In September 2018, the Journal of the American Medical Association (JAMA) published a useful article on the management of chronic wounds.
As a Houston, Texas medical malpractice attorney, I regularly handle lawsuits involving inadequate care provided to patients who develop chronic bedsore wounds.
Recently, I settled a case on behalf of a client where bedsores were an issue. The patient walked into the hospital for an orthopedic surgery procedure. After a few days on the acute-care side of the hospital, he was transferred to an inpatient rehabilitation unit for a brief admission. As soon as he arrived on the rehabilitation side, nurses noted that he already had skin breakdown on his bottom, and the sacral area.
What I found strange about that case is that a physical medicine doctor ordered a wound care consultation shortly after the patient arrived at the inpatient rehabilitation unit. A trained wound care consultant saw the patient throughout his admission, but the actual interventions and preventative measures were lacking.
The registered nurses taking care of the patient noted in the medical records that the patient’s pressure wounds were deteriorating, but never notified anyone. It seemed to me that the wound consultants were just going through the motions. In the end, the patient developed severe bedsores that took over three months of inpatient hospital or facility treatment to resolve.
According to the JAMA article, around 4.5 million people in the United States have chronic wounds. In addition to bedsores or pressure injuries, chronic wounds may also be caused by arterial or venous insufficiency, diabetes, the presence of a foreign body, and infection.
Experts recommend that healthcare providers consider different treatments to help chronic wounds heal.
First, the physician or nurse must select the correct wound dressing. The idea behind using wound dressing is to maintain a moist environment for the wound, prevent or treat infection, and reduce friction. For wounds with heavy exudate (secretions), an absorbent dressing is preferred, while dry wounds need a moisturizing dressing, like hydrogel. When wet-to-dry dressings are used, healthcare providers should be careful to make sure that the wound is appropriately moisturized. A dehydrated wound bed is painful and prevents healing.
In some cases, negative-pressure wound therapy, with a wound VAC device, can help a chronic wound heal. The correct way to use a wound VAC device is to apply sterile foam dressing that covers the wound, which is then topped by another film that sticks to the normal skin around the wound. A suction device is applied to the dressing and a drainage tube that connects to a portable vacuum machine. Medical research has established that negative-pressure wound therapy decreases the wound size and healing time, in comparison with standard wound care.
In my experience, patients are particularly at-risk for developing bedsores or pressure injuries when they are immobile or otherwise find it difficult to get up and around. In these situations, the standard of care requires the attending physician to order a pressure-relieving specialty mattress. In addition, nurses must be available to encourage and assist patients in getting out of bed, but when they are unable to do so, they must also reposition them every two hours to minimize the risk of a pressure injury.
Every wound care expert I have ever deposed has agreed that the best way to treat a pressure injury is to avoid it developing in the first place. Therefore, the standard of care requires both physicians and nurses to do a head-to-toe skin assessment of at-risk patients at least once per shift. Then, doctors and nurses need to have robust communication with each other about developments in patient status and needs.
Finally, it seems that healthcare providers in many facilities resort to over-medicating patients who complain of wound pain. Wound experts agree that the sensation of pain is one of the body’s best defense mechanisms. While it is important to keep the patient comfortable, excessive administration of pain killers dulles that sensation and removes critical information from being available to healthcare providers.
Many of these common deficiencies in wound care prevention and treatment emphasize, to me, the importance of patient advocacy. This can be by the patient him or herself, or family member or friend. Be aware of the risks of skin breakdown in pressure injuries and ask questions. If there are concerns about re-positioning, overmedication, or the patient’s skin being kept clean, speak up and even ask to speak to a nursing supervisor, if necessary.
One of the risks of developing a chronic wound is the huge toll it takes on the body to heal it. From a nutritional perspective, the protein and caloric requirements to heal a wound are astounding. In some patients, this can mean a serious bedsore pressure injury that can be a terminal event, leading to death.
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Robert Painter is a medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits against hospitals, physicians, surgeons, anesthesiologists, and other healthcare providers. A member of the board of directors of the Houston Bar Association, he was honored, in 2017, by H Texas as one of Houston’s top lawyers. In May 2018, the Better Business Bureau recognized Painter Law Firm PLLC with its Award of Distinction.