Advancing Wound Care Through Compliancy with F314 A survival guide for LTC

Intent of F314  The facility must ensure that a wound demonstrates: Optimal improvement, or Optimal improvement, or Does not deteriorate Does not deteriorate Within the limits of:Within the limits of: Residents right to refuse treatments Residents right to refuse treatments Recognized pathology Recognized pathology Normal aging process Normal aging process

Actual Harm  Failure to heal existing wounds  Preventable Pressure Ulcers, including Stage I  Failure to provide ‘standard of care’ treatments

CMS Expectation for Healing  “a clean pressure ulcer with adequate blood supply and innervation should show evidence of stabilization or some healing within 2-4 weeks” CMS F314  “If a pressure ulcer fails to show some evidence of progress within 2-4 weeks, the resident’s overall clinical condition should be re-assessed”

Avoidable- Preventable  A Pressure Ulcer (any stage) is acquired and the facility failed to do one or more: Evaluate resident’s clinical condition Evaluate resident’s clinical condition Evaluate resident’s risk factors Evaluate resident’s risk factors Define and implement interventions that are consistent with individual needs, goals, and standards of practice Define and implement interventions that are consistent with individual needs, goals, and standards of practice Monitor and revise interventions as needed Monitor and revise interventions as needed

Deep Tissue Injury  “This damage can lead to an unavoidable stage III or IV,” or  “The progression of a Stage I to an ulcer with eschar or exudate within days after admission.”  Indicators: Purple or very dark area with profound redness, edema, or induration Purple or very dark area with profound redness, edema, or induration

Stage I indicators  Indicators present after minutes of removing pressure to the site  Observable, pressure related alteration of intact skin  Indicators include: Skin temperature changes Skin temperature changes Tissue consistency Tissue consistency Sensation Sensation Defined area of persistent redness, blue or purple hues Defined area of persistent redness, blue or purple hues

Standard of Care  Assessing Risk  Classifying wound types to provide specific interventions  Moist Wound Healing techniques  Pain Management  Infection control  Appropriate Interventions  Debridement as appropriate  Nutritional Interventions  Continence management

Risk Assessment  Pressure Ulcers can develop in 2-6 hours  In LTC, most pressure ulcers occur within the first 4 weeks after admission, or with acute illness  Comprehensive Assessment evaluates risk factors for developing ulcers, and/or for causing delay in healing of existing ulcers  Assessment should identify factors that can be removed, modified, or stabilized

Risk Assessment  RAI  Risk tool on admission, weekly x 4, quarterly and with change in condition  Do not focus on scores, focus on actual categories  Risk Factors, pressure points, nutrition, hydration, moisture, mobility  **Refusals, End of Life and Multi Organ Failure**

Classification of Wounds  Clinicians are expected to document clinical basis to permit classification, especially if the ulcer has characteristics of pressure, but is determined Not to be pressure.  Surveyors provided with description of common wound types: Venous, Arterial, Diabetic, Perineal Dermatitis

Expected Documentation of Wound Characteristics to support Dx  Underlying condition contributing to ulcer  Ulcer edges  Wound bed  Location  Size  Condition of surrounding tissues  Exudate  Pain

Pressure Ulcers  “any lesion caused by unrelieved pressure that results in damage to underlying tissues.”

Arterial Ulcer  Result of Arterial occlusive disease When non-pressure related disruption or blockage of the arterial flow to an area causes tissue necrosis.  Intermittent claudication  Mod-severe PVD  Arteriosclerosis  Inflammatory or autoimmune disorders  Significant vascular disease (CVA, MI)

Arterial Ulcer Characteristics  Location: distal part of lower extremity  Wound Bed: dry and pale with minimal to no exudate  Diminished or absent pulses  Coolness to touch  Increased pain with exercise or elevation  Delayed capillary refill  LE hair loss  Toenail thickening

Diabetic Neuropathic Ulcer  Must have Diagnosis of Diabetes  Must have peripheral neuropathy  Ulcer on foot: mid- foot, ball of foot, top of toes, also with Charcot deformity

Venous Hypertension  Due to one or many factors Loss of or compromised valve function Loss of or compromised valve function Vein obstruction (DVT, Obesity, malignancy) Vein obstruction (DVT, Obesity, malignancy) Failure of the calf muscle to pump Failure of the calf muscle to pump * Leads to edema, induration, hemosiderin staining, dermatitis, ulceration

Venous Ulcer characteristics  Location: Medial Ankle- Pretibial area  Most common Lower extremity wound  May occur off and on for years  Moist wound base  May be superficial  Minimal to copious drainage  Increased pain with dependency

Perineal Dermatitis  Rash due to reaction from incontinence, not pressure related.  Resident’s skin is at greater risk for pressure breakdown

Infection Control  All chronic ulcers are colonized  Avoiding infection is vital to healing  Infected wounds delay healing and increase chance of cross-contamination  Factors that increase infection: Size of ulcer Size of ulcer Location Location Local perfusion Local perfusion Host immunocompetency Host immunocompetency # and type of microbial bodies # and type of microbial bodies Presence of necrosis Presence of necrosis

Best Practices to Decrease Bioburden  Select dressings that offer bacterial barrier properties and minimize airborne distribution with dressing changes (hydrocolloids)  Avoid dressings that do not (gauze)  Systemic Antibiotics are considered essential for acute, advancing, infection in chronic wounds  Topical Antibiotics are not justified or recommended

Best Practices Infection Control  Antiseptic solutions for cleansing should be avoided  If selecting Antiseptic solutions for wound treatments, like Dakins, clinician must weigh benefits vs risks. It is currently not accepted as standard practice among most wound care experts.

Best Practices Infection Control  Cadexomer Iodine: time released, effective against MRSA, safe and effective. Wound must be moist.  Time released Silvers Broad spectrum Antimicrobials Broad spectrum Antimicrobials Safe and effective Safe and effective Non toxic to fibroblasts Non toxic to fibroblasts Allows for moist wound healing Allows for moist wound healing

Non-Cytotoxic Topical Antimicrobials  Consider Cadexomer iodine or Time released Silvers for the following indications: 1 or more signs of infection are present 1 or more signs of infection are present If less obvious signs, like increased exudate or friable base, are noted If less obvious signs, like increased exudate or friable base, are noted Increased local wound pain Increased local wound pain Delayed healed Delayed healed

Treatment Selection  “A facility should be able to show that its treatment protocols are based upon current standards of practice and are in accord with facility’s policies and procedures as developed with the medical director’s review and approval.”

Expectations with Treatments Expectations with Treatments  Stage III and IV ulcers must be covered  No Particular dressing promotes healing of all ulcers  Balance to maintain a moist wound bed, and a dry peri area is required for optimal results  Stable eschar on foot/ heel area should not be debrided unless infection or instability are detected.

Surveyor Instruction in Pain Management  Goal: eliminate wound pain  Stage III and IV ulcers can be as painful as a Stage I or II  Inappropriate dressings and trauma during treatment can be route of pain

Pain Management  Most wound pain occurs with dressing change due to: dried dressing, desiccated wound base, strong adhesives and poor exudate control.  Selecting appropriate product to allow for moist wound healing will significantly decrease pain  Avoid gauze and wet-dry treatments  Pre-medicate prior to dressing change

Expected Interventions  Reposition in chair every hour, minimum  Reposition in bed every 2 hours, minimum  Teachable residents reposition every 15 minutes  No one should sit in a wheel chair for prolonged periods of time (time for a meal) without modifications to chair (seat cushions)

Appropriate Interventions  Static surfaces (gel, foam): may be appropriate for prevention, or healing, if resident can position off wound site.  Dynamic (air): consider for non-healing wounds, or if resident can not assume a variety of positions  Repositioning is still required, heel floating is still required.

Debridement Options  Types: Autolytic Autolytic Enzymatic Enzymatic Mechanical Mechanical Sharp or surgical Sharp or surgical Bio-debridement Bio-debridement Polyacrylate Polyacrylate  Consider: Condition of resident Condition of wound Goals of resident Location of wound Viability of wound Underlying conditions Anticoagulants Arterial status Bioburden

Autolytic  Defined: use of moisture retentive dressing to allow devitalized tissue to self- digest by the action of enzymes in wound fluids  Pro: pain-free, decreased frequency of dressing change  Con: slower, requires adequate circulation, can not be used with infected wounds

Enzymes Derived from:  Plant Derived (Papaya) Papain and Urea Accuzyme Accuzyme Gladase Gladase Ethezyme Ethezyme Ziox Ziox Copper Chlorophyll Panafil: Panafil: Gladase C Gladase C Ziox Ziox  Biologically Engineered Collagenase Painless, may be appropriate for maintenance therapy and used in conjunction with sharp debridement.

Mechanical  Each must be considered carefully and performed by a professional knowledgeable about Pros, Cons, Indications and Contraindications.  Whirlpool  Pulse Lavage  Wet-dry (not wet-moist)

Sharp or Surgical  Immediate removal of devitalized tissue  Surgical Often necessary in the case of infected, necrotic wound  Sharp may be performed at bedside: must consider wound location, viability, circulation, use of anticoagulants, pain management, skilled clinician availability

Bio-Debridement  Selective debridement of necrotic tissues by sterile maggots  Decreasing bacteria and infection in wound tissues  Requires skilled clinicians to apply ‘retention’ dressing that takes approximately minutes.  Some reports of pain  ‘Yuck’ factor

Polyacrylate  Polyacrylate pad moistened with ringers solution  Draw necrosis out of wound while maintaining a moist wound bed  Debrides at a rate of 38%  No discomfort

Avoidable vs. Unavoidable  Must be addressed in the case of: New Pressure Ulcer New Pressure Ulcer Non-healing Ulcer Non-healing Ulcer Wound pain Wound pain Infection Infection

Successful LTC Centers  Internal policies and procedures are in harmony with Best Practice and CMS regulatory requirements  Understand that Non-compliance is more expensive than Compliance.