Table 1.

Operationalizing the dependent variables

Guideline or VA Handbook recommendation	Operationalizing the skin assessment elements	“Gold standard”	Accepted (direct quote from medical record note)
1. Assessment components
Describe in detail an existing pressure ulcer: anatomical location and general appearance, size (length, width, depth, and wound area), stage, exudate/ odor, necrosis, undermining, sinus tracts, infection, healing, wound margins/ surrounding tissue.	Assessment of skin integrity	Full body skin assessment documented	“Denies problems with skin”
	Assessment with measurements for existing ulcers	Assessment of PrUs with measurements	“2 stage III ischial wounds and a stage II left heel wound”
Monitor and assess the pressure ulcer on a consistent, ongoing basis to determine the adequacy of the plan of care.	Documentation of a treatment plan for existing ulcers	Detailed description of PrU treatment plan	“had flap surgery”
2. Inter-disciplinary/specialist consultations for existing PrUs
An Interprofessional Pressure Ulcer Committee is established and sustained to develop, implement, monitor, and evaluate the Pressure Ulcer Prevention Program; A certified Wound Care Specialist (registered nurse, physician, physical therapist, occupational therapist, physician assistant, or podiatrist) is a member of the Interprofessional Pressure Ulcer Committee;	Consultation made to a wound care specialist, if warranted	Documentation of assessment and plan completed by wound care specialist	“osteomyelitis found”
	Consultation made to a Podiatrist, if warranted	Documentation of assessment and plan completed by Podiatry	“Refused to follow with ID or Podiatry”
Refer appropriate individuals with complex, deep stage III pressure ulcers (i.e., undermining, tracts) or stage IV pressure ulcers for surgical evaluation.	Consultation made to a plastic surgeon, if warranted	Documentation of assessment and plan by plastic surgeon	“not a good candidate for further surgery”
3. Nutritional assessment and treatment
Assess nutritional status of all SCI individuals on admission and as needed, based on medical status	Nutritional evaluation or consultation completed	Documentation of assessment and plan completed by Clinical Dietician	“appetite: fair”
Implement aggressive nutritional support measures if dietary intake is inadequate or if an individual is nutritionally compromised.	If a nutritional deficit existed, was there an intervention?	Nutritional supplementation ordered	“already receiving Ensure via peg 1-3x a day”
4. Review supplies/medications
Cleanse pressure ulcers at each dressing change.	Were relevant supplies reviewed/ renewed, if necessary?	Provider discussed with patient/ caregiver dressing changes and ordered supplies	“none needed”
Describe medications that can increase PrU risk or complicate management of existing PrUs.	Were relevant medications reviewed/ renewed, if necessary?	Provider and patient reconciled medications, refilled those in need	“resides in nursing home”
5. Assess equipment
Poor posture, long periods spent on bowel or shower chairs and inadequate offloading from a wheelchair cushion are frequent causes of pressure ulcers.	Assessment of bathroom equipment	PT evaluated shower chair and commode brought to clinic	“pt ambulates without devices”
Pressure mapping, seating assessment, and equipment evaluation are vital components of a comprehensive prevention program.	Assessment of transfer equipment	Formal PT evaluation completed of patient's sliding board and lift system	“caregiver uses lift”
Assessment ability to change and control body position.	Assessment of patient ability to transfer	Patient's ability to safely transfer was assessed	“dependent in all ADLs”
Use pressure-reducing bed support surfaces for individuals who are at risk for or who have pressure ulcers.	Mattress evaluation	Mattress surface quality evaluated	“NH resident”
6. Wheelchair evaluation
Prescribe wheelchairs and seating systems according to individualized anthropometric, ergonomic, and functional principles.	Wheelchair evaluation	Individualized PT evaluation of wheelchair functioning	“Has a manual wheelchair”
Use appropriate wheelchair cushions with all individuals with SCI.	Wheelchair cushion evaluation	Wheelchair cushion evaluated by PT for proper placement and support	“Uses wheelchair but can walk without any aid”
Inspect and maintain all wheelchair cushions at regularly scheduled intervals.	Wheelchair pressure mapping evaluation	Patient performed pressure mapping and made recommendations for support surface	“Patient didn't bring chair”
7. Functional assessment
Assess function whenever a Veteran returns home, or if there is a significant deterioration in the Veteran's functional status, especially mobility.	Functional assessment performed	KT, OT, or PT performed a functional assessment and provided a treatment recommendation or plan	“Followed by KT”
8. Patient education
Prescribe a power weight-shifting wheelchair system for individuals who are unable to independently perform an effective weight shift.	Counseling on importance of weight shifts	Patient was educated on importance of shifting weight while sitting in wheelchair to prevent skin breakdown	“The pressure ulcer prevention protocol was not needed- patient is not at risk”
Use cushions and positioning aids to relieve pressure on pressure ulcers or vulnerable skin areas by elevating them away from the support surface.	Counseling on importance of pressure relief	Patient instructed to perform pressure reliefs every 15 minutes when sitting in wheelchair	“Reminded to avoid pressure on the open area”
Develop, display, and use an individualized positioning regimen and repositioning schedule.	Counseling on importance of turning	Education documented on the importance of a turning schedule	“Pt refused to be turned q 2”
Teach Veterans and/or designated family members, surrogates, or authorized decision makers how to perform regular (daily) skin inspection…identify and remove the cause of early breakdown…until healed.	Education on what to do if new breakdown or skin worsening	Patient was instructed to call the SCI clinic immediately with any skin breakdown, redness, or worsening appearance of ulcer.	“check the skin daily for any redness”
9. Assess PrU risk factors and co-morbid conditions
Assess demographic, physical/medical, and psychosocial risk factors associated with pressure ulcer prevention.	Assessment of co-morbid conditions	Co-morbid conditions and patient specific risk factors assessed and addressed	(required—Problem List)
Factors that increase risk for development of pressure ulcers: incontinence-bowel and/or bladder; excessive perspiration; and abnormal fluid accumulation (e.g. edema)	Screening for bowel incontinence	Provider and patient discussed bowel care management and addressed any voiding problems	“has bowel care M,W, F”
	Screening for bladder incontinence	Provider and patient discussed bladder management and addressed any voiding problems	“foley catheter in place”
	Screening for excessive sweating or moisture	Sweating and/or moisture issues discussed between patient and provider	“On propantheline”
10. Assess psycho-social risk factors
Identify the potential psychosocial impacts of pressure ulcers and immobility and provide referral for therapeutic interventions based upon the individual's characteristics and circumstances.	Psychological assessment performed	Patient received an evaluation by psychiatry with treatment recommendations, if warranted	“History of psychotic disorder”
	Cognitive assessment performed	Assessment of cognitive status done by provider	“Pt has dementia”
If risk level changes, revise prevention plan to be consistent with the Veteran's current condition.	Assessment of availability and involvement of caregivers or support system	Assessment done on patients ability to function independently at home and support system evaluated	“Maximum resources are in place”
	If warranted, address issues with the availability and involvement of caregivers or support system	Caregivers trained by staff on how and when to perform patient's ADLs	“Will resume home health services after discharge”
	Assessment of social or vocational status	Discussion with patient the need for psychosocial or vocational intervention	“works pretty much full time”
	Screened for substance abuse issues	Screened for use of cigarettes/tobacco, alcohol, or illegal substances	“known alcoholic”