Rachel Pedreira

Efficacy of Monitoring Devices in Support of Prevention of Pressure Injuries: Systematic Review and Meta-analysis.

GENERAL PURPOSE:To present a systematic review of the literature assessing the efficacy of monitoring devices for reducing the risk of developing pressure injuries. TARGET AUDIENCE:This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES:After participating in this educational activity, the participant should be better able to:1. Explain the methodology of the literature review and its results.2. Discuss the scope of the problem and the implications of the research. ABSTRACTOBJECTIVE: To assess the efficacy of monitoring devices for reducing the risk of developing pressure injuries (PIs).DATA SOURCES: The authors systematically reviewed the literature by searching PubMed/MEDLINE and CINAHL databases through January 2016.STUDY SELECTION: Articles included clinical trials and cohort studies that tested monitoring devices, evaluating PI risk factors on patients in acute and skilled nursing settings. The articles were scored using the Methodological Index for Non-randomized Studies.DATA EXTRACTION: Using a standardized extraction form, the authors extracted patient inclusion/exclusion criteria, care setting, key baseline, description of monitoring device and methodology, number of patients included in each group, description of any standard of care, follow-up period, and outcomes.DATA SYNTHESIS: Of the identified 1866 publications, 9 met the inclusion criteria. The high-quality studies averaged Methodological Index for Non-randomized Studies scores of 19.4 for clinical trials and 12.2 for observational studies. These studies evaluated monitoring devices that measured interface pressure, subdermal tissue stress, motion, and moisture. Most studies found a statistically significant decrease in PIs; 2 studies were eligible for meta-analysis, demonstrating that use of monitoring devices was associated with an 88% reduction in the risk of developing PIs (Mantel-Haenszel risk ratio, 0.12; 95% confidence interval, 0.04–0.41; I2 = 0%).CONCLUSIONS: Pressure injury monitoring devices are associated with a strong reduction in the risk of developing PIs. These devices provide clinicians and patients with critical information to implement prevention guidelines. Randomized controlled trials would help assess which technologies are most effective at reducing the risk of developing PIs.

Unintended consequences of quality improvement programs on the prevention of hospital-acquired conditions: Avoiding the temptation to bite into low-hanging fruit:

Hospital-acquired conditions such as pressure injuries, falls, and infections are common, costly, and deadly. Addressing the simultaneous needs of evidence-based prevention guidelines for multiple conditions can be challenging for clinical teams. Current payment incentives created by The Centers for Medicare and Medicaid Services using the Agency for Healthcare Research and Quality Patient Safety Indicator 90 (PSI90) measure impact how clinical resources are allocated by prioritizing conditions that are simpler and less costly to prevent. Pressure injury prevention guidelines may be one of the more complex programs for hospitals to implement due to the financial investment in nursing time and technology. However, a quality improvement program focused around pressure injury prevention holds good value by tackling many of the tangential conditions caused by issues related to the decubitus patient and mobility, including fall injury, venous thromboembolism, catheter-associated urinary tract infection, and sepsis. Hospitals should reconsider their prioritization of different patient safety indicators, and The Centers for Medicare and Medicaid Services should create more focused payment incentives on harmful hospital-acquired conditions such as pressure injury that are independent of composite measures of harm, including PSI90.

Abstract 8.40 A POST-OPERATIVE PROTOCOL FOR AUTOLOGOUS FREE FLAP BREAST RECONSTRUCTION OPTIMIZING RESOURCES AND PATIENT SAFETY

METHODS: A Markov model was used to simulate the effects of standard prevention compared to tibial neurolysis on the long-term costs associated with foot ulcers and amputations. This model included eight health states. A baseline analysis was built on a five-year model to determine the cumulative incidence of foot ulcers and amputations with each strategy. Subsequently, a cost-effectiveness analysis and cohort-level Markov simulations were conducted with a model composed of 20 six-month cycles. The outcomes explored were quality adjusted life years (QALYs); the incremental cost-effectiveness of tibial neurolysis in comparison with standard treatment and the net monetary benefits of tibial neurolysis. A sensitivity analysis was also performed.

Abstract P11. Craniosynostosis Surgery: A Painless Procedure? A Single Institution’s Experience in Post-operative Pain Management

RESULTS: A total of 46,617 patients with orofacial clefts were identified, 14.6% with isolated cleft lip (CL), 51.7% with cleft lip and palate (CLP), and 33.7% with isolated cleft palate (CP). The incidence of patients requiring EFA increased from 2000 (3.7%) to 2012 (5.8%) (p<0.001). After controlling for comorbidities, the incidence was again found to increase throughout the study period (3.3% to 5.0%, p<0.001). Patients with comorbidities were noted to have higher rates of EFA that increase significantly between 2000 and 2012 (12.8% to 18.6%, p=0.019). Treatment in an urban teaching hospital was an independent risk factor for EFA (OR 4.65). Race and income were not independent risk factors.

Surgical Factors Associated with Prolonged Hospitalization after Reconstruction for Oncological Spine Surgery

Background: Posterior trunk reconstruction is increasingly possible as a result of advances in spinal instrumentation, reconstructive approaches, and perioperative critical care. Extensive cases often require a muscle flap or complex closure to obliterate dead space. Postsurgical wound complications and subsequent reoperations can lead to neural injury, higher hospital costs, and longer hospitalizations. We aim to identify risk factors that are associated with increased length of stay (LOS) for patients receiving flaps to close a spinal defect. Methods: A single institution, retrospective cohort study was performed on all patients from 2002 to 2014 who received a muscle flap to close a spine defect. Medical and perioperative variables that were significantly associated with LOS (P < 0.05) in univariate analysis were included in a stepwise regression model. Results: A total of 288 cases were identified. Presence of instrumentation, preoperative chemotherapy, wound dehiscence, cerebrospinal fluid leak, partial/total flap loss, and medical morbidity occurrence were all independently associated with increased LOS in a combined multivariate model (P < 0.02 for each of the 6 variables). Importantly, Kaplan–Meier analysis demonstrated that postoperative wound dehiscence increased LOS by 12 days. Conclusions: Spinal tumor resections often create large cavitary defects that necessitate the use of muscle flaps for closure. Patients who have received adjuvant chemotherapy require instrumentation, or those who develop specific wound-related or medical complications are at increased risk for prolonged hospitalization after spinal reconstruction. Thus, implementing measures to mitigate the occurrence of these adverse events will reduce costs and decrease the length of hospitalization.

Use of a Multivector Mandibular Distractor for Treatment of Pediatric Proximal Interphalangeal Joint Pilon Fractures: A Case-Based Review

Background The difficulties in surgical treatment of pilon fractures of the finger include fragment reconstitution and posthealing stiffness. In adults, external fixation with traction and early active range of motion (AROM)/passive range of motion (PROM) during healing is considered necessary for avoiding joint stiffness and attaining realignment. The authors present a unique approach to pediatric pilon fractures that uses open reduction and multivector external fixation with delayed AROM/PROM. Initial immobilization and significant traction allowed for joint realignment and prevented noncompliance with staged distraction. The authors believe this immobilization leads to a superior outcome because, unlike adults, children tend to avoid stiffness and a larger distraction force allowed for sufficient joint realignment to regain range of motion (ROM). Methods A right-handed 13-year-old boy sustained a right ring finger fracture and presented 12 days later. Radiographs revealed a comminuted Salter-Harris 4 fracture of the middle phalanx. The patient underwent open reduction and placement of multivector external fixation using a pediatric mandibular distractor/fixator. Significant traction was applied to distract the finger to length. Results Hardware was removed 6 weeks postoperatively and AROM was initiated after splinting. The patient started PROM 8 weeks postoperatively. Strengthening was initiated 2 weeks later. ROM improved and rehabilitation was continued. The patient exhibited nearly equal grip strength 12 weeks postoperatively. At 14 months follow-up, radiographs showed complete healing and joint realignment. There was no deformity or pain and finger length was restored. Conclusion Management of pediatric pilon fractures is rarely described and presents unique considerations. Early-stage traction and immobilization using a multivector mandibular fixator/distractor is suitable in a child because noncompliance is avoided and there is a decreased risk for stiffness. Combining early immobilization with subsequent-staged AROM, PROM, and strengthening resulted in no loss of ROM and maintained articular symmetry.