Non traumatic lower extremity amputations in younger patients: an 11-year retrospective study.

The purpose of this study was to assess morbidity and mortality in patients undergoing non traumatic lower extremity amputations ≤65 years to identify the specific needs of these younger patients. A retrospective study was conducted to determine the demographics, comorbidity and mortality with below-knee amputations and above-knee amputations from 1998 to 2008. A total of 203 amputations were performed on 176 patients who were ≤65 years. Major comorbidities and associated physical findings were peripheral vascular disease, diabetes, pain, gangrene, hypertension, ulcer, local wound infection and hypercholesterolemia. Compared to patients who were not deceased post-amputation, those deceased had a higher prevalence of diabetes, renal failure, coronary artery disease (CAD) and sepsis. Significant predictors of mortality were renal failure (hazard ratio [HR] = 4·19; 95% CI 1·96-8·93), CAD (HR = 3·33; 95% CI 1·42-7·81) and amputation site (above-knee) (HR = 3·26; 95% CI 1·51-7·04). This study showed that younger patients may benefit from an interdisciplinary approach in treating local foot ulcers aggressively and optimising their cardiovascular, renal and diabetic risk factors.

Early prevention of pressure ulcers among elderly patients admitted through emergency departments: a cost-effectiveness analysis.

STUDY OBJECTIVE: Every year, approximately 6.2 million hospital admissions through emergency departments (ED) involve elderly patients who are at risk of developing pressure ulcers. We evaluated the cost-effectiveness of pressure-redistribution foam mattresses on ED stretchers and beds for early prevention of pressure ulcers in elderly admitted ED patients. METHODS: Using a Markov model, we evaluated the incremental effectiveness (quality-adjusted life-days) and incremental cost (hospital and home care costs) between early prevention and current practice (with standard hospital mattresses) from a health care payer perspective during a 1-year time horizon. RESULTS: The projected incidence of ED-acquired pressure ulcers was 1.90% with current practice and 1.48% with early prevention, corresponding to a number needed to treat of 238 patients. The average upgrading cost from standard to pressure-redistribution mattresses was $0.30 per patient. Compared with current practice, early prevention was more effective, with 0.0015 quality-adjusted life-days gained, and less costly, with a mean cost saving of $32 per patient. If decisionmakers are willing to pay $50,000 per quality-adjusted life-year gained, early prevention was cost-effective even for short ED stay (ie, 1 hour), low hospital-acquired pressure ulcer risk (1% prevalence), and high unit price of pressure-redistribution mattresses ($3,775). Taking input uncertainty into account, early prevention was 81% likely to be cost-effective. Expected value-of-information estimates supported additional randomized controlled trials of pressure-redistribution mattresses to eliminate the remaining decision uncertainty. CONCLUSION: The economic evidence supports early prevention with pressure-redistribution foam mattresses in the ED. Early prevention is likely to improve health for elderly patients and save hospital costs.

Support surfaces for intraoperative prevention of pressure ulcers in patients undergoing surgery: a cost-effectiveness analysis.

BACKGROUND: Patients who undergo prolonged surgical procedures are at risk of developing pressure ulcers. Recent systematic reviews suggest that pressure redistribution overlays on operating tables significantly decrease the associated risk. Little is known about the cost effectiveness of using these overlays in a prevention program for surgical patients. METHODS: Using a Markov cohort model, we evaluated the cost effectiveness of an intraoperative prevention strategy with operating table overlays made of dry, viscoelastic polymer from the perspective of a health care payer over a 1-year period. We simulated patients undergoing scheduled surgical procedures lasting ≥90 min in the supine or lithotomy position. RESULTS: Compared with the current practice of using standard mattresses on operating tables, the intraoperative prevention strategy decreased the estimated intraoperative incidence of pressure ulcers by 0.51%, corresponding to a number-needed-to-treat of 196 patients. The average cost of using the operating table overlay was $1.66 per patient. Compared with current practice, this intraoperative prevention strategy would increase slightly the quality-adjusted life days of patients and by decreasing the incidence of pressure ulcers, this strategy would decrease both hospital and home care costs for treating fewer pressure ulcers originated intraoperatively. The cost savings was $46 per patient, which ranged from $13 to $116 by different surgical populations. Intraoperative prevention was 99% likely to be more cost effective than the current practice. CONCLUSION: In patients who undergo scheduled surgical procedures lasting ≥90 min, this intraoperative prevention strategy could improve patients' health and save hospital costs. The clinical and economic evidence support the implementation of this prevention strategy in settings where it has yet to become current practice.

Health policy and the delivery of evidence-based wound care using regional wound teams.

As clinicians practicing wound management in all three sectors of the healthcare system, the authors have articulated specific issues relating to wound management. There is a lack of awareness of the extent of the problem. Best practice guidelines have been developed, however, their adoption and transfer into practice have been inconsistent. Basic education in the field is minimal or absent across all disciplines. Institutions and agencies lack the infrastructure and financial resources to support optimal healthcare delivery in wound prevention and management. As a result, there are significant problems and inconsistencies in access to wound care across Ontario. This paper reviews the issues and background as related to pressure ulcer, diabetic foot ulcer and venous leg ulcer. Finally, the authors make specific health policy recommendations regarding the implementation of regional wound care teams.

Vacuum-assisted wound closure of deep sternal infections in high-risk patients after cardiac surgery.

BACKGROUND: Sternal wound infections are a serious complication arising from cardiac surgery. Recently, the general application of negative pressure to wounds by vacuum-assisted closure (VAC) therapy has shown enhanced granulation and wound contraction. Here we examine the effect of VAC on sternal wounds. METHODS: We collected and statistically analyzed quantitative VAC performance data and outcomes with a retrospective review on a consecutive cohort of 22 patients treated with VAC for post-cardiac surgery wound complications. RESULTS: Sternal wound infections became evident on average at 21.0 days after surgery, associated with dehiscence (82%), sternal instability (59%), fluid collection by computed tomography (73%), and osteomyelitis (41%). Cultures most commonly identified Staphylococcus aureus (50%). Prompt irrigation and debridement were performed on all patients, and VAC therapy was applied at approximately 7.3 days after diagnosis. Vacuum-assisted closure induced granulation of 71% of the sternal wound area by 7 days, with a daily drainage of approximately 84 mL. By 14 days, there was a 54% reduction in wound size, and patients were discharged after approximately 19.5 days and placed on home therapy. Vacuum-assisted closure was discontinued at approximately 36.7 days with an average reduction in sternal wound size of 80%. Extensive secondary surgical closure, requiring muscle flaps, was avoided in 64% of patients, whereas 28% of patients required no surgical reconstruction for wound closure. No complications were related to VAC use. CONCLUSIONS: In contrast to our earlier studies, adjunctive VAC therapy markedly reduced required surgical interventions, reoperation for persistent infections, and the hospitalization period. Thus, VAC provides a viable and efficacious adjunctive method by which to treat postoperative wound infection after medial sternotomy.