Effect of Weekly Specialized Surgeon-led Bedside Wound Care Teams on Pressure Ulcer Time-to-heal Outcomes

Results From a National Dataset of Long-Term Care Facilities

Adam W. Levinson, MD, MS; Hugh J. Lavery, MD; Armando P. Santos, MBA; Nayana Parekh, MD, MHA; Frank S. Ciminello, MD, MS; Robert J. Marriott, MD

Disclosures

Wounds. 2019;31(10):257-261. 

In This Article

Abstract and Introduction

Abstract

Introduction: Delayed healing of pressure ulcers (PUs) in long-term care facilities (LTCFs) is associated with increased morbidity and expense.

Objective: The authors hypothesize that guideline-based, weekly coordinated care using specialized wound care surgeon-led bedside teams (SLBTs) may improve PU time-to-heal (TTH) outcomes when compared with usual care (UC).

Materials and Methods: Using a deidentified United States nationwide database, the authors retrospectively compared TTH outcomes of PUs diagnosed in LTCFs treated by either weekly SLBTs or UC. The SLBTs included an external specialized wound care surgeon (with or without a physician assistant and nurse practitioner) collaborating with facility nurses. Usual care was defined as all patient encounters not known to incorporate this team process. Variables assessed included patient age, gender, and comorbidities. The primary outcome measure was TTH; the TTH outcomes then were compared graphically and statistically between groups. Statistical significance was double-sided P < .05.

Results: In 2014, there were 39 459 consecutive PUs treated by UC and 5985 by SLBTs. The 5985 SLBT wounds originated from 3435 patients in 10 states and all geographic regions (mean age, 76.6 years; 55.9% female; 42.8% with hypertension; 23.7% with diabetes). The mean TTH for wounds managed by SLBTs was 47.5 days (median, 21 days) versus 69.0 days (median, 28 days) for wounds managed by UC, corresponding to an absolute TTH decrease of 21.5 days in wounds managed by SLBTs versus UC. Wounds managed by SLBTs also were significantly more likely to heal in less than 28 days (P < .0001).

Conclusions: Pressure ulcers managed by coordinated nursing and weekly SLBTs appear to heal significantly faster than wounds managed by UC. Further studies are required to confirm these hypothesis-generating results.

Introduction

The management of chronic, nonhealing wounds, and specifically pressure ulcers (PUs), in patients in long-term care facilities (LTCFs) is an area of continued research. Delayed or failed healing of these wounds is associated with increased morbidity, sepsis, hospital readmission, and mortality, as well as significant expenditures of time, money, and limited staffing resources.[1–4] A review of death and severe harm incidents reported to the British National Reporting and Learning System[4] found PUs were the most common patient safety incident in 2011 to 2012, accounting for 19% of all reports. In the United States, up to 24% of patients in LCTFs will acquire a PU, with an average cost of as much as $70 000 per ulcer and potential total annual costs of $11 billion.[5] Similarly, the estimated annual cost in the United Kingdom in 2004 was between £1.4 billion and £2.1 billion.[6]

In addition to efforts to decrease incidence, numerous regulatory initiatives have been implemented to improve the outcome of patients with existent PUs in LTCFs.[1,4,7–9] However, it remains unclear precisely which factors most affect PU time-to-heal (TTH) outcomes.[5] Further, although increased physician or surgeon involvement has been encouraged,[10,11] it remains unclear if additional direct bedside management of PUs in LTCFs by a surgeon is beneficial to patient or ulcer outcomes. Many LTCFs have medical directors or staff who are not surgically trained and thus may be uncomfortable or unable to immediately surgically debride these wounds at the bedside during regular rounds. In this article, the authors sought to determine whether guideline-based,[1,2,4,7,9] weekly coordinated care between facility nursing staff and specialized wound care surgeon-led bedside teams (SLBTs) might improve PU TTH outcomes when compared with usual care (UC).

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