05/06/2013 // Concord, CA, USA // LifeCare123 // Greg Vigna, MD, JD // (press release)
LifeCare123.com Medical Perspective: Pressure ulcers, also called decubitus ulcers, is a serious and catastrophic complication in the chronically disabled that has serious consequences such as chronic infections, life threatening sepsis, malnutrition, depression, loss of independence, amputation, depression, psychosis, loss of independence, and potentially death. Risk factors include conditions such as stroke, spinal cord injury, traumatic brain injury, and serious orthopedic trauma.
Comprehensive management of deep ulcerations (Grade 3 and Grade 4 decubitus ulcers) that extend into muscle and to bone often requires hospitalizations between four and twelve weeks, long-term IV antibiotic therapy, intensive nutritional support, input from physicians from multiple specialties, and multiple surgical procedures including debridement (removal of nonviable tissue) and myocutaneous flaps that close the wound. Cost associated with myocutaneous flap closure of the Grade 3 and Grade 4 decubitus ulcers cost between forty and one hundred thousand dollars.
Routine post-flap management requires strict bed rest ranging from three to six weeks with as little movement on the bed as possible to prevent shear and tension on the post-operative flap on a clinitron bed that is a high tech ‘air-fluidized’ bed with air pumped into a sand filled bed that decreases all meaningful pressure on the person lying on the bed. This bed essentially allows a person to lie in one spot without causing a new pressure sore. Patients are required to lie like a board on a clinitron bed, have all bowel movements in bed, and basically lay looking at the ceiling for three to six weeks. It is not unusual for patients to get acutely psychotic post-operatively from a lack of environmental stimulation causing a condition of clinitron bed psychosis.
Pre-flap management is nearly equally as miserable compared to post-flap management. These patients often present to the hospital clinically ill from symptomatic infection, malnourished, and depressed from loss of independence required because of the disabling condition that lead to the ulcer as well as non-surgical management restricting sitting and activity that patients often attempt prior to surgical intervention in attempts to avoid surgery.
Cost of hospital rental for a clinitron bed is significant (between $80-$120 per day) and often produces what hospital administrators believe is staggering and unjustified cost. A small study comparing post-operative myocutaneous flap outcomes and tissue pressures in patients with spinal cord injuries in two groups one of which used the standard clinitron bed and one that used a type of air mattress called a dry-floatation mattress that was 1/3 the cost of the clinitron bed. The small study revealed that the outcomes following flap surgeries were similar between the two groups despite measurements that indicated that there was increased tissue pressures at the flap in the air mattress group.
My opinion regarding this study is based on nearly three decades of management of post-flap patients with a variety of disabling conditions. There is nothing worse and as demoralizing for a patient to have a failed flap which I classify as a meaningful wound after 6 weeks that interferes with sitting and independent function that requires ongoing medical care. From my experience flaps fail in 10-20 percent of patients despite state of the art medical care, perfect surgical technique with minimal tension on the surgical margins, optimization of the pre-surgical wound, and optimizing nutrition prior to surgery. There is no justification for a hospital to limit the use of clinitron beds in a post-surgical flap patient. Individual facilities cannot claim that their flap outcomes with low tech dry-floatation are as good as they were when using clinitron beds since there is no way to compare the two in such a diverse patient population. Patients on a low-tech dry-floatation bed need to be turned. This leads to tension, shear, and unjustified increased tissue pressure that may jeopardize the flap leading to the dreaded failed flap.
Patients, providers, and families expend great effort in attempting closure of Grade 3 and Grade 4 decubitus ulcers. Patients die, become progressively debilitated, suffer a loss independence, and become progressively depressed directly because of decubitus ulcers. All necessary and appropriate care must be utilized for these patients, and that would include the use of clinitron beds after flap closure. Cost cutting and the rationing of state of the art medical care should not compromise this unfortunate population and all attempts must be made to obtain a successful flap outcome. The prospect of using less expensive beds that have inferior pressure relieving capabilities is a repulsive idea that is the result of unjustified rationing of medical services brought on by aggressive hospital administers trying to save cost and the expense of patients who suffer from chronically disabling conditions.
Life Care Planner Perspective of Life Care Solutions Group’s Dr Greg Vigna:
A properly constructed life care plan will serve as a guide to future medical, rehabilitation, and day to day needs of a catastrophically injured patient. A life care planner is a medical professional with experience in the case management of catastrophically injured patients. Further, a life care planner, as a expert in case management, should be able to research the facilities that offer the state of the art wound care to optimize wound healing in an unfortunate patient with this preventable complication. A wound care center that doesn’t offer clinitron bed management following flap surgery may be more interested in profits than delivering the best medical care. Further, life care planning involves evaluating and recommending all care necessary to prevent this type of complication going forward as a patient ages which would include equipment evaluations, physical therapy, aid and attendant care, and wheel chair and wheel chair accessories needs.
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