Assessment and Treatment of Chronic Wounds Aimée D. Garcia, M.D.,CWS Assistant Professor, Baylor College of Medicine Director, Wound Care Clinic and Consult S ervice Michael E. DeBakey Houston VA Medical Center Houston, Texas
S peaker Disclosure Dr. Garcia has disclosed that neither she nor members of her immediate family have any actual or potential conflict of interest.
Obj ectives 1. Review wound types and risk factors. 2. Discuss management priorities and treatment plans based on proper wound assessment.
Wound Repair Is a Complex Cellular and Biochemical Response to Inj ury
Wound Healing Physiology Phases of Wound Healing Hemostasis (0-3 hours) Inflammatory (0-3 days) Proliferative (3-21 days) Remodeling/Maturation (21 days-1.5 yrs.)
Factors that Impact Wound Healing Nutrition Medications Infection Immobility Radiation Therapy Vascular Insufficiency Chronic Medical Diseases Aging
Nutrition in Wound Healing CMS and AHRQ specifically identify nutrition status as a significant risk factor for skin breakdown Fibroblasts cannot synthesize collagen without adequate nutrition Wound contraction inhibited by malnutrition Protein deficiency poses greater risk for infection Muscle wasting increases risk for pressure inj ury and wound trauma
Nutritional Assessment Patient History Physical Exam Laboratory Testing Clinical Assessments
Assessment of Protein Metabolism Visceral protein blood levels S erum albumin: 3.3-4.5 g/ dl Transferrin: 200-400 mg/ dl Prealbumin: 20-40 mg/ dl Total Lymphocyte counts 1500-3000 cells/ mm 3
Nutritional S upport Treatment Options Oral nutritional support Enteral tube feeding Parenteral nutrition Get a Nutrition consult early in the management of chronic wounds if nutrition is a concern
Position of the Academy of Nutrition and Dietetics. J Acad Nut r Diet . 2019
Medications and Radiation Compromised Wound Healing S teroids Anti-inflammatory drugs Antimitotic drugs Radiation therapy
Wound Infection Overgrowth of Microorganisms Resultant Tissue Destruction Local symptoms Wound deterioration Erythema, edema, drainage (purulent), tenderness, warmth, induration and/ or crepitus S ystemic symptoms Fever, leukocytosis, confusion, tachycardia, hypotension, malaise
https://doi.org/10.1111/j.1742-481X.2007.00388.x
Bacterial Burden and Wound Infection Negative Impact on Wound Healing Prolongs the inflammatory stage Induces additional tissue destruction Delays collagen synthesis Prevents epithelialization
Colonization vs. Infection Colonization Bacteria in wound bed, not affecting the environment Critical Colonization Wounds with more than 100,000 organisms/ gram will not heal S uspect bacterial burden if a clean wound shows no improvement after 14 DAYS of topical therapy Infection Invasion of the soft tissues
Wound Cultures Traditional swab culture detects only surface bacterial colonization/ contamination May not reflect the invasive organism causing infection Quantitative Wound Culture recommended for determining infection Documents bacterial burden Identifies bacteria actually invading wound tissue
Quantitative Wound Cultures Tissue Biopsy Needle Aspiration Quantitative S wab Technique
Antimicrobial Therapy Determination of wound infection Identification of organism by culture or gram stain prior to therapy Do not use systemic therapy if infection is local Consideration of pharmacology and toxicology
Aging S kin Decrease dermal-epidermal turnover Decreased subcutaneous fat deposition Decreased elastin Decreased dermal blood flow Flattening of the rete ridges Thinning of the skin
Maj or Types of Wounds Pressure Inj uries Vascular Ulcers Arterial Ulcers Venous S tasis Ulcers Neuropathic/ Diabetic Foot Ulcers Others Pyoderma gangrenosum, malignancies, calciphylaxis
Definition of Pressure Inj ury A pressure inj ury is localized inj ury to the skin and/ or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. International NPUAP-EPUAP Pressure Ulcer Definition
Epidemiology Pressure inj ury in vulnerable populations (elderly and those with limited mobility) are common Acute care – incidence ranges from 0.4% to 38% with 2.5 million treated annually at cost of $11 billion/ year (1) 1. Pressure ulcers in America. Adv S kin Wnd C are 2001;14(4): 208 - 215
Pressure Inj uries Used to be: Nursing issue only Physicians “ passive participants” Currently: Multidisciplinary: Dietitians Physical therapists Occupational therapists Physicians Nurses Physician Assistants/ Nurse Practitioners Patients Family members 26 Wake. What clinicians need to know. The Permanent e Journal 2010
Pressure Inj uries – What Changed? Cost 1996 – $64 billion(1.2% of health care costs) 2006 – $11 billion - hospital stays -PU as 1 or 2 dx (1) $3500 – >$60,000/ person (depending on stage) (1) CMS Oct 2008 – withhold reimbursement for HAC 1 HCUP 2008 data 27
CMS : Present on Admission for Acute Care Pressure inj uries in acute care are “ reasonably preventable” One of eight original conditions selected as a present on admission/ hospital-acquired condition (POA/ HAC) October 1, 2008 – CMS denied payment for HAPU Hospitals took notice
CMS Regulations Documentation requirements for care settings Influences Reimbursement Citations and fines Public reporting
Present on Admission S tage 3 or 4 pressure inj uries Location documented on admission by CMS — defined professional legally responsible for making a medical diagnosis – are eligible for reimbursement Physician MLP (nurse practitioner, clinical nurse specialist, physician assistant)
CMS : Unavoidable Pressure Inj uries CMS revised guidance for health care surveyors for LTC F Tag 314-pressure inj uries Identified pressure inj uries=s as most cited condition in health quality checks (1) Variances in survey findings between state and federal surveyors CMS Goal –To provide more detailed and consistent guidance to surveyors Added section on prevention and the definition of unavoidable pressure ulcer for long-term care 1. Williamson, J Pressure’ s On . http:/ / mcknights.com/ pressures-on/ 107737/ . Pub 3/ 1/ 08
Unavoidable Pressure Inj ury Pressure inj ury develops despite evaluation of clinical condition and pressure ulcer risk factors There needs to be definition and implementation of interventions consistent with needs, goals, and recognized standards of practice Must be monitoring and evaluation of the impact of the interventions Must be revision of the approaches to prevention and treatment as appropriate Ayello, Lyder, Research and Public Policy Context. Pressure ulcers: prevalence, incidence, an implication for the future. NPUAP , 2012
Pressure Inj ury S taging CMS requires S taging on their designated assessment forms in LTC and home care
CMS Mandated Assessment Instruments Home Care – OAS IS C (January 2010) requires documentation POA Long-Term Care – Resident Assessment Instrument (RAI) MDS 3.0 S ection M – (October 2010) requires documentation if S tage II,III, or IV or unstageable were POA Inpatient Rehabilitation Facilities and Long-Term Care Facilities – IRF-P AI (June 2012)
Common Sites of Pressure Injuries Occiput (<1% ) Scapula (<1% ) Spine (<1% ) Elbow (<1% ) Sacrum & Coccyx (65%) Trochanter (9%) Ischium (4% ) Knee (3% ) Tibia (2% ) Heel & Ankle (15%)
Wound S taging Clinicians commonly describe pressure inj uries using a six-stage classification system to define the depth of tissue involved
Wound S taging The basis for: Developing treatment protocols S electing reduction support surface Obtaining reimbursement for a variety of wound– related products
Rules of S taging Only used for pressure inj uries S tage all pressure inj uries at the deepest level of damage Once a pressure inj uries is staged, it remains at that stage Reverse-staging/ back-staging* should never be used to describe the healing of a pressure inj uries
CLASSIFICATIONS S tage 1 – Non-blanchable erythema of intact skin
S tage 2 – Partial thickness skin loss with exposed dermis
S tage 3 – Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. S lough and/ or eschar may be visible.
tage 3 Pressure Inj ury S
S tage 4 – Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. S lough and/ or eschar may be visible.
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