Subeschar culture using a punch instrument in unstageable wounds

Socioeconomic effects of pressure ulcer

A pressure ulcer is defined as localized ischemic skin or soft tissue damage resulting from disruption of the blood supply by pressure over the bony prominence. However, it is not just a wound that causes pain to individuals, but also a complex disease that causes socioeconomic losses. In 2019, total 30,983 patients with pressure ulcers were treated at medical institutions in Korea, and 76 billion Korean won (KRW) was spent on this treatment. Inpatient care cost amounted to 65.5 billion KRW, whereas outpatient care cost amounted to 9.8 billion KRW. The average hospitalization cost per patient was 6,696,605 KRW, and the average hospitalization period was 57.4 days, averaging 116,707 KRW per patient per day. The average outpatient care cost per patient was 421,134 KRW, and the average period in the clinic was 8.9 days, calculated at 47,428 KRW per day. The development of pressure ulcers inevitably causes socioeconomic losses and puts strain on limited medical resources; therefore, the best socioeconomic solution is prevention. Prevention has been shown to be much more efficient in cost-effective studies on treatment and prevention. Therefore, investment of more resources to prevent the development of pressure ulcers is the best solution to reduce the related socioeconomic burden.

Surgical treatment of pressure ulcer: various flaps and other surgical methods

Pressure ulcers remain a common health problem, particularly among physically limited or bedridden older adults, and they can cause significant morbidity and mortality. Conservative management is ineffective for stage III or IV pressure ulcers, and surgery to create flap coverage becomes inevitable. Basic surgical principles for the treatment of pressure ulcers include complete excision of the ulcer, surrounding scar, underlying bursa, and soft tissue calcification; radical removal of underlying bone and any heterotropic ossification; padding of bone stumps and filling dead space; resurfacing with large regional pedicled flaps; and grafting the donor site of the flap, if necessary. For effective edge resection, all the flaps should be designed to be as large as possible, placing the suture line away from the area of direct pressure, and the flap design should also not violate adjacent flap territories to preserve all options for coverage if a breakdown or recurrence dictates further reconstruction. There are surgical methods for stage III or IV wide range pressure ulcers: reconstruction surgery using a skin flap, muscle flap, fascia-skin flap, or free flap. The skin graft is not generally recommended as a surgical procedure for stage III or IV pressure ulcers because it cannot provide enough strength to cover the wound. This review presents various surgical treatments of pressure ulcers including muscle, musculocutaneous, perforator-based, and free flap.

Stage-related implications of community-acquired pressure injuries for the acute medical inpatients

AIMS

To analyse the prevalence of any-stage pressure injuries at hospital admission and their impact on short-, mid- and late-term mortality. Patient characteristics associated with pressure injuries and the impact on hospital costs were also investigated.

BACKGROUND

In medical patients acutely admitted to hospital, no study analysed the presence of pre-existing pressure injuries and the related short- and long-term mortality according to the overall stages of severity thereof.

DESIGN

Retrospective cohort study following the STROBE guideline.

METHODS

In a population of 7217 acute medical inpatients, the presence and staging of pressure injuries were assessed at hospital admission. The impact of pressure injury on 30-, 180- and 365-day mortality was analysed by multivariate Cox regression models.

RESULTS

The prevalence of community-acquired pressure injuries was 14.9% (stage-1: 8.1%; stage-2: 3.5%; stage-3: 1.6%; stage-4: 1.1%; unstageable: 0.5%). Hemiplegia/paraplegia, anaemia, poor functional status, high nutritional risk, clinical instability and systemic inflammatory response, but not hydration status, were found to be associated with the occurrence of stage-2-and-above pressure injuries. An increasing difference was found in Diagnosis-Related Groups (DRG) weight according to pressure injury stages. A distinct and progressively increasing risk-of-death for any-stage pressure injury was shown after 365-days. A significantly increased mortality risk for all considered time intervals was found for unstageable and stage-4 pressure injuries.

CONCLUSIONS

In acute medical inpatients, the presence of community-acquired pressure injuries is part of a multidimensional clinical complexity. The presence and staging of pressure injuries have an independent dramatic impact on of early-to-late mortality and hospital costs.

RELEVANCE TO CLINICAL PRACTICE

This study documented as community-acquired pressure injuries are highly prevalent and represents an independent predictor of outcomes in strict dependence of the progression of thereof stage. The presence of community-acquired pressure injuries should be interpreted as a critical marker of frailty and increased vulnerability.