Almost 6 percent of the world population and over 9.3 percent of the population of the United States have been diagnosed with type 2 diabetes.1–3 Furthermore, the frequency of pre-diabetes in the U.S. is greater than 14 percent.1–3 Of those diagnosed with diabetes, approximately 25 percent will develop a diabetic foot ulcer (DFU) over their lifetime with over 30 percent of those experiencing recurrent ulcerations.4
With the increasing incidence of DFUs, hospitalization rates for the treatment of DFUs are also rising.5 Hospitalization and treatment for DFUs present an enormous financial burden to both the healthcare industry as well as society, accounting, on average, for greater than $5,000 per wound in people with chronic wounds.6,7 In the U.S., the average daily hospital expense for a DFU is $2,400.8 This daily price is limited to basic expenditures for stay, not including procedures or examinations that patients may have. This basic “room and board” cost has doubled since 1999 and continues to increase annually.8
I would like to propose the early discharge of certain patients from the hospital prior to receiving a confirmatory “clean margin.” This practice, considering daily hospitalization cost, may facilitate a lower total cost of care as well as reducing select complications via a reduction in hospital length of stay.6
Current Keys To Osteomyelitis Treatment
We have historically divided osteomyelitis into two nebulous and not often distinct categories: acute or chronic. The term “acute” often describes bone infection arising from a new wound or a first occurrence diagnosis. Widely accepted treatment modalities for acute osteomyelitis include surgical resection of infected bone with appropriately narrow antibiotic therapy until the return of a pathologically “clean” margin. Patients often have repeat surgeries in an effort to achieve surgical “cure” of the infection.
We often use the term “chronic” if the patient has a longstanding wound or prior treatment for “acute” osteomyelitis. The treatment of chronic osteomyelitis is often more nuanced than the management of acute osteomyelitis and may include a myriad of often overlapping options including intravenous (IV) antibiotics, antibiotic-impregnated spacers and/or surgical resection of infected tissues. In the case of acuity, when it comes to bone biopsies, specifically margins of bone to be evaluated by pathology and for microbial growth, one typically acquires these biopsies during surgical intervention.
The results of these pathology procedures help further narrow treatment options. Often patients remain hospitalized awaiting these results, sometimes for long periods of time. In certain cases, one may be able to plan for additional outpatient surgery and provide wound care based on intraoperative findings and patient-physician communications on an outpatient basis while the biopsy results are being processed.
The following are three simplified patient cases to outline instances in which the hospital discharged patients soon after surgery, sometimes well before producing a final pathology report.
Case Study One: When A Patient With Osteomyelitis Has A Digital Amputation
A 67-year-old Caucasian male with longstanding, controlled type 2 diabetes complicated by peripheral neuropathy presented to the emergency department on referral by his primary care physician for evaluation of cellulitis and a purulent wound to his left distal second digit. Significant findings were limited to the digit.Otherwise, the patient did not have a significant medical presentation and did not have leukocytosis. An X-ray demonstrated radiographic evidence of osteomyelitis to the distal phalanx of the second digit.
The patient was hospitalized for intervention. After a discussion of his radiographic and physical findings, the patient, my colleagues and I agreed upon a distal digital amputation. The patient had surgical resection of the distal phalanx and the body of the intermediate phalanx. As cellulitis was limited to the distal digit, he had flap closure. During the surgery, the base of the intermediate phalanx was hard and appeared healthy. We sent the base for pathologic evaluation for marginal osteomyelitis.
The following day, after a satisfactory incision inspection, the hospital discharged the patient home with seven additional days of oral antibiotics. The pathology report, which came four days after the surgery, was negative for osteomyelitis at the margin site. Subsequent follow-up wound care led to complete and uneventful healing.
Case Study Two: When There Is A Delay In A Decision On A Definitive Treatment
A 32-year-old Hispanic male patient with undiagnosed type 2 diabetes and an otherwise noncontributory past medical history went to the emergency department with complaints of worsening odor and drainage from a wound on his right great toe. The wound started as a blister after the patient wore new steel toe work boots.
Laboratory results demonstrated mild leukocytosis, elevated C-reactive protein (CRP) and hemoglobin A1c >10%. He had a circular macerated wound to the medial right interphalangeal joint that was 1 cm in diameter with minimal erythema, serosanguineous drainage and a positive probe-to-bone test. There was radiographic evidence of osteomyelitis to the medial aspects of the head of the proximal phalanx and base of the distal phalanx of the hallux. Upon the patient’s hospitalization, magnetic resonance imaging (MRI) revealed evidence of osteomyelitis to a large portion of the head of the proximal phalanx, a septic interphalangeal joint and questionable osteomyelitis permeating the base of the distal phalanx.
My colleagues discussed with the patient surgical options including amputation, arthroplasty or limited debridement and biopsy. The patient was reluctant about definitive surgery at the time of presentation. Ultimately, we performed a bone biopsy with wide debridement of nonviable tissue and bone. We sent the bony fragments to pathology including a Jamshidi core biopsy (CareFusion) of the mid-body of the distal phalanx. Suspicion was high for residual osteomyelitis. We initiated simple wound care measures.
Following lengthy team discussions with the hospitalist, local infectious disease specialist and the patient, the hospital discharged the patient 48 hours after surgery with self-care dressing changes and a peripherally inserted central catheter line. Under the care of the infectious disease specialist, the patient began daily outpatient IV antibiotic infusions. The pathology report returned after a total of seven days postoperatively (including a three-day weekend) with all samples positive for acute osteomyelitis. With these results in consideration, the patient subsequently decided upon amputation, which we performed on an outpatient basis. The patient went on to heal uneventfully.
Case Study Three: When A Patient Has A Longstanding Chronic Wound With Known Osteomyelitis
A 45-year-old Native American female presented to the emergency department on a recommendation by a home healthcare nurse for worsening appearance of a chronic lateral left foot wound (five months in duration). Her past medical history is significant for uncontrolled type 2 diabetes, peripheral arterial disease (PAD), end-stage renal disease (ESRD) (hemodialysis) and a prior isolated transmetatarsal amputation of the left foot.
The patient was asymptomatic with mild leukocytosis, hemoglobin A1c> 12% and a highly elevated CRP. The foot was in an equinovarus position with a large ulceration at the base of the fifth metatarsal. The 5 cm x 4 cm wound margin was severely hyperkeratotic with maceration immediately adjacent to the base, which appeared granular and well-perfused. There was a 1 cm x 0.1 cm sinus that was draining serous fluid, which probed to a soft feeling fifth metatarsal base. Radiographs demonstrated evidence of osteomyelitis to the base of the fifth metatarsal as well as the lateral cuboid.
Upon the patient’s hospitalization, MRI demonstrated changes consistent with osteomyelitis of the entire remaining fourth and fifth metatarsals, the cuboid, and the anterior process of the calcaneus. During treatment planning, the patient adamantly refused further amputation or significant surgical intervention. The patient agreed to wound debridement with partial resection of the remaining fifth metatarsal and needle biopsies of the base of the fourth metatarsal, cuboid and anterior calcaneus. My colleagues and I performed surgery as discussed and sent all bony samples for pathologic evaluation. Wound care continued in a similar fashion as it had before.
After lengthy discussions and planning with the patient, hospitalist, infectious disease specialist and case management, the hospital discharged the patient 48 hours later to resume home healthcare dressing changes. An infectious disease specialist followed the patient upon discharge. Subsequent infusion of IV antibiotics was coordinated with dialysis. The pathology report returned after a total of five postoperative days. All samples were positive for “acute on chronic” osteomyelitis. This means there are fibrous changes to the bone marrow (chronic) as well as acute infection cells (bacteria and polymorphonuclear leukocytes).
The patient elected to complete the previously prescribed outpatient antibiotic regimen and wound care. She subsequently returned to the hospital 14 weeks later with a complication of gas gangrene to the same limb and had a more proximal amputation.
Pertinent Considerations For Discharging Patients With Osteomyelitis Prior To Final Pathology Results
In each of the prior three case presentations, despite their variations, there are circumstantial similarities that allowed discharge of the patients to their homes without final pathology results. In each of these cases, the patient had adequate acute care, postoperative patient treatment was not compromised and the healthcare providers honored the patient’s wishes.
The following are suggested parameters when considering discharging patients prior to receipt of final pathology results.
1. There should be no evidence that discharge would put the patient at further risk of worsening health or prognosis. The third patient was not presently at risk for a significantly different outcome during hospitalization given her history and adamant refusal of amputation.
2. Adequately address and control the patient’s comorbid conditions. The patient in the second case received instruction as to his diabetes care and will have follow-up on an outpatient basis. The third patient’s uncontrolled diabetes was due to non-adherence and I reinforced the importance of adequate glucose control.
3. The dressings are simple or outpatient home healthcare is in place to facilitate dressing changes.
4. If the patients opts to proceed with further surgical intervention, it could occur on an outpatient basis. Outpatient surgery would have been appropriate for the patients in the first and second cases. Patient three refused amputation of any form in her presenting state.
5. Discuss complicated cases with an infectious disease specialist and agree upon a treatment plan. The second and third patients both had follow-up as outpatients with the infectious disease specialist involved in their hospitalization.
6. The patient was waiting for pathology results alone for disposition planning. We had previously established home healthcare for the third patient.
The benefits of discharging certain patients prior to confirmatory pathology diagnosis is multifaceted but mainly secondary to decreasing the hospital length of stay. There is a direct reduction in the cost of patient care associated with a decreased length of stay. Rudimentary extrapolation of the potential basic hospital expenses avoided in the presented cases, based on average estimates, would total over $24,000 (10 days of hospitalization) combined.8
A shorter hospitalization stay further reduces the risk of additional healthcare- acquired infections. Nosocomial infections are the most frequent adverse event in healthcare and as many as 7 percent of all hospitalized patients will acquire at least one treatment-related infection.9 Each additional day of hospitalization increases the risk of nosocomial infection, which subsequently increases hospitalization, increasing additional risk, etc.10,11 Von Koch and coworkers also found that patients returning to the familiarity of home recuperate from hospitalization quicker and experience improved mental outcomes in comparison to remaining admitted postoperatively.12 Additionally, we know that increased hospitalization leads to a propensity for physical decompensation in older adults, resulting in decreased aerobic capacity and limb strength.13
As is commonplace in medicine, there is no “blanket” application recommended for this practice. There are many shortcomings and potential risks in this approach.
The foremost concern is responsibility for appropriate follow-up. Who would assume the lion’s share of responsibility concerning the reading and discussion of the pathology report, initiating or altering the antibiotic regimen, and further surgical planning? Would institutional assignment to these roles promote good follow-up while guarding cost savings?
Are hospital documentation methods as they presently stand sufficient in effectively communicating plans to all parties involved? Certain hospital facilities may provide a structure in which patients can have follow-up on an outpatient basis by those specialists who follow them as inpatients. Perhaps this would be the infectious disease specialist in the prior cases. These specialists seem to provide an understandable and simple continuity of care. There are, however, differently structured institutions with strictly hospital-based specialists and no ability to follow patients in an outpatient setting. Would these hospital specialists be required to communicate with a community-based specialist?
Additionally, there is the reality that patients may not want or be able to return to follow up with the primary surgeon after hospitalization. In these cases, significant discourse between the hospital and community specialists will be required if this approach to disposition is desired. These communications, without direct assignment, however, still beg the question: Who is ultimately responsible for appropriate follow-up?
Notwithstanding the many foreseeable situations in which this approach may not work, there are certainly those cases in which this approach will be beneficial. In certain circumstances, the appropriate utility of clear and open communication, good clinical judgment, and confidence from experience will allow the successful implementation of this discharge format to the benefit of the patients and society. This simple alteration in disposition considerations may be an effective process for reducing cost, decreasing hospital-associated morbidity and providing good patient care without a significant change in outcome.
Dr. Hatch is a third-year resident within the Tucson Medical Center/Midwestern University residency program in podiatric medicine and surgery.
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13. Kortebein P, Symons TB, Ferrando A, et al. Functional impact of 10 days of bed rest in healthy older adults. J Gerontol A Biol Sci Med. 2008; 63(10):1076–81.