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

Outcomes and Findings

Bardia Anvar, MD; Henry Okonkwo, PA-C


Wounds. 2017;29(7):215-221. 

In This Article

Materials and Methods

A retrospective chart review was performed on patients with PIs in the SSCIT region in the Skilled Wound Care practice (Los Angeles, CA) during the year 2011. These patients were evaluated and managed by providers of the Skilled Wound Care Surgical Group over the 12-month period. The providers in this group are both surgeons and surgical physician assistants who provided these visits and procedures. At the time of this study, these patients were all treated and cared for while at the nursing facility or skilled nursing facility. Patients in more than 100 different nursing homes were examined. In addition, 2128 electronic health records (maintained in a SQL Server database [Microsoft Corporation, Redmond, WA]) of patients that were identified to have at least 1 wound located in the SSCIT region, regardless of stage or procedure rendered, were reviewed. The results of the query were then imported into FileMaker software (Santa Clara, CA) to examine important patterns and relations. The study population was refined from a patient population of 2128 with SSCIT wounds to 227 patients who were visited 8 or more times during stays in nursing home settings and were found to have a PI(s) located in the SSCIT region.

The indication for debridement of wounds was the occurrence or presence of necrosis, slough, or necrotic bioburden in the wound. Bioburden was identified as a thin irregular film on the surface of the wound that could not be removed with irrigation; adequate removal was identified by visible bleeding in the wound bed. Bedside debridement was performed on patients using a sharp excisional approach down to and including the level of skin, subcutaneous, muscle, and/or bone tissue depending on the level of injury. Written informed consent was obtained from patients, family members, responsible parties, or conservators depending on the patient's ability to consent. Pain control was managed by preprocedural oral narcotics and 20% benzocaine anesthetic to topically anesthetize the wounded area and for patient comfort. The procedures were carried out while the patients remained in their nursing home bed, and the patients were turned to the appropriate position to expose the wound. Depending on the condition of the wound and the provider's judgment, the wounds were either cleansed with normal saline or betadine prior to debridement. The use of normal saline as a surgical preparation technique is not the standard of care in wound preparation prior to bedside surgical debridement. For the providers in this study, their decision not to use antiseptic agents in all debridement procedures was based on individual clinical judgment, extensive nature of the wound, and risk/benefit of betadine to allow for wound healing.[11]

Debridement was carried out with either sterile disposable 5-mm curette or scalpel along with other usual instruments. Patients on active anticoagulation did not receive debridements of any kind in the investigators' practice, and they were excluded from this study. Dissectional debridements were carried out to the plane of tissue that demonstrated visible active bleeding. Hemostasis was obtained with either direct pressure to the wound bed or the application of chemical cautery with silver nitrate. There were no incidents of post procedure wound hemorrhage. At the conclusion of the procedure, dressing choice was dependent on practitioner judgment. Dressing changes were conducted once daily in the nursing facility until the wound epithelialized. Instructions and dressing orders were given to the treatment nurse at the conclusion of the bedside procedure. Figures 1 and 2 show a representative sample of the type of bedside debridement performed.

Figure 1.

Sacrum and right ischium pressure injuries predebridement.

Figure 2.

Sacrum and right ischium pressure injuries postdebridement.

Management of the 319 individual wound sites met specific requirements that included (1) sharp excisional debridement of devitalized tissue, including slough, necrotic tissue, and bioburden at least once during the care process; (2) daily dressing changes and wound care by a trained nursing home licensed vocational nurse (LVN) or registered nurse (RN); and (3) use of a pressure-reducing specialty mattress.

Assessment of wound status was established via weekly wound measurement and physical examination by a licensed surgeon or physician assistant and a treatment nurse (LVN or RN) at the nursing home. All measurements were recorded in centimeters as Length x Width x Depth.