WORKSHOP ON SKIN CONDITIONS AND NEW TECHNOLOGIES IN WOUND CARE Vycki Nalls, GNP-BC, CWS, ACPHN Jeanine Maguire, MPT, CWS
What is the ‘Triple Aim’? J ■ Triple Aim: Best Outcomes, Highest Satisfaction, Lowest Price ■ The shift is NOW occurring from fee-for-service to payment for outcomes ■ Measures: – Quality Measures (specifically: section M for pressure ulcers, function – Claims (rehospitalizations) ■ All Post-acute care providers – IMPACT Law 2014 now in effect ■ But what will impact all Acute Care AND who they will partner with post-acute – Rehospitalizations
Statistics v u PUs affect one in nine U.S. LTC residents and prevalence's of greater than 20% have been reported. Because LTC is the fastest growing segment of the U.S. healthcare continuum, cost-effective PU prevention solutions are urgently needed. u Maryland has a 1.3% average of pressure ulcers for short stay residents with new or worsening wounds, which is the same for the national average. u Maryland Long term care residents who are HIGH RISK have an average of 6.8% pressure ulcers compared to the national average of 5.8%
What are the facts… J ■ Up to 3 million PUs Reported per year in U.S. ■ Cost > 11 BILLION annually in U.S. ■ JAMDA article: > 26% of hospital readmissions have PU ■ > 60,000 deaths/year in U.S. ■ 2 nd most common cause of litigation – many now in the millions ■ Pressure Ulcers= MDS Quality Measures= 5 Star (admissions) ■ F314 can and has closed centers down to admissions ■ Family perception = litigation ■ Cost of a stage 4 $129,000
Pressure Injury Fast Facts V u New Definitions now available from the NPUAP (April 2016) u Definition: localized damage to skin and/or underlying soft tissue over a bony prominence or device u Can be intact skin or open u Results from intense/prolonged pressure and/or in combination with shear u Tissue tolerance - affected by pressure, shear, microclimate, nutrition, perfusion, co- morbidities, condition of the soft tissue u Medical Device Related Pressure Injury - use staging system u Mucosal Membrane Pressure Injury - do not use staging system
NPUAP Pressure Injury Stages (updated April 2016) (J) Full Intact skin, non-blanchable erythema; changes in sensation, temp, or firmness may Stage I I precede visual changes; does not include purple/maroon areas Partial-thickness loss; wound bed pink/red, moist; intact or ruptured serum-filled Stage I II blister; NO granulation tissue, slough of eschar; does not include MASD, IAD, ITD, MARSI, skin tears, burns abrasions Full-thickness loss; adipose tissue visible, depth depends on anatomical location; may Stage I III have undermining/tunneling; no fascia, muscle, tendon, ligament, cartilage, and/or bone exposed Full-thickness loss, exposed OR directly palpable fascia, muscle, tendon, ligament, Stage I IV cartilage, bone; may have undermining/tunneling, epibole, slough/eschar Full-thickness where extent of tissue damage cannot be determined d/t Unstag ageab able slough/eschar; NOTE: Stable eschar on an ischemic limb or heel should NOT be removed Intact/non-intact localized area of non-blanchable deep red/maroon/purple; Deep T p Tissue I e Injury epidermal separation revealing a dark wound bed or blood-filled blister. May evolve to (DT DTI) open wound or may resolve without tissue loss http://www.npuap ap.or org/resources/educational al-and-cli linical al-reso sources/npuap-pressu sure-injury-stag ages /
Balancing: Clinical, Regulatory, (J) Business, Legal risks, practice acts ■ Difficult to balance al all as aspec ects that impact care for prevention and treatment of wounds 1. 1. Clinic ical al perspective with standards of care and best practices – requires intense wound prevention and care education, knowledge and well- developed skills 2. 2. Regulat ator ory perspective with reporting and survey processes 3. 3. Busi siness ss perspective – ensuring business has enough money to pay salaries, provide care with supplies and equipment, make profit to make it worth while to owners to keep buildings open 4. 4. Legal r ris isks – lawyers, OIG 5. 5. Practic tice a acts ts –some nursing professionals push their practice acts in LTC- LPN
6 steps Providers can take to improve outcomes j 1. Ensure Dx is correct 2. Question findings 3. Direct in Root Cause 4. Determine ‘wound’ prognosis 5. Collaborate with the inter-professional team 6. Communicate and lead
Ensure the wound type, or Dx, is correct j ■ Wounds are frequently mislabeled as ‘pressure’ – Moisture Associated Skin Damage – Neuropathic Ulcers ■ Question the causative findings ■ Was the patient examined in sitting, side lying, supine and with their devices in place (splints, etc…) ■ Was the cause pressure and related to positioning?
HEA HEAL A ABIL ILITY J Add th the “ “heala lability” con oncept t into o you our com ompr prehensive pa pati tient a t and wou ound a assessments ts
Determine patient wound prognosis j ■ Determine outcome and document rational ■ AMA – Good for healing (Medicare expects evidence of healing every 1-2 weeks) – Anticipate a delay (based on what findings) – Palliative, healing not expected, in some cases further decline may be anticipated (based on what findings)
Clinicians should be able to distinguish: v Healable Have adequate blood supply • Can heal if underlying causes addressed Maintenance • Healing potential • Patient / resident or health system barriers compromising healing • Patient/ residents may be nonadherent to treatment; resource limitations Nonhealable • Includes palliative wounds • Cannot heal due to irreversible causes/ illnesses • Critical ischemia; non treatable malignancy
Practice Pearls-Sibbald 2015 v ■ All chronic wounds should be classified as hea heala lable, e, no nonh nhealable, or ma maint ntena nanc nce ■ Moisture-balance dressings important for healable wounds ■ Moisture reduction often more appropriate for nonhealable or maintenance wounds ■ Sharp surgical debridement is appropriate for healable wounds, with conservative surgical debridement of slough more important for the nonhealable and maintenance wound.
Homeostasis v u Principles of physiological homeostasis u Physical equilibrium u corrective mechanism u constancy maintained in the face of continuous change u Active risk factors and comorbidities make it harder for the body to maintain balance
Factors that Impact Wound Healing v u Tissue perfusion/Central circulatory function – do they have adequate blood flow? u Adequate oxygenation? BPs stable? Orthostatics? u Nutritional Status – ASPEN guidelines u Chronic illnesses - DM, renal disease, malignancy, impaired digestion, neurological disorders u Inflammatory/Autoimmune disorders/Immunosuppresion u Coagulation disorders (including medication induced) u Age
Root Cause: Process Symptom? J ■ Ask the center DON- any other in-house acquired pressure ulcers this week? This unit? ■ Should a root cause analysis be done? ■ Guide AWAY from ‘knee-jerk’ quick fix solutions ■ Guide to sustainable process improvement that involve the team
Root Cause: Patient Symptom j ■ What tipped the scale of homeostasis? ■ Review co-morbid conditions ■ Review medications ■ Discuss any changes ■ Evaluate blood flow ■ Detail your findings with the inter-professional team and within documentation
Collaborate with Inter-Professional Team j ■ Refer to nursing for appropriate formulary Guideline for wound treatments and bed surfaces ■ Refer to therapy for sharps, modalities to promote healing, mobility, contracture management ■ Refer to Dietitian for evaluation and recommendations ■ Is Vascular Consult required? ■ ABI? ■ Concerns with Osteo? Infection? ■ What are Advanced Directives? What will tests mean for care options?
Case study - What do you think? V ■ Long term care resident ■ PMH: COPD, CHF, HTN, morbid obesity, mechanical lift to wheelchair, mild cognitive impairment, incontinent of bladder/bowel ■ Stage IV wound present for over a year ■ Went to plastic surgeon, who attempted to close wound surgically ■ Returned to the facility with a wound vac, new diagnosis of atrial fibrillation (and now on anticoagulants), and BPs running 90s/50s. ■ Healable?
Communication… Live well, die well (Advanced Directives, Communication GL, leading the team) J V ■ The tx’s are less important than the medical management and homeostasis. ■ Hydrogel vs. hydrocolloid means very little to outcomes if the patient has been mis-dx’d and is not able to heal ■ Practice medicine/evaluate co-morbidities/meds… lead the team in understanding homeostasis, dx, prognosis…
What does exercise and strengthening have to do with wound healing? J ■ Increases circulation ■ Decreases pressure ■ Is a wound a musculoskeletal injury?
Anticipating a delay in healing? How to add some influence… J ■ Low Frequency Ultrasound (US Mist) – FDA approved to promotes wound healing – Decreases Bioburden & Biofilm ■ Electrical Stimulation – Medicare approved, increases neoangiogensis – Reduces edema – Decreases pain – Promotes healing
Impact your Outcomes…. J ■ Electromagnetic Therapy – Increases circulation – Decreases pain ■ Pulsed Lavage – Mechanically Debrides – Decreases Bioburden & Biofilm
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