Background: 

Management of stage III and IV pressure ulcers remains a difficult problem with reported recurrence rates of 12 to 82%. Screening spinal cord injury patients prior to pressure ulcer flap surgery provides the opportunity to determine and to address individual risk factors that may impact healing and pressure ulcer recurrence. We designed and operationalized a standardized screening pathway to measured the impact on 30-day hospital readmission and length of hospital stay (Figure 1). 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:

Outcomes included readmission rates, length of stay (LOS) and flap failure rates. 

Results: 

208 candidates were deferred from surgery due to ongoing medical risks such as smoking or uncontrolled diabetes (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.