Making your facility a center of excellence for wound care

Shark Bird, MD, CMD, CWSP

Scope of the problem

• History of wound care

• Prevalence of Wounds in PALTC

• Population demographics

• Predicted prevalence in the future

Prevalence and contributing factors (2009)

• Pressure ulcer prevalence in LTC = 12-19.7% • Heel 26%

• Coccyx/sacrum 20%

• Ear 19%

• Major contributing factors • Braden score less than 18 (84%)

• Serum Albumin less than 3 (74%)

• Fecal/urine incontinence (73%)

• Fragile skin (67%)

• Bedbound (63%)

Ref #6

Graph trends in wound prevalence

Ref #11

Graph trend in aging population

Ref#12

Evolution of wound care

• 2200 BC…..”the clay tablet” three healing gestures: • Washing of wounds

• Making the plasters (dressings)

• Bandaging the wounds

• Dressings have evolved: “Pound together fur-turpentine, pine-turpentine, tamarisk, daisy, flour of inninnu strain; mix in milk and beer in a small copper pan; spread on skin; bind on him, and he shall recover.”

• Join me later today to partake in the healing portion of this dressing…...beer!

• Egyptians were the first to use Honey

• 18th and 19th century introduce surgery, antibiotics and aseptic technique

• 20th century marks the advent of modern wound healing

Ref #1,2

Last year

• Walter Conlan, MD and Charlene Demers, ARNP presented an overview of wound care

• Types of wounds

• Basic wound care treatment options

• Adjunctive therapies

• This year we will build on this and introduce the concept of a “Center of Excellence in Wound Management”

Ref#3

Tenants of wound care: lightening review and update of last years

information

• Pressure Injuries

• Venous Ulcers

• Arterial Ulcers

• Diabetic Neuropathic Ulcers

• Traumatic Ulcers/Skin Tears

• Post Surgical Dehiscence

• Atypical Wounds

April 2016 NPUAP updated definitions

NPUAP Release

• Arose from a need to better define intact skin which is not a true ulcer

• Formalized at a consensus meeting in Chicago on April 8-9, 2016

• Simplified numbering system

• Added additional etiologies to the definitions

New staging

• Stage 1 pressure injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.

• Changes include use of Arabic numbers instead of Roman numerals, and replacing the word “ulcer” with ”injury”

New staging

• Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).

• Changes include use of Arabic numbers instead of Roman numerals, and replacing the word “ulcer” with ”injury”

New Staging

• Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.

• Changes include use of Arabic numbers instead of Roman numerals, and replacing the word “ulcer” with ”injury”

New staging

• Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.

• Changes include use of Arabic numbers instead of Roman numerals, and replacing the word “ulcer” with ”injury”

New staging

• Deep Tissue Injury (DTI) and Unstageable necrosis remain the same with the exclusion of the word “ulcer” and inclusion of the word “injury”

Additional Etiologies

• Medical Device Related Pressure Injury: This describes an etiology. Medical device related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system.

• Mucosal Membrane Pressure Injury: Mucosal membrane pressure injury is found on mucous membranes with a history of a medical device in use at the location of the injury. Due to the anatomy of the tissue these injuries cannot be staged.

Devices used that place Patient at risk of P.U.

• Nasogastric tubes

• Feeding tubes

• Endotracheal tubes

• Tracheostomy tubes/collars/straps

• Oxygen delivery – Mask – Nasal cannula

• IV/PICC line/Central lines

• Anti-Embolic stockings

• Foley catheters/condom catheters

• Fecal management systems/tubes

• NPWT

• Restraints

• Bedpans

• Abdominal binders

• Identification bands

• Orthopedic – Casts – Cervical collars – Back braces

Items to consider

• With the use of the new etiologies, the staging will still be as with typical pressure injuries, with the exclusion of Mucosal Membrane injury

• ICD 10 mapping and billing will still be based on the stage of the wound even though the new terms no longer includes the word “ulcer”

Case #1

• 65 year old female with dementia, CAD, HTN, Hyperlipidemia, and COPD.

• Recently returned from hospital from a fall and hip fracture ORIF

• Present with a sacral ulcer 5 cm x 4 cm on admission.

Pearls of Wound Management

• Multidisciplinary approach is key

• Removal of cause is paramount (90%). Dressing choice is minimal

• Removal of necrosis at bedside to prevent infection

• Optimize nutrition

• Track progress and monitor outcomes

Arterial Ulcers

• Non pressure related, interruption or blockage of blood flow

• Distal portion of the lower Extremity, ankle, top of foot, toes

• Wound bed dry and pale, minimal exudate

• Intermittent cluadication, decreased pulses, pain on elevation, cool to touch, decreased capillary refill

Venous Ulcers

Open layer of skin and or subcutaneous tissue Venous hypertension from compromised

valves, partial or complete venous obstruction, muscle pump failure (paralysis) Pretibial area Wound bed moist and granulating, with

minimal to copious exudate. Pain in dependant position. Often recurring.

Neuropathic Ulcers

• Peripheral neuropathy from Diabetes

• Ball of foot over metatarsal heads, top of toes

• Resembles arterial, frequently infected

• Dx of DM required, with impaired sensation, may have Charcot deformity.

Surgical Wounds

• Typical Post surgical wounds should be clean, well approximated, and little to no drainage

• If early on a breakdown occurs, notify the surgeon as continued care may still be within the global period

• Signs of concern: non-healing, increased erythema, increased or pus drainage, wound separation, increased pain

Ref #5

Wound Treatment Options • Driven by condition of wound bed and surrounding

tissue.

• Treatments may optimized to create an optimal healing environment, in an economical way.

• A given wound may have several appropriate treatment options

• Treatment should be changed in non-healing wound after 2-4 weeks if no known cause for healing delay

Basic Treatment Catagories

Moisture donating

Moisture absorbing

Enzymatic

Hemostatic

Antimicrobial

Cavity filling

Stimulatory

Substrate providing

Artificial membranes

Treatment Decisions

• If you have necrotic tissue—Debride it

• If it is too wet—Absorb it

• If it is too dry—Moisten it

• If there is a cavity—Fill it

• If there is infection—Kill it

• If there is bleeding—Stop it

• If there is odor—Eliminate it

Frequency of Treatment

• When possible a single treatment is best

• Multiple products increases cost.

• Many treatments can be changed every other day or less (every three days, three times per week, or even weekly)

• Nursing time is part of treatment cost

Debridement Options

Autolytic: Slowest, uses bodies own enzymes to slowly eat away necrotic tissue

• Mechanical: Physical removal of necrotic tissue, ie wet-to-dry, pulse levage, whirlpool, ect…

• Enzymatic: Chemical enzymes that debride away necrotic tissue over a period of days to weeks.

• Surgical/Sharp debridement

Surgical Sharp Debridement

• Removal of necrotic tissue with a curette or blade. • Well documented effectiveness in healing and prevention of infection. • Removal of senescent cells in the presence of little visible slough • Repeated proceedures necessary to achieve optimal effect. • Preformed by a trained clinician ( Physician or trained Nurse

Practitioner). • Reduces the need for expensive enzymatics

Current Enzymatic Debriding Agents

• Collegenase (Santyl) • Obtained from bacteria • Selective debridement of tissue types • Viewed as working from wound base up

• Avoid use with heavy metals • When possible, quicker removal of necrosis can be achieved via

surgical debridement

Antimicrobials

• Antibiotics: Over-use may lead to resistant bugs

• Silver: Bacteriostatic, no known resistance, not an antibiotic, therefore no resistance develops, but patient sensitivity can

• Avoid treating cultures of biofilm

Bleeding Wounds

• Pressure will stop most bleeding, don’t rub

• Silver Nitrate cautery

• Monsel’s Soln.

• Quick Clot

Wound Cultures

• Avoid cultures in well healing wounds without signs of infection

• Gold standard is tissue biopsy after removal of necrotic tissue and slough

• Lavine technique when biopsy not possible

• Biopsy should be performed by trained clinician.

Cavity Filling

• Calcium Alginate (maxorb)

• Hydrofibers ( aquacel)

• Iodaform

• Silvasorb Cavity

• Hydrogel impregnated gauze

Stimulatory Agents

• Collegen Dressings (Fibercol, Puracol, Cellerate)

• Growth Factors ( Regranex, Oasis)

• Trypsin containing agents ( Xenoderm, Granulex)

Tissue dressings

• Apligraf

• Skin Grafts

• Skin Flaps

Older Treatments to Avoid

• On rare occasions these treatments may still be appropriate.

• Wet-to-dry

• Dakin’s Solution

• Betadine, Iodine, ect…

Developing a wound care team

• Clinicians, including medical directors, physicians, physician extenders, nurses, and therapists, all have received varying degrees of education regarding wound management. Too often, however, clinicians avoid practicing wound management because they may lack specialized training or wound care itself has evolved beyond what they were taught years ago. Regardless, clinicians who are willing to incorporate their area of expertise and work with the health care team can contribute to significant improvement in outcomes.

• A team approach will incorporate expertise from multiple disciplines to complete the comprehensive program provided to your residents/patients.

Elements of a wound care team

• Wound care nurse (or floor nurse/unit nurse assigned task of wounds)

• CNA’s

• Patients

• Family members

• Director of nursing

• Medical Director

• Physical Therapist

• Dietician

• Administrator

• Maintenance

• Central Supply

• Part B billing company

• Wound physician

Elements of a successful wound care team

• Thorough assessment of patients upon admission (show form)

• Appropriate consult of wound care specialist

• Weekly reassessment of wound progress

• Adjunctive support staff as part of the wound care team

• Clinicians, including medical directors, physicians, physician extenders, nurses, and therapists, all have received varying degrees of education regarding wound management. Too often, however, clinicians avoid practicing wound management because they may lack specialized training or wound care itself has evolved beyond what they were taught years ago. Regardless, clinicians who are willing to incorporate their area of expertise and work with the health care team can contribute to significant improvement in outcomes.

Goals of a quality wound care program

• Optimize outcomes for patients

• Reduce hospitalizations

• Reduce cost

Effect of bedside delivery of wound care

• Lewin group study

• Study of 4000 participants with 2000 in each arm.

• Conducted in 2006 and published in Ostomy Wound Management, October 2010. • 21 day reduction on average in time to heal wound

• Reduction in wound infection and wound related hospitalization

• Reduction in wound related amputations

• Significant savings to Medicare

Ref #7

Measuring outcomes

• Pressure Ulcer Scale for Healing (PUSH)

• Alternative for all wounds

Ref # 8,9

REferences • 1. A Brief History of Wound Healing. Oxford clinical communications. Yardley, PA: OrthoMcNeil Pharmaceuticals and Janssen-Cilog; 1998.

• 2. Shah JB. The History of Wound Care. The Journal of the American College of Certified Wound Specialists. 2011;3(3):65-66. doi:10.1016/j.jcws.2012.04.002.

• 3. Walter Conlan’s Presentation

• 4. Maguire J., MPT, CWS, Wound Care Management Today’s Geriatric Medicine Vol. 7 No. 2 P. 14

• 5. Bird S., Acute and Chronic Wound Management

• 6. Jenkins M, O’Neal E. Pressure Ulcer Prevelence and Incidence in Acute Care. Adv Skin Wound Care. 2010 Dec 23 (12):556-9

• 7. Davanso, J. et. Al, A Retrospective Comparison of Clinical Outcomes and Medicara Expenditures in Skilled Nursing Facility Residents with Chronic Wounds. Ostomy Wound Management. 2010:56(9):32-52

• 8. NPUAP PUSH tool

• 9. Vohra Score

• 10. Holden-Mount,S. et al. NPUAP Medical DeviceRelated Pressure Ulcers: Pediatrics & Adults, ©2015 National Pressure Ulcer Advisory Panel | www.npuap.org

• 11. shahin, E. et al, Is There Relationship between Quality Indicators and Acquired Pressure Ulcers in Austrian Hospitals and Nursing Homes, Journal of Surgery Volume 3, Issue 2-1 , March 2015, Pages:1-7

• 12. US Census Bureau estimation of American population aging (2009)