At Englewood Post-Acute and Rehabilitation, we pride ourselves on having a 100 percent success rate with all the Advanced Tissue Closure patients we have been fortunate enough to take care of. Following protocol and an interdisciplinary approach of care is what makes us so successful.

Specific Protocol

Protocol for the advanced tissue closure patient is very specific and must be adhered to for successful outcomes.

  • Complete Bed Rest: Head of bed at 0 degree in a Clinitron bed except during meal time and for 30 minutes after meals. Head of bed shall be at 30 degrees for a maximum of 60 minutes only.
  • Check proper Clinitron function Q4 hours and PRN power failure
  • No weights necessary while on Clinitron bed
  • Urinary Catheter Protocol
  • No showers/No bed pans
  • JP drain tubing will be stripped, emptied and amount recorded every four hours, with q24° totals
  • Weight shifts every two hours while in Clinitron bed
  • Turn and reposition every two hours when placed on a Recover Care mattress
  • Patient to use Incentive Spirometer at bedside, after education and successful return
  • Sutures, staples, and JP drains removed per surgeon’s order
  • Log roll only
  • SCDs to lower extremities; check/verify proper function and document every shift
  • Any patient transport via ambulance must be provided with a Hover mattress
  • Offloading boots PRN for offloading (when not on Clinitron bed)

Therapy Stretching (Flexion)

  1. The wound care team will prescribe the Stretching portion of the Flap Protocol. Typically, the stretching program will span from the postoperative days 23 to 30, with guidance from the Physical Therapy/Occupational Therapy teams. The goal is to achieve gradual hip flexion to a minimum of 90 degrees and a maximum of 120 degrees, or to the patient’s maximum range of motion if less than 90 degrees.
  2. PT/OT will examine the flap surgery site(s) before, during and after stretching, noting tightness, color, warmth, induration, blanching, wound dehiscence and/or drainage from the surgical site. Any suspected complication will be noted in their documentation and the wound team will also be notified.
  3. Hold flexion if any wound concerns are noted during assessments until further evaluation by the wound care team. Continue to reposition patient and check mattress every two hours to ensure proper function.

Therapy and Nursing Sitting

  1. The prescribed Sitting portion of the Flap Protocol will be dictated by the physician from the LTACH. Typically, the sitting program will begin around postoperative day 30 and will be guided by the Physical Therapy/Occupational Therapy teams. Sitting will begin at the edge of the bed. The surgical site will be assessed by the therapist before and after each episode of sitting.
  2. Hold sitting if any wound concerns are noted and bring to the attention of the wound care team and hospitalist physician caring for the patient.
  3. If no wound concerns are noted during the sitting protocol, the program will advance
    • The patient will sit in two separate episodes for five minutes each time, totaling 10 minutes on day one. Each day forward, the sitting time will increase by five minutes each episode (10 minutes sitting time increase per day); up until the first day that one hour total is reached (30 minutes sitting time, twice per day).
    • The patient should go back to bed for a minimum of one hour between episodes of sitting.
    • From each day forward, after sitting a for a total of one hour, sitting time will advance 30 minutes each day, again, in two evenly divided 15-minute episodes, up to four hours total sitting time per day (two, two-hour blocks of sitting).
    • The patient should go back to bed for a minimum of one hour between episodes of sitting.
    • After four hours of total sitting time per day, the patient may begin sitting in three-hour episodes, increasing one hour each day thereafter.
    • Ultimately, the goal of the sitting program is to achieve sitting tolerance for a full day while practicing wound prevention strategies and offloading every 15 minutes while in the chair.
    • Caution will be exercised to avoid overly excessive hip flexion during the sitting program.
    • Caution to avoid mechanical lifts that require pressure on or over the surgical site.
    • During the sitting protocol, good posture, proper positioning, proper foot pedal adjustments and specialty cushions are very important. Staff will ensure good wound prevention techniques are in place during the sitting program.

Therapy Training to Caregivers

Therapy training to caregivers is crucial for success.

  • To reposition, please lift the patient; do not slide or pull them. Lifting will prevent shearing.
  • If the patient is not positioned in their chair properly, please stand them up to reposition them. Do not pull.
  • Assess the patient’s entire suture line before getting the patient up.
  • If there is any redness/breakdown, etc. Do not get the patient up. Let the patient stay in bed for the remainder of the day, and have the surgical site “rest.” Reassess the next day before getting the patient up.
  • After the patient completes their sitting “minutes” and is back in bed, the patient’s suture line should be reassessed for redness or s/s of infection or skin breakdown.
  • Please note: here may be a slight amount of bleeding due to the small internal sutures or staple removal, but this does not affect the sitting routine. The patient can continue sitting as scheduled. Cover the site with a Band-Aid or small dressing. Once the bleeding stops, remove the dressing and leave the site open to air.
  • Remember to weight-shift for one minute every 15 minutes of sitting.

Discharge Planning

  1. The patient is ready to graduate the Flap Program after they have completed the sitting protocol as described. When medically appropriate, the patient may be discharged from the inpatient care setting to an appropriate disposition.
  2. The facility (E.P.A.R.) will consider arranging home health care to continue monitoring patient progress upon discharge from the inpatient setting. Home health care may continue to ensure adequate nutrition, pressure prevention and hygiene. Home health may potentially provide assistance with regards to equipment and physical and occupational therapy needs as well. Consider that care following discharge may help reduce hospital returns and readmission.
  3. The facility (E.P.A.R.) will make appropriate follow-up appointments with the patient’s primary care provider. Patient should follow up with their primary physician one to six weeks following discharge.

View poster: Advanced Tissue Closure Protocol for Therapy (PDF format)

By Kyle Hazen, PTA, RPM, Englewood Post-Acute and Rehabilitation, Englewood, CO