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Vohra Wound Management Ameet Vohra MD, CWS Medical Director.

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Presentation on theme: "Vohra Wound Management Ameet Vohra MD, CWS Medical Director."— Presentation transcript:

1 Vohra Wound Management Ameet Vohra MD, CWS Medical Director

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

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

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

5 Historical Perspective Historical Perspective Dress the wound – cover it up, hide it Dress the wound – cover it up, hide it Hale was old English for holy & heal 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 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 >65 yrs will double by 2040 >85 yrs will quadruple by 2040 >85 yrs will quadruple by 2040 Declining skin functions with age Declining skin functions with age -barrier -barrier -immune -immune -healing -healing Increased MMPs Increased MMPs

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

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

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

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

11 State Surveys State Surveys The future of surveys? The future of surveys? New CMS guidance F314 New CMS guidance F314 How to satisfy the state How to satisfy the state The Initial Assessment: DTI / Staging The Initial Assessment: DTI / Staging What is an unavoidable ulcer What is an unavoidable ulcer cms.internetstreaming.com cms.internetstreaming.com

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

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

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

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

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

17 Litigation – Perceptual Issues Communication Communication - understand and value family perspective - multidisciplinary communication - involve family early - communicate regularly - document all communication

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

19 Litigation - Rising More informed consumers More informed consumers Blatant advertising Blatant advertising Earlier hospital / Rehab center discharges Earlier hospital / Rehab center discharges Precedent of generous settlements Precedent of generous settlements Inadequately trained clinicians Inadequately trained clinicians Sympathetic juries perceive wounds as indicators of poor care 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 identification of skin deterioration Early contact with the responsible party Early contact with the responsible party -Explain why it happened -Explain why it happened -Explain plan of action -Explain plan of action -Explain realistic objectives -Explain realistic objectives -Encourage meeting wound care -Encourage meeting wound care Specialist Specialist

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

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

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

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

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

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

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

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

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

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

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

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

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

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

35 When is it not a pressure ulcer? Arterial (Doppler) Arterial (Doppler) Venous Venous Diabetic Diabetic Traumatic Traumatic Inflammatory Inflammatory

36 Arterial Ulcers Arterial Ulcers Interruption or blockage of blood flow Interruption or blockage of blood flow Distal portion of the lower Extremity, ankle, top of foot, toes Distal portion of the lower Extremity, ankle, top of foot, toes Wound bed dry and pale, minimal exudate Wound bed dry and pale, minimal exudate Intermittent cluadication, decreased pulses, pain on elevation, cool to touch, decreased capillary refill Intermittent cluadication, decreased pulses, pain on elevation, cool to touch, decreased capillary refill Critical ischemia = ulcer/gangrene + ankle systolic pressure < 60mmHg Critical ischemia = ulcer/gangrene + ankle systolic pressure < 60mmHg

37 Neuropathic Ulcers Peripheral neuropathy from Diabetes Peripheral neuropathy from Diabetes Ball of foot over metatarsal heads, top of toes Ball of foot over metatarsal heads, top of toes Resembles arterial, frequently infected Resembles arterial, frequently infected Dx of DM required, with impaired sensation, may have Charcot deformity. Dx of DM required, with impaired sensation, may have Charcot deformity.

38 Venous Ulcers Venous Ulcers Open layer of skin and or subcutaneous tissue Open layer of skin and or subcutaneous tissue Venous hypertension from compromised valves, partial or complete venous obstruction, muscle pump failure (paralysis) Venous hypertension from compromised valves, partial or complete venous obstruction, muscle pump failure (paralysis) Pretibial area Pretibial area Wound bed moist and granulating, with minimal to copious exudate. Wound bed moist and granulating, with minimal to copious exudate. Pain in dependant position. Often recurring. Pain in dependant position. Often recurring.

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

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

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

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

43 Modern Wound Management Debridement: Sharp / Enzymatic Debridement: Sharp / Enzymatic Control of Biofilm / bioburden Control of Biofilm / bioburden Culture when clinically infected Culture when clinically infected Control exudate / odor Control exudate / odor Frequency of dressing changes: balance Frequency of dressing changes: balance Moist wound bed healing Moist wound bed healing - avoid wet-dry, dakens, peroxide, - betadine (except <5% for <10 days)

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

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

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

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

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

49 Treatment Options Debridement/curettage Debridement/curettage Silver Silver Antibiotics Antibiotics

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

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

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

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

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

55 Individualized Care 1. Holistic approach 2. Identify risk factors 3. Realistic objectives 4. Select optimal wound dressings 5. Depart from established protocols/algorithm 6. Nutritional supplementation 7. Pain evaluation

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

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

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

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

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

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

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

63 Wound Microbiology Wound Microbiology Pepto streptococcus Pepto streptococcus Bacteroides Bacteroides Streptococcus spp. Streptococcus spp. Coliforms Coliforms Clostridium 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. 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 Pseudomonas Aeroginosa Fusabacterium Fusabacterium Streptococcus pyogenes Streptococcus pyogenes P. Acnes P. Acnes Pneumotella Pneumotella Evidence that several common colonizing microbes actually facilitate healing. Evidence that several common colonizing microbes actually facilitate healing. Future challenge = target only deleterious microorganisms. Future challenge = target only deleterious microorganisms.

64 Nutrition: Protein Baseline 1g / Kg / day Skin / Tissue damage 1.5g / Kg / day High stress 2.0g / Kg / day

65 Nutrition: Vitamins & Minerals Nutrition: Vitamins & Minerals Baseline 1 multi-vitamin / day Skin / Tissue damage 1 multi-vitamin / day + 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 The Future Growth factors Growth factors Novel support surfaces Novel support surfaces New antimicrobial therapy New antimicrobial therapy Expanded physical therapy support Expanded physical therapy support -Anadyne, Ultrasound, Pulse lavage, Electrostim, UV -Anadyne, Ultrasound, Pulse lavage, Electrostim, UV Maggots Maggots Skin Grafts Skin Grafts

67 Wound Care Documentation Wound Care Documentation


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