Developing and evaluating outcomes of an evidence-based protocol for the treatment of osteomyelitis in Stage IV pressure ulcers: a literature and wound electronic medical record database review.

Osteomyelitis affects up to 32% of full-thickness pressure ulcers and increases treatment costs and the risk of systemic complications. Current diagnosis and treatment practices are variable. A literature and retrospective chart review, using a wound electronic medical record (WEMR), were conducted to develop an evidence-based protocol of care for treatment of osteomyelitis in pressure ulcers and to evaluate outcomes of care. The seven steps in the protocol of care include: 1) acknowledgment of osteomyelitis risk in patients with Stage IV pressure ulcers, 2) clinical evaluation for local or systemic signs of infection upon initial presentation, 3) radiographic evaluation (magnetic resonance imaging or bone scan), 4) surgical debridement to remove all nonviable tissue and/or scarred and infected bone, 5) obtaining pathology reports from sterile bone biopsy and deep microbial cultures, 6) targeted systemic antimicrobial therapy, and 7) tissue reconstruction following resolution of infection. WEMR data review (177 patients) identified 50 patients with osteomyelitis (prevalence 28%). Of those, 41 underwent 87 bone debridements for osteomyelitis. Eight (20%) patients experienced complications elated to treatment. Average time to discharge following debridement was 4.3 +/- 5.7 days and 76% of wounds with more than two consecutive WEMR entries showed a decrease in area at their final visit. The outcomes observed are encouraging and the WEMR facilitates implementation and evaluation of the treatment protocol. Ongoing data acquisition will help assess outcomes and refine the current management protocol and should improve diagnosis and care.