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72-year old female history spina bifida, has been wheelchair-bound for last 10 years. Has long-term colostomy and had suprapubic urinary cath placed about a year ago but still leaking urine from urethra (free-flowing urine, actually). Has been coming to hospital outpatient services 3-5 times a week for 1-1/2 years for unhealable/maintenance stage IV ischial pressure ulcer with copious drainage. The patient is unable to transfer from her wheelchair without friction/shear forces. She states that she transfers to bed at night, “usually;” I’m not so sure. She is in the wheelchair (she does have a foam cushion) at least 16-18 hours a day, at least. She has been encouraged to spend some daytime hours in her bed for pressure relief, but she does not.
Wound care is part of our Critical Access hospital outpatient services. There are no certified wound care nurses or physicians within 200 miles. The local general surgeon refused the referral. The patient refuses home health care (hospital has a shuttle service that gets her in for her appointments), refuses to go out of area for surgical attention/LTAC (fearful that if she leaves town she will never come back home).
At outset the wound measured 4 cm X 3 cm X 3.5 cm with a 3 cm tunnel and ~2 cm undermining and epibolic edges. The observable wound bed is smooth, shiney sometimes red, sometimes pale/grayish at the base. Currently the wound is 3.5 cm X 3 cm X 2.5 cm with a 2.2 cm tunnel and 3 cm undermining and epibolic edges. The periwound skin is remarkably resilient and intact. The family practice doc has used silver nitrate on the wound edge a couple of times....

We have used silver hydrofiber, mupirocin, iodoform packing strip at intervals as the contact layer, with hydrofiber and/or gauze filler and foam with adherent silicone foam secondary dressings. NO dressing has ever stayed on longer than 12 hours, so her wound is continuously contaminated with urine (at best).

Any suggestions?
Jun 9, 2020 by Kathryn , RN, BSN, PHN MBA
9 replies
Samantha Kuplicki
MSN, APRN-CNS, AGCNS-BC, CWS, CWCN-AP, RNFA
Hi Kathryn, thanks for your question! My first inclination is to rule out any sort of bone involvement or osteomyelitis. If this workup is negative, I recommend initiating NPWT to isolate the area from contamination and assist with granulation tissue formation. This is an off label use, but also consider applying the foam to the roller/stalled edges of the wound in order to stimulate acute healing--much in the same way AgNO3 is used. Since she already comes to the clinic on a regular basis--3x/week changes shouldn't be problematic. I would ask she wear some sort of silk undergarments or slips if possible to reduce shear and dislodgement of the vac drape. This may be a challenged due to incontinence but it could be of assistance. I'm sure others will have some great input as well. Also, nutrition should be as good as possible so might explore that avenue as well. Might she be a candidate for a suprapubic catheter? Just some thoughts. This all, of course, will be less useful if she is not able to offload properly. You might discuss with her that improper offloading will likely eventually lead to loss of independence, which seems to be a motivating factor for her.
Jun 9, 2020
Kathryn
RN, BSN, PHN MBA
Thank you so much for your quick response, Samantha! Good idea for the osteomyelitis eval. I have thought that the NPWT is our final viable option and appreciate the suggestion of foam contact with the epibole. She already has a suprapubic catheter but still free-flowing urine from her urethra. Her urologist flies in once a month from the other side of the continent, and I have suggested that she ask him about whether a bladder neck procedure might be appropriate, but nothing has happened so far with that. She wears an incontinent brief with 4 layers of peripads added (yes, really) and I was able to finally get her out of sweatpants and into a skirt instead. She takes meals-on-wheels and also gets food sometimes from the soup kitchen run by the church next door to where she lives. I have discussed ad nauseum offloading, and she had a physical therapy home visit X1 for eval and HEP, then no more. When she comes to the outpatient clinic, she prefers to lean over the bed rather than get into the bed for her wound care, since lateral transfer is more difficult. I'm sort of at my wits' end, and out of ideas. I'd like to figure out how we could get her admitted for 3 days to subacute, get the V.A.C. on her, then move her to swing bed, and then, if the wound isn't healed yet, to the local SNF. Nobody wants her.
Jun 9, 2020
Kathryn
RN, BSN, PHN MBA
I don't want to wait until she becomes septic.
Jun 9, 2020
Samantha Kuplicki
MSN, APRN-CNS, AGCNS-BC, CWS, CWCN-AP, RNFA
Unfortunately sounds like the type of patient that may have to decline to that point to get to the plan of care she needs. My background is CAH wound care as well and these are some of the toughest patients. The latter part about subacute and getting vac was exactly my initial thought, but it didn't sound like she would voluntarily agree. Has she tried any type of female wicking catheter device instead of peripads? That way she could maybe decrease to changing clothing when incontinent of stool. I would find a way to at minimum get her into bed for eval and ease of dressing placement. Maybe pick the top 3 things that MUST change to continue her care and speak to her about not being able to be seen if she is willingly non adherent with plan of care. I have to have the discussion with my CAH patients especially that I cannot continue to bill their insurance for service that I'm incompletely providing and demonstrating that the plan of care is not progressing. It's a hard conversation but I've been there multiple times.
Jun 9, 2020
Samantha Kuplicki
MSN, APRN-CNS, AGCNS-BC, CWS, CWCN-AP, RNFA
Unfortunately sounds like the type of patient that may have to decline to that point to get to the plan of care she needs. My background is CAH wound care as well and these are some of the toughest patients. The latter part about subacute and getting vac was exactly my initial thought, but it didn't sound like she would voluntarily agree. Has she tried any type of female wicking catheter device instead of peripads? That way she could maybe decrease to changing clothing when incontinent of stool. I would find a way to at minimum get her into bed for eval and ease of dressing placement. Maybe pick the top 3 things that MUST change to continue her care and speak to her about not being able to be seen if she is willingly non adherent with plan of care. I have to have the discussion with my CAH patients especially that I cannot continue to bill their insurance for service that I'm incompletely providing and demonstrating that the plan of care is not progressing. It's a hard conversation but I've been there multiple times.
Jun 9, 2020
Elaine Horibe Song
MD, PhD, MBA
Hi Kathryn

Sounds like a challenging situation indeed, especially because the patient refuses to offload and there is this constant flow of urine into the wound. Samantha's suggestions are great, I know she has lots of experience in CAH settings. I'd echo what she mentioned, if patient is not able to offload properly or remove other co-factors that impede healing, it'll be hard to get the ulcer healed. Guidelines recommend against sitting on wheelchairs for patients with Stage IV PU/PI. She'd need to be on a group 2 support surface, adhere to repositioning schedule, and have incontinence managed (as mentioned, a female wicking catheter like the purewick system could help in this case while she waits for the next intervention by her urologist). If patient agrees, your idea of getting her admitted so that wound vac can be applied, and she can be properly offloaded, etc, could be a good option at this point. And if pt. needs to be convinced, Samantha's points can be pretty helpful.

A few resources: 
- Assessment of infection/osteo in PU/PI: https://woundreference.com/app/topic?id=pressure-ulcersinjuries-introduction-and-assessment#infection-associated-with-pu/pi29
- NPWT for PU/PI: https://woundreference.com/app/topic?id=pressure_ulcer_injury_treatment#biophysical-interventions
- Plan reassessment for PU/PI: https://woundreference.com/app/topic?id=pressure_ulcer_injury_treatment#plan-reassessment
Jun 9, 2020
Kathryn
RN, BSN, PHN MBA
Samantha, I do think she would consent to admission to our hospital, and even to the local SNF; she's just very afraid of being transferred out of area. Do you have any ideas about how we could convince the hospitalist to take her on for the 3-day acute and then swing bed until SNF has a bed? Our RHC coordinator has told me that the SNF "doesn't take patients with wounds," but the doc that does wound care in our outpatient department does wound care once a week at the SNF, so that information doesn't jibe. Clearly, I can't get cooperation from the clinic coordinator, so have to find some kind of back door.
Jun 9, 2020
Elaine Horibe Song
MD, PhD, MBA
Chatted with Cathy Milne, APRN, just wanted to add a couple of comments she made:  
Since this patient has a high likelihood of having osteo, it'd be important to get the workup for osteo done first before considering wound vac. [If osteo is present, it'll be easier to get her admitted, but in this case, it'll likely be for debridement, systemic antibiotics and wound vac or flap when osteo is controlled]. If osteo not present, wound vac is a possibility. Regardless, patient needs to get offloading strategy taken care of prior to procedure so that the main cause of PU/PI can be treated and recurrence avoided. Wheelchair pressure mapping is recommended - even if the ulcer eventually heals, she'll develop it again if not on adequate wheelchair. Another question Cathy asked is whether the patient's paraparesis is flaccid or spastic - if spastic, can have a physiatrist evaluate for botox injections. Cathy also recommended emphasizing that her refusal to offload will lead to serious consequences such as osteo, bladder/bowel/systemic infection, and so forth. Even if she gets admitted, there is no guarantee that she won't be sitting on her wheelchair all day if she doesn't understand/want to adhere to the offloading/repositioning plan.
Jun 9, 2020
Kathryn
RN, BSN, PHN MBA
Thank you, everyone! I'll discuss these comments with the physician. I appreciate all of your time and consultation. This is a great forum!
Jun 10, 2020
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