Enhancement In Treatment Of Patients With Pressure Ulcers: A Quality Improvement Initiative And Review
Author Block: Ping Song, MD, Joyee Tseng, BS, MS, Sydney Davis, BS, Andrew Li, MD, Michael Wong, MD. UC Davis, Sacramento, CA, USA.
Accepted to present at the California Society of Plastic Surgeons Conference
Purpose: Quality improvement of pressure ulcer management has been extensively examined in several specialties and settings. However it has yet to be studied from a plastic surgery perspective, specifically on encounters via the Emergency Department(ED). The aim of this paper is to describe our institution’s multidisciplinary experience, led by our plastic surgery service, with a pilot study to streamline care for patients presenting in the ED with a pressure ulcer.
Methods: Authors retrospectively identified patients who presented to the UC Davis ED with a pressure ulcer and seen by the Plastic and Reconstructive Surgery (PRS) team from June 2016 to May 2017 (n=36). Patient characteristics were defined using summary statistics and their SIRS criteria analyzed. A novel algorithm for workup of pressure ulcer patients that included a urinary analysis (UA) to be ordered if two or more SIRS criteria was present before a PRS consult was implemented in the ED starting June 2017. A second retrospective review of this prospectively maintained database was performed between June 2017 to March 2020. Summary statistics and a descriptive analysis was conducted to examine the effect of the new algorithm.
Results: From June 2016 to May 2017, 50% of pressure ulcer consults (18/36) had two or more SIRS criteria at initial PRS consultation. Of these SIRS positive patients, 50% (n=9) had a diagnosis of urinary tract infection or urosepsis treated subsequent to PRS consultation. After implementation of our ED algorithm, there was an 87.75% reduction in total pressure ulcer consults per month. Only 6 (24%) patients met SIRS criteria at time of consultation, and 50% of all patients had a UA test ordered and treated appropriately, prior PRS consultation. Conclusions: Our multidisciplinary approach regarding the evaluation and treatment of patients presenting to the ED with concomitant pressure ulcers resulted in significant changes to how this vulnerable patient population receive care. The development of our management algorithm was based on a review of our institution’s historical practice patterns. We found that our multidisciplinary approach resulted in significant improvements on several metrics in streamlining the care of patients seen in the ED who carry a diagnosis of pressure ulcers. Our experience can benefit all providers who care for this challenging patient population.
Factors influencing healthcare utilization following major head and neck oncologic surgery in the elderly
Accepted to present at the AHNS 10th International Conference on Head and Neck Cancer
Often, patients that present with head and neck squamous cell carcinoma (HNSCC) are in the seventh decade of life with various comorbidities that are linked to heavy tobacco and alcohol abuse. The incidence of newly diagnosed HNSCC in the elderly is expected to increase by more than 60% by the year 2030. Optimizing postoperative care is vital for patients as they recover from major head and neck surgery to avoid complications, minimize hospital readmissions, and decrease healthcare expenditure. To our knowledge, there are no studies that investigate healthcare utilization in the elderly after major head and neck surgery. The aim of this study is to identify patient factors associated with increased postoperative healthcare use in the first year after surgery.
Patients 60 years or older with HNSCC of the aerodigestive system who underwent ablative head and neck surgery with at least a neck dissection with or without a free flap reconstruction between 2009-2019 at a single tertiary care center were retrospectively analyzed. Data collected included patient demographics, preoperative comorbidity scores, social variables, and perioperative risk factors. Fisher’s exact or Chi-square tests were used to identify risk factors which increased healthcare utilization, which included number of emergency department (ED) visits, hospital readmissions, otolaryngology clinic appointments (including surveillance), and telephone encounters related to their head and neck treatment in the first year after surgery.
Of 135 patients, the mean age was 70.6 +/− 7.2 years (range, 60-89), mean LOS was 8.61+/−7.92 (range, 1-56), 33.8% underwent a laryngectomy, 32.3% underwent free flap reconstruction, and 33.9% had no free flap reconstruction or laryngectomy. Overall, there were 37 (21.8%) patients with at least one ED visit without hospitalization, 69 that were readmitted (40.6%). There was a mean of 6.0+/− 3.7 otolaryngology clinic visits and 2.4 +/−2.2 telephone encounters. The presence of a gastric tube at discharge was associated with an increased number of ED visits (p=0.028), readmissions (p=0.004), and phone encounters (p=0.006). Patients who lived 12.5 to 49.9 miles from our institution had higher ED visits (p=0.043), while patients that lived <12.5 miles had more clinic appointment visits (p=0.047). Age, living situation, marital status, type of surgery, comorbidity indexes, presence of tracheostomy at discharge, skilled nursing facility placement, and postoperative adjuvant therapy were not significant in any healthcare utilization outcome.
Postoperative healthcare utilization for elderly patients that undergo major head and neck cancer surgery for HNSCC is not uncommon. Gastric tube presence at the time of discharge and distance living from hospital of initial surgery were significantly associated with healthcare utilization in the elderly patient population. Age and the type of surgery rendered - whether that that was a laryngectomy or a free flap reconstruction - were not significant factors. Healthcare teams should identify patients at risk for increased postoperative morbidity to lessen the burden on patients and their families.
Lee A.Q., Ijiri M., Rodriguez R., et al. Novel patient metastatic pleural effusion-derived xenograft model of renal medullary carcinoma demonstrates therapeutic efficacy of Sunitinib. Front Oncol (2021). https://doi.org/10.3389/fonc.2021.648097
Abstract submitted to the annual American Society of Hematology Meeting and Exposition
Research proposal: "Evaluating the impact of social determinants of health on morbidity and mortality of pregnant women with sickle cell disease in California"