1. The Power of Pressure Ulcer Treatment
Pressure Ulcer reduction and Preventions Project
Outcomes Congress

2. Purpose of Series
The purpose of this session is to provide education related to best practices regarding pressure ulcer treatment.
This program is consistent with guidelines set forth in F-314 and is based on evidence based practice, standards of care, and guidelines discussed in current literature.
The purpose of this series is to provide education related to best practices regarding pressure ulcer prevention, assessment, treatment and documentation.
These programs are consistent with guidelines set forth in F-314 and evidence based practiced, standards of care, and guidelines discussed in current literature.
The series is divided into 4 parts which are: Prevention of Pressure Ulcers, Assessment of Pressure Ulcers, Treatment of Pressure Ulcers and Documentation of Pressure Ulcers.
Each program will stand alone…however the 4 sessions together give a comprehensive view of Pressure Ulcer Prevention and Care and the accompanying regulations from CMS.
In addition there will be information on supplemental forms, websites, and publications to provide more support for your wound care prevention and care programs at your facilities.

3. Disclaimer
The information presented in this presentation constitutes an introduction to a topic that has been prepared and provided for educational and informational purposes only. It is for the attendees general knowledge and is not a substitute for legal or medical advice.
Legal and or medical advice requires appropriate licensure, expert consultation and an in-depth knowledge of your situation. Although every effort has been made to provide accurate information herein, laws and precedents are always changing and will vary from state to state and jurisdiction to jurisdiction.
As such, the material provided herein is not comprehensive for all legal and medical developments and may inadvertently contain errors or omissions. This review, we hope, will give a starting point for thinking about the way you practice wound care in that you begin to understand the need for thorough knowledge and careful documentation about the care of the residents. American Medical Technologies shall not be held liable for any situation that may result directly or indirectly from use or misuse of this information.

4. Objectives Verbalize the intent of F-314.
Discuss wound bed preparation for pressure ulcer treatment
Describe treatment interventions for pressure ulcers that meet the standards of care and/or best practices criteria
Recognize staff education needs related to pressure ulcers

5. What is the F314?
A guide to ensure that all nursing homes are held to the same standards in the survey process regarding pressure ulcer prevention and treatment
Medicare wants providers (LTC) to be aware of the current standards and PrU prevention and care
Use it to create an effective Wound Care and Risk Management program
Surveyors use it to assess a facility’s risk assessment and wound care protocols and procedures
An outline for best Wound Care practice
It should be used as a tool
F314 guideline’s purpose is to ensure that everyone is held to the same standards and to motivate everyone to decrease their prevalence of PrU.
F-314 is for pressure ulcers only
F-309 addresses the other most frequent types of wounds - arterial, venous, neuropathic, surgical
The F314 should be viewed as a tool to assist in developing a solid wound care program. Its contents can be a useful guide for acute care as well.
It is not something to fear and scramble with when the survey window starts to approach.
By adherence to the F314 skin tag, a facility can develop a program that is not only compliant with the guidelines, but one that best addresses community acquired pressure ulcers (PrUs) and heals them, reduces facility acquired PrUs to only those that were unavoidable, and a program that ensures caregivers are competent to deliver the care appropriately and effectively.
Use the F-314 & F-309 regulations as a tool to guide your facility's wound prevention and care program. 5
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6. F314 Interpretative Guidelines
Topics covered in the F314
OVERVIEW
PREVENTION
ASSESSMENT
Subsections include:
Risk Factors
Pressure Points and Tissue Tolerance
Under-Nutrition and Hydration Deficits
Moisture and Its Impact
INTERVENTIONS
MONITORING
-They cover Prevention and Assessment in addition to what we will focus on treatment interventions…however, it is not within the scope of this program to teach you “HOW” to do the different types of treatment.
-That would require much more time and frankly onsite education to do hands-on skills in a return demonstration format
With that said: Let me reiterate that each facility needs to have a copy of the F-314 and F-309 guidelines and the associated tags in a wound prevention and care binder.
Go onto the CMS web site and download a copy of these regulations.
-Put this document into a binder that becomes part of the orientation process, AND use it to provide inservices for all levels of staff. 6
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7. CMS: Avoidable Pressure Ulcers
Resident developed a pressure ulcer and the facility DID NOT DO one or more of the following:
Evaluate the resident’s clinical condition and pressure ulcer risk factors
Define and implement interventions that are consistent with resident needs, goals, and recognized standards of practice
Monitor and evaluate the impact of the interventions
Revise the interventions if appropriate
-Let’s review CMS’s definitions of Avoidable and Unavoidable PrUs.
-An Avoidable PrUs…according to F-314…is given as a citation when the Resident developed a pressure ulcer and the facility DID NOT DO one or more of the following:
-Evaluate the resident’s clinical condition and pressure ulcer risk factors
-Define and implement consistently the interventions that are consistent with resident needs, goals, and recognized standards of practice
-Monitor and evaluate the impact of the interventions
-Revise the interventions if appropriate 7

8. CMS: Unavoidable Pressure Ulcers
Resident developed a pressure ulcer even though the facility:
Evaluated the resident’s clinical condition and risk factors
Defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice
Monitored and evaluated the impact of the interventions
Revised interventions as appropriate
Unavoidable PrUs on the other hand is when the resident developed a PrU even thought the facility:
-Evaluated the resident’s clinical condition and risk factors
-Defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice
-Monitored and evaluated the impact of the interventions
-Revised interventions as appropriate
-Perhaps the residents is in the latter stages of life…on hospice…have great pain when being turned…and the family and resident have requested you cease and desist with the turning schedule…you explain that with all the other risk factors…nutrition challenges…multi organ failure…etc…that not turning will put the resident as even higher risk for PrU formation…that is acceptable…but you must document it appropriately.
You must show…unequivocally…through your documentation and interdisciplinary communications…that you did everything correctly 8

9. Physical Factors that May Influence Pressure Ulcer Treatment Choices
Location
Status of ulcer bed
Size, stage, depth
Exudate
Necrotic tissue
Presence or absence of granulation tissue or epithelialization
Pain
Periwound condition
Erythema, edema, induration
Maceration
Dryness or fragility
Shearing, friction or both
According to AMDA this is a list of Physical Factors the May Influence Pressure Ulcer Treatment Choices
-Location
-Status of ulcer bed
-Size, stage, depth
-Exudate
-Necrotic tissue
-Presence or absence of granulation tissue or epithelialization
-Pain
-Periwound condition
-Erythema, edema, induration
-Maceration
-Dryness or fragility
-Shearing, friction or both
All of which must be assessed and taken into consideration as you prepare your POC for treatment of the resident’s wound/s.
-BTW…This AMDA document is one that you MUST have in your library for pressure ulcer prevention and care. Loan or give one as a present to your Medical Director if they don’t already have one. Review some of the content with them.
Pressure Ulcers in the Long-Term Care Setting; Clinical Practice Guideline; AMDA 2008

10. F309: § Quality of Care
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicle physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
Under this guideline are the definitions for specific wound etiologies other than PrUs
Arterial
Diabetic neuropathic ulcer
Venous insufficiency ulcer
§ of F-314 Relates to Quality of Care and states:
-Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
-Under this guideline are the definitions for specific wound etiologies other than PrUs
Arterial
Diabetic neuropathic ulcer
Venous insufficiency ulcer
-You will want to review these definitions in the F-314 guidelines.

11. F314 - INTERVENTIONS
Comprehensive assessment should provide the basis for defining approaches to address residents at risk of developing or already having a pressure ulcer
A determination that a resident is at high risk to develop a pressure ulcer has significant implications for preventive and treatment strategies, but does not by itself indicate that development of a pressure ulcer was unavoidable.
Effective prevention and treatment are based upon consistently providing routine and individualized interventions.
According the F-314 Regulations the comprehensive assessment should provide the basis for defining approaches (treatment interventions) to address residents at risk of developing or of already having a pressure ulcer
F-314 discusses that having determined a resident is at high risk to develop a pressure ulcer has significant implications for preventive and treatment strategies
But does not by itself indicate that development of a pressure ulcer was unavoidable.
F-314 goes on to stress that effective prevention and treatment are based upon consistently providing routine and individualized interventions.
CMS Manual System Department of Health & Human Services (DHHS) Pub State Operations Provider Certification Centers for Medicare & Medicaid Services (CMS); Transmittal 5 Date: November 19, 2004

12. F314 Interpretative Guidelines 483.25(c)
Based upon the assessment and the resident’s clinical condition, choices and identified needs, basic or routine care should include interventions to:
a) Redistribute pressure (such as repositioning, protecting heels, etc)
b) Minimize exposure to moisture and keep skin clean, especially of fecal contamination;
c) Provide appropriate pressure redistributing, support surfaces;
d) Provide non-irritating surfaces;
e) Maintain or improve nutrition and hydration status, where feasible.
-In the F-314 Interpretative Guidelines paragraph (c) states:
-Based upon the assessment and the resident’s clinical condition, choices and identified needs, basic or routine care should include interventions to:
a) Redistribute pressure (such as repositioning, protecting heels, etc)
b) Minimize exposure to moisture and keep skin clean, especially of fecal contamination (Makelbust: residents with fecal incont are 22 x more likely to develop a PrU); mention the IADIT tool and request a copy at
c) Provide appropriate, pressure redistributing, support surfaces;
d) Provide non-irritating surfaces;
e) Maintain or improve nutrition and hydration status, where feasible.
CMS Manual System Department of Health & Human Services (DHHS) Pub State Operations Provider Certification Centers for Medicare & Medicaid Services (CMS); Transmittal 5 Date: November 19, 2004 12
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13. F314 Interpretative Guidelines 483.25(c)
The facility should be aware that the resident's drug regimen may worsen risk factors for development of pressure ulcers or for non-healing pressure ulcers
For example, drugs causing lethargy or anorexia or creating/increasing confusion should be identified and addressed
-In addition, the facility should be aware that the resident's drug regimen may worsen risk factors for development of pressure ulcers or for non-healing pressure ulcers (for example, by causing lethargy or anorexia or creating/increasing confusion or residents on steroids with chronic wounds…steroids stop the inflammatory phase of wound healing and cause profound insulin resistance causing the residents blood glucose to elevate…which also contributes to non-healing wounds…)
-and that these impediments to healing should be identified and addressed.
-The interventions mentioned on the previous slide should be incorporated into the plan of care and revised as the condition of the resident indicates.
CMS Manual System Department of Health & Human Services (DHHS) Pub State Operations Provider Certification Centers for Medicare & Medicaid Services (CMS); Transmittal 5 Date: November 19, 2004

14. F314 & Repositioning Repositioning is a common, effective intervention
Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning
Assessment of a resident’s skin integrity after pressure has been reduced or redistributed should guide the development and implementation of repositioning plans
Such plans should be addressed in the comprehensive plan of care consistent with the resident’s need and goals.
The care plan for a resident at risk of friction or shearing during repositioning may require the use of lifting devices for repositioning
Positioning the resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing
-F-314 discusses Repositioning as a common, effective intervention for an individual with a pressure ulcer or who is at risk of developing one.
-Assessment of a resident’s skin integrity after pressure has been reduced or redistributed should guide the development and implementation of repositioning plans. (tissue tolerance- part of ongoing assessment)
-Such plans should be addressed in the comprehensive plan of care consistent with the resident’s need and goals.
-Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning.
-The care plan for a resident at risk of friction or shearing during repositioning may require the use of lifting devices for repositioning.
-In addition, “Positioning the resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing.”
CMS has defined very specific details for surveyors to consider regarding the intervention of repositioning. It would be in the best interest of your residents and staff if you were to develop an inservice that would address repositioning, support surface interventions, and give this inservice to new employees, require the inservice to be given to staff who is observed transferring and positioning residents incorrectly and as a quarterly refresher.
-Please refer to CMS Manual that the surveyors use which is listed again…at the bottom of this slide.
CMS Manual System Department of Health & Human Services (DHHS) Pub State Operations Provider Certification Centers for Medicare & Medicaid Services (CMS); Transmittal 5 Date: November 19, 2004

15. F314 & Support Surfaces and Pressure Redistribution
Support surfaces should be chosen by matching a device’s potential therapeutic benefit with the resident’s specific situation
Multiple ulcers
Limited turning surfaces
Ability to maintain position
Effectiveness of pressure redistribution devices is based on their potential to address
Individual resident’s risk
Resident’s response to the product
The characteristics and condition of the product
Examples of these surfaces or devices include:
4-inch convoluted foam pads
Gel pads
Air fluidized beds
Low loss air mattresses
-CMS had defined some of the types of support surfaces or devices that may benefit residents with or at risk for PrUs
-The guideline states that “Appropriate support surfaces or devices should be chosen by matching a device’s potential therapeutic benefit with the resident’s specific situation; for example, multiple ulcers, limited turning surfaces, ability…or inability to maintain position should be taken into consideration.
-The effectiveness of pressure redistribution devices (e.g., 4-inch convoluted foam pads, gels, air fluidized mattresses, and low loss air mattresses) is based on their potential to address the individual resident’s risk, the resident’s response to the product, and the characteristics and condition of the product.
-Pressure redistribution refers to the function or ability to distribute a load over a surface or contact area.
-Redistribution results in shifting pressure from one area to another and requires attention to all affected areas.
-Pressure redistribution has incorporated the concepts of both pressure reduction (reduction of interface pressure, not necessarily below capillary closure pressure) and pressure relief (reduction of interface pressure below capillary closure pressure).
-Examples of these surfaces or devices include:
4-inch convoluted foam pads, --Gel pads.--Air fluidized beds,--Low loss air mattresses

16. F314 - MONITORING
At least daily, staff should remain alert to potential changes in the skin condition and should evaluate and document identified changes
For example, a resident’s complaint about pain or burning/itching at a site where there has been pressure or a nursing assistant’s observation during the resident’s bath that there is a change in skin condition should be reported so that the resident may be evaluated further
F-314 discusses Monitoring the resident’s skin and states:
-At least daily, staff should remain alert to potential changes in the skin condition and should evaluate and document identified changes.
-For example, a resident’s complaint about pain or burning/itching at a site where there has been pressure or a nursing assistant’s observation during the resident’s bath that there is a change in skin condition should be reported so that the resident may be evaluated further.
This is where you will rely heavily on your well-trained and constantly vigilant nursing assistants. IN most LTC facilities like the hospital and home care settings, the CNA sees the resident’s skin more frequently than the nurse and should report to nursing any suspected or easily discernable changes in skin conditions. Implement easy ways for them to document and report ANY skin change(s) regardless of how minor it may seem….. You may want to keep an index card where you record the CNA’s name that reported the skin changes and at the end of the week or month – give a little reward for their diligence in reporting changes. Positive reinforcement “warm fuzzies” go a long way. DO something equally creative for the nurses – track the units progress and reward the nurses for instituting mid coarse changes that improve heal times or progression.
I like to refer to the CNAs as the Lifeguards in LTC- empower them and recognize the value they bring to your facility.

17. ASSESSMENT AND TREATMENT OF PRESSURE ULCER(S)
It is important that each existing pressure ulcer be identified
Whether present on admission or developed after admission
Factors that influenced the PrU development
Potential for development of additional ulcers
Factors causing deterioration of the pressure ulcer(s) be assessed and addressed (Prevention!!!)
Any new pressure ulcer suggests a need to reevaluate the adequacy of the plan for preventing pressure ulcers
-It is important that each existing pressure ulcer be identified, whether present on admission or developed after admission
-And that factors that influenced the PrUs development, AND the potential for development of additional ulcers… or…for the deterioration of the current pressure ulcer(s) be recognized, assessed and addressed (see discussion under Prevention regarding overall assessment and interventions).
-Any new pressure ulcer suggests a need to reevaluate the adequacy of the plan for preventing pressure ulcers.

18. F314 - TYPES OF ULCERS
At the time of the assessment, clinicians should document the clinical basis for any determination that an ulcer is not pressure related, especially if the injury/ulcer has characteristics consistent with a pressure ulcer, but is determined not to be one
According to CMS clinician means:
Physicians
Advance practice nurses
Physician assistants
Certified wound care specialists
Refer back to F-309 for CMS description of the most frequently encountered types of wound other than PrUs…they are asking for the etiology of the wound/s (arterial, venous, diabetic neuropathic)
Also provide the:
Location
Shape
Ulcer edges and wound bed
Condition of surrounding tissues
All of which factor into your treatment plan
This is an important concept related to wounds in your facility.
The surveyor will want to ensure that you have appropriately evaluated and assessed your resident and the wound…and that you have a correct diagnosis on the etiology of the wound.
So…with this in mind the F-314 guideline states:
-”At the time of the assessment, clinicians should document the clinical basis for any determination that an ulcer is not pressure related, especially if the injury/ulcer has characteristics consistent with a pressure ulcer, but is determined not to be one.
-According to CMS clinician means:
Physicians, Advance practice nurses, Physician assistants, Certified wound care specialists
Please refer back to F-309 for CMS description of the most frequently encountered types of wound other than PrUs…CMS is asking for the correct etiology of the wound/s
Is it Arterial, Venous, diabetic neuropathic (remember, unless you are an MD or APN, you can SUGGEST a clinical working diagnosis or better yet, describe the wounds’ characteristics to enable the MD/APN to do the actual diagnosis)
AND…how do you know this…did you do an ABI to assess objectively blood flow to the lower extremity if you suspect an arterial wound on the foot…
How did you describe the venous wound…did it have the characteristic hemosideran deposits…that red/brown staining in Caucasian and Hispanic skin or more purplish or even black staining on dark African American skin.
When you called the wound diabetic…is it in the correct place for a diabetic neuropathic wound…BTW…these wound only and I repeat only occur on the plantar surface of the foot in an ambulatory resident. Just because a resident had diabetes does not make any wound on the body a diabetic neuropathic wound.
- CMS is also looking for documentation of the;
Location, Shape, Ulcer edges and wound bed, Condition of surrounding tissues
-All of which factor into your treatment plan
- Ultimately the quality of your documentation will determine how well you do under survey and for clearing spelling out caring for the resident

19. F314- DRESSINGS AND TREATMENTS
A facility should be able to show that its treatment protocols are based upon current standards of practice
Are in accord with the facility’s policies and procedures
And these policies and procedures are developed with the medical director’s review and approval
-F-314 discusses that the dressing and treatment protocols you use should be based upon current standards of practice…
-And that these treatment interventions are in accordance with the facility’s policies and procedures.
-And last…but NOT LEAST that these policies and procedures are developed with the medical director’s review and approval.
-You MUST and I repeat MUST get your medical director involved in the wound prevention and treatment protocol, policy and procedure process.
-It is not just to protect the facility but to protect your medical director…medical directors are getting cited due to inadequate involvement and recognition of issues related to substandard care for residents with wounds…
-Help your medical director by giving him or her a copy of the CMS guidelines related to wounds (F-314 & F309 and the related potential tags we discussed during the last few presentations
-And give them a copy of the AMDA Pressure Ulcer in the Long-Term Care Setting, Clinical Practice Guidelines.
CMS Manual System Department of Health & Human Services (DHHS) Pub State Operations Provider Certification Centers for Medicare & Medicaid Services (CMS); Transmittal 5 Date: November 19, 2004

20. F314 - Clean vs Sterile Technique
Present literature suggests that pressure ulcer dressing protocols may use clean technique rather than sterile
Appropriate sterile technique may be needed for those wounds that recently have been surgically debrided or repaired
CMS-F-314 guidelines go so far as to discuss Clean vs Sterile Techniques when doing dressing changes and performing other treatment interventions such as debridement.
WOCN position statement on this is available…
-The guidelines state:
- “Present literature suggests that pressure ulcer dressing protocols may use clean technique rather than sterile, but that appropriate sterile technique may be needed for those wounds that recently have been surgically debrided or repaired.”
-Be aware…the surveyor will probably want to see you perform a dressing change on a resident. It would be in the interest of your facility if you had a dressing change protocol spelling out how dressing changes will be performed by your treatment nurse or others performing this task.

21. D.I.M.E. Principles of Wound Bed Preparation
Debride Non- viable or deficient
Infection or inflammation
Edge of wound non advancing or undermined
Moisture imbalance
Non-viable tissue-defective matrix & cell debris
High bacterial counts or prolonged inflammation
Desiccation or excess fluid
Non-migrating keratinocytes Non-responsive wound cells
Impairment
Dressings
Compression
Intervention
Antimicrobials
Biological agents Adjunct Therapies
Debridement
Debridement
-F-314 discusses debridement as a treatment intervention for PrUs and other types of wounds.
-There are 3 things I’ve personally found to be inadequately performed related to wound care in the LTC setting.
-Now…this is my personal experience…yours will probably differ…so recognize that the next statements are what is affectionately known by people I’ve been honored to teach…as Jo Opinions.
Frequently I’ve seen mistakes in diagnosis of the wound…calling an arterial wound a venous or pressure ulcer
Inappropriate dressing choices based on the wound bed condition and exudate characteristics
Inadequate or inappropriate debridement of the wound bed…
-Before a clinician can choose the correct intervention the diagnosis must be right on…or it is simply luck and not skill that the wound heals…the resident’s body was able to heal or improve the wound in spite of the interventions performed…not because of them.
-The International Advisory Panel on Wound Bed Preparation offered the TIME principles for wound management which is an excellent tool for recognizing and managing the barriers to healing.
-This model addresses proposed pathophysiology, clinical actions of the DIME principles and the effect of that action on the wound.
-Debridement may be episodic or continuous to remove the non-viable tissue and cellular debris…as cells die they leave they remnants in the wound bed…
-In addition sharp and mechanical debridement are the only way to remove biofilm accumulation from the wound bed.
-Infection or inflammation may be addressed with topical or systemic antimicrobial/anti-inflammatory agents.
-Moisture balance can be achieved by either adding moisture to a dry wound with a dressing such as a hydrogel. -Absorptive dressing may the appropriate choice for wounds with moderate to large amounts of exudate.
-Compression therapy may reduce chronic wound fluid associated with edema among residents with venous insufficiency.
-For the non-advancing wound edge, interventions include addressing the cause and implementing corrective measures: biological agents, skin grafts, debridement and/or adjunct therapies.
-What you are trying to achieve is to restart or facilitate the keratinocyte migration
Low bacterial counts & controlled inflammation
Restore cell migration
Avoid maceration
Stimulate keratinocyte migration
Outcomes
Restore wound base & ECM proteins

22. D-I-M-E Framework Aims to optimize the wound bed by:
reducing edema and exudate
reducing the bacterial burden
correcting the abnormalities contributing to impaired healing
European Wound Management Association (EWMA). Position Document: Wound Bed Preparation in Practice. London: MEP Ltd, 2004.
Sibbald GR, Orsted H, Schultz GS, et al; Preparing the Wound Bed 2003: Focus on Infection and Inflammation; Ostomy Wound Management, Nov 2003, Vol 49, Issue 11 p24-49

23. Goal of D-I-M-E
Facilitate the normal endogenous process of wound healing
For instance:
Debridement can be used as an intervention for tissue management, but can also impact on inflammation and infection control
Wound edge migration
European Wound Management Association (EWMA). Position Document: Wound Bed Preparation in Practice. London: MEP Ltd, 2004.
Sibbald GR, Orsted H, Schultz GS, et al; Preparing the Wound Bed 2003: Focus on Infection and Inflammation; Ostomy Wound Management, Nov 2003, Vol 49, Issue 11 p24-49

24. Types of Debridement Types of debridement include: Autolytic Enzymatic
Mechanical
Sharp
Surgical
Biodebridement (maggots)

25. Enzymatic Debridement Enzymatic Debridement
Day
Pulsatile Lavage + Enzyme
Post Sharp Debridement
enzyme begun
Day
Repeat Sharp Debridement
-A single method of tissue debridement is rarely utilized throughout the entire process of wound bed preparation.
-For example a clinician may choose to schedule sequential conservative sharp debridements at the bedside and augment the process by the application of enzymatic debriding agent in between.
Or they may use mechanical debridement such as wound scrubbing, pulsed lavage or low-frequency ultrasound prior to sharp surgical debridement to clear away topical debris and soften the necrotic tissue to facilitate the debridement process.
Day
Enzymatic Debridement
Day
Enzymatic Debridement
Day

26. NPUAP: February 2007
“The National Pressure Ulcer Advisory Panel has redefined the definition of a pressure ulcer and the stages of pressure ulcers
Suspected DTI
Stage I
Stage II
Stage III
Stage IV
Unstageable
-In February 2007 The “The National Pressure Ulcer Advisory Panel redefined the definition of a pressure ulcer and the stages of pressure ulcers, including the original 4 stages and adding 2 stages on deep tissue injury and unstageable pressure ulcers.”
-We reviewed this information last month
-When choosing your interventions it is important that you are aware of the depth of the wound…for instance…stage I and II pressure ulcers are partial thickness wound and will not have necrotic tissue in the wound bed…anytime…and I repeat anytime…you see slough or eschar in a wound you have a full-thickness wound.
-Stage III and IV wounds are full-thickness wounds and will need careful attention to detail by a skilled wound care clinician to get the best and fastest outcomes leading for infection prevention and wound closure.
-Please realize that full thickness wound only heal to 80% of their previous tensile strength.
-AND…when you have a new wound in an old full-thickness wound the second wound only heals to 80% of the previous tensile strength from the previous wound…
-Can you see where this is leading…
-Each time a resident has a full-thickness wound in the same location of a previous wound the scar tissue is much more fragile…putting them at higher risk for another wound in the same location.
-Also…we don’t heal wounds…we facilitate wound closure…
-Wound healing continues for up to at least 2 years after closure with collagen remodeling and strengthening of the scar tissue.
-So I never say I healed the wound…my interventions helped close the wound…ultimately the resident body heals itself…you are simply a facilitator…
-Some wound closure facilitators are better than others…what can I say.
-So....You MUST be able to correctly recognize the NPUAP definitions AND apply appropriate treatment interventions depending on the characteristics of the wound and the residents overall medical condition 26 26

27. Dressing and Treatment Caveats Thomas, JAMDA Oct 2006
Stage III, IV ulcers should be covered
Determination of the need for a dressing for a Stage I, II ulcer is based upon individual practitioner’s clinical judgment and facility protocols based upon current clinical standards of practice
Current literature does not indicate significant advantages of any single specific product
Current literature suggests that PrU dressing protocols may use clean technique rather than sterile
Appropriate sterile technique may be needed for those wounds that have recently been surgically debrided or repaired 27

28. Debridement Caveats Thomas, JAMDA Oct 2006
Variety of methods available
Mechanical, sharp, surgical, enzymatic, autolytic
Must be appropriate for the resident and clinical wound presentation
Stable, dry, intact, and adherent eschar on the foot/heal should not be debrided unless signs/symptoms of local infection or instability
Wet-to-dry dressings (a form of debridement) or irrigations may be appropriate in limited circumstances, but repeated use may damage healthy granulation tissue and may lead to excessive bleeding and increased pain
A facility should be able to show that its treatment protocols are based upon current standards of practice and are in accord with the facility’s policies and procedures as developed with the medical director’s review and approval 28

29. Resident Right’s of Refusal: Resident Choice
Resident has the right to refuse therapy or to be non-compliant
Facility is expected to address the resident’s concerns
A violation of resident rights is referenced in F154 & F155
Offer relevant alternatives
Mere refusal or noncooperation is not an excuse for
worsening of a pressure ulcer
In general, the documentation should include the resident’s right to refuse therapy
Informed refusal should be documented
Alternative treatment/s should be discussed with the resident
Resident Choice
-The right of a resident to refuse therapy or to be noncompliant with therapy is addressed in the new guidelines.
-The facility is expected to address the resident’s concerns and offer relevant alternatives, if the resident has refused specific treatments.
-A violation of resident rights is referenced in F154 and F155.
Mere refusal or noncooperation is not an excuse for worsening of a pressure ulcer. In general, the documentation should include the resident’s right to refuse therapy
-However, informed refusal should be documented
-And alternative treatment should be discussed with the resident
-And documentation of the recommended alternatives

30. Treatment Pearls for DTI
Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
DTI may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.

31. Deep Tissue Injury (DTI)
Tissue injury that appears as dark discoloration, deep bruising, hematoma
Borders are irregular and not well demarcated
Typically acute formation
Long OR times
Falls
Splints
Single episode of pressure
Damage to deeper structures has already occurred
Skin may still be intact because of its higher resistance to hypoxia
Heralding sign of an impending stage III or IV

32. Progression of DTI Eschar formation – common at heels
Necrosis and formation of full thickness wound
Infection and abscess formation – usually requires surgical intervention
DTI have potential for rapid deterioration
DTI may take time to “declare” itself.
Heels  intact and dry  protect
Heels  moist and draining  tx aggressively as appropriate for the pt

33. DTI Progression
First identified in January…resolved in June of the same year. Typical location and progression of DTI. Heels are difficult areas to manage!

34. Management / Treatment
Complete and immediate pressure relief
No massage to affected area
Protect from other factors
i.e., incontinence, friction, shear
May use dry dressing if desired but no topical until “declared”
Monitor closely for deterioration
Nutritional support

35. What is different? Recommendation:
When a suspected DTI presents with intact skin (before the eschar forms and demarcates) it should be considered a Stage I for coding on the MDS This is usually evident upon the initial presentation of the suspected DTI and/or within the first few days.
Over the course of several days, suspected DTI evolve. Once the eschar matures/develops/forms/demarcates OR if the suspected DTI presents as an intact blood blister, then these lesions should be considered “Unstageable” and coded as a Stage IV for MDS 2.0 purposes only.
Surveyors are being taught that you MUST stage INTACT SKIN as MDS M1 (which is a pressure ulcer) and should be coded as a Stage I pressure Ulcer
Until the MDS is revised, it is best to follow the MDS guidelines and in the wound documentation section, describe in greater detail what you see.

36. The Bacterial Burden Infection Contamination Colonization
Critical Colonization
Local |
Systemic
Contamination: the presence of bacteria at a wound site without multiplication
Colonization: the presence and multiplication of bacteria at a wound site without s/s of infection
Critical Colonization: bacteria that multiply to cause a delay in healing often with increased pain but not an acute host reaction
Infection: the deposition and multiplication of bacteria in the tissue causing a host reaction. Host reaction = tissue injury (invasion of bacteria into viable tissue).
Chronic wounds have a predisposition for colonization.
Biofilm: complex aggregation of microorganisms marked by the excretion of a protective and adhesive matrix.
Infection

37. Classic Signs/Symptoms of Infection
Dolor (pain)
Rubor (erythema)
Calor (warmth)
Edema/swelling
Purulence
Fever
Acute Wound Infection
Chronic Wound Infection
From: Vazquez J, Keast D. Contemporary Issues in Wound Infection: Managing Risks, Treating the Problem. Wounds. November 2006 Supplement.

38. Secondary Signs/Symptoms of Infection
Critically colonized
Bacterial burden
Local wound infection
Delayed healing
Change is wound bed color
Friable granulation tissue
Absent/abnormal granulation tissue
Abnormal color
Serous drainage
Pain at wound site
From: Vazquez J, Keast D. Contemporary Issues in Wound Infection: Managing Risks, Treating the Problem. Wounds. November 2006 Supplement.
*Friable granulation tissue…
In a chronic nonhealing wound, the prolonged inflammatory state interferes with normal healing; the new matrix is broken down by inflammatory products as quickly as it is constructed. This can make the granulation tissue produced, defective.
For example: a high bacterial burden triggers the release of excess vascular endothelial growth factor (VEGF) producing excessive but abnormally weak vascular endothelial buds. The subsequent granulation tissue can easily be digested by the MMPs and it appears very friable.

39. Wound Culture When is it appropriate?
If resident exhibits signs and symptoms of infection obtain culture
When wound extends to bone or fails to heal, assess for signs of osteomyelitis
Grayson et al, demonstrated that a simple clinical test of probing to bone was predictive of osteomyelitis with a sensitivity of 66%, specificity of 85%, positive predictive value of 89%, and negative predictive value of 56%.
Tissue biopsy provides most definitive quantitative analysis about the wound and organisms.
Guidelines for the treatment of pressure ulcers
Wound Rep Reg (2006) by the Wound Healing Society
Whitney et al.
Infection
3.1 Treat distant infections (urinary tract, cardiac valves, and cranial sinuses) with appropriate antibiotics in pressure-ulcer-prone residents or residents with established ulcers.
3.2 Remove all necrotic or devitalized tissue by sharp, enzymatic, biological, mechanical or autolytic debridement.
3.3 If there is suspected infection in a debrided ulcer or if contraction and epithelialization from the margin are not progressing within two weeks of debridement and relief of pressure, determine the type and level of infection in the debrided ulcer by tissue biopsy or by a validated quantitative swab technique.
3.4 For ulcers with ≥ 1,000,000, CFU/gram of tissue or any tissue level of beta hemolytic streptococci following adequate debridement, decrease the bacterial level with a topical antimicrobial. Once in bacterial balance, discontinue the use of topical antimicrobial to minimize any possible cytotoxic effects due to the antimicrobial agent or bacterial resistance to the agent.
3.5 Obtain bacterial balance <100,000, CFU/ gram of tissue and no beta hemolytic streptococci in the pressure ulcer before attempting surgical closure by skin graft, direct wound approximation, pedicle, or free flap
3.6 Obtain a bone biopsy for culture and histology in cases of suspected osteomyelitis associated with a pressure ulcer.
3.7 Once confirmed, osteomyelitis underlying a pressure ulcer should be adequately debrided and covered with a flap containing muscle or fascia. Antibiotics, guided by culture results, should be used for 3 weeks.

40. Wound Culture Proper technique Always clean the wound first
Levine technique
Replace swab in medium (send to lab)
Recommend calcium alginate or rayon culture, as these are biodegradable, in lieu of cotton tip
Levin technique- rotating swab culture over a 1 cm2 area of wound with sufficient pressure to extract fluid from within the wound tissue.
Moisture with saline first…
Cotton fibers can remain behind and cause a granuloma within the wound bed- body rejects foreign object, pearl analogy- wet swab first with saline unless using calcium alginate swab
Swab the wound, not the goop or eschar
Note: biopsy is the most definitive method of quantifying bacteria

41. Antimicrobial Therapy Adapted from Sibbald et al 2001
Critical Colonization
Increasing wound size
Increasing exudate
Friability, bright red
Increased odor
Deep Tissue Infection
Erythema, edema > 2 cm
Probes to bone
Pain
Tenderness
New areas of breakdown
Topical
(Immunocompromised pt may
Require systemic)
Systemic
+/- Topical
Dr Sibbald redefined this in 2006…NERDS and STONES.
The most important vectors of infection are the hands of healthcare providers. Use of gloves and hand washing!!!
Research suggests that topical antibiotic therapy be limited to two weeks. (Baranoski S, Ayello E. Wound Care Essentials. LWW, 2003.)

42. Antimicrobial Therapy
Systemic antibiotics are not required for PrUs with only clinical signs of local infection.
A period of 2 weeks is a reasonable trial with topical agents before considering systemic treatments or re-examining the treatment of the cause/ability of the ulcer to heal.

43. Preparing the Wound Bed Adapted from Sibbald RG et al 2006
Resident with a Wound
Treat the Cause
Local Wound Care
Resident-Centered Care
Persistent Inflammation or
Infection
Moisture Balance
Debridement
Wound bed prep- 3 key components:
Identify and ameliorate underlying cause of wound
Address resident-centered concerns. Cultural sensitivities, wishes, desires, pain, and psychosocial aspects. If not taken into consideration, pt not likely to comply with POC.
Local wound care has 3 major components:
Removal of nonviable tissue (debridement: sharp, mechanical, surgical, chemical, autolytic, biological)
Manage inflammation and infection
Appropriate dressing selection to maintain moisture balance at wound bed (PASTA ANALOGY)
If all components are in place and the wound is not closing/responding, an edge effect (failure of epithelial cells to migrate across granulation tissue) may be the cause, and biological agents, skin grafts or substitutes, and adjunctive therapies should be considered.
Edge of the Wound

44. Wound Care Products
The first recorded use of an occlusive wound dressing 1615 BC.
Wounds were left open to the air to form a scab until Winter advocated the concept of moist wound healing in 1962, based of a pig model.
In 1963, in a human experiment, Hinman and Maibach showed that occlusive dressings accelerate healing.

45. Wound Care Products Over 6000+ products available
Consider the following:
wound related factors (etiology, severity, environment, size, anatomic location, infection)
resident related factors (vascular status, medications, nutritional status)
dressing related factors (availability, durability, characteristics, “cost”)

46. Dressing Considerations
What do you need the dressing to do?
Create or maintain moist wound bed
Provide for non traumatic removal
Create a bacterial barrier
Protect healthy cells
Consider
Ulcer location
Cost and frequency of change
Is the dressing user-friendly

47. Dressing Considerations Adapted from: Baranoski, 1999.
Minimize trauma to wound bed
Eliminate dead space
Assess and manage exudate
Support the body’s tissue defense system
Use non-toxic wound cleansers
Remove infection, debris, necrotic tissue
Environment maintenance- thermal insulation and moist wound bed
Surrounding tissue- protect from injury and bacteria
Minimize trauma esp. with dressing removal
Lightly pack dead space, undermining and tunneling. If too tight, it can create hypoxia/ischemia.
Best wound cleanser is saline and body temperature.

48. Wound Dressing Selection for PrUs
Obliterate
dead space
Obliterate
dead space
Prevent infection
Prevent infection
Promote granulation
Promote granulation
Absorb
Absorb
Absorb
Insulate
Insulate
Insulate
Hydrate
Hydrate
Hydrate
Protect
Protect
Protect
Protect
Cover
Cover
Cover
Cover
Stage I
Stage II
Stage III
Stage IV

49. Amount of Drainage Dressing Choice Slight Heavy Hydrocolloid
Calcium Alginate
Hydrogel
Gauze
Thin Film
Hydrofiber
Collagen
Foam
When used as primary
Dressing Choice

50. Dressing Occlusive Continuum From: Myers, B
Dressing Occlusive Continuum From: Myers, B. Wound Management Principles and Practice, Prentice Hall, 2008.

51. A Few Words About Gauze…
Moisture retentive dressings vs. Gauze
Studies have demonstrated that bacteria can pass through SIXTY-FOUR layers of dry gauze
The infection rate with gauze dressings was 3X higher than with moisture retentive dressings
Gauze dressings will NOT prevent bacterial contamination
Think about a wound’s location….other methods for bacterial contamination?
Gauze dressing changes released greatest bacteria in colonized wounds
Decline of airborne bacteria, almost 30 minutes
Removal of moisture retentive… almost no bacteria released
Bacteria is necessary for wound healing, but can be deleterious to healing if colonization occurs. Attention must be paid to the bacterial burden of a wound.
An invitro study by Lawrence in 1994, showed bacteria was able to penetrate 64 layers of dry gauze. . Moistened gauze demonstrated even less of a barrier to bacterial penetration.
Studies have shown that wounds dressed with gauze are more susceptible to infection vs. semi occlusive dressings.
Important NOT to let bacterial levels reach the point where bacteria begin to invade tissues (infection). Colonization (the attachment of bacteria to wound surface) in high enough #s of bacteria can impede wound healing.
Study by Lawrence in 1992.
Most chronic wounds have polymicrobial colonization Brook 1998, Bowler possibilities for cross infection are high.

52. Dressings & Thermoregulation
Normothermia
37˚C is optimal for cellular functioning
Hypothermia
causes vasoconstriction
decreases cellular activity
decreases collagen deposition
weakens host resistance to wound infection
Most chronic wounds are hypothermic
Normothermia- new in the last 10 years…
Most wounds are hypothermic… 5.6 degrees below core body temp.
Decreased cellular activity- particularly neutrophils

53. Dressings & Thermoregulation
Semi-occlusive dressings = 33-35˚C
Gauze dressings = 25-27˚C
4-6 hours for metabolic function to return to ‘optimal levels’ after each dressing change
With dressing changes, wound bed temperatures have been measured at 21 degrees C
With TID dressings (with gauze), temperature is decreased for hours of the day

54. Real Cost of Wound Care The price of the dressing
The labor cost of changing the dressing
Ancillary supplies and services used in changing the dressing
Cost of the duration of care
We must not confuse the price of a dressing with the cost of care!!!
The simple act of the labor assoc. with a dressing change can make advanced dressings less costly.
Liza Ovington, in her article Hanging Wet to Dry Out to Dry… provided a number of references on cost…
“Several studies have been done to establish that advanced wound dressings can be cost-effective simply by taking into account the cost of labor. A more expensive dressing that requires less frequent dressing changes and results in shorter healing times has been found to be much less expensive to use.
Colwell et al demonstrated that even when the cost of the semiocclusive dressing and ancillary supplies was $6.15 per dressing change versus $0.47 for wet-to-moist gauze, the daily cost of care for the semiocclusive dressing was only $3.55 versus $12.26 for the gauze because the former required less frequent changes than the latter.
Xakellis and Chrischilles showed that while the materials cost of a semiocclusive dressing was more than 3 times higher than saline gauze, the nursing time required for use was one-eighth that of the saline gauze. The cost in use of the semiocclusive dressing according to national nursing wages at the time was $15.90 versus $25.31 for the gauze dressing.
Bolton proposed that a true, total cost of care should include yet another variable: the quality of the healing outcome in terms of clinical effect. Adding this variable underscores the idea that an inexpensive product is not really inexpensive if it does not produce the desired results (i.e., timely healing and improved quality of life for the resident).
These researchers found moisture-retentive dressings actually decrease the costs of care relative to gauze, primarily through their impact on clinician labor, but also as a consequence of improved healing. Add to this the implications for decreased costs related to a lower incidence of infections and pain and semiocclusive dressings are a more logical alternative than ever before. “

55. Wound Care Team Recommendations from AMDA
Interdisciplinary wound care team (IDT)
Team may consist of
Designated wound care nurse
Nursing assistant
Dietitian
Physical or occupational therapist
Practitioner (MD, DO, NP, PA)
At lease one team member should have training in wound care
The team should have access to a wound care specialist
These are some recommendations from AMDA regarding the Wound Care Team.

56. Ensure Quality Education & Communication
Education for the prevention of pressure ulcers should be:
Structured, organized, and comprehensive and directed at all levels of health care providers
Should include information on the following items:
The etiology and risk factors predisposing to pressure ulcer development
The Braden Scale & the MDS & their relevance to planning care
Skin assessment
Staging of pressure ulcers
Selection and/or use of support surfaces
Development & implementation of an individualized skin care program
Demonstration of positioning/transferring techniques to decrease risk of tissue breakdown
Instruction on accurate documentation of pertinent data
University of Iowa Pressure Ulcer Prevention and Treatment Algorithm

57. Pressure Ulcer Resources Recommended to be Used by Surveyors for LTC
University of Iowa: Evidence Based Protocols
Prevention and Treatment of Pressure Ulcers
AHCPR Guidelines for Prevention of Pressure Ulcers
U.S. Department of Health and Human Services, Agency for Health Care Research and Quality. (1992). Pressure ulcers in adults: Prediction and prevention
(AHCPR Publication No ). Rockville, MD: Author.
AMDA Clinical Practice Guidelines for Pressure Ulcers ( or to order)

58. Pressure Ulcer Resources Recommended to be Used by Surveyors for LTC
National Pressure Ulcer Advisory Panel
Pressure Ulcer Prevention: A Competency-based Curriculum
Pressure Ulcer Treatment: A Competency-based Curriculum
PUSH tool
Numerous other resources

59. Wound Care Resources Recommended to be Used by Surveyors for LTC
WOCN Guidelines
Guidelines for Management of Wounds in
residents with LEAD (arterial)
Guidelines for Management of Wounds
in residents with LEND (neuropathic)
Guidelines for Management of Wounds in
residents with LEVD (venous)
Guidelines for the Prevention & Management of Pressure Ulcers

60. Feet Can Last a Lifetime

61. Surveyor Webinar for Survey Process F314 & F309

62. Valuable Resources/Tools
Click on nursing home; select pressure ulcers; then select show tools
Valuable forms and tools for all aspects of PrU care and all team members involved in that care
Incontinence associated dermatitis intervention tool

63. Questions? For information about this or other educational activities, please contact

65. References CMS Used to Create the F314, F309 Regulations
1 Cuddigan, J., Ayello, E.A., Sussman, C., & Baranoski, S. (Eds.). (2001). Pressure Ulcers in America: Prevalence, Incidence, and Implications for the Future. National Pressure Ulcer Advisory Panel Monograph (pp. 181). Reston, VA: NPUAP. 2 Gardner, S.E. & Frantz, R.A. (2003). Wound Bioburden. In Baranoski, S. & Ayello, E.A. (Eds.), Wound Care Essentials: Practice Principles. hiladelphia, PA: Lippincott, Williams, & Wilkins. 3 Ayello, E.A. & Cuddigan, J.E. (2004). Debridement: Controlling the Necrotic/Cellular Burden. Advances in Skin and Wound Care, 17(2), Bergstrom N., Bennett, M.A., Carlson, C.E., et al. (1994). Treatment of Pressure Ulcers in Adults (Publication ). Clinical Practice Guideline, 15, Rockville, MD: U.S. Department of Health and Human Services, Agency for Health Care Policy and Research.

66. References CMS Used to Create the F314, F309 Regulations
5 Thompson, P.D. & Smith, D.J. (1994). What is Infection? American Journal of Surgery, 167, Ayello, E.A., Baranoski, S., Kerstein, M.D., & Cuddigan, J. (2003). Wound Debridement. In Baranoski. S. & Ayello, E.A. (Eds.) Wound Care Essentials: Practice Principles. Philadelphia, PA: Lippincott Williams & Wilkins 7 Bergstrom, N., et al. (1994). Clinical Practice Guideline, Ayello & Cuddigan. (2004). Advances in Skin and Wound Care, Sherman, R.A. (1998). Maggot Debridement in Modern Medicine. Infections in Medicine, 15(9), Piper, B. (2000). Mechanical Forces: Pressure, Shear, and Friction. In Bryant, R.A. (Ed.) Acute and Chronic Wounds. Nursing Management (2nd ed., pp ). St.Louis, MO: Mosby.

68. References CMS Used to Create the F314, F309 Regulations
11 Kosiak, M. (1961). Etiology of Decubitus Ulcers. Archives of Physical Medicine and Rehabilitation, 42, Frequently Asked Questions: Pressure Ulcer Staging and Assessment, Question 202 (2000, July 28). Retrieved July 1, 2004 from 13 Lyder, C., Yu C., Emerling, J., Empleo-Frazier, O., Mangat, R., Stevenson, D. & McKay, J. (1999). Evaluating the Predictive Validity of the Braden Scale for Pressure Ulcer Risk in Blacks and Latino/Hispanic Elders. Applied Nursing Research, 12, Lyder, C. (2003). Pressure Ulcer Prevention and Management. Journal of the American Medical Association, 289, Fuhrer M., Garber S., Rintola D., Clearman R., Hart K. (1993). Pressure Ulcers in Community-resident persons with spinal cord injury: Prevalence and Risk Factors. Archives of Physical Medicine Rehabilitation, 74,

69. References CMS Used to Create the F314, F309 Regulations
16 Cuddigan, Ayello, Sussman, & Baranoski S. (Eds.). (2001). NPUAP Monograph, Ayello, E.A., Braden, B. (May-June 2002). How and Why to do Pressure Ulcer Risk Assessment. Advances in Skin and Wound Care, 15(3), Bergstrom, N. & Braden, B.A. (1992). A Prospective Study of Pressure Sore Risk Among Institutionalized Elderly. Journal of the American Geriatric Society, 40(8), Gosnell S.J. (1973). An Assessment Tool to Identify Pressure Sores. Nursing Research, 22(1), Bergstrom, N., Braden, B., Kemp, M., Champagne, M., Ruby, E. (1998). Predicting Pressure Ulcer Risk: A Multistate Study of the PredictiveValidity of the Braden Scale. Nursing Research, 47(5), Bergstrom N. & Braden, B.A. (1992). Journal of the American Geriatric Society,

70. References CMS Used to Create the F314, F309 Regulations
22 Braden, B. (2001). Risk Assessment in Pressure Ulcer Prevention. In Krasner, D.L., Rodeheaver, G.T., Sibbeald, R.G. (Eds.) Chronic Wound Care: A Clinical Source Book for Healthcare Professionals (3rd ed., pp ). Wayne, PA: HMP Communications Pub. 23 Ayello, E.A., Baranoski, S., Lyder, C.H., Cuddigan, J. (2003). Pressure Ulcers. In Baranoski S. & Ayello, E.A. (Eds.) Wound Care Essentials: Practice Principles (pp. 245). Philadelphia, PA: Lippincott Williams & Wilkins. 24 Cuddigan, J., Ayello, E.A., Sussman, C., & Baranoski, S. (Eds.). (2001). NPUAP Monograph, 27 & Ferguson, R., O’Connor, P., Crabtree, B., Batchelor A., Mitchell J., Coppola, D. (1993). Serum Albumin and Pre-albumin as Predictors of Hospitalized Elderly Nursing Home residents. Journal of the American Geriatric Society, 41, Covinsky, K.E., Covinsky, K.H., Palmer, R.M., & Sehgal, A.R. (2002). Serum Albumin Concentration and Clinical Assessments of Nutritional Status in Hospitalized Older People: Different Sides of Different Coins? Journal of the American Geriatric Society, 50,

71. References CMS Used to Create the F314, F309 Regulations
27 Maklebust, J. & Sieggreen, M. (2001). Pressure Ulcers: Guidelines for Prevention and Management (3rd ed., pp. 49). Springhouse, PA: Springhouse.
28 Lyder, C. (1997). Perineal Dermatitis in the Elderly: A Critical Review of the Literature. Journal of Gerontological Nursing, 23(12), 5-10.
29 Bergstrom N., et al. (1994). Clinical Practice Guideline, Agency for Health Care Policy and Research (AHCPR). (1992). Pressure Ulcers in Adults: Prediction and Prevention (Publication ). Clinical Practice Guideline, 3.
31 Wound Ostomy Continence Nurses Society. (2003). Guidelines for Prevention and Management of Pressure Ulcers (pp. 12). Glenview, IL: Author.
32 Kloth, L.C. & McCulloch, J.M. (Eds.) (2002). Prevention and Treatment of Pressure Ulcer. Wound Healing: Alternatives in Management ( 3rd ed., pp ). Philadelphia: FA Davis Company.

72. References CMS Used to Create the F314, F309 Regulations
33 Jones, V., Bale, S., & Harding, K. (2003). Acute and Chronic Wound Healing. In Baranoski, S. & Ayello, E.A. (Eds.), Wound Care Essentials: Practice Principles (pp ). Philadelphia, PA: Lippincott Williams & Wilkins. 34 Cuddigan, J., Ayello, E.A., Sussman, C., & Baranoski, S. (Eds.) (2001). NPUAP Monograph, Morrison, M.J. (Ed.). (2001). The Prevention and Treatment of Pressure Ulcers. London: Mosby. 36 Bullen, E.C., Longaker, M.T., Updike, D.L., Benton, R., Ladin, D., Hou, Z., & Howard, E.W. (1996). Tissue inhibitor of metalloproteinases-1 is decreased and activated gelatinases are increased in chronic wounds. Journal of Investigative Dermatology, 106(2), Ayello, E.A. & Cuddigan, J. (2003). Jump start the healing process. Nursing Made Incredibly Easy! 1(2), Bergstrom N., et al. (1994). Clinical Practice Guideline, 15.

73. References CMS Used to Create the F314, F309 Regulations
39 Gardner, S.E., Frantz, R.A., & Doebbeling, B.N. (2001). The Validity of the Clinical Signs and Symptoms Used to Identify Localized Chronic Wound Infection. Wound Repair and Regeneration, 9, Gardner, S.E. & Frantz, R.A. (2001). A Tool to Assess Clinical Signs and Symptoms of Localized Chronic Wound Infection: Development and Reliability. Ostomy/Wound Management, 47(1), Cutting, K.F. & Harding, K.G. (1994). Criteria for Identifying Wound Infection. Journal of Wound Care, 3(4), Bergstrom N., et al. (1994). Clinical Practice Guideline, American Geriatric Society. (2002). American Geriatric Society Guideline: The Management of Persistent Pain in Older Persons. Journal of American Geriatric Society, 50(6), S205-S Gomez, S., Osborn, C., Watkins, T. & Hegstrom, S. (2002). Caregivers team up to manage chronic pain. Provider, 28(4), Dallam, L.E., Barkauskas, C., Ayello, E.A., & Baranoski, S. (2003). Pain Management and Wounds. In Baranoski, S. & Ayello, E.A. (Eds.). Wound Care Essentials: Practice Principles (pp ). Philadelphia, PA: Lippincott Williams & Wilkins.

74. References CMS Used to Create the F314, F309 Regulations
46 Ayello, E.A., Baranoski, S., Lyder, C.H., & Cuddigan, J. (2003). Pressure Ulcers. In Baranoski, S. & Ayello, E.A. Wound Care Essentials: Practice Principles (pp. 257). Philadelphia, PA: Lippincott Williams & Wilkins.
47 Schultz, G.S., Sibbald, R.G., Falanga, V., Ayello, E.A., Dowsett, C., Harding, K., Romanelli, M., Stacey, M.C., Teot, L., Vanscheidt, W. (2003). Wound Bed Preparation: A systematic Approach to Wound Management. Wound Repair Regeneration, 11,1-28.
48 Association for Professionals in Infection Control and Epidemiology, Inc. (March/April 2001). Position Statement: Clean vs. Sterile: Management of Chronic Wounds. Retrieved July 6, 2004 from resource center.
49 Black, J.M. & Black, S.B. (2003). Complex Wounds. In Baranoski, S. & Ayello, E.A. (Eds.). Wound Care Essentials: Practice Principles (pp. 372) Philadelphia, PA: Lippincott Williams & Wilkins.
50 Bergstrom N., et al. (1994). Clinical Practice Guideline, 15.