11/24/2010 Complex Wound Care with Negative Pressure Wound Therapy (NPWT): Adverse Events & Litigation Thursday, November 17, 2010 Thursday, November 17, 2010 Med League Support Services Webinar Med League Support Services Webinar 1 Pat Iyer Welcome to the Webinar 2 What you need to do For best results, close other programs. p g 3 3 1
11/24/2010 The GoToWebinar Attendee View 4 How to Participate Today • Open and close your Panel • View, Select, and Test your , , y audio • Submit text questions • Q&A addressed throughout the program. 5 6 2
11/24/2010 Diane Krasner PhD RN CWCN CWS MAPWCA FAAN Diane Krasner PhD RN CWCN CWS MAPWCA FAAN Wound & Skin Care Consultant & Wound & Skin Care Consultant & WOCN/Special Projects Nurse WOCN/Special Projects Nurse Rest Haven Rest Haven – York York York PA York PA 7 Wecome to Tonight’s Webinar! Who are you? 8 Welcome to Tonight’s Webinar! Have you used NPWT in your Have you used NPWT in your clinical practice? clinical practice? 9 3
11/24/2010 Objectives By the end of this presentation, the By the end of this presentation, the participant will be able to: participant will be able to: � Explain the rationale for the use of negative Explain the rationale for the use of negative pressure wound therapy (NPWT) pressure wound therapy (NPWT) � Evaluate the standards of care for the entire Evaluate the standards of care for the entire healthcare team related to the use of NPWT healthcare team related to the use of NPWT 10 Objectives (continued) � Identify sources for standards of care for Identify sources for standards of care for NPWT NPWT � Recognize common problems related to the use Recognize common problems related to the use of NPWT that leave facilities open to adverse of NPWT that leave facilities open to adverse events and litigation events and litigation � Analyze a complex wound care case involving Analyze a complex wound care case involving NPWT and a wrongful death NPWT and a wrongful death 11 Resources NPWT Product Listing www.woundsource.com Individual device manufacturers have educational and clinical materials on their websites NPWT Overview chapter in Chronic Wound Care (4 th edition) www.chronicwoundcarebook.com 12 4
11/24/2010 Why is litigation Why is litigation related to NPWT on the rise? related to NPWT on the rise? 13 • Increased usage -> increased potential for misuse • Used for complex & difficult wounds • Steep learning curve for using the device • Each wound patient’s wound plan of care must be individualized individualized • A team approach is essential to optimize healing outcomes with NPWT 14 • Increased acceptance of NPWT by the international wound healing community • Since 1995 more than 1 million patients treated • Evidence-base for NPWT increasing N W g - Over 300 peer-reviewed articles - Over 15 RCTs 15 5
11/24/2010 NPWT: Defined � A device that applies negative pressure A device that applies negative pressure (sub (sub- -atmospheric pressure atmospheric pressure – – suction) via a suction) via a pump ranging from 50 to 200 mmHg to the pump ranging from 50 to 200 mmHg to the p p p p g g g g g g wound beds of acute and chronic wounds wound beds of acute and chronic wounds (e.g. wounds, burns, ulcers, flaps and (e.g. wounds, burns, ulcers, flaps and grafts). grafts). 16 NPWT stimulates wound healing by: � Creating a local environment that enhances wound healing Creating a local environment that enhances wound healing � Removing wound Removing wound exudate exudate (drainage) from the wound (drainage) from the wound � Decreasing edema (swelling) D D Decreasing edema (swelling) i i d d ( ( lli lli ) ) � Increasing local perfusion (blood flow) Increasing local perfusion (blood flow) � Increasing angiogenesis (new blood vessel formation) Increasing angiogenesis (new blood vessel formation) � Promoting granulation tissue formation Promoting granulation tissue formation � Reducing dressing change frequency Reducing dressing change frequency 17 NPWT: Devices � FDA Group 2 Devices (different from FDA Group 2 Devices (different from wound care dressings) wound care dressings) � Indications, Contraindications, Warnings � Indications, Contraindications, Warnings Indications, Contraindications, Warnings Indications, Contraindications, Warnings � Require a Physician’s Order Require a Physician’s Order � Reimbursed by Medicare and Medicaid for Reimbursed by Medicare and Medicaid for qualifying wounds qualifying wounds 18 6
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11/24/2010 Case 1 s/p Abdominal Surgery with Dehiscence 25 Case 1 26 Photo 27 9
11/24/2010 NPWT: Indications � Acute wounds Acute wounds � Chronic wounds Chronic wounds � Traumatic wounds Traumatic wounds Traumatic wounds Traumatic wounds � Dehisced wounds Dehisced wounds � Partial thickness burns Partial thickness burns 28 NPWT: Indications (continued) � Ulcers (Diabetic, Pressure) Ulcers (Diabetic, Pressure) � Flaps Flaps Fl Fl � Grafts Grafts 29 NPWT: Contraindications � Presence of exposed Presence of exposed anastomotic anastomotic sites (sites where structures join) sites (sites where structures join) � Exposed vasculature Exposed vasculature Exposed vasculature Exposed vasculature � Exposed nerves Exposed nerves � Exposed organs, necrotic Exposed organs, necrotic tissue (dead tissue) with tissue (dead tissue) with eschar eschar present present 30 10
11/24/2010 NPWT: Contraindications (continued) � Untreated Untreated osteomyelitis osteomyelitis (bone y (bone ( � infection) infection) � Non Non- -enteric and unexplored fistulas enteric and unexplored fistulas � Malignancy in the wound Malignancy in the wound 31 NPWT: Risk Factors to consider before use � High risk for bleeding/hemorrhage High risk for bleeding/hemorrhage � Anticoagulants or platelet Anticoagulants or platelet aggregation factors aggregation factors � Friable vessels / infected blood Friable vessels / infected blood vessels vessels 32 NPWT: Risk Factors to consider before use � Vascular Vascular anastomosis anastomosis � Infected wounds Infected wounds � Osteomyelitis Osteomyelitis � Exposed organs, vessels, nerves, Exposed organs, vessels, nerves, tendon and ligaments tendon and ligaments 33 11
11/24/2010 NPWT is NOT: A suction device A suction device A method of wound A method of wound A method of wound A method of wound debridement debridement A type of dressing A type of dressing 34 NPWT: Learning Curve Variables � Suction pressures from 50 Suction pressures from 50- -200 mmHg 200 mmHg � Intermittent or continuous suction Intermittent or continuous suction � Frequency of Dressing Changes Frequency of Dressing Changes F F f D f D i i Ch Ch � Type of Foams / Dressings Type of Foams / Dressings � Contact layers Contact layers These variables should be specified in the These variables should be specified in the physician’s orders physician’s orders 35 NPWT: Learning Curve 36 12
11/24/2010 NPWT: Interprofessional Issues & Patient-Centered Concerns � Informed consent / other options Informed consent / other options presented presented � Coordination with other modalities, e.g. � Coordination with other modalities e g Coordination with other modalities, e.g. Coordination with other modalities e g hyperbarics hyperbarics, MRI , MRI � Pain management Pain management � Patient/caregiver training (trouble Patient/caregiver training (trouble- - shooting, emergencies) shooting, emergencies) 37 Case 2: Insect Bite Lower Leg � Chronic wound present for over one year Chronic wound present for over one year � Using Using povidone povidone- -iodine wet iodine wet- -to to- -dry dry dressings dressings � Exquisitely painful Exquisitely painful 38 39 13
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11/24/2010 43 NPWT: Standards of Care � Specific orders for an individual Specific orders for an individual patient & wound patient & wound e g VAC Therapy @ 125 mmHg e g VAC Therapy @ 125 mmHg e.g. VAC Therapy @ 125 mmHg e.g. VAC Therapy @ 125 mmHg continuous x 48 hours, then continuous x 48 hours, then intermittent. Change dressing q intermittent. Change dressing q 48 hours x 2 weeks with 48 hours x 2 weeks with Granufoam Granufoam, then reevaluate. , then reevaluate. 44 NPWT: Sources for Standards of Care � Manufacturer’s clinical Manufacturer’s clinical guidelines guidelines � Consensus statements/Reports Consensus statements/Reports � Clinical Literature Clinical Literature 45 15
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