04/15/2013 // Concord, CA, USA // LifeCare123 // Greg A. Vigna M.D., J.D. // (press release)
The management of patients with deep Grade III and Grade IV Decubitus Ulcers requires a facility that can deliver a coordinated effort from allied health professionals and physicians from multiple specialties to best manage the treatment of patients with these diagnoses. It is this author’s opinion these patients are often too complex and receive care at facilities that are simply incapable of providing the care that patients need. Many facilities are simply not capable of delivering the scope of services necessary because of the lack of physician skill or support or suffer from the lack of coordination of care by allied health providers. Facilities that are caring for patients with these diagnoses without offering the coordinated multidisciplinary approach to decubitus management that will be discussed below may be in fact causing more harm than good by over utilizing antibiotics which is giving rise to resistant bacteria and exposing patients to ineffective treatments and surgeries. Not to mention a study that found the average patient with deep Grade III or Grade IV Decubitus has dissipated $120,000 spread out over four hospitalizations, while not improving the patient’s quality of life or outcome.
I will be presenting what I believe is the minimum services that are essential for the care of a patient with deep Grade III and Grade IV Decubitus Ulcers from the experience I gained during my residency at Baylor in Houston in Physical Medicine and Rehabilitation and a wound care program that I have coordinated in Northern Louisiana at a Long Term Acute Hospital for the past 12 years, understanding that a minority of decubitus ulcers require myocutaneous flap closure, states Greg Vigna M.D., J.D.
The most important aspect of a wound care program is clearly the plastic surgeon in my opinion. It has been my experience that there are simply some wounds that are best served by operative management by way of myocutaneous flap. A lack of a plastic surgeon or another physician trained in flaps that would lead the patient down the wrong path to a treatment that may not offer the best odds of success. Patients should think twice about admission to a facility that does not offer these services because simply the options are limited.
There must be one physician overseeing the patient’s medical issues and rehabilitation. The medical issues are more often than not significant since patients with deep Grade III or IV decubitus ulcers are chronically ill. Patients must be maximized nutritionally and will require a licensed dietician working with physicians to maximize nutrition to support healing. Interventions will include calorie count, oral supplements, nutrition by vein, and feeding tubes that all of which will be necessary at some point when managing patients with decubitus ulcers. Simply malnourished patients will not heal. Speech therapy is necessary to evaluate and treat swallowing dysfunction that may interfere with proper nutrition.
Infectious disease issues are significant issues and these patients are after infected or colonized with very resistant bacteria such as psuedomonas or acintobacter because of repeated, ineffective prior hospitalizations. The hospital must have strict enforcement of isolation of patients with resistant organisms to prevent cross contamination of patients. Prolonged IV antibiotics based on tissue cultures and bone cultures are necessary to treat bone infections and complex soft tissue infections since infected wounds will not heal. IV antibiotics must be used around the time of closure of a decubitus ulcer for a duration depending on the depth and involvement of bone. Orthopaedic surgeons may be required to assist with the plastic surgeon in surgery to provide more aggressive intraoperative care which may include removal of dead bone, placement of antibiotic beads into adjacent bone, and removal of infected underlying hardware. General surgeons are needed for the more complex bedside debridements or intraoperative debridement of infected or dirty wounds prior to flap closure. Internal medicine is needed to handle the complexities of multiple medical diagnoses involving multiple organ systems. Diabetes must be managed appropriately because elevated blood sugars will interfere with wound healing. A hematologist has been useful on the rare occasion that there is unexplained bleeding postoperatively despite normal preoperative testing. There are new treatments such as Factor Seven which has stopped prolonged bleeding following a debridement despite normal bleeding studies prior to surgery.
Physiatrists are often instrumental in the care of these patients because they are trained in determining psychosocial aspects of the patient that led to the ulcer, trained in the preoperative and postoperative care of these patients, and trained in managing patients with disabilities that predispose patients to the formation of decubitus ulcers such as spinal cord patients and brain injured patients. Physiatrists provide spasticity management and treatment of joint contractures that will predispose patients to decubitus ulcers. A physiatrist in the preoperative phase of treatment should be able to identify those patients that will likely have difficulty with being compliant with postoperative care to prevent flap failure.
Beside dieticians there are numerous allied health providers necessary for the care of these patients. Nurses must be knowledgeable and trained in the post-opetative care of these patients. They must be diligent to strip the drains, position the patient correctly, and be able to identify complications such as postoperative hematomas that may compromise a flap. Wound care nurses must be familiar with the specialty beds necessary for the management of wound patients and the indications when an air mattress is appropriate and the occasions a clinitron bed is necessary. They must be familiar with the numerous wound care products in the market and their indications of use. Physical therapists and occupational therapists are essential for a patient’s success and ongoing health maintenance. They must understand post-operative management of patients, including the timing and duration of sitting after a flap, indications to decrease sitting duration, and the proper joints to range after flap closure. Physical therapists and occupational therapists must re-educate patients on proper pressure relief techniques for prevention of reoccurrence and evaluate equipment such as cushions.
It has been my observation from over 12 years of managing complex wounds in private practice that patients who have been referred to our facility have often been through futile attempts of conservative efforts over a period of months, undergone numerous hospitalizations, been on prolonged bed rest, which has led to depression, profound malnutrition, and chronic infections. These patients have often been in multiple facilities none of which had the capability to comprehensively manage their diagnosis. Finally by the time they get to our facility they have now been colonized or infected with difficult to treat bacteria that requires toxic antibiotics to treat and more extensive invasive surgical management had they been referred earlier. It is my opinion that both the payor source (government and insurance) and patients must be informed consumers of the best facility that has the services necessary to manage these diagnoses to decrease morbity, mortality, and cost for these patients.
Life Care Planner Perspective:
A life care plan should include all medically necessary and appropriate care that will prevent complications, improve outcomes, and improve the psychosocial aspects of a catastrophic patient’s life. This plan should include therapy, wheel chairs and their replacement, routine medical treatments such as spasticity management, and aggressive medical treatments that are required in the future. A life care plan should include all medical care, equipment, and aid and attendant needs of a patient and be able to accurately predict changes in these needs as a patient ages to prevent complications such as decubitus ulcers. A life care planner is often a physiatrist and will be trained in the treatment of decubitus ulcers and should be an excellent resource to both the patient and providers to recommend a center of excellence for wound healing with the scope of services discussed above.
Lawyer Perspective:
It is simply unacceptable for a client to develop a decubitus ulcer while under the care of a health care provider. In fact the National Quality Forum of the United States has identified Grade III and Grade IV Decubitus Ulcers as ‘never events which are inexcusable actions in a health care setting, the “kind of mistake that should never happen.” With this strong policy statement for the government there should be ample evidence for knowledgeable Concord serious injury attorneys to prove a breach in the standard of care that would support monitory damages for past medical costs related to treatment of the decubitus ulcer, costs related to prevention of reoccurrence, damages for pain and suffering and disfigurement, and this would support a cause of action for wrongful death.
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