“Hospitals and nursing homes know how to point the finger at other providers and many times will point the finger back at the patient and their families. The only path to change is by punishing them financially and taking depositions of those who are responsible. We do our own investigation for the benefit of our clients and future patients of the negligent healthcare facility” …Greg Vigna, MD, JD, national malpractice attorney”
Don’t be fooled by being told it is a Grade I Decubitus Ulcer”… Greg Vigna, MD, JD, national malpractice attorney
Pressure Sore Staging:
“Skin is the most resistant soft tissue to pressure. Muscle is most susceptible soft tissue to pressure. By the time injuries to the skin are observed the underlying damage is already done. Two to three weeks you will have a big hole” …Dr. Greg Vigna, national malpractice attorney
Staging of Decubitus Ulcers:
Decubitus ulcer classification is primarily visual but may be by palpation. There are four
stages (I-IV) but it must be understood that a Stage I decubitus ulcer may have a deep tissue
component not yet visible on clinical exam. Suspected deep tissue injury would include
subcutaneous bruising suggestive of a Grade III-IV decubitus ulcer.
Stage I: Non-blanchable redness over a bony prominence
Stage II: Partial dermis loss
Stage III: Full thickness tissue loss
Stage IV: Full thickness tissue loss with exposed bone, tendon, or muscle.
“Decubitus ulcers are either superficial or deep. Superficial decubitus ulcers are injuries to the skin and adjacent soft tissues are generally caused by shear forces that essentially pull on the skin. Deep tissue injuries are on the other hand are caused by pressure from inadequate turning or incomplete pressure reliefs that leads to irreversible damage and death of the muscles induced by a loss of blood flow from pressure on the arterial supply to muscle cells”… Greg Vigna, MD, JD, national malpractice attorney
Surfaces at Risk:
“Deep tissue injuries to muscles depend on the amount of pressure and duration of pressure. The rule of thumb is that a dependent patient lying in bed MUST be repositioned every two hours. Patients who cannot provide a pressure relief when sitting MUST be repositioned every 15-20 minutes because of the relative increase in pressure on the buttock in sitting when compared to lying” … Greg Vigna, MD, JD, national malpractice attorney
“Deep tissue injuries are caused by a failure of healthcare facilities to provide timely repositioning of patients who are physically dependent. These are medically frail patients that the healthcare facility is entrusted to keep safe. This type of hospital acquired injury should never happen as the result is heartbreaking, the individual suffering is immense, and the cost of future care is enormous” … Greg Vigna, MD, JD, national malpractice attorney
“A deep tissue injury may simply present as bruising of skin, loss of pigmentation, or non-blanchable redness of intact skin, only to declare itself as a deep Grade III or IV ulcer a few weeks later. In other words, any skin breakdown must be identified by reliable and scheduled skin assessments for patients who are dependent on repositioning in bed or when up in a chair and vigilant pressure reliefs provided for by nursing staff” …Greg Vigna, MD, JD national malpractice attorney
Ex. Stage I sacral decubitus: Requires side to side lying with the head of bed not higher than 30 degrees.
Ex. Stage III sacral decubitus: Requires side to side lying with the head of bed not higher than 30 degrees.
If adequate pressure relief cannot be obtained because of patient related factors that might include pain or multiple decubitus ulcers, patients require a clinitron bed to ensure absolute off-loading of the bed sore or sores.
Ex. Ischial decubitus ulcer: Off-loading either requires no sitting, or if superficial decubitus ulcer is confirmed, limited sitting with adequate pressure reliefs every ten minutes.
Populations at Risk:
- Nursing home residents
- Dependent patients in transit from one facility to another
- Spinal cord injured patients
- Critically ill patients
“Populations at risk haven’t changed overtime as those at risk all have impairments in mobility because of disability or acute medical illnesses. What has changed over the past two decades is the quality of care at the bedside in hospitals and nursing homes across the country. Resources have been diverted from patient care to non-essential expenses that include dividend payments to shareholders and inflated allocations to hospital administrations who aren’t being held accountable for the errors within the walls of the facilities that they oversee” … Greg Vigna, MD, JD, national malpractice attorney
Multidisciplinary Approach to Management of Grade III & Grade IV Decubitus Ulcers
Patients with Grade III and Grade IV decubitus ulcers are medically complex. They tend to be debilitated, malnourished, and are often septic. These patients require a level of care that allows for a multitude of services and time to heal. A Long-Term Acute Care (LTAC) facility has a licensure that allows for patients to stay one to two months.
Plastic Surgery: Surgical debridement & Musculocutaneous Flaps
A plastic surgeon is an essential member of a multidisciplinary team, as they have the skills to provide surgical debridement and musculocutaneous flaps.
Surgical debridement is a mainstay of treatment of Grade III and IV decubitus ulcers. Grade III and Grade IV decubitus ulcers that have necrotic tissue with or without infection will not heal. Essential management is early surgical debridement to viable tissue, which is medically necessary as wounds will not heal if dead tissue remains in the wound base.
Musculocutaneous flaps is a mainstay of treatment of Grade III and IV decubitus ulcers once there is a stable wound base, nutrition of a patient is optimized, and infection has been treated. Surgical options for flap closure depend on the location of the wound. The most common locations are below, understanding that with virtually any location on the body, there are options for closure: