Thursday, February 21, 2008
Bedsores and surgery - an exercise in futility?
A little blurb in today's New York Times "Fighting Bedsores With a Team Approach" got me thinking about pressure sores
In the Plastic Surgery and wound care literature there are literally thousands of papers published re. to the surgical treatment of pressure sores ulcers. Many very elegant operations where soft tissue and muscle flaps are rotated to cover these wounds have been described.
These ulcers add an estimated burden nearly $10 Billion USD of expenditures and an additional 2.2 million Medicare hospital days to the United States healthcare system. The cost of treatment of large ulcers can approach nearly $50,000, depending on the stage of development. For reconstructive surgery candidates, costs might be an additional $25,000+ per patient in surgical charges. The actual costs of preventing and treating pressure ulcers in hospitals are not easy to figure as costs are distributed across many providers and settings for nursing and clinical care, but the likely overall costs are stunning, with perhaps 5% or more of our total healthcare costs attributable in some way to patient care involved with these wounds.
What's the dirty secret about these wounds?
Almost all approaches besides letting these wounds heal by scarring (secondary intention) have abysmal track records. Data from medicare patients and from the VAMC have suggested that in excess of 90% of these reoccur within a year. When you consider the tremendous expense of these surgeries and post-operative convalescence, you have to wonder why we've treated these the way we have. Increasingly, you're seeing more plastic surgeons no longer attempt such aggressive closures which is evidence-based medicine at work.
If you are going to try to close these wounds, you've got to pick your spots. The only people I consider good candidates for closure are high functioning young paraplegics and older patients who have a reversible condition that led to the ulcer (ie. a hip fracture). A patient who can't relieve pressure themselves is an absolute contraindication in most instances to me.
As developing pressure sores are one of the indicators of quality that hospitals are being penalized for by the feds, we're seeing alot more of these documented. Many of these patients are nursing home medicare beneficiaries who bring with them multiple medical comorbidities, thin skin, immobility, incontinence, and nutritional problems. It is literally impossible to prevent breakdowns over bony areas and that shouldn't be the goal. We should try to prevent them from progressing to advanced stages for pragmatic care of these patients.
Lawsuits over pressure sores are a growth industry for the trial lawyers. Frequently when you talk to patients' families, they have poor understanding of the how's and why's of why these wounds develop which contributes to their anger sometimes and leads to them suing the nursing home or hospital. I try to explain it in simple terms with the concept that it is unrealistic in vulnerable patients to prevent pressure sores indefinitely as it is impossible to deliver perfect nursing care 24/7/365. Breakdowns are inevitable and should be expected, and the goal should be to minimize the damage.