Optimizing Outcomes In The Management Of Stage III And IV Pressure Ulcers
Krishna S. Vyas, MD, PhD, MHS1, Humza Saleem, MD2, Charat Thongprayoon, MD1, Steven L. Moran, MD1.
1Mayo Clinic, Rochester, MN, USA, 2Mayo Clinic, Jacksonville, FL, USA.
PURPOSE: Management of stage III and IV pressure ulcers remains a difficult problem with reported recurrence rates of 12 to 82%. Our goal was to develop and to implement a multidisciplinary pressure ulcer pathway to improve outcomes.
METHODS: We retrospectively reviewed spinal cord injury patients assessed for a stage III & IV pressure ulcer of the ischial tuberosity, trochanter or sacrum. Data was collected on 160 patients post-pathway (2014 to 2018) and 168 pre-pathway for internal control (2010 to 2014).
Patients completed 5 consultations: Medicine (for comorbidities/medications); Physical Medicine (for bowel/bladder/spasticity); Seating (for equipment/transfers/rehabilitation); Dietetics (for nutritional optimization); Social Work (for insurance/discharge planning)
RESULTS: 208 candidates were deferred from surgery due to ongoing medical risks (Table 1). 38 patients underwent flap reconstruction. Implementation of the pathway decreased inpatient stay from 26 days to 8 days (p<0.001), transitional facility stay from 31 to 19 days (p<0.04), 30-day readmission rate from 21% to 3% (p<0.001), and 2-year flap failure rate from 17% to 5% (<0.04) (Table 2).
CONCLUSIONS: Patients who completed the recommended pathway consultations with emphasis on optimization of risk factors achieved better outcomes on all metrics. Surgery should be reserved for those who are medically optimized to avoid complications. 
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