Implementation and clinical impact of an interdisciplinary tool to promote skin integrity after flap surgery in Veterans with spinal cord injury

Context/Objective: Pressure injury (PrI) recurrence is common among persons with spinal cord injury and disorders (SCI/D) who undergo reconstructive flap surgery for pelvic stage 4 PrI (S4PrI). This paper describes the development and implementation of the Minneapolis Spinal Cord Optimization, Rehabilitation and Empowerment (SCORE), a preoperative interdisciplinary tool for risk assessment and mitigation, and reports its effect on the one-year flap failure rate (significant breakdown). Design: Retrospective review. Setting: Minneapolis Veterans Affairs Health Care System (MVAHCS) SCI/D Center, a tertiary care center. Participants: 141 Veterans with SCI/D and pelvic S4PrI underwent 204 interdisciplinary assessments for flap surgery. Interventions: The Minneapolis SCORE was developed by the MVAHCS SCI/D Center and first implemented in 2012. The eight domains of the tool and continuous improvements in tool implementation for risk assessment and mitigation are described. Outcome Measures: Per-year incidence rate of flap failures within one year of surgery from 2009 to 2019. Results: 48.3% (28/58) of S4PrI assessments during 2009–2011 (pre-SCORE) led to flap surgery the same year, increasing to 59.6% (87/146) of assessments after SCORE implementation during 2012–2019. The one-year flap failure rate abruptly decreased from 40.5% (15/37) of the 2009–2012 surgeries to 7.7% (6/78) of the 2013–2019 surgeries (P <.0001). Characteristics of patients by time period, operative status, and flap outcome are presented. Conclusion: After an initial learning curve in tool implementation and subsequent tool refinement, the use of the Minneapolis SCORE before flap surgeries was associated with improved flap integrity at one year. Successful use of the tool requires collaborative problem-solving between the patient and interdisciplinary team.