The Costs and Outcomes of Treating a Deep Pressure Ulcer in a Patient with Quadriplegia

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1 The Costs and Outcomes of Treating a Deep Pressure Ulcer in a Patient with Quadriplegia Eli S. Schessel, MD; Ralph Ger, MD; and Robert Oddsen, MD Abstract The cost of pressure ulcers, especially Stage III and Stage IV ulcers, is substantial. A 27-year-old man with a 6-year history of quadriplegia developed an ischial pressure ulcer. Twelve months of treatment with wet-to-dry dressings were followed by admission to several facilities and 15 months of care with biological dressings and negative pressure wound therapy (NPWT). When admitted to the authors wound care center, the wound measured 4.5 cm x 3.2 cm with exposed bone. A review of his insurance records showed that paid claims totaled $242,350, including $52,992 for NPWT rental costs. The patient was considered a good candidate for minimally invasive surgical intervention with external tissue expanders. Following a 14-day course of antibiotics to treat his infection, the wound was debrided and the tissue expanders applied. After 16 days, the wound was closed. The patient returned to work 6 weeks after the procedure. At the 23-month follow-up, the wound remained closed. Insurance payments for the care that resulted in wound closure totaled $43,814. This case study illustrates the potential of the external tissue expansion technique to close deep pressure ulcers within a relatively short amount of time at comparatively lower cost. Studies including control treatments are needed to confirm these conclusions. Keywords: pressure ulcer, quadriplegia, ischial, external tissue expanders Index: Ostomy Wound Management 2012;58(2):41 46 Potential Conflicts of Interest: The authors acknowledge that they own stock in Progressive Surgical Products (Westbury, NY), the manufacturer of the external tissue expander. Demographics indicate the population of persons 65 years and older is expected to increase to 55 million, and the population older than 85 years is expected to reach more than 6.6 million in Because the risk of developing chronic conditions increases with age, this demographic trend is expected to grow the demand for both human and financial resources in the healthcare system. The elderly and patients with spinal cord injuries are at high risk for developing chronic wounds such as pressure ulcers. It is estimated that 1.3 to 3 million elderly adults develop a pressure ulcer each year, 2 and approximately 60,000 people die each year from complications related to pressure ulcers, 3 such as infections, loss of albumin, and anemia. Pressure ulceration is among the most common complications of spinal cord injury and can become a life-threatening complication when characterized by necrosis of the fascia, subcutaneous tissue, and muscle. 4 The costs of pressure ulcers to the healthcare system is estimated to be $11 billion each year. 5 Stage III and Stage IV are the most advanced types of pressure ulcer and the most costly to heal; healing takes twice as long as partial-thickness ulcers occurring in the same practice. 6 It is important to close these wounds quickly to reduce healthcare cost and improve patient quality of life. These wounds can be treated using an assortment of methods, from dressings to negative pressure wound therapy (NPWT) to complex surgical flap procedures. 7 One option involves a minimally invasive surgical method to close pressure ulcers using external tissue expanders, ongoing wound care, and the judicious use of sutures to quickly close the wound and fill the wound cavity with subcutaneous padding. A clinical series 8 on the use of external tissue expansion to close 650 dehisced, chronic, and traumatic wounds found that this method resulted in skin that can withstand the rigors of everyday life, and most wounds were closed in 7 to 14 days. This case study describes the history, costs of care, and outcome of a patient with quadriplegia who developed a Stage IV ischial pressure ulcer. Dr. Schessel is Chief Emeritus, Division of Plastic Surgery, Flushing Hospital Medical Center, Flushing, NY. Dr. Ger is retired. Dr. Oddsen is a medical engineer consultant. Please address correspondence to: Eli S. Schessel, MD, th Road, Forest Hills, NY 11375: WoodWest3@aol.com. FEBRUARY 2012 OSTOMY WOUND MANAGEMENT 41

2 Ostomy Wound Management 2012;58(2):41 46 Key Points The authors describe the history of a young patient with quadriplegia and a long-standing, deep, pressure ulcer. Following several hospital admissions, various treatments, and substantial costs, the wound remained unhealed. During his last admission, a minimally invasive surgical technique using tissue expanders was used, and the patient returned to work with a healed wound after 6 weeks. The authors conclude that more research is warranted to compare the costs and outcomes of standard secondary healing and minimally invasive surgical techniques for deep pressure ulcers. Case Study History. Mr. K, a 27-year-old man with a 6-year history of quadriplegia, developed an ischial pressure ulcer in September His records showed the wound was initially treated at a university hospital plastic surgery unit from September through December 2007 with minimal improvement. Two months later, Mr. K presented for treatment at another university hospital. From February through April 2008, the wound was recorded as starting to show signs of infection and osteomyelitis. Subsequent records show Mr. K received treatment for his pressure ulcer at another hospital s wound center (A) from September through December 2008 (see Table 1). At that time, MRI results showed the presence of osteomyelitis. Mr. K was treated with systemic antibiotics, the wound was surgically debrided on several occasions, and the wound was treated with Integra biological dressing (Integra, Plainsboro, NJ) and NPWT (Kinetic Concepts, San Antonio, TX). The wound did not heal. Subsequently, Mr. K received wound care at home. In February 2009, Mr. K was admitted to another hospital wound center (B), where he remained until November 2009 (see Table 1). During this period, he was prescribed multiple antibiotics and the wound was managed with a biological dressing and NPWT. The plastic surgeon recommended no further surgery, and Mr. K was discharged to home care with occasional outpatient visits. The ulcer remained unhealed for 15 months. A review of his Blue Cross/Blue Shield medical record and actual insurance payments related to the care of the pressure ulcer from September 2008 through December 2009 showed payments totaling $242,350 (see Table 1). One month later, on January 11, 2010, Mr. K was admitted to the authors hospital medical center with an unhealed ischial pressure ulcer that measured 4.5 cm x 3.2 cm with exposed bone (see Figure 1a). Proposed approach. Considering Mr. K s history, external tissue expansion was considered. External tissue expansion combines three time-tested principles tissue approximation, tissue expansion, and secondary wound healing to close the wound with the patient s own local site skin and subcutaneous tissue. For the past 12 years, the authors have used external tissue expansion to close 650 dehisced, traumatic, and chronic pressure ulcers. 12 It has been the authors experience that the prevention or eradication of infection is essential for a successful result with external tissue expansion. Opinions differ as to the role of cultures in the management of bacterial infections, because it is common for wounds to grow a variety of organisms. Nevertheless, certain organisms, such as Staphylococci and Streptococci, may affect healing, and their presence should be noted. The fact that many organisms are merely contaminants is well known, but the onset of a post-procedural infection requires recognition and active treatment. Infected wounds should not be closed because doing so will entrap infected material and increase the risk of wound dehiscence and resultant complications. Similarly, before applying external tissue expanders, the wound must be free of pus, urine (piss), feces (poop), particles, and pressure ( Schessel s five Ps ). The wound should be irrigated (cleaned), surgically debrided (cut), and either covered with a graft or closed, preferably with local tissue ( Schessel s 4 Cs ). Because culture results from Mr. K s pressure ulcer showed the presence of Klebsiella pneumoniae and Enterococcus faecalis, a 14-day course of amoxicillin clavulanic potassium and vancomycin every 12 hours was prescribed. External tissue expansion is contraindicated for sacral pressure ulcers located 2 cm from the anus unless a temporary diverting colostomy is in place. In Mr. K s case, the ulcer was not too close to the anus, inflammation and infection were controlled, he was medically stable, and his albumin level was >2. He was considered a good candidate for minimally invasive surgical repair of the pressure ulcer by external tissue expansion. Procedure. Expansion of local skin and subcutaneous tissue was achieved utilizing Proxiderm (Progressive Surgical Products, Westbury, NY) external tissue expanders (see Figure 1b). The external tissue expander consists of two tissue hooks that are inserted through the epidermis and dermis and deeply into the subcutaneous tissue. One tissue hook is inserted 2 cm from the wound margin; the other tissue hook is inserted 2 cm from the opposing wound margin. A mechanism slowly brings the wound margins together over a period of time. The procedure is performed in the operating room or at bedside. On January 11, 2010, Mr. K s wound was cleansed and surgically debrided under local anesthesia. Extensive ostectomy also was performed in the OR, and a muscle flap was rotated over the bone (see Figure 1c). Per standard procedure, a line of 2/0 nylon sutures was placed 2 to 3 cm from 42 OSTOMY WOUND MANAGEMENT FEBRUARY

3 PRESSURE ULCER IN A PERSON WITH QUADRIPLEGIA TABLE 1: Pressure ulcer treatment related insurance payments September 8, 2008 through December 16, 2009 Date Payment Charges/description September 8 to December 8, 2008 Hospital Wound Center (A) September 26, 2008 $2,349 Radiology (MRI) October 23, 2008 $32,388 Hospital payments October 23, 2008 $1,764 Physician payments December 11, 2008 $40,374 Hospital payments December 11, 2008 $1,909 Physician payments December 26, 2008 $6,212 Physician visit payments 9/19/08 to 12/26/08 February 9, 2009 to November 9, 2009 Hospital Wound Center (B) February 19, 2009 $14,448 Hospital payments February 19, 2009 $2,780 Physician payments May 7, 2009 $2,349 Radiology (MRI) July 2, 2009 $4,228 IV Infusions 6/2/09 to 7/2/09 July 6, 2009 $2,049 Radiology (MRI) July 23, 2009 $11,490 Hospital payments July 23, 2009 $6,452 Physician payments October 8, 2009 $9,534 Hospital payment October 8, 2009 $2,024 Physician payment November 18, 2009 $12,517 Hospital payment November 18, 2009 $1,230 Physician payment December 15, 2009 $8,031 Physician visit payments 2/13/09 to 12/15/09 Home health care October 30, 2008 $3,966 Advanced Care 10/24/08 to 11/14/08 November 5, 2008 $105 HH Labs 10/29/08 to 11/5/08 December 21, 2009 $18,501 Coram Healthcare Center 1/4/09 to 12/21/09 the wound margin, 2 cm apart. Sutures were tied alternately, leaving the ends about 7 cm long or left untied and secured by steri-strips. The tied sutures decrease the size of the wound and assist in obliteration of potential dead space. The tissue hooks of the external tissue expanders were inserted through the skin into deep subcutaneous tissue 2 to 3 cm from the wound margins and secured to the patient by encircling and tying the long ends of the previously untied sutures around the tissue expander. External tissue expanders were placed 2 to 3 cm apart (see Figure 1d) and combine dressings were placed between, under the ends and on top of the expanders, and held in place with Elastoplast (Smith & Nephew, London, UK). In general, clean wounds are evaluated every 2 days and contaminated wounds are evaluated daily; in Mr. K s case, the wound was evaluated every 2 days. At that time, the tissue expanders were removed, the wound cleansed, debrided, and irrigated, and the untied sutures tied. If granulation tissue formation is insufficient to facilitate final closure, the process of suture and tissue expansion is repeated. On the fourth day post-expansion, a French catheter with multiple holes was placed subcutaneously for deep irrigation through the catheter twice per day for 5 days (see Figure 1e). Mr. K was discharged home on January 27, Subsequent 10-minute daily saline soaks were provided by a home care aid, followed by cleaning with ½ strength peroxide and the application of bacitracin ointment. A combine dressing and nonallergic tape were placed over the wound. This process was continued for 1 month until sutures were removed. Mr. K was reminded about the importance of avoiding pressure on the surgical area for 4 to 6 weeks after surgery. He returned to work 6 weeks after surgery with a motorized wheelchair and a silicone Negative pressure wound therapy device rental November 30, 2008 $5,628 Rental 11/20/08 to 12/31/08 December 16, 2009 $47,364 Rental 1/1/09 to 12/16/09 November 25, 2009 $4,708 General hospital (ER) TOTAL $242,350 FEBRUARY 2012 OSTOMY WOUND MANAGEMENT 43

January 27, 2010 $ 38,566 Hospital payments January 27, 2010 $5,248 Physician payments TOTAL $43,814 support pad. At 23 months, the pressure ulcer had not recurred (see Figure 1f).

4 TABLE 2. External tissue expansion pressure ulcer treatment-related insurance payments January 11 through January 27, 2010 Date January 11 to January 27, 2010 Charges/Description Cost Hospital medical center January 27, 2010 $ 38,566 Hospital payments January 27, 2010 $5,248 Physician payments TOTAL $43,814 support pad. At 23 months, the pressure ulcer had not recurred (see Figure 1f). A review of insurance payments for this episode of care showed that the direct insurance cost for closing this pressure ulcer was $43,814 (see Table 2). Discussion Pressure ulcers have been found on 5,000-year-old mummies in Egypt and continue to be an ever-present and resource-intensive problem within society. The time and resources required to manage and heal Stage III and Stage IV pressure ulcers are especially high. 6 Traditionally, wounds have been managed to promote epithelialization by creating a moist wound environment. In the mid 20th century, the potential for moisture barrier dressings to reduce healing time, pain, scarring, and infection rates was realized. 9 A current popular mode of wound management is the application of NPWT to the wound. The average healing time of Stage III and Stage IV trochanteric and trunk wounds averaging 22.2 cm 2 using NPWT is 97 days; closure occurs as granulation tissue 10 forms and becomes scar tissue. Because NPWT reduces edema through evacuation of water molecules, it also may remove low molecular weight proteins. The authors hypothesize that studies to ascertain the effect of NPWT on the risk of hypoproteinemia should be conducted, especially in patients with pressure ulcers. In addition, surgical approximation of the wound edges results in more durable tissue than the scar tissue that typically forms following secondary intention healing. 7 In the 1970s, the need for more expedient and resilient skin coverage of large and/or deep wounds led to the development of tissue flap techniques. Tissue flaps involve detaching the tissue from its original site, transferring the tissue flap to the wound by advancement or rotation, and suturing the tissue flap to cover the wound. This major operative procedure is performed under general anesthesia 7 and contraindicated in many elderly patients. In the 1990s, a minimally invasive surgical technique that uses external skin expansion and dedicated wound care was introduced to close chronic and traumatic wounds. A clinical series 11 of 125 patients with lower extremity wounds closed Figure 1a. August 5, 2009: Unhealed ischial pressure ulcer after 15 months of treatment. Wound measured 4.5 cm x 3.2 cm with exposed bone. Figure 1b. External tissue expander. by external tissue expansion confirmed that tissue expansion stimulates angiogenesis. In vitro models 12 also have demonstrated that tissue expansion increases the production of growth factors that include epidermal, fibroblast, transforming families, platelet-derived growth factor, and angiotensin II. A study 13 of 20 patients subjected to breast reconstruction by means of tissue expansion indicated substantial mitotic activity, suggesting the formation of new tissue. Results of the recent study 8 support 1- to 2-week healing and desired skin characteristics. A clinical series 14 of 52 decubitus ulcers (sacral, trochanteric, ischial, and heel), a clinical series 15 of 74 pressure ulcers (foot and ankle), and a clinical series 16 of 16 dehisced abdominal wounds all supported using tissue expansion to close the wounds. 44 OSTOMY WOUND MANAGEMENT FEBRUARY

IC A TE PRESSURE ULCER IN A PERSON WITH QUADRIPLEGIA PL Figure 1d. January 11, 2010: A line of sutures is placed. External tissue expanders are applied and secured to the patient. U Figure 1c.

D O N O T D When a Stage III or Stage IV pressure ulcer develops, a basic management decision has to be made. Nonsurgical secondary intention healing can take months.

5 IC A TE PRESSURE ULCER IN A PERSON WITH QUADRIPLEGIA PL Figure 1d. January 11, 2010: A line of sutures is placed. External tissue expanders are applied and secured to the patient. U Figure 1c. January 11, 2010: Wound is debrided with extensive ostectomy and rotation of a muscle flap over the bone. D O N O T D When a Stage III or Stage IV pressure ulcer develops, a basic management decision has to be made. Nonsurgical secondary intention healing can take months. A 1990 study 17 of 19,889 elderly patients at 51 nursing homes showed that, when using traditional gauze-based dressings, 29% of Stage III pressure ulcers and 38% of Stage IV pressure ulcers remained unhealed after 2 years. A 2-year study 18 in a Canadian urban health region involving seven healthcare organizations (acute, home, and extended care) revealed a pressure ulcer can increase nursing time up to 50%, as well as increase direct costs. In addition to its effect on patient quality of life, an open wound also remains at risk for the development of complications including infections, anemia, and osteomyelitis that, as illustrated by the passing of Christopher Reeves, can lead to death. Emotional suffering and physical pain are an important cost often quantified in litigation. A review19 of medical malpractice cases regarding patients at risk for pressure ulcers in long-term care facilities indicated that the patient achieved a verdict or settlement in 68% of cases, and the median monetary recovery was $250,000. In a 2003 case in California, a jury awarded $3 million in damages against a nursing home for allowing an elderly woman to die of bedsores. 20 Using external tissue expansion, most pressure ulcers are closed in 7 to 14 days. 8 In this case study, Mr. K was discharged after 16 days, sutures were removed after 1 month, and he returned to work 6 weeks following surgery. Insurance company costs for his treatment were $43,814. This is in stark contrast Schessel_0212.indd 45 Figure 1e. January 20, 2010: Appearance at fourth day post-expansion. A French catheter with multiple holes is placed subcutaneously for deep irrigation through the catheter twice per day. FEBRUARY 2012 OSTOMY WOUND MANAGEMENT 45 2/3/12 4:31 PM

Figure 1f. December 22, 2011: Patient was discharged on January 27, 2010. No recurrence at 23 months.

6 Figure 1f. December 22, 2011: Patient was discharged on January 27, No recurrence at 23 months. with attempted wound closure during a period of 15 months at a cost of $242,350, of which $52,992 were rental charges for the NPWT system. The final result was an unhealed pressure ulcer. If the ulcer initially had been closed by external tissue expansion, $198,356 would have been saved. According to data from the CMS and the Healthcare Cost and Utilization Project, 9 a nationwide database of hospital inpatient stays, in 2006, 503,300 hospital stays noted pressure ulcers as a diagnosis, and pressure ulcer hospital costs totaled $11 billion. Conclusion Pressure ulcer treatment represents a significant expenditure of private health insurance as well as Medicare and Medicaid funding. A pressure ulcers is both a high-cost and high-volume adverse event. With limited resources and manpower available, the open nonhealing pressure ulcer is a challenge to the healthcare professional. It is essential to find new modalities to provide a better quality of life for these patients at a reduced cost to the healthcare system. This case study illustrates the potential of the external tissue expansion technique to close deep pressure ulcers within a relatively short amount of time while reducing cost. Studies including control treatments are needed to confirm these conclusions. n References 1. A Profile of Older Americans 2009 Administration of Aging, US Department of Health and Human Services. aging_statistics/profile/2009/docs/2009profile_509.pdf. Accessed January 20, Lyder C. Pressure ulcer prevention and management. JAMA. 2003;289: Allman RM. Pressure ulcers among the elderly. N Engl J Med. 1989;320(13): Citak M, Backhaus M, Tilkorn D, O Loughlin P, Meindl R, Muhr G, Fehmer T. Necrotizing fasciitis in patients with spinal cord injury. Spine. 2011;36(18):E1225 E Russo CA, Steiner C, Spector W. Hospitalizations related to pressure ulcers among adults 18 years and older 2006: US Agency for Healthcare Research and Quality. Statistical Brief # Bolton L, McNees P, van Rijswijk L, deleon J, Lyder C, Kobza L, et al. Wound healing outcomes using standardized assessment and care in clinical practice. J WOCN. 2004;31(2): Treatment of Pressure Ulcers, Clinical Practice Guideline Number 15. US Department of Health and Human Services. AHCPR Publication No Schessel ES, Ger R. Closure of difficult wounds by external tissue expansion. WOUNDS. 2010;22(6): van Rijswijk L. Bridging the gap between research and practice. Am J Nurs. 2004;104(2): Philbeck TE Jr, Whittington KE, Millsap MH, Broines RB, Wight DG, Schroeder WJ. The clinical and cost effectiveness of externally applied negative pressure wound therapy in the treatment of wounds in home healthcare. Ostomy Wound Manage. 1999;45(11): Ger R, Schessel ES. Prevention of major amputations in nonischemic lower limb lesions. J Am Coll Surg. 2005;201(6): De Filippo RE, Atala A. Stretch and growth: the molecular and physiologic influences of tissue expansion. Plast Reconstr Surg. 2002;109(7): Austad ED, Thomas SB, Pasyk K. Tissue expansion: dividend or loan? Plast Reconstr Surg. 1986;78(1): Schessel ES, Ger R. The management of pressure sores by constant-tension approximation. Brit J Plast Surg. 2001:54(5): Schessel ES, Lombardi CM, Dennis LN. External constant tissue expansion of soft tissue for the treatment of ulceration of the foot and ankle. J Foot Ankle Surg. 2000;39(5): Schesssel ES, Ger R, Ambrose G, Kim R. The management of the postoperative disrupted abdominal wall. Am J Surg. 2002;18(3): Brandeis GH, Morris JN, Nash DJ, Lipsiz LA. The epidemiology and natural history of pressure ulcers in elderly nursing home residents. JAMA. 1990;264: Clarke H, Bradley C, Whytock S, Handfield S, van der Wal R, Gundry S. Pressure ulcers: implementation of evidence-based nursing practice. J Adv Nurs. 2005;49(6): Bennett RG, O Sullivan J, DeVito EM, Remsburg R. The increasing medical malpractice risk related to pressure ulcers in the United States. J Am Geriatr Soc. 2000;48(1): Annie Mae Ollison v. Eskaton Homestead of Fair Oaks et al., Sacramento Superior Court, 00AS Available at: com/verdicts/case.asp?n=00as05801&s=ca&d= Accessed January 20, OSTOMY WOUND MANAGEMENT FEBRUARY

Closure of Difficult Wounds by External Tissue Expansion

Closure of Difficult Wounds by External Tissue Expansion REVIEW WOUNDS 2010;22(6):151 157 From the 1 Flushing Hospital & Medical Center, New York, NY Address correspondence to: Eli S. Schessel, MD 108-33 70th Rd. Forest Hills, NY 11375 Phone: 718-793-1822 Email: