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A multidisciplinary quality improvement approach to pressure sore consults: Enhancement in care delivery to this vulnerable patient population.
Ping Song MD, Sydney Sawyer BS, Ashley Truong BS, Andrew Li MD, Michael Wong MD University of California Davis, Sacramento CA

Background: The goal of this project is to evaluate the effect of our institution's quality improvement initiate to streamline the initial workup and treatment planning for patients presenting to the UCD ED with a diagnosis of pressure sore. Historically, half of all pressure sore consultations seen by the PRS service had concomitant systemic signs of infection. Furthermore, half of these patients were eventually diagnosed as having and treated for a urinary tract infection or urosepsis, or a total of 25% of all presenting patients with a pressure sore had urosepsis. The authors implemented an algorithmic approach, including point-of-care urinalysis, during initial evaluation in the emergency department. Furthermore, if two or more SIRS criteria were met, the patient must have a targeted sepsis workup prior to Plastic and Reconstructive Surgery (PRS) consultation. If all other sources of SIRS are ruled out, then the pressure sore should be evaluated as an explanation, potentially prompting more urgent debridement. The authors goal is to optimize the evaluation and treatment planning for patients who present to the ED with concomitant diagnosis of pressure sores.

Methods: We retrospectively identified patients who presented to the UC Davis ED with a pressure ulcer and seen by the Plastic and Reconstructive Surgery (PRS) Team from June 2016 to May 2017 (n=36). Patients characteristics were defined using summary statistics and their SIRS criteria analyzed. A new algorithm for triaging pressure ulcer patients was implemented in June 2017. A second retrospective review of a prospectively kept database of patients who presented to the UC Davis ED with a pressure ulcer and seen by the PRS Team from June 2017 to March 2020 was performed. Summary statistics and a descriptive analysis was conducted to examine the effect of the new algorithm on patient care.

Results: From June 2016 to May 2017, fifty percent of pressure ulcer plastic consults patients (18/36) met SIRS criteria at ED presentation. Of these SIRS patients, 9 (50%) had a diagnosis of urinary tract infection or urosepsis, 6 (33.3%) had sepsis of undefined origin, and 3 (16.7%) had other diagnoses such as osteomyelitis or acute respiratory distress syndrome. After implementation of the new care algorithm, there was an 87.75% reduction in total pressure sore consults per month. Only 6 (24%) patients met SIRS criteria.

Conclusion: Our multidisciplinary approach to the improvement in evaluation and treatment of patients who present to the ED with concomitant pressure sores suggest that these patients received more appropriate and expeditious care at time of initial presentation. The implementation of this new algorithm using coordinated efforts significantly improved the efficiency of patient care by allowing for underlying inflammatory concerns to be addressed first. Our findings form the foundation to improve the overall care delivery to this vulnerable patient population both in patient experience and resource utilization.

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