Undergraduate Research in Assistive Technology: Design and Development of a Preventive Weight Shifting App to Reduce the Risk of Pressure Ulcers in Wheelchair Bound Patients With Spinal Cord Injuries (Phase 1)1

A pressure sore or ulcer is caused due to pressure that is exerted on the patient support interfaces for an extended period of time. Persistent pressure reduces blood flow to the area of interfaces causing the skin to breakdown. Two variables that play a critical role in the development of pressure ulcers are the presence of acute pressure for a prolonged period of time [1,2].Approximately 5–30% of all hospitalized patients develop pressure ulcers depending on their condition [3]; 28.9% patients in communities and 27% in nursing homes develop pressure ulcers [2]. It is most common among patients with spinal cord injuries or elderly patients with physical disabilities. Seventy percent of all pressure ulcers are among the elderly [4]. Pressure ulcers cause discomfort, pain, and reduced mobility leading to loss of independence in addition to various medical complications such as hospitalizations, risks of infections, morbidity, mortality, and isolation due to the odor that emanates from the ulcer site. Pressure ulcers cause a significant increase in healthcare management and costs [2,3,5].In a study conducted by Brienza et al. [5] wheelchair bound patients from nursing home were given a skin protectant or a segmented foam cushion. It was observed that the incidence of pressure ulcers was lower in patients who were given skin protection or cushions. Thus, shifting weight or positions iteratively as a means to reduce pressure on the areas of interface will increase blood flow to the tissue under pressure. Hence, frequent repositioning or weight shifting has a potential to reduce the incidence of pressure ulcers [2]. Several studies have suggested frequent redistribution of weight or repositioning as a preventive care in the reduction of pressure ulcers [5]. Incessant release of pressure every 15–30 min, by shifting or titling, moving out of the wheelchair and into bed every few hours is essential to avoid decubitus ulcers [2,7]. Patients bound to wheelchair after spinal cord injuries have less sensation and are likely to forget to perform weight shifting [6]. To remind a patient to shift weight frequently, a mobile app was developed.An undergraduate student developed an app to prevent pressure ulcers. The iOS platform was used for the development of the app for mobile devices. The app was programed in Objective-C and iOS with Xcode as the integrated development environment. The purpose of this project is to help wheelchair bound patients with spinal cord injuries, perform exercises such as weight shifting and tilting to prevent pressure sores. The app not only provides notifications and reminders every 15, 30, 45, and 60 min to perform weight shifting but also tracks the time the patient has spent in wheelchair and recommends frequent moving out from wheelchair into a bed to relieve pressure on the patient support interfaces. The app uses the accelerometer to track the movement of the patient during the weight shifting exercise. This data is stored in the cloud to be analyzed. The app is capable of collecting data such as total time spent doing exercises and the total number of exercises that the patient performed. This data will be used for further research by the therapists and also for evidence-based practice to improve the quality of care (Fig.1).The app has the following features:The app is designed to reduce the incidence of pressure ulcers. The design includes: an educational component that provides information on the causes, and prevention of pressure ulcers. It also helps the patient perform periodic skin inspections by providing step-by-step instructions with pictures to spot early signs of tissue breakdown. The range of motion during weight shifting and titling is tracked using an accelerometer. The app is designed to walk the patient through the steps of weight shifting and titling. Therapists or the caregivers can set up the frequency of weight shifting by setting notifications and reminders. In addition, every few hours the patient is notified to get out of the wheelchair to relieve pressure by recording and calculating the hours spent in the wheelchair.The app has a data collection mechanism that records frequency, duration, range of motion in the position changes, and the skin condition. This data can be analyzed and used for future recommendations to patients based on the evidence collected from the app to prevent ulcers. Patient engagement is encouraged by the app feature that can send the therapist any feedback or ask questions via email or phone creating a channel of communication between the patient and therapist.Phase 1 of the project is the design and development of the app. Phase 2 of the project is the implementation phase where volunteer patients will use the app and the data collected will be used for evidence-based practice of weight shifting to improve the quality of care by preventing decubitus ulcers. The data will be analyzed for recovery patterns in correlation to the weight shifting duration and frequency. The app was installed on an iPod and given to the therapists for testing. The therapists' reports were positive. Feedback from the therapists was taken to improve the app. The app implementation phase will start in Spring 2016 after the Institutional Review Boards (IRBs) have been approved. This is an effective way to proactively prevent pressure ulcers. The mobile device will hang from the wheelchair users neck or sit in the shirt pocket to give the wheel chair user free access to their hands so it does not interfere with their daily routine.The study also introduced the student to the possibilities of using technology to improve the quality of healthcare. The student observed that the project gave him a better understanding of the benefits of the app.