Background
Spinal cord injury (SCI) is a life-threatening and debilitating injury with tremendous immediate and long-term extensive impact on the medical, social, psychological and economic aspects of clients, their caregivers and the society [
1‐
3]. The annual incidence rate of SCI is 44 cases per 1, 000, 000 people in Tehran [
4], and 5.5 to 195.4 cases per million in European countries [
5]. Spinal cord injured patients have a high risk of developing pressure ulcers due to motor and sensory impairments, immobility, changes in skin composition, and prolonged hospital stays [
6,
7]. PUs are a serious, costly, and life-long complication of SCI. Around, 30–40% of clients with spinal cord injuries develop pressure ulcers during the acute and rehabilitation phases [
8].
Pressure ulcer and its treatment is one of the most challenging clinical problems in hospitals specially among patients with spinal cord injury [
9]. Even though several pressure ulcer classification systems are available, National Pressure Ulcer Advisory Panel (NPUAP) is the commonest method. According to the NPUAP consensus development conference, pressure ulcers are classified based on severity from suspected deep tissue injury through unstageable, with suspected deep tissue injury representing the earliest stage of pressure ulcer formation, and unstageable is defined as “full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed” [
10].
Though PU is largely preventable patient safety problems, they have major impacts to the affected individual and on the health care system. It highly affects the psychological, physical, social well-being and the quality of life of the affected individuals [
11‐
13]. Likewise, it leads to recurrent hospitalizations, multiple surgeries, potentially devastating complications, increased costs for patient care, morbidity and early mortality [
9,
14,
15]. PU carry a significant economic burden, with treatment costs of a PU far exceeding preventive costs. For example, a study done in Canada, revealed that the total monthly cost for treatment of PU among SCI was 18,758 USD [
3]. Pressure ulcer may account for 25% of the overall cost of treating paraplegic and tetraplegic persons [
16]. Moreover, a study done in Canada showed average monthly cost for treatment of PU in patients with SCI was $4745 [
17].
Large differences have been reported on the magnitude of PUs patients with SCI in different studies. For instance, it varying from 11 to 50% in the current publications [
6,
18]. Similarly, a study done in Switzerland reported that the incidence of PU was 2.31 per patient-year [
18]. Poor pressure relief practices lead to PU development in persons with SCI [
10]. Management and care of PU has become a serious public health challenge, with longer hospital stays than for other causes. Preventive measures to decrease the development of PUs consisted of basic skin care, pressure dispersion using fenestrated foams and alternating weight-bearing sites by regular frequent positioning [
7]. In addition, the key targets for interventions has been advocated to reduce the burden of pressure ulcers in patient with SCI. These interventions includes identification of risk factors, patient education, acute intensive care, and support body surfaces [
19].
The etiology of PUs is complex and rooted in multiple risk factors. Studies suggest that risk factors for PU in patient with SCI include duration after SCI (> 1 year) [
20], age (older age), sex (being male) [
20,
21], poor nutritional status [
22], quadriplegia [
23‐
25], smoking [
6,
26], comorbidity [
23,
27], severe Braden scores [
28], weight (being underweight) [
26], lower level of education [
20,
21], and lack of an intimate partner [
21] were some of the risk factors associated with PU. Similarly, it has been reported that patients with higher-level spinal cord injuries are more susceptible than those with lower-level lesions [
13]. Hence, identification of risk factors used as benchmarks to design appropriate prevention measure, to improve client safety and efficient utilization of resources.
PUs among SCI clients remains unrelenting problem and a major issue in nursing care across the globe. Prevention of PU is a key role of nurses, and is considered a quality indicator of nursing care [
29]. Thought most previous studies have been conducted, to assess the magnitude of PU in acute care setting, intensive care unit, and on public hospitals; however the global magnitude of PU among patient with SCI remains unknown. Hence, this study aimed to estimate the global burden of PU among spinal cord injured patients. Findings from the current study could be serve as benchmark for institutional health care policy-makers to implement appropriate preventive measures to reduce and prevent PU. In addition, it will assist clinicians in estimating burden of PU as part of an overall quality indicator for facilities and an assessment of the effectiveness prevention strategies.
Discussion
The current meta-analysis provided up-to-date knowledge on the magnitude of PU among spinal cord injured patients. The present findings revealed that the global pooled prevalence of PU in patients with SCI was 32.36% (95% CI: 28.21, 36.51%). This finding is much higher than a meta-analysis study done on global prevalence of PU in public hospitals at14.8% [
54]. This indicated that PU is highly prevalent among patients with spinal cord injury, and reflect an inadequately prevention and management of PU risk factors.
The result of the subgroup analysis based on study design (cross-sectional vs cohort) showed that the highest pooled prevalence of PU was observed from those studies with cohort design 34.85% (95%CI: 28.50, 41.19). This variation might be in case of cohort design the outcome variable was obtained through observation, skin assessment, physical examination, and with certain follow up time, whereas in cross-sectional studies data were collected with document review and self-report. Therefore, these situations may contribute for variation across study designs. Similarly, the result of subgroup analysis based on continent revealed that the highest magnitude of PU was reported in Africa 41.94%, followed by Europe 37.47%. The possible explanations for this variation might be due methodological differences, variation in quality of care, differences in health seeking behavior between the populations, policy and strategy difference [
9,
55].
This study has clinical implications in that the increase burden of PU in SCI patients should alarm policy makers and clinician to enhance patient awareness on the impact of PU, to adhere preventive measures, to improve patient safety, to minimize treatment cost, and to design treatment strategies for PU among patients with SCI. In addition, the finding serves as a bench mark to health care professional to provide a attention on the application of standardized care, and represents a marker of quality of care.
The current review and meta-analysis has some limitations: First, inclusion of English only articles, when this was international based review; Second, this study do not identify the predictors of pressure ulcers among patients with spinal cord injury; Third, it may not be representative of the entire content, as no data were found form all of the globe; and fourth, all included studies were reported hospital-based data.
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