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H - Skin Integrity

Canadian SCI Experts in Skin Integrity rank among the best in the world. Clinicians and scientists likely to influence practice in the next five years: Cher Smith, OT; Peter Aikman, MD (Hospital Medicine); Roberta MacLean, RN; and Melanie Elerker, RN, Halifax: Contributors to the interdisciplinary SCI team at the Nova Scotia Rehabilitation Centre who provide expertise in the maintenance of skin integrity, in individuals with SCI.   Stéphane Côté, RN, Montréal: Years of first-hand experience and expertise in SCI skin integrity issues, and a resource for the SCI Rehabilitation program at IRGLM.   James Mahoney, MD (Plastic Surgery); Gary Sibbald, MD (Dermatology); Ethne Nussbaum (PT Research); Linda Norton, OT (W/C Vendor); Colleen McGillivray, MD (Physiatry); Cathy Craven, MD (Physiatry); Nicole Mittmann (Economics), Diane Leber, RN; Toronto: Published clinicians, researchers and skin integrity experts. Dr. Pamela Houghton, PhD PT (Scientist), London: Published researcher working with supportive interdisciplinary research and clinical team of Karen Campbell, RN (Scientist); David Keast, MD (General Practice); Chris Fraser (Dietitian/Consumer); Laura Titus, OT (Scientist); Sherry Green, RN, who are well versed in SCI skin integrity knowledge generation for electrical stimulation healing, as well as prevention and management. Dalton Wolfe, PhD (Neuroscience); Jane Hsieh, MSc (Scientist); Anna Kras Dupuis, RN MSc, London: Knowledge translation experts who are conduits of best practice adoption in SCI-related pressure ulcer prevention and management. Dr. Wolfe is principal investigator for a multi-centre feasibility study of in-home prevention and management of pressure ulcers in individuals with SCI, using the internet for care delivery.  Karen Ethans, MD (Physiatry) and Alan Casey, MD (Physiatry), Winnipeg: Actively participate in the pressure ulcer internet clinic multi-centre study and local pressure ulcer strategies, in collaboration with local patient advocacy groups. Vivian Mushahwar, PhD (Biomedical Sciences), Edmonton: Internationally recognized for work in the development of Smart-e-Pants technology, shown to be effective in the prevention of skin breakdown, in individuals with SCI. Mary Mark, RN, Edmonton: Nursing skin care expert. Chester Ho, MD (Physiatry); Denise Hill, MD (Physiatry), Calgary: Published pressure ulcer clinician researchers who participate in the Internet Pressure Ulcer Clinic multi-centre study. Cathy Flaman, PT; and Cheryl Oga, OT, Calgary: Skin integrity specialists.   Key Clinical Issues: What’s Needed Currently, there are seven clinical practice guidelines, and at least four key references that provide clinicians with evidence-based practices, in the prevention and management of pressure ulcers. Despite the diversity of healthcare providers and the plethora of resources, many issues relating to the need for rehabilitation leadership in best practice implementation (BPI) remain. Therefore, in order to optimize clinical care, these three priority areas must be addressed: 1. Establish process(es) for implementation of BPI related to the prevention and management of pressure sores. 2. Reach consensus on key modifiable risk factors (e.g., ischial pressures, blood flow, behavioural and psychosocial predictors), and take systematic actions to enable implementation of specific strategies to prevent pressure ulcer development, post-SCI. 3. Implement specific, effective pressure ulcer management (ultraviolet therapy and electrical stimulation therapy) educational strategies and methods, across all facilities in Canada that treat individuals with SCI. Concurrently, to encourage self-management, research efforts need to expand into the realm of behaviour modification among individuals. This should begin in the inpatient setting prior to rehabilitation discharge and community living. This aim will be realized if the culture and capacity for BPI is developed across the continuum of care, particularly among community service providers (family physicians and visiting nurses), who deliver the majority of care over an individual’s lifetime. To meet this goal, a change environment (e.g., awareness, readiness, funding) is required, to merge with health policy changes, and to address: • The 95% lifetime prevalence of pressure ulcers among individuals with SCI • Significant healthcare costs resulting from pressure ulcers ($2.1 billion/annum; Theta final report 200810) and economic burden (loss of workforce contribution) • Recurrence risks that increase with development of each pressure ulcer5 • Catastrophic impacts to quality of life and additional secondary health conditions as a result of pressure ulcers. The primary barrier to implementation of a much-needed change environment is the current focus on acute care issues which pre-empts awareness of rehabilitative healthcare. Since pressure ulcers are usually first recognized during rehabilitation, pressure ulcer prevention and management is not prioritized in a field focused on acute care urgencies. There is a lack of awareness of the scope or importance of the problem in the media, community and among policy makers. For example, it is not well known that actor Christopher Reeve died of pressure ulcer complications.11 SKIN INTEGRITY | BODY STRUCTURE AND FNUCTION 89


H - Skin Integrity
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