Integrated clinical care pathway for managing necrotising soft tissue infections

Identify Early and Involve Everyone: Interdisciplinary Comprehensive Care Pathway Developed for Inpatient Management and Transitions of Care for Heart Failure Patients Reported Using SQUIRE 2.0 Guidelines

Introduction

Heart failure accounts for 1-2% of overall healthcare costs. While the link between re-hospitalization and mortality is unclear, care pathways that standardize inpatient management and establish outpatient follow-up improve patient outcomes and reduce morbidity.

Aim

To implement a comprehensive interdisciplinary care pathway for heart failure patients with the goal of optimizing inpatient management and improving transitions of care.

Methods

To address this clinical need, New York-Presbyterian Brooklyn Methodist Hospital (NYP-BMH) identified resources needed to optimize patient care, developed an inpatient admission order set (so-called “power plan”), and implemented a multidisciplinary clinical care pathway. The Plan-Do-Study-Act cycle addressed the implementation obstacles. Interdisciplinary rounds guided day-to-day management and addressed barriers. Our team developed a sustainable care pathway, and measured the utilization of pharmacy, nutrition, physical therapy, case management, and social work resources; outpatient appointments were made prior to discharge. We used the Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 guidelines to guide our planning and evaluation of this quality improvement initiative.

Results

Our intervention markedly increased the number of heart failure hospitalizations that were identified on admission, and the use of pharmacy/nutrition services was greater after the intervention. The utilization of our “power plan” promoted adherence to a series of evidence-based best practices, but these measures had no significant impact on readmissions as a whole. The involvement of the case management support team increased outpatient appointments made for patients prior to discharge and aided in the transition of care from inpatient to outpatient management.

Conclusion

The management of heart failure patients starts in the hospital and continues in the community. Patients who are treated in a standardized dedicated care pathway have reduced morbidity and better outcomes. Identifying these patients early, involving a comprehensive team, and transitioning their care to the outpatient setting improves the quality of care in these patients.

Determinants of Mortality in Necrotizing Soft Tissue Infections

Background

Necrotizing soft tissue infections (NSTI) are frequently encountered, with a high mortality despite advances in health care.

Material and Methods

Patients presenting with NSTI were prospectively followed up in an attempt to identify factors that were significantly associated with mortality.

Results

There were a total of 86 patients [65 males (75.6%) and 21 females (24.4%)] with an overall mortality of 33.7% (29 patients). The average age was 50.37 years and trauma was the commonest aetiology (34 patients, 66.7%). The average duration of symptoms prior to presentation was 10.56 days; the lower limb was most commonly involved (62 patients, 72.09%). Fifty nine patients had comorbidities (commonest being diabetes mellitus in 41). Age above 50 years, symptoms for more than 8.5 days, involved surface area more than 15.5%, of the total body surface, on-admission pulse rate more than 99 beats/minute, systolic blood pressure less than 103 mm Hg, Glasgow scale less than 12, need for inotropes, low hemoglobin, high leukocyte counts, uraemia, deranged coagulation, low serum albumin, and high levels of lactic acid were significant for mortality. On multivariate analysis, only age above 50 years, presence of acidosis and low serum albumin significantly affected survival.

Conclusion

NSTI carry high mortality. The identification of potential risk factors associated with mortality might help in guiding and optimizing the management of patients who present with NSTI.

A special case: treatment of a patient with necrotising fasciitis

The case study in this article describes the rapid and accurate diagnosis of a critically ill patient with necrotising fasciitis (NF). Full-thickness patchy skin necrosis of the right thigh, buttock and flank was detected on admission. Prompt radical debridement together with aggressive fluid resuscitation and broad-spectrum antibiotic administration was initiated. Case ascertainment was used to evaluate the effectiveness of a debridement and wound treatment regime,using a monofilament debridement product, negative wound pressure treatment and, after the critical period had ended, a bio-cellulose+ polyhexamethylene biguanide (PHMB) dressing, followed by a collagen dressing. NF after open haemorrhoidectomy represents a life-threatening complication to otherwise healthy patients. Accurate diagnosis, prompt critical care and surgical treatment, together with debridement using the monofilament product and effective wound bed preparation, lead to a successful outcome.

Necrotizing Fasciitis: A Study of 48 Cases

Necrotizing fasciitis represents a group of highly lethal infections characterized by rapidly progressing inflammation and necrosis. The aim of the study was to analyze the clinical profile, microbial flora, and predisposing risk factors in patients with necrotizing fasciitis. Lastly, we aimed to formulate a protocol for management of necrotizing fasciitis. Forty-eight cases of necrotizing fasciitis patients who reported to our hospital between April 2007 and September 2009 were included in the study. The commonest predisposing factors were age greater than 50 years (58 % cases) and diabetes mellitus (52 % cases). The commonest site involved was extremity (70.8 %). Majority of infections were polymicrobial (87.5 %). Repeated aggressive debridement was the commonest surgical procedure performed. Early and aggressive surgical debridement, often in multiple sittings, supplemented by appropriate antibiotics and supportive therapy, forms the key to a successful outcome in necrotizing fasciitis.