Serial Surgical Debridement of Common Pressure Injuries in the Nursing Home Setting

Outcomes and Findings

Bardia Anvar, MD; Henry Okonkwo, PA-C

Disclosures

Wounds. 2017;29(7):215-221. 

In This Article

Abstract and Introduction

Abstract

Objective. This study examined the efficacy of bedside surgical debridement in a nursing home population.

Materials and Methods. A retrospective chart review was performed of sacrum, sacrococcyx, coccyx, ischium, and trochanter (SSCIT) region pressure injuries in the Skilled Wound Care practice (Los Angeles, CA). The patient population was refined from 2128 to 227 patients visited 8 or more times during nursing home stays found to have 1 or more SSCIT pressure injuries. Of the 227 patients, there were approximately 319 individual SSCIT wounds, with an average of 1.4 SSCIT wounds per patient. Bedside surgical debridement was performed using a sharp excisional technique on 190 of 319 (59.5%) SSCIT wounds.

Results. An analysis of the square surface area of the 190 debrided wound sites revealed a mean ulcer surface area of 20.76 cm2. Of those 190 wound sites, 138 (73%) had a reduction in square surface area, and 52 (27%) had no change or an increase in square surface area and were categorized as nonresponders. Of the wounds that did improve by a reduction in wound surface area, the average wound surface area reduction was 6.81 cm2 at 4 weeks (25%), 8.91 cm2 reduction at 8 weeks (33%), and 10.87 cm2 reduction at 12 weeks (40%). From the 190 wound sites, there were a total of 43 (23%) wounds that had a square surface area of 0 (reepithelialized), which has a healing rate of 23%.

Conclusion. Traditional bedside debridement provides excellent results in reducing the square surface area for a majority of wounds. Whether used alone or as an adjunct to any treatment plan, the use of surgical sharp equipment aids in achieving good wound healing and advancing the rate of wound closure. Although wound healing requires many components, sharp debridement can effectively remove devitalized tissue and is a proven significant component to advancing wound closure.

Introduction

Pressure injuries (PIs) are a common and important problem among patients in the nursing home population. Pressure injury occurrence in the nursing home population has both a high incidence and prevalence, and a vast array of management options exist to heal and curtail these wounds. A National Center for Health Statistics Data Brief[1] showed that of the 1.5 million US nursing home residents in 2004, about 159 000 (11%) had PIs of any stage. Of those residents with a stage 2 PI or higher, only 35% received wound care services by specially trained professionals or staff.[1] This suggests that a minority of nursing home residents with stage 2–4 PIs received wound care in accordance with the clinical practice guidelines in 2004.[2]

Pressure injuries occur as a result of continuous pressure in areas of bony prominences across an individual's body. These ulcers are more commonly found in patients with certain risk factors or diagnoses that are contributory to their development. Pressure injuries are defined by the National Pressure Ulcer Advisory Panel-European Pressure Ulcer Advisory Panel as "a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear"[2] — the key words are boney prominence.

For patients, PIs can have a hefty cost. They have been shown to have a mean pain intensity corresponding to moderate pain.[3] This pain is usually controlled in the nursing home setting with oral pain medications, but the discomfort of having a PI is significant.[4] In addition, patients live with the deforming injury, on some occasions foul odor, and potentially restricted activities. The presence of a PI increases a nurse's workload by 50% for the patient and adds $20 000 to a hospital bill.[5]

Although multiple groups have elucidated methods for the prevention of PIs in the nursing home population, the basic biology underlying chronic wounds and the influence of age-associated changes on wound healing are poorly understood.[6] To the best of the authors' knowledge, there are currently no published studies documenting wound healing rates in the practice of bedside debridement for the nursing home population. Multidisciplinary wound care in nursing homes has been reported to save costs and improve wound healing, even without the use of serial surgical debridements.[7]

There are some wounds, however, that contain significant slough, necrosis, devitalized tissue, infected tissue, and bioburden, which can only be healed with surgical debridement. Although a singular debridement in a hospital operating room may remove a majority of the damaged tissue, frequently there is further breakdown, necessitating ongoing debridement. Debridement is the process of removing tissue from a wound by multiple processes happening over a specific or a continual period of time.[8] The authors' practice has changed the delivery model in the nursing home to provide bedside surgical debridement. However, the question arises as to the efficacy and safety of debridement procedures in the nursing home setting.

Steed et al[9] found that diabetic foot ulcers sharply debrided on a routine basis healed more consistently than ulcers that were not well debrided and maintained. They also demonstrated that 16% of debrided ulcers healed in 20 weeks versus 4.3% of controls. Yet, Steed et al[9] did not examine PIs. Nursing home patients are more regularly confined to bed, have a much greater challenge to wound healing, and may have impediments to reaching centers for wound care, given the high cost. In the authors' experience, they found that prior to their presence as wound care physicians in the nursing facility, the majority of patients with necrotic wounds were managed with chemical enzymatic debriding agents. Surgical debridement removes tissue immediately, whereas enzymatic debridement removes tissue over time. Regular bedside surgical debridement not only removes dead tissue but also friable tissue, necrotic bioburden, and hypergranulation.[10]

Debridement is a time-proven method to prevent wound infection, sepsis, and death. The role of debridement to heal wounds at the bedside in a nursing home setting is yet to be thoroughly examined. This study specifically focuses on the long-term outcome of performing serial surgical debridement in the nursing home patient population who are referred for necrotic PIs confined to the sacrum, sacrococcyx, coccyx, ischium, and trochanter (SSCIT).

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