Serial Surgical Debridement of Common Pressure Injuries in the Nursing Home Setting: Outcomes and Findings

Objective. This study examined the efficacy of bedside surgical debridement in a nursing home population. Materials and Methods. A retrospective chart review was performed of sacrum, sacrococcyx, coccyx, ischium, and trochanter (SSCIT) region pressure injuries in the Skilled Wound Care practice (Los Angeles, CA). The patient population was refined from 2128 to 227 patients visited 8 or more times during nursing home stays found to have 1 or more SSCIT pressure injuries. Of the 227 patients, there were approximately 319 individual SSCIT wounds, with an average of 1.4 SSCIT wounds per patient. Bedside surgical debridement was performed using a sharp excisional technique on 190 of 319 (59.5%) SSCIT wounds. Results. An analysis of the square surface area of the 190 debrided wound sites revealed a mean ulcer surface area of 20.76 cm². Of those 190 wound sites, 138 (73%) had a reduction in square surface area, and 52 (27%) had no change or an increase in square surface area and were categorized as nonresponders. Of the wounds that did improve by a reduction in wound surface area, the average wound surface area reduction was 6.81 cm² at 4 weeks (25%), 8.91 cm² reduction at 8 weeks (33%), and 10.87 cm² reduction at 12 weeks (40%). From the 190 wound sites, there were a total of 43 (23%) wounds that had a square surface area of 0 (reepithelialized), which has a healing rate of 23%. Conclusion. Traditional bedside debridement provides excellent results in reducing the square surface area for a majority of wounds. Whether used alone or as an adjunct to any treatment plan, the use of surgical sharp equipment aids in achieving good wound healing and advancing the rate of wound closure. Although wound healing requires many components, sharp debridement can effectively remove devitalized tissue and is a proven significant component to advancing wound closure.

Pressure injuries (PIs) are a common and important problem among patients in the nursing home population. Pressure injury occurrence in the nursing home population has both a high incidence and prevalence, and a vast array of management options exist to heal and curtail these wounds.  A National Center for Health Statistics Data Brief¹ showed that of the 1.5 million US nursing home residents in 2004, about 159 000 (11%) had PIs of any stage. Of those residents with a stage 2 PI or higher, only 35% received wound care services by specially trained professionals or staff.¹ This suggests that a minority of nursing home residents with stage 2–4 PIs received wound care in accordance with the clinical practice guidelines in 2004.²

Pressure injuries occur as a result of continuous pressure in areas of bony prominences across an individual’s body.  These ulcers are more commonly found in patients with certain risk factors or diagnoses that are contributory to their development. Pressure injuries are defined by the National Pressure Ulcer Advisory Panel-European Pressure Ulcer Advisory Panel as “a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear”² — the key words are boney prominence. 

For patients, PIs can have a hefty cost. They have been shown to have a mean pain intensity corresponding to moderate pain.³ This pain is usually controlled in the nursing home setting with oral pain medications, but the discomfort of having a PI is significant.⁴ In addition, patients live with the deforming injury, on some occasions foul odor, and potentially restricted activities. The presence of a PI increases a nurse’s workload by 50% for the patient and adds $20 000 to a hospital bill.⁵

Although multiple groups have elucidated methods for the prevention of PIs in the nursing home population, the basic biology underlying chronic wounds and the influence of age-associated changes on wound healing are poorly understood.⁶ To the best of the authors’ knowledge, there are currently no published studies documenting wound healing rates in the practice of bedside debridement for the nursing home population. Multidisciplinary wound care in nursing homes has been reported to save costs and improve wound healing, even without the use of serial surgical debridements.⁷

There are some wounds, however, that contain significant slough, necrosis, devitalized tissue, infected tissue, and bioburden, which can only be healed with surgical debridement. Although a singular debridement in a hospital operating room may remove a majority of the damaged tissue, frequently there is further breakdown, necessitating ongoing debridement. Debridement is the process of removing tissue from a wound by multiple processes happening over a specific or a continual period of time.⁸ The authors’ practice has changed the delivery model in the nursing home to provide bedside surgical debridement. However, the question arises as to the efficacy and safety of debridement procedures in the nursing home setting.

Steed et al⁹ found that diabetic foot ulcers sharply debrided on a routine basis healed more consistently than ulcers that were not well debrided and maintained. They also demonstrated that 16% of debrided ulcers healed in 20 weeks versus 4.3% of controls. Yet, Steed et al⁹ did not examine PIs. Nursing home patients are more regularly confined to bed, have a much greater challenge to wound healing, and may have impediments to reaching centers for wound care, given the high cost. In the authors’ experience, they found that prior to their presence as wound care physicians in the nursing facility, the majority of patients with necrotic wounds were managed with chemical enzymatic debriding agents. Surgical debridement removes tissue immediately, whereas enzymatic debridement removes tissue over time. Regular bedside surgical debridement not only removes dead tissue but also friable tissue, necrotic bioburden, and hypergranulation.¹⁰

Debridement is a time-proven method to prevent wound infection, sepsis, and death. The role of debridement to heal wounds at the bedside in a nursing home setting is yet to be thoroughly examined. This study specifically focuses on the long-term outcome of performing serial surgical debridement in the nursing home patient population who are referred for necrotic PIs confined to the sacrum, sacrococcyx, coccyx, ischium, and trochanter (SSCIT).

A retrospective chart review was performed on patients with PIs in the SSCIT region in the Skilled Wound Care practice (Los Angeles, CA) during the year 2011. These patients were evaluated and managed by providers of the Skilled Wound Care Surgical Group over the 12-month period. The providers in this group are both surgeons and surgical physician assistants who provided these visits and procedures. At the time of this study, these patients were all treated and cared for while at the nursing facility or skilled nursing facility. Patients in more than 100 different nursing homes were examined. In addition, 2128 electronic health records (maintained in a SQL Server database [Microsoft Corporation, Redmond, WA]) of patients that were identified to have at least 1 wound located in the SSCIT region, regardless of stage or procedure rendered, were reviewed. The results of the query were then imported into FileMaker software (Santa Clara, CA) to examine important patterns and relations. The study population was refined from a patient population of 2128 with SSCIT wounds to 227 patients who were visited 8 or more times during stays in nursing home settings and were found to have a PI(s) located in the SSCIT region.

The indication for debridement of wounds was the occurrence or presence of necrosis, slough, or necrotic bioburden in the wound. Bioburden was identified as a thin irregular film on the surface of the wound that could not be removed with irrigation; adequate removal was identified by visible bleeding in the wound bed. Bedside debridement was performed on patients using a sharp excisional approach down to and including the level of skin, subcutaneous, muscle, and/or bone tissue depending on the level of injury. Written informed consent was obtained from patients, family members, responsible parties, or conservators depending on the patient’s ability to consent. Pain control was managed by preprocedural oral narcotics and 20% benzocaine anesthetic to topically anesthetize the wounded area and for patient comfort. The procedures were carried out while the patients remained in their nursing home bed, and the patients were turned to the appropriate position to expose the wound. Depending on the condition of the wound and the provider’s judgment, the wounds were either cleansed with normal saline or betadine prior to debridement. The use of normal saline as a surgical preparation technique is not the standard of care in wound preparation prior to bedside surgical debridement. For the providers in this study, their decision not to use antiseptic agents in all debridement procedures was based on individual clinical judgment, extensive nature of the wound, and risk/benefit of betadine to allow for wound healing.¹¹

Debridement was carried out with either sterile disposable 5-mm curette or scalpel along with other usual instruments. Patients on active anticoagulation did not receive debridements of any kind in the investigators’ practice, and they were excluded from this study. Dissectional debridements were carried out to the plane of tissue that demonstrated visible active bleeding. Hemostasis was obtained with either direct pressure to the wound bed or the application of chemical cautery with silver nitrate. There were no incidents of post procedure wound hemorrhage. At the conclusion of the procedure, dressing choice was dependent on practitioner judgment. Dressing changes were conducted once daily in the nursing facility until the wound epithelialized. Instructions and dressing orders were given to the treatment nurse at the conclusion of the bedside procedure. Figures 1 and 2 show a representative sample of the type of bedside debridement performed.

Management of the 319 individual wound sites met specific requirements that included (1) sharp excisional debridement of devitalized tissue, including slough, necrotic tissue, and bioburden at least once during the care process; (2) daily dressing changes and wound care by a trained nursing home licensed vocational nurse (LVN) or registered nurse (RN); and (3) use of a pressure-reducing specialty mattress.

Assessment of wound status was established via weekly wound measurement and physical examination by a licensed surgeon or physician assistant and a treatment nurse (LVN or RN) at the nursing home.  All measurements were recorded in centimeters as

Length x Width x Depth.

Of the 227 patients identified to have 8 or more visits and PIs in the SSCIT region, there were about 319 individual SSCIT wounds, with an average of 1.4 SSCIT wounds per patient. Bedside surgical debridement was performed using a sharp excisional technique on 190 of 319 (59.5%) SSCIT wounds (Figure 3).  An analysis of the square surface area of the 190 debrided wound sites revealed a mean ulcer surface area of 20.76 cm². From the 190 wounds, 138 (73%) had a reduction in square surface area, and 52 (27%) had no improvement or increase in size and were categorized as nonresponders. Of the wounds that did improve by a reduction in wound surface area, the average wound surface area reduction was 6.81 cm² at 4 weeks (25%), 8.91 cm² reduction at 8 weeks (33%), and 10.87 cm² reduction at 12 weeks (40%) (Figure 4). Out of the 190 wound sites, there were a total of 43 (23%) wounds that had a square surface area of 0 (reepithelialized) with a mean healing time of 137 days (23% healing rate).

Wounds were identified to be either responsive to debridement therapy by a reduction in mean square surface area or nonresponsive. There were 138 responsive sites (73%) versus 52 nonresponsive sites (27%) (Figure 5). Of the 190 sites, 100 (53%) demonstrated a square surface area reduction > 50%. 

The greatest concentration of wounds in this study requiring debridement was located in the sacrococcyx region (n = 66; 35%), with the lowest number located in the trochanter (n = 12; 6%). The odds ratio for responders to nonresponders was 3:1 for ischium, 3:1 for trochanter, 3:1 for sacrococcyx, 3:1 for sacrum, and 2:1 for coccyx. Thus, the odds ratio for coccyx to other sites is 2:3 (67%), making it more than half as likely to improve the coccyx area through debridement than other sites in general.

On average, all wounds in the debridement group received 16.7 debridements. The responder group received an average of 15.7 surgical debridements, and the nonresponder group received 18.2 debridements. The responder group had an average visit count of 19.4 and the nonresponder group had 19.9. For an overall average, patients were seen on a weekly basis for an average of 117.7 days, with a breakdown of 123.8 days for the responder group and 110.6 days for the nonresponder group. Tables 1 and 2 show the breakdown by wound site, delineating the differences in the average number of visits and debridement to achieve healing.

Further examination revealed the average age of the responder group was 67.56 years and 64.97 years for the nonresponder group. On average, the starting wound surface area was 26.21 cm² for the responder group and 12.22 cm² for the nonresponder group. The average starting depth of wounds was 1.33 cm for the responder group and 1.22 cm for the nonresponder group. Enzymatic debriding agents were used during 55% of the visits for the responder group and 62% of the nonresponder group. At the start of treatment, the average amount of granulation tissue for the responder group was 52% and 53% for the nonresponder group; the average amount of necrosis was 13% (responder) and 4% (nonresponder) and slough was 34% (responder) and 40% (nonresponder).

The action of surgical debridement of wounds can produce rapid removal of severely infected tissue, gross slough, necrosis, and devitalized tissue.¹² Currently, practitioners base the decision to debride upon the physical appearance of the wound tissue. It has been elucidated through many previous studies^3-14 that the presence of devitalized tissue can impede wound healing and cause wounds to worsen. To the best of the authors’ knowledge, the exact timing and periodicity of debridement has not been examined in the nursing home population.

Although many protocols and policies exist to prevent PI formation, PIs have not gone away, and the question of how to best care for these wounds with significant tissue compromise remains.¹³ In the present study, the majority of patients responded to bedside surgical debridement in the nursing home setting; 73% of wounds showed a 25% reduction in size within the first month of debridement, while the minority exhibited either no response or worsened. The investigators found that on the whole the wounds that did not reduce in surface area as a result of surgical debridement began with a smaller surface area and less depth. It may be that the nonresponder group had wounds that were worsening and the debridement only managed the degree of necrotic tissue. Since the nonresponding wounds were smaller, they may have not yet manifested the underlying PI at the bony prominence, and they increased in size as the debridement of the underlying necrotic tissue progressed. Overall, the age characteristics of the 2 patient populations were similar. The starting percentage of granulation tissue was nearly equivalent in both groups; therefore, 1 group did not have a better appearance than the other.

This study also demonstrates that each pressure site responded to treatment, though the coccyx sites demonstrating the greatest difficulty to heal. The difficulty of healing coccyx sites may be due to a variety of factors including the greater proximity of the coccyx to the anus, the protrusion of the coccyx bone, the challenge of offloading this area, or other possible factors.

Pressure injuries are chronic wounds, which are defined by the inability to follow an orderly wound-healing pathway.¹⁴ Chronic wounds are stalled in the inflammatory phase of wound healing, making the process of achieving wound healing difficult. This stalled phase is characterized by an increase in matrix metalloproteinases, a decrease in tissue inhibitor metalloproteinases, and abnormal cellular senescence.¹⁵ The biological characteristics of PIs make wound healing challenging.

The present study demonstrates that despite multiple weekly surgical debridements, the vast majority of the wounds did not heal. Providing surgical wound debridement of PIs without consideration of the overall patient condition and the after care of the patient by nursing staff will most likely not lead to optimal wound healing outcomes.  This study did not examine important related factors such as daily nursing care, dressing selection, risk wound healing factors, and patient medical history. Wound healing is a multifactorial process based on both biology and care. As patients age and develop medical problems, their ability to properly heal wounds diminishes. Skin aging causes cellular senescence, a process where the skin cells no longer divide and multiply. The inability of senescent cells to proliferate can impair tissue regeneration after injury, causing prolonged or permanent tissue damage with age. With respect to wound healing, an excessive number of senescent cells may restrict cell proliferation and disrupt paracrine signaling cascades, thereby retarding the ability of wounds to resolve after injury.¹⁶

Wound care providers must work in concert with ancillary staff to provide optimal wound care on a daily basis to provide wound healing to these patients. Proper selection of wound dressings and appropriate care of periwound skin are also important factors of wound healing. Moisture-associated skin damage from both wound drainage and surrounding urinary and fecal contamination may be contributing factors in the impairment of wound healing.¹⁷ In this study, the investigators only examined outcomes of surgical debridement and did not examine other important factors such as nursing care, wound dressing selection, and periwound skin care. Although the aim of this study was to establish baseline healing characteristics in patients who received serial debridement based on visual assessment, further studies must be done to delineate other options to reduce the repetition of tissue breakdown.

In order to heal wounds long term, it is important for wound care practitioners to go beyond the process of surgical debridement in order to provide wound healing. Although surgical wound debridement has been shown to be beneficial in removing necrotic tissue, slough, and infection, it has not demonstrated optimal wound healing in this study.

The results of this study can serve as a guideline for practitioners in the field treating chronic PIs located in the SSCIT region. Practitioners should monitor wound sizes closely for response and efficacy. If practitioners are performing a debridement, they should assess for size reductions at each visit and monitor strategy accordingly.

Further studies may be performed to clarify debridement numbers needed to heal a wound. In addition, studies should examine why certain wounds or patients are harder to heal than others. Takahashi et al¹⁸ found a number of important factors that make wound healing more challenging: number of ulcers per resident, hemoglobin levels, and others. Other results have suggested debridement may induce more immediate wound healing week-to-week, and a “more is better” approach to surgical debridement may be correlated to improved wound healing rates and more frequent wound closure.¹⁹ It is important to reduce wound rates on patients, as this can improve patient morbidity and mortality.

In this study, there were a few limitations. One of which is practitioner compliance in recording correct measurements, tissue percentages, and other data. Practitioners may have used different recording techniques, which may have allowed for error. While the investigators believe this error would have entered into both groups and would not affect the results to the degree that would affect trend observation, it is still a potential limitation.

Between the 2 groups, the responders were seen slightly longer than the nonresponders, indicating that there may have been better follow-up in the first group. Nonresponding wounds must be examined by practitioners for other factors which may inhibit wound healing, such as poor nutrition, inadequate offloading, terminal illness, and multiple comorbidities.

The choice of wound dressing was left to the judgment of individual providers and the results of these dressing choices were not examined, most importantly the enzymatic debridement dressing category. The investigators did not examine response to the enzymatic debriding agents, whether alone or in conjunction with surgical debridement. They did find that enzymatic debriding agents were employed 55% of the time for the responder group and 66% of the time for the nonresponders.

Traditional bedside debridement, a time-proven method, provides excellent results in reducing the square surface area for the majority of wounds. Whether used alone or as an adjunct to any treatment plan, the use of surgical sharp equipment to remove devitalized tissue from the surface of the wound bed aids in achieving good wound healing and advancing the rate of wound closure. Devitalized tissue can retard wound closure and be a source of wound infection and wound inflammation.¹⁴ Rapid removal of these identified barriers to wound healing is easily achieved by sharp debridement. Although wound healing requires many components, using a technique like sharp debridement can effectively remove devitalized tissue and is a proven significant component to advancing wound closure.

Affiliations: Skilled Wound Care, The College of Long Term Care, Los Angeles, CA

Correspondence:
Bardia Anvar, MD
12021 Wilshire Blvd #745
Los Angeles, CA 90025
bardia.anvar@skilledwoundcare.com

Disclosure: The authors disclose no financial or other conflicts of interest.