May 12, 2017
Management of stages 3 and 4 pressure ulcers remains a difficult problem. Reported recurrence rates of 12 to 82 percent indicate that this problem has not been sufficiently addressed. No standard protocol exists for perioperative surgical assessment and management.
Prolonged hospitalizations and high recurrence rates in patients with pressure ulcers are associated with increased medical expenses. Average hospital length of stay (LOS) in these patients ranges from one to 38 weeks, and secondary comorbidities such as malnutrition, uncontrolled diabetes, bone infections, and cardiac or respiratory compromise can increase LOS even further. Given these statistics, care providers from Physical Medicine and Rehabilitation, Nursing, and Plastic Surgery at Mayo Clinic's campus in Rochester, Minnesota, recently tested the impact of using a collaborative care model with patients diagnosed with stages 3 and 4 pressure ulcers with referral for surgical intervention.
Clinical objectives and team
A team led by occupational therapist Darcy R. Erickson, O.T., MAOL, ATP, and clinical nurse specialists Jody K. Leise, APRN, CNS, M.S., and Therese M. Jacobson, APRN, CNS, D.N.P., developed a comprehensive standardized interdisciplinary pathway designed to minimize preoperative and postoperative risk factors for pressure ulcers. The team's primary goals were to reduce acute care hospital LOS and improve post-surgical outcomes. The team also included physician assistant Jessica L. Widmer, P.A.-C., and was championed by Steven L. Moran, M.D., chair of Plastic and Reconstructive Surgery.
This interdisciplinary quality improvement project involved 110 patients diagnosed with stage 3 or 4 pressure ulcers, the majority of which also had a neurologic diagnosis such as spinal cord injury. The interdisciplinary team created and used standardized preoperative, perioperative and post-acute pathways to address management of multiple care needs along the continuum.
Key elements of the preoperative pathway included interdisciplinary assessments. Four consults, performed primarily in the outpatient setting, aimed to optimize the patient before surgery to prevent postoperative complications or discharge issues. Preoperative consults were performed by:
- PM&R providers to address bowel/bladder function, spasticity and/or pain management
- Occupational or physical therapists from the seating clinic for equipment recommendations, activities of daily living, transfers and rehabilitation plans
- Dietitians and endocrine providers to address nutrition recommendations and diabetes management
- Social workers to address insurance benefits, discharge planning and post-surgical support needs
Acute hospital perioperative care included several key elements:
- Use of fluid or air immersion specialty mattress or bed immediately post-op and throughout hospital stay
- Use of 30-degree maximum head of bed elevation during meals, or if respiratory issues are a concern
- Access to hospital-based clinical nurse specialist as resource for specialty beds, transfer pads, photography and skin concerns
- Transport to post-acute care between days 7 and 10
- Confirmation of pre-op plan and facilitation of transport to next facility by hospital-based social worker
The post-acute care pathway included bed rest until day 21, stretching and other activities to prepare patients for sitting, at-home rehabilitation after follow-up with plastic surgery or physical medicine and Seating Clinic providers, and telehealth visits to assess readiness for sitting protocol.
Project results and learnings
Erickson's team collected and analyzed data from retrospective chart review of 110 patients who had flap surgery between 2011 and 2014 and who completed no preoperative consults (pre-intervention group) and 28 patients who participated in pathway and/or had surgery between 2014 and 2015 (post-intervention group). The post-intervention group included two patients who had no surgery and no hospitalization and six patients who had no surgery. Key findings included:
- 46 percent of post-intervention patients (N = 13) completed all four of the preoperative consults
- Average acute care hospital LOS: 33.05 days for pre-intervention patients; 10.72 days for 13 patients who completed all four preoperative consults; 17.62-day average for 26 post-intervention patients
- Acute (30-day) hospital readmission rate: 12.7 percent for pre-intervention patients; 4.5 percent for post-intervention patients completing all four preoperative consults; 13.63 percent average for 22 post-intervention patients (surgical cases)
- Average costs associated with the acute hospital stay after surgery decreased by 28 percent when compared to baseline data
"Overall, patients who completed all four of the recommended pre-surgical consultations, with emphasis on preoperative optimization of causative risk factors for pressure ulcers, achieved better outcomes on all quality metrics measured," says Erickson.