
 a prospective observational cohort study of patients presenting for home carealmost 1/5 of patients with advanced cancers suffer from pressure ulcersnone of the patients enrolled had a new pressure ulcer during home carepressure ulcer resolved completely with care in 40% of the patientsthis care could be provided at a median cost of rs .
a prospective observational cohort study of patients presenting for home care almost 1/5 of patients with advanced cancers suffer from pressure ulcers none of the patients enrolled had a new pressure ulcer during home care pressure ulcer resolved completely with care in 40% of the patients this care could be provided at a median cost of rs .
the national pressure ulcer advisory panel ( npuap ) defines pressure ulcers ( pu ) as a form of  localized tissue injury that develop as a result of pressure or pressure in combination with friction / shear . 
hendrichova et al . , from italy had found a rate of 22.9% in cancer patients treated at a palliative care unit .
brink et al . , found a prevalence rate of 10.5% in patients under home care for terminal cancers .
dealey et al . , estimated that the cost of treating pus in uk ranged between  1,21414,108 depending on the severity of the ulcer . the healthcare system in india
is overburdened and few facilities are available for providing end - of - life care .
invariably , most of the care is delivered at home and caregivers are family members .
the kerala model of palliative care depends on a network of trained volunteers and nurses who provide homecare services through regular visits .
in addition to developing a trained cadre of community - based care providers , several innovative methods are used to bring down the cost of care .
our homecare service consists of trained palliative care nurses who conduct regular homecare visits for terminal cancer patients supported by a trained palliative care physician . for logistic reasons ,
while there are few publications on the burden of pus in indian patients in hospital settings , we could not find any data in patients suffering from cancer . in the present paper , we present data on prevalence of pu ,
the effectiveness in terms of healing , duration of persistence as well as the expenditure incurred for this care in a cohort of homecare patients with cancer included for a prospective study .
after obtaining irb approval , patients presenting for home care were included in this prospective observational study ( ctri number : ctri/2014/03/004477 ) .
patients were selected for homecare service provided they resided within a distance of 35 km from the center .
patients were followed up at fortnightly interval till death . as a part of the homecare process , a trained nurse would visit the house of the patient and provide care and education .
visits were conducted as per a preplanned route plan at fortnightly intervals . during each visit ,
the data collected included the size , location , and stage of pu if any .
all pus were staged by the nurse using the npuap staging scheme . in patients without pus , caregivers were trained in the importance of regular postural changes , maintaining hygiene and nutrition . during each visit , the trained nurse assessed if any pus had developed in the interim . in patients with pre - existing pus , similar
in addition , simple saline dressings were instituted using cloth strips cut from cotton dhotis .
these strips were boiled in a steamer that is meant for steaming pancakes ( idlis ) for at least 20 minutes . instead of using commercially available normal saline , normal drinking water mixed with 2 tsp salt per liter of water would be boiled for 5 minutes and used for cleansing . for patients with foul smelling / malodorous wounds metronidazole tablets
the cost of medications and other consumables supplied to the patient as well as the cost of staff and salary was borne by the hospital . the fixed cost per visit which included payment for the nurses salary , driver salary , and car fuel costs worked out to be rs .
the salary paid per hour was derived from the monthly salary for the driver and nurse .
the total costs of consumable items like medications given to each patient were derived from the medicine records maintained prospectively for each visit .
the cost of metronidazole tablets and sticking tapes used in patients with pu was included in the wound care costs .
the total costs of visits were calculated by adding the total expense per visit with the expenses incurred in consumable items like medicines .
the total cost was divided by the total number of days in home care to obtain the cost per day for each patient .
data on demographic variables , cancer site , stage , treatment received , and performance status at first visit was recorded on a datasheet .
median and interquartile range were calculated for continuous variables , while frequencies were calculated for categorical variables .
logistic regression analysis was conducted to find out the influence of various prognostic factors on the healing of pus .
duration of persistence of pus was estimated from the date it was noticed first till the date it was healed . in patients with pu at the first visit , the date of first visit was taken as the start date .
patients were censored at the date of death if the ulcer was not completely healed by then .
for purpose of analysis , cancers with less than 10 patients were grouped together as a single category .
table 1 shows the demographic profile of the patient population in the study . out of these , 27 ( 25% )
patients were unfit for any chemotherapy , surgery , or radiotherapy and were referred for palliative care . in these patients ,
23 had progressive disease after receiving treatment for their cancer outside the hospital while 4 were not treated in view of their advanced age and performance status .
the sociodemographic and disease related profile of the 108 patients included in the study nineteen ( 17.6% ) patients had received curative intent treatment with surgery or radiotherapy while 62 ( 57.4% ) had received palliative treatment prior to registration for home care . in the 62 patients treated with palliative intent after diagnosis ,
palliative chemotherapy had been delivered in 25 patients while the rest ( n = 37 ) received palliative radiotherapy .
the distribution of pus as per prognostic categories in 21 patients with pus , complete healing of the pus was seen in 9 ( 42.9% ) while in another 5 ( 23.8% ) , reduction in the stage was observed . in 5 ( 23.8% ) patients ,
the stage of pu did not change while in 2 ( 9.5% ) patients , an increase in stage was noted .
figure 1 is a waterfall plot showing the change in the stage of pus between the first and the last homecare visit .
both the 2 patients who had an increase in the stage of pu during homecare visits had an initial stage 1 pu that subsequently increased to stage 2 before they died .
waterfall plot showing the extent of change in the stage of pu between the 1st and last homecare visit .
patients with complete resolution of pu are depicted by hatched bars while solid bars represent patients where pus did not resolve completely . as can be seen none of the patients with grade 34 pressure ulcers had a complete resolution . however , in these patients , a decrease in stage was observed in 3 patients while in other 3 the stage remained stable table 3 shows the influence of various factors on the healing of pus . on logistic regression analysis financial status , paralysis , and performance status significantly influenced the healing pus .
influence of various prognostic factors on the resolution of pus during home care median estimated duration of persistence of any pu in these 21 patients was 56 days ( 95% ci : 0117 days ) [ figure 2 ] .
the median duration of survival of patients with stage 12 pu was 75 days versus 37.5 days for stage 34 pu ( p = 0.22 , ns ) .
in the 21 patients with pu , any pu was observed by the homecare team in a median of 3.5 visits ( iqr : 2.54.5 ) . in this same group ,
numbers at risk at each time point are shown below the graph the median total expenditure incurred in caring for the patients with pus was rs .
2323.40 ( iqr : rs . 1878.402768.40 ) and the median daily expenditure was rs .
this includes the cost of homecare visits where care for pu had to be provided as well as visits were pu care was not provided as the pu had healed .
the total cost incurred by the hospital in caring for patients in the homecare services was rs .
the expenditure incurred by the hospital in caring for the 21 patients with pu was rs .
the present study showed that almost 20% patients with advanced cancer taken up for homecare services suffer from pu in our population .
this figure is comparable to that reported by hendrichova et al . , but higher than that reported by brink et al .
this high prevalence of pu at presentation points to the need for sensitization of oncologists towards this common but unappreciated problem faced by patients with terminal cancers .
poor performance status and presence of paralysis predicted an increased risk of presenting with pus in this cohort of patients [ table 2 ] .
the causes behind development of pu is poorly understood and is not a result of a single factor . in a recent systematic review coleman
et al . , have identified three major domains that predict an increased risk of pu development .
these domains are mobility / activity , skin perfusion ( e. g. , diabetes ) and skin condition , particularly existence of a stage i pu , as important predictors of development of pu . due to the small number of patients with pu , only the single domain of reduced mobility / activity ( in form of paralysis and performance status ) emerged as significant .
the limited lifespan of these patients also influenced this as parameters related to limited skin perfusion and existing pu are likely to be significant only with longer duration of follow - up .
in the present study , 40% of the pus had completely healed before the last homecare visit .
the median time taken for complete healing of pressure ulcers was 56 days from the date of registration in homecare services .
this is comparable to the results reported by mcnees et al . , where 44% of pressure ulcers and wounds had healed in cancer patients and the median time taken for healing was 55 days ( 49 days ) .
, in their study only 10% of pressure wounds had healed prior to the death of the patient .
in contrast to stage i and ii pus , majority of which healed in the present study , none of the stage iii - iv pu healed completely .
however , 50% of these patients had a reduction in stage and none had a worsening in the stage .
brandeis et al . , have shown that with good nursing care majority of the pressure ulcers heal within a period of 1 year . in the present cohort ,
the limited lifespan of the patients with advanced pressure ulcers ( median survival with stage 34 ulcer : 37.5 days only ) prevented complete healing .
, in patients surviving less than 180 days ( 6 months ) , none of stage iv pus healed completely .
in fact the authors hypothesized that such pus may represent a reflection of the underlying disease burden and be a part of the spectrum of the overall co - morbidity preceding death in such patients .
the healing of the pus in the present study was influenced by the baseline performance status and presence of paralysis . while patients with poorer performance status had a poorer chance of healing of pu , paradoxically in all three patients with paralysis the ps healed .
two patients had a stage i pu and one had a stage ii pu all three of which had healed completely by the end of the homecare visits .
this finding is likely to be due to chance because of the small number of patients .
the model of homecare service as delivered through our center is a derived from the kerala model of home - based palliative care services .
an advisory model is adopted and patient 's relatives are entrusted with providing nursing care without relying on hiring specialized nurses . this model was borne out of necessity , as there is a triple combination of high patient load , lack of trained nursing manpower , and poor financial status in our part of the world . in developed nations , the cost of caring for pus alone can exceed $ 2 billion ( ~1% of total healthcare budget ) as reported by severens et al .
such expenditure is not possible in our country where the total healthcare budget is only $ 6 billion .
additionally , the nature of family ties in our part of the world is such that usually want to take care and nurse the sick patient .
the role of the homecare team is to educate and empower the caregiver in the family by teaching them simple and cost effective methods of caring for the patients , as well as allaying their apprehensions and misgivings .
however in most such palliative homecare services , trained physicians are not available . as a result in the event of any untoward event relatives
are forced to turn to local hospitals where patients may not have been primarily treated for their cancer .
the present homecare team on the other hand has a close communication with the palliative care specialist as well as other oncologists in the hospital . as a result , in the event of any emergency or sudden problem ,
thus both the patients as well as the caregivers are assured of continuity of care .
the present study is thefirst study which reports the prevalence and outcomes of pus in terminal cancer patients managed using the kerala model of palliative home care .
the strengths of this study are its prospective nature wherein detailed observation of the patients condition was made by a trained palliative care team .
the low cost of the present model is evident in the fact that the total expenditure for caring of 21 patients with pu was rs .
this compares very favorably to the cost incurred for caring and preventing pu in a long term care facility in 539 patients as reported by xakellis et al . due to resource limitations
, we could only include patients who resided within a distance of 35 km from the institute .
given the hybrid nature of our homecare model , the outcome data can not be readily generalized to patients referred to other homecare services in india .
it is also unknown if the effectiveness of care as used in this model compares favorably to the more established and expensive methods of wound care .
the costs reported are direct costs incurred by the hospital as indirect costs incurred by the patients relatives in caring for the patients with pu were not recorded .
the actual indirect cost of such a care model needs to be further studied using prospective studies . in this study ,
, a recent cochrane review has also shown that there is little evidence that use of structured pu risk assessment tool is useful in reducing the risk of developing pu .
our prospective study demonstrates that there is a high prevalence of pus in patients referred to home care with terminal cancers .
the hybrid model of homecare service delivery , as adopted in the present study , was able to prevent new pus from developing in the patient population .
in addition , complete healing was seen in 40% of the patients , with an average expenditure of rs .
 aim : to report the prevalence and outcomes of pressure ulcers ( pu ) seen in a cohort of cancer patients requiring home - based palliative care.materials and methods : all patients referred for home care were eligible for this prospective observational study , provided they were living within a distance of 35 km from the institute and gave informed consent . during each visit , 
 caregivers were trained and educated for providing nursing care for the patient . 
 dressing material for pu care was provided to all patients free of cost and care methods were demonstrated . 
 factors influencing the occurrence and healing of pus were analyzed using logistic regression . 
 duration for healing of pu was calculated using the kaplan meier method . 
 p < 0.05 are taken as significant.results:twenty-one of 108 ( 19.4% ) enrolled patients had pu at the start of homecare services . 
 none of the patients developed new pu during the course of home care . 
 complete healing of pu was seen in 9 ( 42.9% ) patients . the median duration for healing of pu 
 was found to be 56 days . 
 median expenditure incurred in patients with pu was rs . 
 2323.40 with a median daily expenditure of rs . 
 77.56.conclusions:the present model of homecare service delivery was found to be effective in the prevention and management of pus . 
 the high prevalence of pu in this cohort indicates a need for greater awareness for this complication.clinical trial registry number : ctri/2014/03/004477 
Clinical Trial Registry Number:
HIGHLIGHTS
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONCLUSION