Heel Ulcer Incidence Following Orthopedic Surgery: A Prospective, Observational Study
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A sample of orthopedic patients was followed as they entered or exited acute care hospitals and rehabilitation centers and after they returned home to the community.
Setting. The research took place in an urban center in Ontario, Canada. Two levels of care within three sites in the city were included in the study. One location was an academic tertiary care facility with a total of 850 beds that has two acute care sites in same city. The first acute care site (AC1) features 36 inpatient acute orthopedic surgery beds; in this non-trauma center, 1,300 elective hip and knee replacements are performed annually and 200 patients with fractured hips are treated each year. The second acute care site (AC2) is the trauma center for the region; the orthopedic unit has 35 beds for people undergoing non-elective surgeries and four beds in the Critical Care Trauma Unit. The rehabilitation (Rehab) center has 50 beds and receives most of its patients from AC1. The criteria for admission to rehabilitation are 1) the need for rehabilitation in a center with 24-hour care and/or 2) the need for rehabilitation and simultaneous geriatric inpatient care.
Ethics approval. Before beginning the study, ethics approval for the project was obtained from the research ethics board at the local university as well as the individual review boards at the three hospitals.
Inclusion/exclusion criteria. Recruitment took place at AC2 and the Rehab center. Individuals at AC2 who underwent lower extremity orthopedic surgery due to an elective or emergency procedure were recruited to participate in the study. Participants were included if they were >18 years of age and they or their substitute decision maker provided written informed consent to participate in the research study. Individuals were excluded if they were actively dying, already had a heel ulcer, or if it was impossible to examine their heels due to extreme pain or because a cast or other device covered the heels.
Study design. In this prospective observational study, a convenience sample of patients (n = 72) admitted to AC2 and the Rehab center were approached from December 2006 to August 2007 (see Figure 1). Participants either were discharged directly home from AC2 (n = 15) or were referred to the Rehab site (n = 57) before going home. The majority of study participants (n = 57) were recruited consecutively upon admission to the Rehab center from either AC1 (n = 35) or AC2 (n = 22) and not assessed in AC2; a subset of participants (n = 15) was assessed on admission and discharge form AC2. These participants went directly home and were assessed there 1 month later. If the participant had an HPU on admission to Rehab, it was assumed to have occurred in one of the two acute care sites. Patients were reassessed at discharge from Rehab to see if a HPU had occurred while the patient was in rehabilitation. If a HPU was noted on admission to Rehab, researchers reported whether the HPU evolved or resolved over the course of rehabilitation. Fifteen (15) participants were recruited while in AC2 and were assessed at admission and at discharge or at the average LOS (7 days). Because these patients did not require an inpatient rehabilitation stay, they were discharged and followed at home for 1 month. All but two of the 70 study participants were followed in the community 1 month after discharge from either AC2 or Rehab.
Study procedures. Each individual underwent a bedside assessment, including direct examination of both heels, completion of the Braden Risk Assessment Scale, and a medical chart review. The use of any therapeutic surfaces or heel protective devices also was noted. A skin assessment of both heels was again performed at the bedside on admission at AC2 or Rehab and at discharge from the facility (or after average LOS).