The National Quality Forum made the occurrence of Grade III and Grade IV decubitus ulcers as “…Inexcusable actions in a health care setting…”

The National Quality Forum of the United States made the occurrence of a Grade III and Grade IV decubitus ulcers as a “Never events which are inexcusable actions in a health care setting, the kind of mistake that should never happen.” Dr. Greg Vigna, practicing physician, national neurological injury attorney, and Certified Life Care Planner states that “Patients with traumatic brain injury and spinal cord injury are extremely at risk for bed sores and early referral to a center of excellence with comprehensive wound care is necessary to prevent further morbidity and mortality.”

Unfortunately, many patients with hospital acquired bed sores are referred to long-term acute care hospitals and skilled nursing facilities that do not have the scope of medical professionals to allow for comprehensive wound care. Dr. Vigna states, “During my observation from over 12 years of managing complex wounds it was not uncommon for patients to go through six months of futile attempts of conservative management and have suffered from numerous hospitalizations, been on prolonged bed rest, which has led to depression, profound malnutrition, and chronic infections. It is my opinion that patients must be carefully case managed and directed to the most appropriate facility that has the services necessary to manage these diagnoses to decrease morbidity, mortality, and cost for these patients.”

“Patients must be carefully case managed and directed to the most appropriate facility that has the services necessary to manage these diagnoses…” – Dr. Greg Vigna

What medical specialists are required to manage a deep Grade III and Grade IV Decubitus Ulcers:

  1. Plastic Reconstructive Surgeons-Myocutaneous Flaps
  2. Internal Medicine- Antibiotic management and medical follow-up
  3. General Surgeons-Debridement of wounds and amputations, placement of PEG tubes
  4. Orthopedic Surgeons-Debridement of wounds, debridement of bone, and management of open joints
  5. Physiatrist-Team leader

What services are required to manage a deep Grade III and Grade IV Decubitus Ulcers:

  1. Clinitron Bed for post-operative pressure relief without need for repositioning
  2. Prolonged IV antibiotic therapy
  3. Parenteral nutrition: IV Nutrition
  4. Percutaneous endoscopic gastrostomy (PEG) tubes
  5. Wound care nursing
  6. Physical Therapy
  7. Dieticians-IV Nutrition management and caloric assessment

Physiatrists are often instrumental in the care of these patients because they are trained in determining psychosocial aspects of the patient that led to the ulcer, trained in the preoperative and postoperative care of these patients, and trained in managing patients with disabilities that predispose patients to the formation of decubitus ulcers such as spinal cord patients and brain injured patients. Physiatrists provide spasticity management and treatment of joint contractures that will predispose patients to decubitus ulcers. A physiatrist in the preoperative phase of treatment should be able to identify those patients that will likely have difficulty with being compliant with postoperative care to prevent flap failure.

Beside dieticians, there are numerous allied health providers necessary for the care of these patients. Nurses must be knowledgeable and trained in the post-operative care of these patients. They must be diligent to strip the drains, position the patient correctly, and be able to identify complications such as postoperative hematomas that may compromise a flap. Wound care nurses must be familiar with the specialty beds necessary for the management of wound patients and the indications when an air mattress is appropriate and the occasions a clinitron bed is necessary. They must be familiar with the numerous wound care products in the market and their indications of use. Physical therapists and occupational therapists are essential for a patient’s success and ongoing health maintenance. They must understand post-operative management of patients, including the timing and duration of sitting after a flap, indications to decrease sitting duration, and the proper joints to range after flap closure. Physical therapists and occupational therapists must re-educate patients on proper pressure relief techniques for prevention of reoccurrence and evaluate equipment such as cushions.

Dr. Vigna comments, “Unfortunately patients who suffer from catastrophic decubitus ulcers are often referred to lessor capable facilities because of insurance issues. The goal of my law firm is to make sure our clients are referred to the best facility to get the care they need and deserve. We understand the cost of care and future care related to decubitus ulcers.”