Temple University School of Podiatric Medicine Journal Review Club

Editor's note: This post is part of the Temple University School of Podiatric Medicine (TUSPM) journal review club blog series. In each blog post, a TUSPM student will review a journal article relevant to wound management and related topics and provide their evaluation of the clinical research therein.

Article Title: Pressure Injury Progression and Factors Associated With Different End-Points in a Home Palliative Care Setting: A Retrospective Chart Review Study Authors: Artico M, D’Angelo D, Piredda M, et al

Journal: J Pain Symptom Manage 2018;56(1):23-31

Reviewed by: Arden Harada, class of 2021, Temple University School of Podiatric Medicine

Introduction

In the setting of palliative care, there are several risk factors for developing pressure injuries, which include immobility, skin moisture, and poor nutrition. With the fragile and severe state of these patients, the aim of the palliative care team shifts toward maintenance and stabilization of wounds instead of prevention of pressure injuries. Both professionals and home caregivers must work together to improve patient outcomes and deliver high-quality wound care. Initially, the plan of wound care may be to heal the injury; however, when this is not possible, the goal shifts toward wound palliation. This study evaluated data on pressure injury healing rates in a mixed setting of home and/or hospital care. The first aim evaluated the proportion of healed pressure injuries in home palliative care service and characterized injuries that did not heal. The second aim was to identify predictive or associative factors of caregivers and patients by looking at the outcomes of wound healing.

Palliative vs. Curative Wound Care

Methods

Using STROBE (STrengthening the Reporting of OBservational studies in Epidemiology) recommendations, a retrospective chart review was conducted on home palliative care settings in rural northeastern Italy over three years. The charts included patients who had at least one pressure injury, survived six months or less, and died in their home under palliative care or were transferred elsewhere but died within seven days. The professional team involved nurses, physicians, psychologists, and nurse assistants. Worldwide-accepted guidelines were followed in educating home caregivers about wound prevention strategies, and all patients had a pressure redistribution device available. Wound palliation prioritized pain reduction and control of exudate and odor.

Depending on the condition of the patient, professionals visited the home from once per week to daily. Wound healing was staged 1 to 4 according to the National Pressure Ulcer Advisory Panel (NPUAP), in which stage 1 identified resolution of non-blanchable erythema and changes in temperature or firmness. Healing stages 2 to 4 considered the amount of complete re-epithelialization of skin. The Pressure Ulcer Scale was used to score any changes to the wound, including size, exudate amount, and tissue type. Patient data included age, diagnoses, body mass index (BMI), Braden Scale for Wound Healing, and Karnofsky performance status (signified status in palliative care). Variables of the home caregiver involved number per patient, family role, gender, and age of main caregiver. Analysis of data used IBM SPSS statistics software, and a P value <0.05 was accepted.

Results

Following the inclusion criteria, 124 of 669 patient charts were evaluated. Over the study period, 38 pressure injuries reached stage 1 or 2 of wound healing. A total of 118 pressure injuries had varied results, in which 75 were deteriorating. Stage 3 and 4 injuries were present at intermediate end points, in which no complete healing occurred once patients reached their last weeks of life. In addition, wound healing improved in patients younger than 70 years, with a BMI >15 and <30 kg/m2, and with artificial nutrition. Patients under deep sedation had poor outcomes with healing and an increased risk of wound deterioration. In consideration of the quality of the main caregiver, there were two statistically significant groups, male caregivers and spouses, with doubled wound healing rates.

Conclusion

This study provided an insight into wound healing within the palliative care setting. With appropriate care, an NPUAP stage 1 wound has a decreased risk of injury progression, and relief of symptoms was possible. Stage 1 and 2 wounds were completely healed, and this healing can be considered a realistic goal within two weeks. With continued palliative care, there was a progressive loss of BMI secondary to decreased appetite. The study found a higher percentage of artificial nutrition provided in the home palliative care setting that also helped in wound healing rates. Weight and BMI were predictive factors in complete wound healing; these findings require further investigation to potentially improve patient care. The characteristics of caregivers, including men and spouses, had contributed to the healing rate and success of the palliative wound care. Future studies are needed to confirm gender association of caregivers to better educate in home care settings. The limits of this study include use of retrospective methods to evaluate data and small sample size. This evidence offers an appropriate goal of care and management strategies for wound care in end-of-life patients.

About the Author

Arden Harada is a second-year student at Temple University School of Podiatric Medicine (TUSPM) in Philadelphia. She graduated from the University of Portland, Oregon in 2016 with a Bachelor of Science in Biology. She writes article reviews and blog posts on several topics in podiatry, including dermatology and surgery. Arden holds a keen interest in diabetic limb salvage, wound care, and reconstructive surgery and strives eventually to return home to Hawaii to care for the growing underprivileged diabetic community. Dr. James McGuire is the director of the Leonard S. Abrams Center for Advanced Wound Healing and an associate professor of the Department of Podiatric Medicine and Orthopedics at the Temple University School of Podiatric Medicine in Philadelphia.