this software was to develop templates specific to this study that were printed, used for data collection, and subsequently scanned into an electronic file. Data were verified and then exported to an Excel file for data analysis. All quantitative analyses were performed using Statistical Analysis System software (SAS 9.3, SAS Institute Inc, Cary, NC).

Phase I: beliefs about using the SCI-PUMT.
Participants. To evaluate the intent to use the SCI-PUMT in clinical practice, a sample was selected of 5 physicians and 3 advanced registered nurse practitioners (ARNPs) (ie, “providers”) and 3 CWCNs (11 participants in total). This volunteer convenience sample represented the majority of providers and all of the CWCNs in the SCI/D Center. Providers and CWCNs were informed regarding the minimal risk and potential benefits for participating in the study via a letter approved by University of Alabama’s IRB. Completion of the questionnaire served as consent to participate in the study.

Processes/Procedures. Content and face validity of the Beliefs about Using the SCI-PUMT questionnaire was established by eliciting feedback from the 3 CWCNs whose primary responsibilities were to prevent, assess, and make recommendations for the treatment of veterans with PrU in the SCI Center. Validation focused on the design and content of the questionnaire. Modifications and/or item updates were incorporated into the final version before the initial phase of data collection (see Figure 2). Participants were asked to complete the questionnaire, which generated data regarding the intent to use the SCI-PUMT and attitudes, subjective norms, perceived behavioral control, and barriers related to these intentions.

This questionnaire was designed by the investigator to assess both direct and indirect measures of the TPB. The idea that behavioral intent is paramount in determining behaviors (ie, use of the SCI-PUMT) is integral to the tandem theories of TRA and TPB. It was assumed providers and CWCNs were more likely to use the SCI-PUMT if they believed outcomes associated with its use were positive.

The technical use of the SCI-PUMT to assess PrU healing in veterans with SCI was based on a semantic bipolar scale of 11 variables indicative of the intent to use the SCI-PUMT: 1 — extremely likely, 2 — slightly likely, 3 — neither likely nor unlikely, 4 — slightly unlikely, or 5 — extremely unlikely. The anticipated improvement in PrU assessment using the SCI-PUMT was based on a Likert scale of 3 variables that were indicative of the intent to use the SCI-PUMT: 1 — strongly agree, 2 — slightly agree, 3 — neither agree nor disagree, 4 — slightly disagree, or 5 — extremely disagree. Each end of the scale represented strong beliefs, and the midpoint represented no opinion (ie, “neither”). Negative aspects to these rating scales (eg, extremely unlikely, strongly disagree) were included because researchers believed attitudes also were shaped by negative attributes.

Statistical analysis. Due to the small sample and use of ordinal data, nonparametric statistics were used. Descriptive statistics were used for continuous variables (eg, mean, standard deviation, median) contained in the Beliefs about Using the SCI-PUMT questionnaire that was completed by providers and CWCNs. Descriptive statistics were calculated and analyzed for item, subscale, and total scale scores. Comments in the open-ended questionnaire were not thematically analyzed. No analysis was conducted to determine whether the individual providers or CWCNs who intended to use the SCI-PUMT actually did use it.

Phase II: SCI-PUMT and clinical decisions.
Sample. For Phase II of the study, the inclusion criteria were veterans enrolled in the SCI/D Center’s Registry who had a Stage II to Stage IV or unstageable PrU and had at least 2 SCI-PUMT scores on the same ulcer in April 2013. Exclusion criteria stipulated life expectancies of <6 months (ie, palliative care). The EHR was assessed to determine the participant population base in which the SCI-PUMT score appeared in the record. If the SCI-PUMT score was documented in the record, it was assumed the score was considered if the treatment did change. The sample was derived from 69 veterans who had PrUs included on their problem lists or had PrUs documented; 45 of these records were excluded because these did not have two or more SCI-PUMT scores during the study month. The final sample consisted of 24 veterans with 30 PrUs; 4 had multiple PrUs. These records were examined to determine the association between the magnitudes of change in SCI-PUMT total scores and changes recommended by the CWCNs for PrU treatment.²⁵ Confidentiality was ensured by using identification numbers instead of names of providers, CWCNs, and veterans.

Processes/procedures. A SCI-PUMT Clinical Decisions Data Collection form was developed by the investigator to document SCI-PUMT scores and PrU treatments (see Figure 3). The CWCN could input information (document) on the SCI-PUMT in the EHR, but the providers wrote the orders regarding treatment decisions. Decisions were frequently based on the recommendations of the CWCN. This form listed 17 treatments with an option to add additional treatments not contained in the static list. Treatment was documented as a primary dressing (eg, hydrocolloid), debridement (eg, ultrasonic), or other intervention directly linked to PrU treatment. An inference was made that SCI-PUMT scores were considered in making clinical decisions about treatment based on whether the scores indicated that a plateau in healing had occurred (ie, score the same) or the PrU was getting worse (ie, score increased).

Data collection and statistic analysis. De-identified data were entered into a database, checked for errors, and stored on a secure server in the VHA computer system. Descriptive statistics were used for categorical variables (eg, frequencies, percentages) related to data extracted from the EHR regarding SCI-PUMT scores and PrU treatment. The independent variable was the SCI-PUMT score and the dependent variable was the change in PrU treatment. Scores from the SCI-PUMT and recommendations by the CWCN for treatment changes were entered into a 2 x 2 contingency table to calculate the chi-square.

To determine the intent to use the SCI-PUMT in clinical practice and address key constructs of the TPB, the Beliefs about Using the SCI-PUMT questionnaire generated data from providers and CWCNs (N = 11) (see Table 1). Participants overall had a mean rating of 1.80 (SD 0.75), indicating they had minimal to extreme intent to use the SCI-PUMT in clinical practice. Overall, the physicians indicated greater overall intent to use the SCI-PUMT (mean 1.63; SD 0.85) than ARNPs (mean 1.73; SD 0.50) and CWCNs (mean 1.93; SD 0.76).

Regarding the technical use of SCI-PUMT, physicians overall indicated the greatest agreement about the technical use of the SCI-PUMT (mean 1.67; SD 0.92), and the CWCNs indicated the least agreement (mean 2.0; SD 0.88). When the overall agreement of both providers and CWCNs was considered, the most positive responses related to objectivity (mean 1.27; SD 0.47), inclusiveness of the most important variables (mean 1.55; SD 0.52), and helpfulness to assess PrU healing (mean 1.55; SD 0.52). Overall, slight agreement to use the SCI-PUMT was reflected in the variables of convenience (mean 2.27; SD 1.42) and motivation to use the SCI-PUMT (mean 2.18; SD 1.4). Support by the VHA for using the SCI-PUMT was extremely to slightly positive overall (mean 1.45; SD 0.52,) with CWCNs responding the most positively (mean 1.33; SD 0.58) (see Table 1).

With regard to the anticipated improvement in PrU assessment, documentation of the SCI-PUMT resulting in improved PrU assessment netted strong agreement overall (mean 1.2; SD 0.42), whereas clinical management of PrU received less agreement (mean 1.6; SD 0.7). The ARNPs indicated the most agreement that the SCI-PUMT would result in improved PrU documentation (mean 1.0; SD 0.0), and the physicians (mean 1.2; SD 0.45) and CWCNs (mean 1.67; SD 0.33) indicated somewhat lesser agreement.

There were 3 comments by clinicians in the last section of the questionnaire. One CWCN stated she/he “would like to see the amount of exudate included.” A physician commented the tool, “really improved documentation and ease of follow-up.” A physician who indicated he/she was extremely unmotivated to use the tool commented, “This may be a good tool for wound care nursing but is very time consuming and cumbersome for other providers and is very user unfriendly to look at in computerized patient record system (CPRS) notes.”

PrU sites included sacrum/coccyx (15), ischia (8), trochanter (3), heel (2), buttock (1), and toe (1). PrU stages, indicating the depth of the PrU, were unstageable (4), Stage IV (15), Stage III (7), and Stage II (4). Only the CWCNs completed SCI-PUMT scores for veterans in this sample. Over the 4-week period, the SCI-PUMT score 1) remained the same or increased (ie, PrU worsened) with no PrU treatment change on 45% of PrUs; 2) remained the same or increased with a change in treatment on 26% of PrUs; 3) decreased (ie, PrU improved) for 21% of PrUs with no change in PrU treatment; and 4) decreased with a change in treatment for 8% of PrUs (see Table 2).

Results indicated no significant association between recommendations made by the CWCNs regarding treatment and the proportion of a change in SCI-PUMT scores. The significance was not affected if scores increased or stayed the same (c² with 1 degree of freedom = 1.158, P = 0.282) or if the score decreased (c² with 1 degree of freedom = 0.5, P = 0.478).

Attitudes, subjective norms, and perceived behavioral control that impact the intent to use the SCI-PUMT were the key TPB constructs framing this study. Behavioral intent was related to the likelihood of completing the SCI-PUMT and changing the PrU treatment if the score remained the same or increased, indicating the PrU had become worse. Key constructs of the TPB and the association between SCI-PUMT scores and PrU treatment recommended by the CWCNs provide further insight into behavioral intent of clinicians.

Clinicians’ attitudes toward the SCI-PUMT were inherent in the belief that PrU healing was likely associated with attributes of the SCI-PUMT (behavioral belief) and positive attitudes toward the SCI-PUMT (evaluation of the behavior of using the SCI-PUMT to assess PrU healing and guiding treatment). Overall, the CWCNs indicated they slightly intended to use the SCI-PUMT; individual data from the questionnaires ranged from extremely likely to slightly unlikely. However, the CWCN responses overall favored (ie, extremely or slightly) the belief that the SCI-PUMT included most of the important indicators of healing and was helpful in assessing healing in veterans (see Table 1).

Whether clinicians agreed with using the SCI-PUMT to assess PrU healing (normative belief) and were likely inclined to use the SCI-PUMT (motivation to comply) was related to the belief that the VHA approved of using the SCI-PUMT in clinical practice (see Table 1). Overall, the participants believed the SCI-PUMT was only slightly useful in clinical practice. A possible explanation for this finding is that the SCI-PUMT constitutes only one ingredient in making clinical decisions regarding treatment. Clinical decisions are nonlinear and involve considerable attention to personal, professional, and contextual factors.²⁶ For example, knowing a patient’s PrU history of prevention and healing, aptitude of community caregivers, comorbidities, clinician intuition and experience, and multiple other factors must be considered when determining the most appropriate PrU interventions.

Providers and CWCN motivation to use the SCI-PUMT ranged from one end of the continuum to the other (ie, scores of 1 to 5). Almost 50% of the sample (5) indicated they were extremely motivated to use the tool. By contrast, 2 physicians, 1 ARNP, and 1 CWCN were slightly or extremely unmotivated to use the SCI-PUMT. Data indicated the CWCNs were only slightly motivated to use the SCI-PUMT (mean 2.33; SD 1.53). The behavior of completing the SCI-PUMT reflected this level of motivation as indicated by missing data in the EHR. Of the 69 veterans who had PrU diagnoses during the 1-month study period, only 35% had 2 or more SCI-PUMT documented. However, the EHR did reveal that some of the veterans who were not in the sample had 1 SCI-PUMT completed during the study. It also was noted that the CWCNs were not inclined to use the SCI-PUMT if the PrU was <3 cm (a decision with which some clinicians would agree) and/or the veteran had multiple PrUs (which may number >5).

The likelihood of facilitating use of the SCI-PUMT (control belief) and the perceived process and use of the tool as being difficult or easy (perceived power and autonomy) was based on the TPB (see Table 1).²⁴ This construct was evident with questionnaire responses regarding convenience and ease of finding SCI-PUMT scores. Overall, the CWCNs were equivocal about the convenience in using the tool (ie, neither convenient nor inconvenient) and responses ranged from extremely convenient to slightly inconvenient. All 3 CWCNs indicated it was slightly or extremely easy to find the score in the EHR. It is noteworthy that the providers overall believed it was only slightly convenient to find the scores, which may indicate the need for further education regarding access to this information or the need to adopt different or additional documentation strategies.

Barriers to using the SCI-PUMT also were addressed. Not surprising, the area of least positivity was in regard to convenience (mean 2.27; SD 1.42) and efficiency (mean 2; SD 1.18) of the SCI-PUMT. Clinicians in the VHA were required at that time to document using the VA Nursing Outcomes Database (VANOD) for various components of veterans’ health care. Skin care was a major focus of VANOD; documentation was lengthy and recommended use of the PUSH tool, which lacks psychometrics for the SCI population. According to feedback from SCI-PUMT champions on national conference calls, documentation concurrently using both the PUSH and SCI-PUMT to assess PrU healing is redundant and is therefore considered one of the greatest barriers to national adoption of the SCI-PUMT in SCI/D centers. Utilization of the VANOD for this purpose is currently being addressed nationally in the VHA.

SCI-PUMT scores and treatment recommendations. Statistical analysis using data extracted from the veterans’ EHR determined if the magnitudes of changes in PrU treatment were associated with SCI-PUMT scores (ie, behavior) during the study time frame (see Table 2). Orders for treatment of the PrU were written by physicians (27) and ARNPs (12). No significant association was noted between the SCI-PUMT scores and changes in PrU treatment recommended by the CWCN. The significance could have been negatively impacted by the small sample size or missing data for the weeks the SCI-PUMT was not documented in the EHR. Due to missing entries, data were collapsed into 2 categories in the 2 x 2 contingency table instead of the 4 conditions. These collapsed categories represented an increase or no change in SCI-PUMT scores and decrease in SCI-PUMT scores. A trend was observed that SCI-PUMT scores were higher than the expected scores for the increase/no change in SCI-PUMT scores and for the decrease in SCI-PUMT scores when a treatment was changed. This supports the idea that an increase or no change in score was associated with a change in treatment. Given that the expected values were above 5 in all cells, it appeared the Pearson chi-squared was an acceptable statistic. A weaker association between variables was noted when the SCI-PUMT score decreased (PrU improved) but the expected score for no treatment was lower.

The Agency for Healthcare Research Quality (AHRQ) identified a triad of stages that are required to embed an innovation.²⁷ Using the AHRQ’s model, the SCI-PUMT was developed in the initial stage. In the middle stage, the SCI-PUMT was nationally disseminated to SCI Centers using a tool kit and multiple educational strategies suggested by AHRQ. In AHRQ’s last stage of embedding the innovation, the VHA national office promoted the expectation that the SCI-PUMT would be used as the tool of choice for assessing PrU healing in veterans with SCI throughout the SCI Centers. This latter stage of knowledge transfer was essential to promote end-user adoption and institutionalization of the SCI-PUMT.

Optimistically, SCI-PUMT champions will maximize facilitators to adopt the SCI-PUMT and overcome barriers to integrate it into practice. Although this study provided a window into examining clinical decisions in this vulnerable population, future studies could explore other aspects of clinical decision-making regarding the SCI-PUMT using another midrange theory. Item analysis of components contained in the Beliefs About Using the SCI-PUMT resonate positively when considering that SCI-PUMT implementation is only in its formative years and that it takes years to integrate evidence into practice. To date, no variables have changed due to user feedback. The SCI-PUMT may require additional psychometric testing if a variable were to be added or modified.

The primary limitations of this pilot study included: 1) implications for practice are limited due to the small sample size and only 1 VHA facility; 2) the SCI-PUMT constitutes only 1 factor in making decisions regarding PrU treatment; 3) only physicians, ARNPs, and CWCNs were administered the questionnaire, and responses were based on self-report; 4) several weeks during the study period, the SCI-PUMT was not completed; 5) only the EHRs of veterans with PrU who had at least 2 SCI-PUMT scores in the 4-week period were included in data collection; and 6) 4 weeks is a relatively short period of time to evaluate PrU healing, especially with Stage III and Stage IV PrUs. The aforementioned limitations will affect this study’s generalizability to other SCI Centers.

PrUs represent a potentially significant and costly complication for persons with SCI. The evidence-based SCI-PUMT, comprised of 7 manageable variables, was the first tool for assessing PrU healing to have reliability, validity, and sensitivity established specifically for this unique population. A quantitative pilot study to evaluate the impact of the SCI-PUMT on clinical decision making regarding PrU treatment in veterans with SCI suggests this tool provides a mechanism to assist clinicians and researchers in meeting national clinical practice guideline recommendations regarding PrU assessment in persons with SCI. The effect of using SCI-PUMT on PrU plans of care has not been established; replication of the current study is highly encouraged to determine the impact of the tool on PrU outcomes. Data analysis for this pilot study indicated varied intention by providers and CWCNs to use the SCI-PUMT in clinical practice; no significant association was noted between SCI-PUMT scores and PrU treatment in a small sample. The SCI-PUMT is relatively new in clinical practice, and it is expected to gain more momentum as implementation continues. A study is currently underway to identify the barriers and facilitators of SCI-PUMT implications in high and low adopting SCI Centers.

The authors sincerely appreciate the contributions of Gail Powell-Cope, PhD, ARNP, FAAN; Mark McCranie, MA; and Stephen Luther, PhD, all of whom are assets in the HSR&D Center of Innovation on Disability and Rehabilitation Research (CINDRR), Tampa, FL, for their expertise as a researcher, data analyst, and statistician, respectively.

Dr. Thomason is a Nurse Researcher, HSR&D Center of Innovation on Disability and Rehabilitation Research (CINDRR) and Tampa VA Research and Education Foundation, Inc, Tampa, FL. Dr. graves is Associate Professor, Capstone College of Nursing, Tuscaloosa, AL. Dr. Madaris is Assistant Chief Nurse, SCI/Rehabilitation and Program Director, Wound Specialist Program & SCI Homecare, James A. Haley Veterans Hospital, Tampa, FL.

Please address correspondence to: Dr. Susan S. Thomason, HSR&D Center of Innovation on Disability and Rehabilitation Research (CINDRR), 8900 Grand Oaks Circle, Tampa, FL 33637; email: Susan.Thomason@va.gov.