Surgical Therapy for Complex Pelvic Pressure Ulcers: A Review of Outcomes for Five Consecutive Years and a Proposal for a Navigator in the Care Pathway

Dr. Patrick Ting discusses the background and results of his original research, Surgical Therapy for Complex Pelvic Pressure Injuries: A Review of Outcomes for Five Consecutive Years and a Proposal for a Navigator in the Care Pathway. Additional authors include Glenn E. Herrmann, MD. Read the full article here.

Transcript:

Hi, my name is Patrick Ting. I'm a general surgeon with Kaiser Permanente in Denver, and I'm also the Medical Director of the Wound Care Department here.

My article is a retrospective analysis of five years worth of surgeries in which patients presented with advanced pelvic pressure ulcers. We would put them through a pathway to close the wound and there was an analysis of the outcomes, with a big focus on when the wounds failed and what were the factors that possibly led to the failure and how this might lead to improved quality in the future.

When I first became Medical Director, I was suddenly presented with quite a few patients who had been dealing with these complicated ulcers for years. The Wound Care Department was very dedicated in terms of providing dressing changes and non-operative plan, but a certain percentage just would not heal. I think that is borne out by literature and that a significant portion of people who progress to Stage 3 or Stage 4 ulcers, there are things that happen in the ulcers that will keep it from healing. Either there's biological reasons such as chronic infections, senescence and social reasons, poor offloading at home, having multiple other priorities that keep these wounds from healing. But whatever the reason, there is this cohort of patients who are just stuck there and I want to move them along the pathway.

In our organization, there was some limitations to surgical repair and I wanted to get that program started. So I started making connections with plastic surgeons in the community and came upon the protocol which would bring them through. So the study's analysis of about 33 operations we did on 22 patients from 2015 'till 2019, and I continued to follow their outcomes up until about 2021, and the paper is just a summary of what we found.

Oftentimes, I think what really came out was how important the aftercare of surgery is. We did an operation which was probably not completely typical in the field of surgery. Rather than doing a rotational flap, which most articles do describe, we did operations that were a little bit simpler and something that could be done in the bedside in terms of taking these wounds and bringing them together, oftentimes under a local anesthesia. We found that that was advantageous because it avoided aspects such as anesthesia, requiring long hospitalizations. Even though these operations were simpler, we were still getting, I think, reasonable results. I think the key thing is just what happens afterwards, the quality of the care in the recovery institution, how closely we were in touch with patients, making sure that they had adequate cushions and wheelchairs and that the home situation was set up.

So all of these aftercare issues, we think, were the most critical aspects. When patients developed surgical failures or recurrences, the sense that there was something that went astray in the aftercare. Patients who were very dedicated to taking care of the wounds and had family members were the ones who really seemed to do the best. That's why a big aspect of the article is proposing that there's a navigator within the wound care system who can follow these patients and really assure that they get the aftercare they needed. Because oftentimes, the physician or surgeon has so many other things going on that they're not able to make the phone calls and really pay attention to all these details. So my hope is that this is a call for some action to establish these navigator systems and participants to really optimize what is a real complicated and expensive process.

I think research will be focused on hiring these navigators within systems and then comparing the outcomes to historical outcomes and seeing if there is a difference. I think it will be hard to do, for example, like a randomized controlled study, but there's evidence that navigators work in lots of other complicated patient needs when it comes to medically complex patients, cancer care, Crohn's disease. So it would seem logical that patients with as many needs as those with complex wounds would benefit from these navigators and we can take what we've learned from other navigator systems and project it onto wound care.

My sense is in getting to know and work with these patients that they live very, very challenging lives. Oftentimes, the degree of their medical challenges make them medical orphans. I think some physicians feel very intimidated working with them. The operations can be complicated, and when there are failures or complications that do happen, it is very, very time consuming. And so, I don't think there are a lot of real mature systems that really have been developed to take care of these people. I do hope as time goes on, we can find ways to help these patients live as much of a fulfilling life as possible at home and really extend the amount of time that they can stay out of hospitals. Oftentimes, their lives is, for lack of a better word, a revolving door in which they are repeatedly in the hospital for wound related issues. It's frustrating to many members and oftentimes, there's confusion about what's the right way to take care of these wounds. Do we do dressing changes? Do we debris? Do we do surgery? And if we do surgery, what next?

Hopefully with future research, some of these protocols will be a little bit more clear. I think there's a lot of heterogeneity in the research world about what to do, and it's so much institution specific. And I think that really is partly necessary. Every surgeon and wound care provider has their skills and what they've learned over time. But hopefully as more of us get together and can report our results and tell each other what works and help us help each other identify which patients may be good candidates for surgery, who actually needs better medical tuning up and optimization before surgery, then a better picture can come into play. With the amalgamation of all this information, we can help more patients. If we can get our healing rates from 60% to 70%, we're talking about hundreds of patients who are spared thousands or tens of thousands of dollars of out-of-pocket costs and insurance companies being spared hundreds of thousands of dollars or millions, it will all be worth it. So that is my inspiration to keep on doing what I'm doing and what I hope that future wound care practitioners will be inspired to do.