Selected Abstracts From The 2005 AASCIN Conference
Evidence-Based Guidelines for Optimal Manual Wheelchair Selection, Setup and Propulsion Techniques
Alicia M. Koontz, PhD, ATP, RET, Annmarie Kelleher, MS, OTR/L, ATP, and Shirley Fitzgerald, PhD
Objectives
• Participants will be able to describe evidence-based clinical practice guidelines concerning wheelchair selection, wheelchair setup, and wheelchair propulsion techniques.
Wheelchairs are the key to providing independence for persons with spinal cord injury (SCI). However, research has discovered a direct causal link between wheelchair propulsion technique and upper limb pain and injuries. The type of wheelchair used and how well it fits the person impacts propulsion technique and risk of developing pain/injuries. Multiple factors need to be considered when selecting a wheelchair such as its durability, reliability, adjustability, and reimbursement. This session will focus on these factors and present evidence-based clinical practice guidelines concerning wheelchair selection, wheelchair setup and propulsion techniques. First, comparative data on the performance and quality of different types of manual wheelchairs will be presented. For example, research has shown that ultralight weight wheelchairs last longer, are more reliable and cost effective compared to lightweight and depot style wheelchairs. Next, participants will be educated on basic wheelchair adjustments that can be made to optimize fit of the wheelchair to the person for enhanced comfort, support, stability and effective propulsion. For instance, making small adjustments to the seat position can dramatically affect propulsion ability and reduce stress on the upper limbs. Lastly, the evidence-based recommendations concerning efficient propulsion techniques will be presented.
Making Transfers Therapeutic for SCI Patients Through the Continuum of Care
Karen McCombe, MA, PT and Kimberly Esposito, MPT
Objectives
• Use basic biomechanical concepts to perform safer, more efficient patient transfers.
• Understand how to create an environment throughout the continuum of care that promotes staff and patient safety, and which works toward independent functional skills that are relevant to the ultimate discharge environment.
• Use information gained to select appropriate transfer method and technique, given patient level of injury and predicted target level of function.
In this presentation we will discuss therapeutic transfers from theoretical and practical standpoints, making the case that therapeutic transfers throughout the continuum can address patient and staff safety, as well as promoting functional skills from acute care onward. We will discuss ways to create a therapeutic environment at all levels of care, and ways to communicate efficiently between disciplines and professional levels of staff to create consistency. We will discuss basic biomechanical concepts which make transfers safer and more efficiently performed by patients and staff, and we will correlate these concepts with videoclips of patients practicing mobility skills. Finally, we will discuss levels of injury with regard to predicted target functional level, and ways to select a transfer technique which is appropriate to patient abilities and which works toward ultimate functional skills.We will discuss ways to create a therapeutic environment at all levels of care, and ways to communicate efficiently between disciplines and professional levels of staff to create consistency. We will discuss basic biomechanical concepts which make transfers safer and more efficiently performed by patients and staff, and we will correlate these concepts with videoclips of patients practicing mobility skills. Finally, we will discuss levels of injury with regard to predicted target functional level, and ways to select a transfer technique which is appropriate to patient abilities and which works toward ultimate functional skills.
Discovering the Ethnonursing Research Method
Susan Imes, MSN, RN, and Denise Landry, EdD, RN, C-FNP
Objectives
• Discuss the importance of nursing research and the link to evidenced based practice; illustrate the differences between the two main paradigms of research-quantitative and qualitative.
• Explore the process of the ethnonursing method, including the key concepts of domain of inquiry, informants, and enablers.
• Illustrate the use of the ethnonursing method through sharing specifics and preliminary findings of a research study by Imes (2004) Discovering the culture care meanings and expressions of Appalachian men with a spinal cord injury.
It is our belief that understanding research and learning more about the different methods is a necessary first step toward evidenced- based practice. Therefore, the researcher has two main paradigms to choose from; quantitative and qualitative. Each of these paradigms has value and will at some point in time be a “best choice” when preparing to conduct research. And within each paradigm are several methods or frameworks from which to choose. The question or “gap” of knowledge, should determine the paradigm and method. One such method is ethnonursing; it is a qualitative research method focused on discovering and documenting the person’s way of knowing and experiencing life with specific emphasis on nursing care phenomena, all within the cultural context of the individual. Key concepts of the ethnonursing method are the domain of inquiry (DOI), informants, and enablers. The information on the ethnonursing research method with emphasis on a current study is provided to the participant to facilitate the discovery of, and to promote the future use of, this method with the spinal cord population.
Intensive Respiratory Rehabilitation of Ventilator-Dependent Patients With Cervical Spinal Cord Injury
Charles Gutierrez, MS, RRT, Frederick Haines, BS, RRT, Cecille R. Pope, MD, Frank R. Bormet, RN, Carlos Ramirez, RN, BSN, and Marilyn Burch, LPN
Objectives
• Identify chest optimization and resistance-endurance training as the main components of intensive respiratory ehabilitation.
• Discuss the main components of the optimization and endurance protocol.
• List five patient care outcomes that improved following protocol-guided optimization and training.
This study examined the relationship between administering daily sessions of protocol-guided chest optimization followed by resistance-endurance training and improved weaning outcomes for ventilator-dependent patients with cervical spinal cord injury (SCI). Intensive respiratory rehabilitation (IRR) is a coordinated, evidence-based intervention that provides medically stable patients with progressive opportunities to wean from mechanical ventilation.
A protocol to resolve secretion encumbrance and improve pulmonary mechanics, was administered daily. The protocol consisted of:
1) positioning in Trendelenberg,
2) mobilizing secretions,
3) hyperinflating lungs,
4) bronchodilating airways,
5) administering on-vent short-term resistance training,
6) administering off-vent short-term resistance training, and
7) administering off-vent long-term endurance training.
Protocol-guided optimization and training were associated with significant improvements in lung compliance, airway resistance, radiographic presentation, SpO2, WBC, cough-breathlessness-sputum (CBS) scale scores, peak cough flow, rapid shallow breathing index, vital capacity, inspiratory (PImax) and expiratory (PEmax) muscle strength. Optimization and training are important components of an intensive respiratory rehabilitation program to significantly improve pulmonary function, and decrease ventilator dependence in patients with SCI.
Looking Back and Stepping Into the Future
Jo Barr, MS, BSN, RN
Objectives
• Review the current clinical developments, medical techniques and surgical approaches for spinal cord injury.
• Delineate the diagnostic studies which contribute to the identification and management of spinal cord injury patient.
• Discuss the changing role of the nurse in caring for the spinal patient.
Until the early 20th century, spinal cord injuries were considered untreatable. Care and treatment of this unique and challenging patient today bears little resemblance to that practiced even in the 1950s. These last fifty years have seen incredible change and improvement. It is timely to step back and reflect on past and delineate the potential avenues toward future treatment. For this is, indeed, a very exciting time in the treatment of this devastating injury.
Evidence-Based Practice in SCI Nursing
Jolene M. Simon, PhD, RN, CRRN
Objectives
• Define evidence-based practice nursing.
• Discuss the use of clinical practice guidelines in evidence-based practice.
• Relate a specific example of using clinical practice guidelines to prevent pressure ulcers in SCI patients.
Evidence-based practice (EBP) is the merging of research evidence with clinical expertise in making clinical decisions for patient care. In practice, questions are asked every day regarding how certain patient care challenges should be addressed. When working in an interdisciplinary team, nursing must be clear, concise, and have evidence to support its position on different patient care issues. Clinical practice guidelines are sources of evidence-based practice. Clinical practice guidelines are recommendations regarding care of individuals with specific conditions made by a panel of experts. Each recommendation is graded on the amount and quality of scientific support present.
The Consortium for Spinal Cord Medicine has developed clinical practice guidelines for acute management of autonomic dysreflexia, neurogenic bowel management and other clinical topics for spinal cord injured adults. When the Spinal Cord Injury Service reassessed its process improvement goal for pressure ulcer prevention, nursing wanted to consider implementing changes in practice. The clinical practice guideline, “Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals,” was reviewed. The purpose of this presentation is to describe the process of using evidence-based practice in pressure ulcer prevention.
Utilizing RN Case Management to Improve Client Outcomes With Compromised Skin Integrity
Robin M. Gehrke, BSN, RN, CRRN, Edie Wiggers, BS, RN, CRRN, and Tamara King, BSN, MSN
Objectives
• Conferees will be able to identify three innovative case management strategies.
• Conferees will be able to verbalize benefits of RN case management for wound care clients posthospitalization.
• Conferees will be able to identify implications for futher nursing research.
Objective: To determine effectiveness of RN case management to successfully prevent progression of partial thickness wounds and reduce complications from skin flap surgery.
Design: Qualitative experimental design comparing a control and an experimental group.
Setting: Out patient wound care clinic of a private specialty hospital.
Participants: 100 adults with a history of partial thickness wounds or recent skin flap surgery.
Interventions: Experimental group received a combination of consultation, education of resource allocations and utilization, behavior contracts and telehealth and incentives. Control group received only the discharge instructions from the hospital where they were treated.
Main Outcome Measures: Severity of pressure ulcers as measured with the Pressure Ulcer Scale for Healing (PUSH tool 3.0).
Results: Within 6 months, significantly improved outcomes within the experimental group were noted. An ehical decision was made to dissolve the control group and every subject was assigned to the experimental group and was given a RN case manager.
Conclusions: Findings support the assumption that the use of RN case managers, post hospitalization, will facilitate patient compliance in wound healing and prevention of skin flap surgery complications.
Implementing Ergonomic Solutions to Safe Patient Handling of SCI/D Inpatients
Carol A. Emerick, MSA, RN, CRRN and Lisa K. Danielson, BFA, RN, CRRN
Objectives
• Review of historical approach to prevention of injury to care givers.
• Identification of high risk task while compensating for mobility needs of SCI/D inpatients.
• Identification of ergonomic solutions implemented on an inpatient rehabilitation unit.
The delivery of nursing care to SCI/D inpatients presents physical challenges to the caregivers who must compensate for mobility deficits. The historical approach to prevention of injury to the caregiver has been to teach good body mechanics, “safe” techniques for repositioning in bed and various manual transfers. Research has shown that manual transfers and repositioning techniques are not safe and in fact contribute to commutative trauma injury to caregivers. This presentation will include a review of high risk tasks for the SCI/D population and a variety of ergonomic solutions to the patient handling tasks that were identified and implemented on a rehabilitation unit to reduce the risk of injury to caregivers.
Managing Acute SCI: The First 72 Hours
Lise Belanger, MSN, RN, and Hilary Jebson, PT
Objectives
• Identify a web-based educational resource for providing clinical care for patients in the first 72 hours after spinal cord injury.
• Identify a complementary web-based educational resource for maintaining spinal precautions.
• Describe how the above two programs can be used to support and standardize clinical practice.
“Managing SCI: The First 72 Hours” is the second Web-based program to address the learning needs of health care providers through a collaborative effort between Vancouver Hospital and the British Columbia Institute of Technology. This has been produced by the same team that created the award-winning program: “Spinal Precautions: Minimizing the Risk of Further Spinal or Neurologic Injury” www.tc.bcit.ca/gait/projects/spinal.shtml With challenging geography and weather conditions in British Columbia, Canada, transfer of SCI-injured patients to BC’s Acute Spine Unit can be delayed by many hours. This web-based program provides health care professionals with a simple, highly interactive and visually rich tutorial about early intervention following SCI. Through a systems-based approach, the tutorial puts into plain language the direction and detail required to provide skilled care for best patient outcomes. While reflecting the BC experience, content is based no current evidence and accepted international standards making it applicable worldwide. Germane to centres with a high volume of SCI patients, the design makes it particularly useful to health care providers only seeing these patients occasionally. The efficacy and efficiency of computer-based educational technologies is far reaching. This program has the potential to improve the standard care for patients with acute SCI.
Short-term Outcomes of Transitioning Home and Acquiring Necessary Knowledge About Self-care (THANKS)
Paula Russum-Hawkins, BSN, RN, CRRN and D.S. Stokic, MD
Objectives
• Describe the five most common areas of SCI self-care knowledge deficits at rehabilitation discharge.
• Verbalize two ways to provide continued self-care education after discharge from rehabilitation.
• Identify two life-threatening complications that can develop following SCI.
Background: As previously reported, THANKS is a telephone education program administered during the first 6-months after inpatient SCI rehabilitation.
Objectives: To determine competencies on 10 self-care topics during 6 months post-discharge.
Design: Prospective telephone interview.
Methods: Between July 2004 and January 2005, we recruited 92 patients admitted for new onset SCI. Ten areas of self-care were reviewed and evaluated (full, partial, or minimal competency) 3 times each during the first 5 months with a final evaluation at 6 months post-discharge.
Results: Across 10 topics 54% of items were scored full competency at visit 1, which increased to 76% at visit 2 and 87% by visit 3. At visit 1, greatest knowledge deficits were related to dysreflexia (14% full competency); circulatory system (29%); nerves/muscles/bones (37%); respiratory system (51%); and skin care (57%). At 6 months, the scores improved to 86%, 97%, 86%, 90%, and 87% respectively.
Conclusions: Self-care knowledge deficits are prevalent at discharge despite in-patient self-care education. Extended provision of education increased self-care knowledge over 6 months post-discharge. Telephone contact has provided SCI persons with positive feedback, identified changes as they developed, and provided early recognition of secondary complications. The relationship between knowledge and incidence of secondary complications remains to be determined.
Biomechanical Assessment of Pressure-Relief and Repositioning Tasks in Persons with SCI
Jeffrey J. Harrow, MD, PhD and John D. Lloyd, PhD
Objectives
• Attendees will learn about a state-of-the-art technological approach to understanding complex human movements.
• Participants will appreciate the biomechanical demands acting on the upper extremities during pressure relief and repositioning tasks in persons with SCI
• Participants will discuss nursing interventions to reduce risk of chronic shoulder disorders during pressure relief and repositioning tasks
Shoulder pain and dysfunction are common complaints among persons living with paraplegia. Two common activities that may contribute to this problem are pressure relief and repositioning using a trapeze. The trapeze is a widely used assistive device that has never been properly evaluated, and may be a significant contributor to shoulder injury over the long term. This study was designed to investigate the biomechanical stressors that lead to shoulder injury using a state-of-the-art 3D measurement technology as they engage in these two tasks. Ten male veterans with paraplegia were recruited to perform pressure relief and repositioning tasks in a laboratory. Human motion, force and EMG of the bilateral anterior deltoid, pectoralis major, latissimus dorsi, tricep and bicep muscle groups was collected using VICON motion tracking technology, force sensing gloves and telemetric electromyography equipment. Findings from this study graphically illustrate the 3D biomechanical demands at the shoulders, elbows and wrists during execution of these tasks. This allows us to identify the high-risk elements of the tasks. This may lead to the development and evaluation of nursing interventions to minimize the risk of developing chronic shoulder disorders.
Biologic and Disease Modifying Agents in Multiple Sclerosis
Matthew R. Sorenson, PhD, RN
Objectives
• Identify available intravenous and injectable disease modifying agents used in the treatment of multiple sclerosis.
• Explore the side effects of disease modifying therapies used in treating MS, and methods of alleviating.
• Discuss the immunologic principles underlying the use of disease modifying agents utilized in the treatment of MS.
Biological agents intended to modify the course of multiple sclerosis (MS) are seeing increasing use. At present, there are two intravenous therapies approved by the Food and Drug Administration for the treatment of MS (Novantrone, Tysabri), along with four injectable agents (Avonex, Betaseron, Copaxone, Rebif). Other biologic agents may also be utilized in the course of treatment (Intravenous immunoglobulin). Nursing is intimately involved in the administration of these agents, and in monitoring for adverse reactions. As well, nursing is often required to provide education to patients and family members regarding in home use. In order to perform these roles successfully, nurses need an adequate knowledge base regarding these therapies. This presentation will integrate research findings with clinical practice by addressing the basic immunologic principles of multiple sclerosis and the role these agents play in modification of disease. Attention will be paid to mechanism of action of each agent, methods of administration,
adverse side effects and methods of alleviating these side effects. A brief summary of other agents in development will be provided. The more prepared nursing is to handle biologic agents, the more prepared and educated the patient.
The Journey to Magnet in Acute Rehabilitation
Kelly M. Johnson, MSN, RN, CFNP, CRRN, CNAA–BC and Jeanine M. Rundquist, MSN, RN, CRRN
Objectives
• State the value and process of the journey to magnet status.
• Identify the administrative and coordinator roles.
• Identify three ways to creatively meet the magnet standards.
Magnet Status is an accreditation from the American Nurses Credentialing Center given to health care facilities for excellence in nursing. The journey to Magnet Status provides not only the designation as a Magnet facility but additional rewards and a sense of fulfillment to nursing programs who participate. Nursing leadership from Craig Hospital will share their experience and their individual journey in preparation for Magnet designation, including nursing department structure, leadership and role development, staff involvement and education, evidence-based practice, research, organization of the application and more.
Feeling Happy: The Experience of Children Living with Spina Bifida
Andra M. Hanlon, PhD, BSN, RN, CNP
Objectives
• Identify the essences of feeling happy for children with spina bifida.
• Identify methodologic challenges in conducting research with children.
• Understand that what children say is important to their health and their quality of life will be enhanced.
Feeling happy is a universal phenomenon of health significant to quality of life. The purposes of this study were to identify the essences of feeling happy for children with spina bifida by listening to the children describe their experiences of health and quality of life, and to contribute to the knowledge base of nursing. Six children living in the community, between the ages of 10 and 12 years of age, were invited to draw their experience of feeling happy and then tell what feeling happy is like for them. The human becoming theory, which guided this study, posits health as ever-changing and cocreated in mutual process with the universe. The Parse Research Method, a phenomenological-hermeneutic approach was used to discover the structure of feeling happy. Three core concepts were discovered and woven together to answer the research question: Feeling happy is uplifting delight with anticipating cherished engagements as tranquility arises amid uneasiness. The findings provide knowledge on feeling happy as an experience of health and quality of life to health professionals, guiding research and practice in caring for children living with spina bifida.
What Is Transverse Myelitis?
Jeanie K. Bachand, EdD, MSN, RN-BC
Objectives
• Identify the etiology and incidence of idiopathic transverse myelitis.
• Describe the clinical features and diagnostic criteria of transverse myelitis.
• Discuss the medical and nursing management of transverse myelitis.
Transverse myelitis(TM) is an uncommon inflammatory disorder that affects a restricted portion of the spinal cord. TM presents with signs and symptoms of motor and sensory dysfunction on both sides of the spinal cord. TM is diagnosed by excluding other conditions with either MRI, myleogram or both. Management of patients with TM includes steroids, plasma exchange, immunomodulatory treatment, prevention of complications, and rehabilitation. This presentation will provide an overview of idiopathic TM including the etiology, incidence, signs and symptoms, diagnostic tests, medical treatment, and nursing management.
Using an Administrative “Dashboard” to Gauge the Health of Your SCI Unit
Laureen G. Doloresco, MN, RN, CNAA–BC and Susan S. Thomason, MN, RN, APRN–BC, CRRN
Objectives
• Describe three elements of an administrative “dashboard.”
• Identify indicators common to the core assessments of quantitative, qualitative, and predictive dashboards.
• Relate how administrative dashboards were customized in a large center for spinal cord injuries and disorders.
“Dashboards” are critical tools for assessing the administrative health of SCI inpatient and outpatient programs. The dashboard includes key elements of clinical quality, finance and resources, team strength, and customer service. This evaluative framework, adapted from the Nursing Leadership Academy, was customized to a 70-bed spinal cord injury/disorders (SCI/D) center in Tampa, Florida. Prior to launching this initiative, the administrative information provided to nurse managers was piecemeal, accessed from multiple sources, and lacked benchmarks and critical thresholds. These obstacles resulted in action delays for correction of impending/actual problems. Mapping the administrative health of SCI/D units was clearly needed. The SCI/D Center at James A. Haley Veterans'’ Hospital initiated administrative dashboards in February 2005 to develop a systematic and meaningful evaluation of administrative outcomes. Dashboards were developed for quantitative, qualitative, and predictive core assessments. The process involved training nurse managers in this management philosophy, deciding indicators to use for each of the key elements, simplifying data retrieval, and clarifying outcomes. This presentation addresses outcomes resulting form the use of administrative dashboards in an SCI/D Center. Best practices in SCI will evolve with the selection of optimal measures, comparison of actual performance against benchmarks, identification of critical thresholds, and initiation of purposeful change.
Developing an SCI Outcomes and Outcomes Research Data Base
Patricia L. Bush, MS, RN, Diane M. Jenkins, MS, Julius Santiago, BS, Ronald King, MS, and Donald Lighter, MD
Objectives
• Develop an understanding of the complexity of data base development and the steps to take to succeed.
• Identify the methods and actions to take to overcome barriers to implementation and data collection.
• Identify how to create actionable reports for outcomes management and outcomes research.
The data available in the industry for SCI care and treatment is largely available from chart reviews, the Model Systems data repository (for adults) or from individual research studies. Pediatric data is hard to capture for meaningful research studies given the small number of patients seen at any given treatment facility. Shriners Hospitals for Children has developed the first international pediatric database for SCI. Over 200 data elements are identified, defined and captured over the course of treatment for pediatric SCI patients served within the Shrine system. Integration of data capture into clinical practice was key to a successful and robust database. Providing report writing capability to the end users from the software program also provides improved access for research studies at the local hospital level. Aggregated data across the system provides more meaningful statistics for both quality improvement efforts and outcomes research. The lessons learned from the development of this system need to be shared with other nurses who are attempting to study the SCI patient populations to improve the care of patients worldwide through evidence based studies and research.
Deciphering Delirium, Dementia, and Depression in Older SCI Patients
Kimberly A. Hickey, MSN, RN-BC, ARRN, CNS
Objectives
• Discuss the importance of being able to distinguish normal age-related changes in older spinal cord injured patients from those changes not considered to be normal.
• Compare key presentation symptoms of delirium, dementia, and depression.
• Identify assessment tools that facilitate the cognitive assessment of older SCI patients.
The population of SCI patients is aging for a myriad of reasons. This trend has significant implications for nursingcare. Cognitive assessment is an essential part of the overall assessment in any age population; this is particularly true in the older population in which there is an increased incidence and prevalence of dementia and delirium, and depression. The presence of any of these alone or in combination confounds the cognitive assessment even without the consideration of the long-term implications of a spinal cord injury. This presentation will discuss normal agerelated changes and frequently seen cognitive pathology in this older population. Practical and evidenced-based tools for assessing dementia, delirium, and depressions will be demonstrated.