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Vohra Wound Management

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Presentation on theme: "Vohra Wound Management"— Presentation transcript:

1 Vohra Wound Management
Ameet Vohra MD, CWS Medical Director

2 Introduction Who are we? -Physician group, focus is long term care
What does the program provide for the facility? -GRAND ROUNDS, Education, Protection

3 Benefits to the facility
Financial Savings / Increase Revenue Liability Protection Education / Certification Compliance with State Guidelines Optimal Medical Management

4 Outcomes Data Fewer Infections: 46% Fewer Amputations: 39%
Fewer instances of gangrene: 42% Fewer hospitalizations: 36%

5 Historical Perspective
“Dress” the wound – cover it up, hide it Hale was old English for “holy” & “heal” Hamlet : “it will but skin and film the ulcerous place, whilst rank corruption mining all within, infects unseen”

6 Population Ageing >65 yrs will double by 2040
>85 yrs will quadruple by 2040 Declining skin functions with age -barrier -immune -healing Increased MMPs

7 Key Points Physician involvement Debridement Deep tissue injury
Skin failure Unavoidable – correct definition Define etiology Individualize care Pain – recognize, treat, document

8 Nursing Home Statistics
16,300 nursing homes nationwide Approx. 1.5 million residents Wound prevalence rate is 9% 140,000 residents with wounds In-house prevalence rate is 0.8%

9 Long Term Care Facility Tags
F314 – Pressure Ulcers F309 – End of Life / Pain Management F305 – Quality of Life F385 – Physician Involvement F501 – Medical Director F281 – Care meets professional standards RN not LPN for admission assessment F157 – Notification of Changes

10 Tags-continued F272 – Comprehensive Assessments
F282 – MD Orders not implemented F279 – Comprehensive care plans F353 – Sufficient staff F280 – Comprehensive care plan revision - “clean ulcer should show evidence of healing within weeks” F441 – Aseptic technique (change gauze/gloves)

11 State Surveys The future of surveys? New CMS guidance F314
How to satisfy the state The Initial Assessment: DTI / Staging What is an unavoidable ulcer “cms.internetstreaming.com” Why they happen? To ensure quality care, facility compliance Future? Could increase How to Satisfy and survive? Documentation of appropriate care. What triggers a survey? Complaints, improper care, routine

12 What will trigger a Citation
Facility failure (protocols) Failure to implement preventive care Failure to diagnose early Failure to treat aggressively Infection of wound – level 3 citation Delay in treatment (esp. nec. inf. Wound) Failure to implement orders Failure to explain / document skin deterioration Failure to individualize management

13 Unavoidable Ulcer If correct risk stratification & prevention
If detected at St 1, treated, & re-assessed “In-spite of early diagnosis, aggressive treatment & appropriate f/u, wound has deteriorated. It is therefore unavoidable.” DR ……… If etiology is not pressure

14 Pro-active Solutions Deep Tissue Injury: understand, recognize, document, treat (esp. heels) Multi-specialty, interdisciplinary team headed by physician Modern protocols, complete formulary Identify other etiologies – get Doppler Educate all the staff Get initial skin assessment right

15 Systematic Approach Identify risk factors, individualize interventions with interdisciplinary team Monitor daily, diagnose early, treat aggressively, follow-up, re-assess Report deterioration / treatment failure to physician early Debridement non-viable tissue “enhances wound healing”

16 Litigation Recent Settlements
Florida (1998) $43 million Texas (1997) $92 million Texas (1997) $83 million Texas (2002) $3.8 million Alabama (1993) $65 million 21% claims > $500,000: median =$250,000

17 Litigation – Perceptual Issues
Communication - understand and value family perspective - multidisciplinary communication - involve family early - communicate regularly - document all communication Often occurs as a result of improper communication. Family members should be included in care plan. Proper documentation is key. Early recognition and intervention of appropriate care.

18 Litigation – Standard of Care
Address failure to prevent / diagnose Establish Realistic Goals Regular follow-up Exceed Standard of Care Demonstrate the quality of care delivered Document to defend

19 Litigation - Rising More informed consumers Blatant advertising
Earlier hospital / Rehab center discharges Precedent of generous settlements Inadequately trained clinicians Sympathetic juries perceive wounds as indicators of poor care Wounds now second leading cause of litigation

20 Damage Control Early identification of skin deterioration
Early contact with the responsible party -Explain why it happened -Explain plan of action -Explain realistic objectives -Encourage meeting wound care Specialist

21 Medical Factors in Law Suit
Low risk patient Wound worse due to wrong treatment Inadequate physician involvement Inadequate pain management Documentation conflict on transfer Abandonment Infection missed causing worse outcome

22 Defense Risk factors – document Skin failure – identify
Peripheral vascular disease – diagnose Diabetes – level of control Involve family early and regularly Document family discussions

23 Anatomy of the Skin Largest Organ of the Body
Subject to injury and failure Layers of the Skin Epidermis Dermis Subcutaneous Muscle and Fascia

24 Skin Failure Diagnosis is based on the clinical condition of the patient. Diagnosis by the physician after a full examination and review of medical history

25 Supportive Factors in the History: (skin failure)
Advanced age Dehydration Advanced carcinomatous disease Protein malnutrition Weight loss Hopsice/terminal condition (for any reason) with life expectancy less than 6 months Single/multi organ failure

26 Supportive Findings on Exam (skin failure)
Multiple wounds at various sites of the body No clear etiology for the wound Multiple skin tears, areas of shear injury Frail, cachectic, poorly responsive patient Declining physical condition

27 Pressure Ulcer Localized injury to skin/underlying tissue
Usually over a bony prominence Due to Pressure (combined with shear and/or friction)

28 Stage I Pressure ulcer Redness only Skin is intact Underlying damage
may not be evident Early recognition is key

29 Stage II Pressure Ulcer
Broken Skin Involves epidermis and/or dermis

30 Stage III Pressure Ulcer
More significant damage to skin Involves epidermis, dermis, and subcu- tanious tissue

31 Stage IV Pressure Ulcer
Most severe damage to skin Involves all layers of skin down to muscle and fascia

32 Unstageable Pressure Ulcer
Can not visualize wound bed Number not assigned until full damage is determined

33 Deep Tissue Injury Change in temperature
Change in consistency: firm/boggy (heels) Change in sensation: pain Bruising / purple discoloration Dark skin: difficult

34 Deep Tissue Injury Etiology is Pressure
Skin intact: tissue below affected Appears as a deep bruise / maroon area May present as a blood-filled blister Evolution to stage 3/4 may be rapid despite optimal treatment Treatment: pain control and off-loading

35 When is it not a pressure ulcer?
Arterial (Doppler) Venous Diabetic Traumatic Inflammatory Some of these conditions are defined in the new state CMS guidance (tag F309). Ensure that the facility does not own everything as a pressure ulcer. We must define the etiology (as recommended by F314) GET THE DOPPLER STUDY Take the group through each of the listed categories of pressure ulcers.

36 Arterial Ulcers 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 Critical ischemia = ulcer/gangrene + ankle systolic pressure < 60mmHg

37 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.

38 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.

39 Diabetes Demographics
2-6% annual risk foot ulceration 15-25% lifetime risk for foot ulcer Diabetes prevalence in US is 7% 20.8 million Americans with diabetes - expected to increase 60% over 22yrs

40 Impact of Diabetes Increases healing time Infection, Phlegmon
Inflammatory state Have low threshold for treating infection Decreases Cell migration Skin contraction Lymphocyte function Monitor HbA1C

41 Heel ulcers & Off-loading Protocol
Bed bound patient: Use cradle/block (sponge or waffle boot) Patient in bed/chair: Use comfortable, padded easy boot Patient ambulatory: Use cradle/block (sponge)/waffle boot in bed, use multipodus boot in chair/whilst walking Label boots: L and R

42 When NOT to use Multipodus boot
Leg edema Leg ischemia Contractures Agitation

43 Modern Wound Management
Debridement: Sharp / Enzymatic Control of Biofilm / bioburden Culture when clinically infected Control exudate / odor Frequency of dressing changes: balance Moist wound bed healing - avoid wet-dry, dakens, peroxide, betadine (except <5% for <10 days) Talk the group through the following points from Modern wound management Moist wound bed healing- there was a study carried out in the 70’s on pig skin which compared moist and dry wound healing. Wet to dry? Sometimes used but has a tendency to remove healthy granulating tissue as well as slough (F314 advises against this technique in the majority of cases) Sharp Debridement- recommended as this removes slough and bio-film and promotes the development of fresh granulations, special mention is made of the positive aspects and benefits of sharp debridement in the F314 tag. Take this opportunity to explain to the group why we perform sharp debridement – CONSERVATIVE APPROACH IN THE NURSING HOME Re-assure the group that it is more like curitage than debridement- simply gently scraping off the top layer of bio film and necrotic tissue with a Q tip to clean the wound. Enzymatic debridement- a technique that we also employ Moist wound healing and the frequency of dressings Exudate/Odor control How/when to culture- Ca Alginate, charcoal, anti microbials

44 Vacuum Treatments Most effective in complex, deep wounds
Use till ulcer base granular Re-eval Rx if no progress in 2- 4 weeks Effective via multiple modalities Becoming standard of care

45 Contra-Indications infection Necrotic tissue
Fistula or exposed organ / vessel Ischemia Non-compliance (other patient-specific impeding factor)

46 Biofilm Layer of non-viable matter
Harbors bacteria that exist synergistically Impenetrable topically and systemically Curettage/Debridement effective in disrupting and removing film

47 Bioburden Quantity of bacteria at wound bed
Contamination-Colonization- CRITICAL BIOBURDEN- Infection Critical bioburden- early diagnosis essential

48 Diagnosis of Critical Bioburden
Pale granulation tissue Increase in odor/exudate/erythema Increase in pain and size of ulcer Failure to improve NO pus/cellulitis

49 Treatment Options Debridement/curettage Silver Antibiotics

50 Debridement/Curettage
Remove infection risk, biofilm, bioburden Remove non-viable tissue Debridement options: -Sharp (infection & pain control) -Enzymatic -Autolytic -Mechanical

51 The Role of Silver Topical Non-antibiotic antibacterial
Long history of safety and efficacy Effective against bacteria, viruses, fungi No resistance development (not an antibiotic) Topical form, minimal systemic absorption 2 weeks therapy approx.

52 When to Culture Abscess fluid Infection not responding to treatment
Must have cellulitis/pus Suspect resistant organism Wound failing to progress after 4-6 weeks

53 Control of Exudate Goal = moist environment
Individualize treatments, BiD to 1/5 days Frequent dressing- control exudate better but interferes with healing and local immune response. Key to success = Balance + Individualize

54 Avoid Wet to dry (mechanical debridement) from US civil war
Dakens solution, Hydrogen peroxide Betadine (except < 5% for< 10 days) Drying out wound bed (except gangrene) Expensive unwarranted therapies Wound care centers

55 Individualized Care Holistic approach Identify risk factors
Realistic objectives Select optimal wound dressings Depart from established protocols/algorithm Nutritional supplementation Pain evaluation Holistic approach Identify risk factors- diabetes, Realistic objectives Select optimal wound dressings Depart from established protocols/algorithm

56 Daily Nursing Assessment
Look for: 1) evidence of infection 2) change in size 3) appearance of bone 4) change in exudate/odor/pain 5) increase in pain Report wound deterioration to physician

57 Pain Assessment Affected by anxiety, neuropathy, time Get full history
Validate patients pain Whatever & whenever patient says it is Document

58 Pain Intervention Address inflammation, infection, edema
Use non-adherent dressing Protect surrounding skin Pre-medicate systemically when dressings painful Document improvement/patient satisfaction

59 Allergens Common allergens: Balsam of Peru (<37%), lanolin (<20%), Neomycin (<15%), Bacitracin, repeated use benzocaine/EMLA Under-diagnosed and under-considered Latex allergy

60 Allergy Intervention Change agent Tacrolimus (Eladil) Steroid cream
NSAID cream Maintain high index of suspician Wound that deteriorates/fails to improve/increases in pain

61 Atypical Wounds Neoplasm- excision Vasculitic- anti-inflamatory
Pyoderma gangrenosum- immuno-therapy Vasculopathy - anticoagulation Cryoglobulinemia – treat cause

62 Wound Chemistry MMPs Interleukins Growth hormones
Inhibitors and stimulators of angiogenesis Hyper-granulation Wound chem. abnormal in diabetic ulcers

63 Wound Microbiology Pepto streptococcus Bacteroides Streptococcus spp.
Coliforms Clostridium Staph aureus (high prevalence rate in non-infected ulcers, 88%, has low incidence of infection vs other microbes eg anaerobes. Staphs may facilitate growth of more toxic microbes eg anaerobes. Pseudomonas Aeroginosa Fusabacterium Streptococcus pyogenes P. Acnes Pneumotella Evidence that several common colonizing microbes actually facilitate healing. Future challenge = target only deleterious microorganisms.

64 Nutrition: Protein Baseline 1g / Kg / day Skin / Tissue damage
High stress 2.0g / Kg / day

65 Nutrition: Vitamins & Minerals
Baseline 1 multi-vitamin / day Skin / Tissue damage + Nutritional supplements Individualize for VitC & ZnSO4 supplements High stress, History Malnutrition / Diarrhea / Highly exudative wounds 1 Multi-vitamin / day VitC 500mg BiD ZnSO4, 220mg QD x14days

66 The Future Growth factors Novel support surfaces
New antimicrobial therapy Expanded physical therapy support -Anadyne, Ultrasound, Pulse lavage, Electrostim, UV Maggots Skin Grafts

67 Wound Care Documentation


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