INCIDENCE AND TYPES OF PRESSURE SORES AND URINARY TRACT INFECTIONS AT CENTRE FOR REHABILITATION OF THE PARALYSED, BETWEEN 1995 AND 1997

INTRODUCTION

Urinary tract infection (UTI) remains a major cause of morbidity in people with spinal cord injuries (1). Pressure sores are also a major complication, the annual incidence being between 23% (2) and 30% (3). Between 7% and 8% of persons with spinal cord injuries are reported to succumb to pressure sores (4). In an epidemiological study carried out at the Centre for Rehabilitation of the Paralysed (CRP), it was found that out of the 247 clients 153 had a history of UTI and 94 had a history of pressure sores (5).

The present study was carried out in an attempt to highlight the incidence of UTI and pressure sore infection, and the organisms involved.

OBJECTIVES OF THE STUDY

The objectives of the study were

1. To establish if there are trends in the incidence and types of infections at CRP,
2. To provide information which could be used to establish infection prevention programmes and appropriate training programmes,
3. To monitor CRP's performance in prevention of pressure sores,
4. To provide a base for future research in this area.

METHOD

The sample for the study included spinal cord injured persons who had been admitted in CRP between January 1995 and December 1997. The data were collected from the CRP pathologylaboratory records and from pathology reports of clients. All clients who had culture and sensitivity specimens analysed were included in the study. The average monthly in-patients numbers between 1995 and 1997 varied from 72 in 1995, 68 in 1996, to 86 in 1997. Records of infection rates were made separately for clients who developed infections during admission. These data were not included in the study.

RESULTS

UTI : During all three years, E-Coli was the most commonly found organism, followed by proteus. All organisms showed a steady reduction over the 3 years, with the exception of klebsiella which remained at a constant level. There was a reduction of 44.6% in the rate of UTI between 1995 and 1996, and between 1996 and 1997, there was a reduction of 35%. Overall there was a reduction of 64% in the UTI rate between 1995 and 1997. Wound infection : During all three years, the most commonly occurring organism was Staphaureas, followed by Proteus. There was a reduction of 15.6% in would infection rate between 1995 and 1996, while there was a reduction of 59.2% between 1996 and 1997. The overall reduction in would infection rate was 65.6% between 1995 and 1997.

DISCUSSION

UTI: Till 1995, the most commonly used methods of bladder management for persons with spinal cord injury in CRP were tapping and expression, and condom drainage. However, the management of choice for failure to empty bladder dysfunction is clean intermittent catheterisation (CIC) (6). In mid- 1995, CRP reviewed its policy of bladder management to adopt the method of CIC, in the hope that it would not only reduce bladder infection rates but also provide injured persons with more effective means to manage their bladder. In Bangladesh, a rubber CIC costs 6 taka per piece, and it would provide a more cost-effective means of bladder management in the hospital and on discharge, for the majority of CRP's clients who are poor. Training and staff development programmes were also initiated to raise awareness and promote acceptance of CIC. In addition, health education programmes for clients were started, with emphasis on bladder management.

The results of the study indicate that these interventions were successful in reducing the rate of UTI in CRP. However, the study does not highlight or compare the number of UTI occurring in those using CIC and those using Foley catheters. Foley catheterisation is generally used for clients who are newly admitted in CRP and for those with complications such as urethral stricture and urethral fistula.

Infections caused by Proteus, E-Coli and Klebsiella organisms continue to occur in CRP. More research is needed to examine why this is so, and to ascertain the steps needed to reduce the incidence of these infections further.

Wound infection: Pressure sores account for one fourth of the cost of caring for clients with spinal cord injury (7). Prevention of the sores would cost less than one tenth the amount spent on treatment (8). Likewise, prevention of infection in those who have developed sores would have various positive effects on treatment and rehabilitation of affected persons. These include faster healing of the pressure sores; reduction in money spent on antibiotics, laboratory tests, dressings and bandages; reduction in the use of valuable nursing time; faster rehabilitation process; and reduction in the psychological trauma faced by the affected persons.

The nursing department of CRP recognised that control of pressure sore infection was a key element in the healing time of pressure sores. In the last 2 years, the department has developed some systems to address the problem. These include the development of individual dressing packs; development of a dressing room with hand basin; development of dressing policies and procedures, especially the aseptic dressing technique; development of a system to assess a nd evaluate pressure sores. and development of an in-house training and staff development training programme.

The results of the study indicate that these interventions have been instrumental in reducing the rate of pressure sore infections. It would appear that 1996 was a period of transition, and that the real effects of the changes became apparent in 1997, once the systems were firmly established.

The incidence of infection caused by the Staphaureas organism remains approximately two thirds higher than any other organism. It would be helpful to examine more closely the particular clients who develop this infection to establish why this is so and what action could be taken to reduce the rate of infection.

Some specific recommendations arise from this study. All pressure sore infections, urinary tract infections and the organisms involved, should be recorded at the ward level. A monthly report should be produced, circulated and discussed at ward staff meetings and with other members of the health care team. The systems that are in place should be monitored regularly. Training in pressure sore prevention and management should be an on-going activity, along with training in bladder management and prevention of UTI. Future data collection on UTI should include the type of bladder management system that is being used at the time of collection of specimens.

CONCLUSION

At CRP, pressure sore infections and urinary tract infections are factors associated with delayed rehabilitation of persons with spinal cord injury. These problems put additional demands on limited resources. They increase the workload of the medical staff and add to the affected persons' anxiety.

This study has shown that with staff commitment, perseverance and willingness to adopt new practices, infection rates reduced significantly at CRP. They have not, however, disappeared. This is an area that requires continuous monitoring, staff training and a strong commitment to health education. It is also an area that requires more in-depth research, so that further reduction can be achieved in infection rates.

REFERENCES

1. Van Kerrebroeck PEV, Kildewijn EL, Scherpenhuizen S, Debruyne FMJ. The morbidity due to lower urinary tract infection in spinal cord injury patients. Paraplegia 1993; 31:320-329.
2. Whiteneck GG et al. Mortality, morbidity and psychosocial outcomes of persons spinal cord injured more than 20 years ago. Paraplegia 1992; 30:617-630.
3. Young JS, Burns PE. Pressure sores and the spinal cord injured patient: Part 11. Model systems. SCI Digest 198 1; 3: 11-26.
4. Dinsdale SM. Decubitus ulcers: role of pressure and friction in causation. Archives of Physical Medicine and Rehabilitation 1974; 55:147-152.
5. Hoque F. Spinal cord lesions in Bangladesh : An epidemiological study. Centre for Rehabilitation of the Paralysed, 1998.
6. Szollar SM, Lee SM. Intravesical oxybutynin for spinal cord injury patients. Spinal Cord 1996; 34: 284-287.
7. Houle RJ. Evaluation of seat devices designed to prevent ischemic ulcers in paraplegic patients. Archives Of Physical Medicine and Rehabilitation 1969; 50: 587-594.
8. Noble PC. The prevention of pressure sores in persons with spinal cord injuries: Monograph 11. International Exchange of Expertise and Information in Rehabilitation, World Rehabilitation Fund, New York, 198 1.

CBR PROJECTS OF SHREE RAMANA MAHARISHI ACADEMY FOR THE BLIND

Shree Ramana Maharishi Academy for the Blind, a voluntary organisation, was established in 1969 with the aim of rehabilitating persons with visual impairment. After 30 years of working in an institutional set-up, the Academy took the decision to work in the community, in order to extend its services to a larger number of people with disabilities. The organisation also changed its practice of providing interventions for a single disability, namely, visual impairment, to include people with all disabilities under its purview. At present, the organisation is involved in running four community based rehabilitation (CBR) projects. Although the approaches followed in these projects are different from one another, all the projects view CBR as a strategy within community development for the rehabilitation, equalisation of opportunities and social integration of all people with disabilities. It is multi-sectoral, multi-disciplinary, and requires to be carried out with the joint efforts of people with disabilities and their families.

The first CBR project, called Sourabha, was started in 1990 in 147 villages in Kanakapura, near Bangalore, with the aim of providing comprehensive rehabilitation services for people with disabilities. During the first year, the focus was on children and on medical rehabilitation. As a result of the interventions, children with disability showed improvement in their mobility, communication skills and self-care, and came out of their houses. Those who could get access into regular schools were integrated into the schools, and many others were provided non-formal education inputs. In-service training programmes were conducted for the CBR team. Mass awareness programmes were conducted to make the community aware of the rehabilitation activities and to change their attitudes towards people with disabilities. Disabled adults were provided with opportunities for economic independence through vocational training and self-employment activities. The project underwent a review in 1993, the findings of which pointed out that community participation was not adequate, severely disabled persons did not have sufficient access to the services, and sustainability was a questionable issue. After the review, group organisation activities were initiated, to empower community based groups. A series of training programmes were conducted to build the capacity of the community. This resulted in the establishment of self help groups, rehabilitation committees and associations of people with disabilities at different levels. At present, almost all the CBR activities are being conducted by the community based groups under the technical guidance of the resource team of the project. After the planned withdrawal of the project in 2002, it is expected that these groups will carry forward the CBR activities.

The learning from the Sourabha project were put into practice in another project called Samanvaya, which was started in 1997. In this project, rehabilitation activities were integrated into the on-going general community development programmes that had been in operation for 3 years in 17 villages in Kanakapura with the objective of poverty alleviation through agricultural development. People with disabilities were integrated into rural development groups. Credit management groups of rural women accepted disabled women and their mothers as members in their groups. Children with disability joined the clubs of their non-disabled peers. Farmers with disability and their parents joined the farmers' networks. Village level workers were trained to address disability and rehabilitation issues.

In 1998, the organisation started a project in 75 villages in a new district, following a different process. In this project, the community was first sensitised through mass awareness programmes and organised into groups. This process made the groups understand their role in the rehabilitation of disabled persons, and also made them want to initiate programmes for them. After the community groups were formed, training programmes were conducted for capacity building of the groups. Information centres were established to provide access to information about disability and rehabilitation. The groups were assisted to build up a liaison with the appropriate government departments. The organisation provided technical and some financial assistance to the groups. As a result of these initiatives, the community groups are in a position to carry forward the rehabilitation programmes on their own.

INSTRUCTIONS TO AUTHORS

The Asia Pacific Disability Rehabilitation Journal is a bi-annual Journal, for private circulation only, for researchers, planners, administrators, professionals, donor organisations and implementing agencies involved in disability and rehabilitation. The major emphasis of the Journal is on articles related to policy development, concept clarification, development of methodology in the areas of service delivery, training of manpower and programme evaluation, and development of technology related to rehabilitation. Other information related to rehabilitation of disabled people that may be of use to implementing agencies, academicians and donor organisations are also welcome. The views expressed in the Journal are those of the contributors alone. Articles sent to the Editor will be published after they are edited to suit the format of the journal, under three different sections, namely, Developmental articles, Original articles, Brief Reports and Letters to Editor, subject to their suitability after PEER REVIEW. They may also be published elsewhere if so desired, after acknowledging the source. Copies of the Journal are mailed free of cost. The Journal and its associate publications are available on the Internet at

Format. The whole manuscript must be typed in double space (including references), and have generous margins. Number all pages in sequence beginning with the title page. Submit TWO COPIES of all elements arranged in the following order, beginning each part at the top of a new page. Sending the article on a diskette (Windows 95 version) will be useful.

Title Page. This should contain the concise title of the manuscript, the names of all authors, and at the bottom of the page, the institution where the work has been carried out, and the address for all correspondence and reprints.

Abstract. The second page should contain an Abstract of not more than 150 words, stating the purpose of the study, the methods followed, main findings (with specific data and their statistical significance if possible), and the principal conclusions. Emphasise new and important aspects of the study or observations.

Text. Articles must be concise and usually follow the format : Introduction, Methods, Results and Discussion. The matter must be written in a manner which is easy to understand, and should be restricted to the topic being presented.

Acknowledgements should be placed as the last element of the text before references.

Measurements should be reported in metric units ( metre, kilogram, litre). Abbreviate measurements according to the standard, internationally accepted style. Provide initial definition of unusual abbreviations.
Tables. These must be self explanatory and few in number. Tables must not duplicate information in the text. Each table must have a short title and should be numbered with Arabic numerals (1,2, etc).

References. In citing other work only references consulted in the original should be included. If it is against citation by others this should be so stated. Abstracts, personal communications and unpublished work may not be used as references, although reference to written communication may be inserted in brackets in the text. Papers accepted but not yet published may be included in the references, by mentioning the Journal's name and adding "In Press" in brackets. Reference to manuscripts not accepted for publication must be made only in the text, in brackets.

References should be numbered and listed consecutively in the order in which they are first cited in the text, and should be identified in the text, tables and legends by Arabic numerals in brackets. The full list of references at the end of the paper should include names and initials of all authors. When there are more than 6 authors, only the first 3 are to be given followed by et al; the title of the paper; the journal title abbreviated according to the style of Index Medicus; year of publication; volume number; first and last page numbers. References to books should give the book title, place of publication, publisher and year; those of multiple authorship should also include the chapter title, first and last page numbers, and names and initials of editors.

E.g.

1. Twible RL. Final Fieldwork Placements of Australian Occupational Therapy Students in CBR Projects in India. ACTIONAID Disability News 1996; 7 (2): 68-72.
2. Pandey RS, Advani L. Perspectives in Disability and Rehabilitation. New Delhi: Vikas Publishing House Private Ltd., 1995.
3. Thomas M, Thomas MJ. Evaluation Based Planning for Rehabilitation Programmes in India. In : O'Toole B, McConkey R, eds. Innovations in Developing Countries for People with Disabilities. Chorley, UK, Lisieux Hall Publications, 1995 : 243-254.

For more detailed information about the Vancouver system, authors should consult 'Uniform requirements for manuscripts submitted to biomedical journals' (Br Med J 1988; 296: 401-405).

Manuscripts and all editorial correspondence should be sent to :
Dr. Maya Thomas, Editor, Asia Pacific Disability Rehabilitation Journal, J-124, Ushas Apartments, 16th Main, 4th Block, Jayanagar, Bangalore - 560011, Karnataka, INDIA.
Ph : 91-80-6633762 Fax : 91-80-6633762 Email : thomasmaya@hotmail.com

The Asia Pacific Disability Rehabilitation Journal has an associate publication called "Friday Meeting Transactions". This newsletter, which is mailed free of cost on request, carries reports of different aspects of CBR application, and the summaries of transactions of the "Friday Meetings" held at Bangalore, India, on the last Friday of every odd month between 2 and 5 pm at Ashirvad, St. Mark's Road Cross, Bangalore - 560 001. These meetings are open to all those who are interested in updating their knowledge on community based rehabilitation and related topics. The "Friday Meeting Transactions" is also available on the Internet at http://www.dinf.ne.jp/doc/prdl/othr/apdrj/apdrj.html Those who wish to receive a printed copy, may contact the Editor, Asia Pacific Disability Rehabilitation Journal.

Title:
ASIA PACIFIC DISABILITY REHABILITATION JOURNAL Vol. 11 @ No. 1 @ 2000

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