Use of behavioral contingencies to promote prevention of recurrent pressure ulcers

OBJECTIVE: To determine effectiveness of an intervention using monetary rewards as a consequence for preventing or reducing severity of pressure ulcers in spinal cord injury (SCI) patients with a history of chronic, recurrent ulcers. DESIGN: Multiple baseline analysis across subjects (time-lagged control), comparing severity of pressure ulcers and treatment costs during baseline and intervention. SETTING: Outpatient wound-care clinic of private, nonprofit specialty hospital. PARTICIPANTS: Nine adults (all with paraplegia) with a history of hospitalizations for treatment of pressure ulcers. INTERVENTIONS: In study 1, participants (n=6) undertook (1) a comprehensive self-care plan, (2) had a graduated schedule of visits with an advanced practice nurse, and (3) received monetary rewards for successfully preventing serious ulcers. In study 2, participants (n=3) undertook interventions 1 and 2, but monetary rewards were in staged phases so a component analysis could compare the effectiveness of visits alone to visits plus monetary rewards. MAIN OUTCOME MEASURES: Severity of pressure ulcers measured with the Pressure Ulcer Scale for Healing (PUSH Tool 3.0); and direct costs of treatment and preventive care for pressure ulcers. RESULTS: In study 1, severity of pressure ulcers-and their related treatment costs-decreased for the 6 participants. Maintenance of effects postintervention was highly variable, with only 3 participants showing long-term improvements. In study 2, for 2 participants, visits alone did not reduce pressure ulcer severity, but visits plus payments did effectively reduce ulcer severity, indicating improved prevention behaviors. CONCLUSIONS: Findings support the assumption that pressure ulcers may recur among some individuals because there are insufficient positive consequences for effective prevention.