Pressure injuries are a serious, lifelong secondary complication of spinal cord injury (SCI) that have the potential to “interfere with physical, psychological and social well-being and to impact overall quality of life” (Consortium for Spinal Cord Medicine 2000, p. 9). Although preventable in most situations, when they occur, pressure injuries may “disrupt rehabilitation, prevent individuals with SCI from attending work or school, and interfere with community reintegration” (Houghton et al. 2013, p. 6). As well, the occurrence of a pressure injury can lead to rehospitalization often with an extended length of stay (Fuhrer et al. 1993; Krause 1998; Consortium for Spinal Cord Medicine 2000). In fact, pressure injuries are reported to account for a disproportionate number of rehospitalization days (Dejong et al. 2013; Middleton et al. 2004) that are also typically much longer than length of stays for other conditions such as urinary tract infections (UTI; Dejong et al. 2013; Middleton et al. 2004; New et al. 2004). Rehospitalization secondary to pressure injuries increase in frequency over time since discharge from initial rehabilitation but peaks at year five as seen in the United States SCI Model Systems 20-year database review (Cardenas et al. 2004).
It has been estimated that pressure injuries can account for approximately one-fourth of the cost of care for individuals with SCI. In the United States alone, it has been estimated that the cost of care for pressure injuries is about 1.2 to 1.3 billion dollars annually while prevention could cost about one-tenth of this amount (Bogie et al. 2000; Byrne et al. 1996). Because of the costs associated with treating pressure injuries, Krause et al. (2001) state, “they [pressure injuries] have received more attention among rehabilitation and public health professionals than any other type of secondary condition associated with SCI” (p107). Despite the attention given to prevention strategies, pressure injuries are common among individuals with SCI (Krause et al. 2001). The most recent econometric analysis of pressure injury resource utilization for community dwelling people with SCI identified that 62% of the cost of pressure injury treatment was attributable to hospital admission costs (Chan et al. 2013). Nursing costs accounted for the greatest cost amongst non-physician health care providers (Chan et al. 2013).
The 2013 Canadian Best Practice Guidelines for the Prevention and Management of Pressure injuries in People with SCI (Houghton et al. 2013) not only provide an updated resource for healthcare professions but also consider the unique challenges of pressure injury management within publicly funded, universally available healthcare. In particular, a comprehensive approach to pressure management as well as self-management and telehealth approaches have been incorporated into these 2013 guidelines, which also serve as a thorough resource handbook for clinicians.
There is a growing body of research evidence to augment clinical decision making for Pressure Injuries. While the growth of level 1 and 2 evidence research in the recent years assists to advance this field, it is important to recognize that not all aspects of pressure injuries can be controlled and that level 3, 4 and 5 evidence research continues to be critical for understanding the unique and person-based aspects of this field. This growth of research is exciting and important to the advancement of the field; however, it is resulting in an ever-growing length of this chapter which needs to be managed. For this reason, in sections where there is a mix of levels of evidence, and the level 5 evidence studies do not add novel or compelling evidence, their contribution will be summarized just prior to the discussion section under the subheading of Summarized Level 5 Evidence Studies. This assures the reader of all the studies reviewed and acknowledges the important contribution of all studies to the field of wheelchairs and seating. Please note that the contribution from these studies will not be included in the related discussion or conclusions.