WORKSHOP ON SKIN CONDITIONS AND NEW TECHNOLOGIES IN WOUND CARE - - PowerPoint PPT Presentation

WORKSHOP ON SKIN CONDITIONS AND NEW TECHNOLOGIES IN WOUND CARE

Vycki Nalls, GNP-BC, CWS, ACPHN Jeanine Maguire, MPT, CWS

What is the ‘Triple Aim’? J

■ Triple Aim: Best Outcomes, Highest Satisfaction, Lowest Price ■ The shift is NOW occurring from fee-for-service to payment for

• utcomes

■ Measures: – Quality Measures (specifically: section M for pressure ulcers, function – Claims (rehospitalizations) ■ All Post-acute care providers – IMPACT Law 2014 now in effect ■ But what will impact all Acute Care AND who they will partner with post-acute – Rehospitalizations

Statistics

u PUs affect one in nine U.S. LTC residents and prevalence's of greater than

20% have been reported. Because LTC is the fastest growing segment of the U.S. healthcare continuum, cost-effective PU prevention solutions are urgently needed.

u Maryland has a 1.3% average of pressure ulcers for short stay residents

with new or worsening wounds, which is the same for the national average.

u Maryland Long term care residents who are HIGH RISK have an average of

6.8% pressure ulcers compared to the national average of 5.8%

v

What are the facts… J

■ Up to 3 million PUs Reported per year in U.S. ■ Cost > 11 BILLION annually in U.S. ■ JAMDA article: > 26% of hospital readmissions have PU ■ > 60,000 deaths/year in U.S. ■ 2nd most common cause of litigation – many now in the millions ■ Pressure Ulcers= MDS Quality Measures= 5 Star (admissions) ■ F314 can and has closed centers down to admissions ■ Family perception = litigation ■ Cost of a stage 4 $129,000

Pressure Injury Fast Facts

u New Definitions now available from the NPUAP (April 2016) u Definition: localized damage to skin and/or underlying soft tissue over a bony prominence or

device

u Can be intact skin or open u Results from intense/prolonged pressure and/or in combination with shear u Tissue tolerance - affected by pressure, shear, microclimate, nutrition, perfusion, co-

morbidities, condition of the soft tissue

u Medical Device Related Pressure Injury - use staging system u Mucosal Membrane Pressure Injury - do not use staging system

V

Full

NPUAP Pressure Injury Stages (updated April 2016) (J)

Stage I I

Intact skin, non-blanchable erythema; changes in sensation, temp, or firmness may precede visual changes; does not include purple/maroon areas

Stage I II

Partial-thickness loss; wound bed pink/red, moist; intact or ruptured serum-filled blister; NO granulation tissue, slough of eschar; does not include MASD, IAD, ITD, MARSI, skin tears, burns abrasions

Stage I III

Full-thickness loss; adipose tissue visible, depth depends on anatomical location; may have undermining/tunneling; no fascia, muscle, tendon, ligament, cartilage, and/or bone exposed

Stage I IV

Full-thickness loss, exposed OR directly palpable fascia, muscle, tendon, ligament, cartilage, bone; may have undermining/tunneling, epibole, slough/eschar

Unstag ageab able

Full-thickness where extent of tissue damage cannot be determined d/t slough/eschar; NOTE: Stable eschar on an ischemic limb or heel should NOT be removed

Deep T p Tissue I e Injury (DT DTI)

Intact/non-intact localized area of non-blanchable deep red/maroon/purple; epidermal separation revealing a dark wound bed or blood-filled blister. May evolve to

• pen wound or may resolve without tissue loss

http://www.npuap ap.or

• rg/resources/educational

al-and-cli linical al-reso sources/npuap-pressu sure-injury-stag ages/

Balancing: Clinical, Regulatory, (J) Business, Legal risks, practice acts

■ Difficult to balance al all as aspec ects that impact care for prevention and treatment of wounds

1.

• 1. Clinic

ical al perspective with standards of care and best practices – requires intense wound prevention and care education, knowledge and well- developed skills 2.

• 2. Regulat

ator

• ry perspective with reporting and survey processes

3.

• 3. Busi

siness ss perspective – ensuring business has enough money to pay salaries, provide care with supplies and equipment, make profit to make it worth while to owners to keep buildings open 4.

• 4. Legal r

ris isks – lawyers, OIG 5.

• 5. Practic

tice a acts ts –some nursing professionals push their practice acts in LTC- LPN

6 steps Providers can take to improve

• utcomes j
• 1. Ensure Dx is correct
• 2. Question findings
• 3. Direct in Root Cause
• 4. Determine ‘wound’ prognosis
• 5. Collaborate with the inter-professional team
• 6. Communicate and lead

Ensure the wound type, or Dx, is correct j

■ Wounds are frequently mislabeled as ‘pressure’

– Moisture Associated Skin Damage – Neuropathic Ulcers

■ Question the causative findings ■ Was the patient examined in sitting, side lying, supine and with their devices in place (splints, etc…) ■ Was the cause pressure and related to positioning?

HEA HEAL A ABIL ILITY J

Add th the “ “heala lability” con

• ncept

t into

• you
• ur

com

• mpr

prehensive pa pati tient a t and wou

• und a

assessments ts

Determine patient wound prognosis j

■ Determine outcome and document rational ■ AMA

– Good for healing (Medicare expects evidence of healing every 1-2 weeks) – Anticipate a delay (based on what findings) – Palliative, healing not expected, in some cases further decline may be anticipated (based on what findings)

Clinicians should be able to distinguish:

Healable Have adequate blood supply

• Can heal if underlying causes addressed

Maintenance

• Healing potential
• Patient / resident or health system barriers compromising healing
• Patient/ residents may be nonadherent to treatment; resource

limitations

Nonhealable

• Includes palliative wounds
• Cannot heal due to irreversible causes/ illnesses
• Critical ischemia; non treatable malignancy

v

Practice Pearls-Sibbald 2015

■ All chronic wounds should be classified as hea heala lable, e, no nonh nhealable, or ma maint ntena nanc nce ■ Moisture-balance dressings important for healable wounds ■ Moisture reduction often more appropriate for nonhealable

• r maintenance wounds

■ Sharp surgical debridement is appropriate for healable wounds, with conservative surgical debridement of slough more important for the nonhealable and maintenance wound.

v

Homeostasis

u Principles of physiological homeostasis u Physical equilibrium u corrective mechanism u constancy maintained in the face of continuous change u Active risk factors and comorbidities make it harder for the body to

maintain balance

v

Factors that Impact Wound Healing

u Tissue perfusion/Central circulatory function – do they have

adequate blood flow?

u Adequate oxygenation? BPs stable? Orthostatics? u Nutritional Status – ASPEN guidelines u Chronic illnesses - DM, renal disease, malignancy, impaired

digestion, neurological disorders

u Inflammatory/Autoimmune disorders/Immunosuppresion u Coagulation disorders (including medication induced) u Age

v

Root Cause: Process Symptom? J

■ Ask the center DON- any other in-house acquired pressure ulcers this week? This unit? ■ Should a root cause analysis be done? ■ Guide AWAY from ‘knee-jerk’ quick fix solutions ■ Guide to sustainable process improvement that involve the team

Root Cause: Patient Symptom j

■ What tipped the scale of homeostasis? ■ Review co-morbid conditions ■ Review medications ■ Discuss any changes ■ Evaluate blood flow ■ Detail your findings with the inter-professional team and within documentation

Collaborate with Inter-Professional Team j

■ Refer to nursing for appropriate formulary Guideline for wound treatments and bed surfaces ■ Refer to therapy for sharps, modalities to promote healing, mobility, contracture management ■ Refer to Dietitian for evaluation and recommendations ■ Is Vascular Consult required? ■ ABI? ■ Concerns with Osteo? Infection? ■ What are Advanced Directives? What will tests mean for care options?

Case study - What do you think? V

■ Long term care resident ■ PMH: COPD, CHF, HTN, morbid obesity, mechanical lift to wheelchair, mild cognitive impairment, incontinent of bladder/bowel ■ Stage IV wound present for over a year ■ Went to plastic surgeon, who attempted to close wound surgically ■ Returned to the facility with a wound vac, new diagnosis of atrial fibrillation (and now on anticoagulants), and BPs running 90s/50s. ■ Healable?

Communication… Live well, die well (Advanced Directives, Communication GL, leading the team)

J V

■ The tx’s are less important than the medical management and homeostasis. ■ Hydrogel vs. hydrocolloid means very little to outcomes if the patient has been mis-dx’d and is not able to heal ■ Practice medicine/evaluate co-morbidities/meds… lead the team in understanding homeostasis, dx, prognosis…

What does exercise and strengthening have to do with wound healing? J

■ Increases circulation ■ Decreases pressure ■ Is a wound a musculoskeletal injury?

Anticipating a delay in healing? How to add some influence… J

■ Low Frequency Ultrasound (US Mist)

– FDA approved to promotes wound healing – Decreases Bioburden & Biofilm

■ Electrical Stimulation

– Medicare approved, increases neoangiogensis – Reduces edema – Decreases pain – Promotes healing

Impact your Outcomes…. J

■ Electromagnetic Therapy

– Increases circulation – Decreases pain

■ Pulsed Lavage

– Mechanically Debrides – Decreases Bioburden & Biofilm

Biofilms V

u Surface layer on chronic wounds u Mature biofilms do not respond to systemic

antibiotics

u can resist up to 1000 x’s the MIC of ABT u Treatment can be difficult; can try topical silver

and PHMB, and/or debridement

v Functional Wound Environment v

Debridement Infection /

Inflammation Control

Moisture

Regulation Migrating Wound

Edges

2 6

Nerds and stones mneumonic for treatment of bacterial burden v

NERDS (3 or more, treat topically)

STONEES (3 or more, treat systemically)

 Nonhealing wounds  Exudative wounds  Red and bleeding wound

surface granulation tissue

 Debris (yellow or black necrotic

tissue) on the wound surface

 Smell or unpleasant odor from

the wound

 Size is bigger  Temperature of 3°- F or more versus

mirror image

 Os (probe to or exposed bone)  New or satellite areas of breakdown  Exudate is increased  Edema/erythema  Smell

Impaired Wound Edges j

Epiboly Callous Maceration

Treating the wound

Generic ic Category Description Indic icat ations ns Advant antage Disad advant antag age Hydrogel Water/glycerin based non- adherent properties; comes in sheets, gels, strips Pressure ulcers, painful wounds Minor burns Necrotic wounds Nonadherent, trauma-free removal; rehydrates wound; reduces pain; can be used with topical meds; softens/loosens necrosis; 24- 72hr change Some require 2nd dressing; may macerate periwound; not recommended for draining wounds Foam Hydrophyllic polyurethane coated, nonadherent layer absorptive dressing Pressure ulcers Dermal ulcers Surgical wounds Nonadherent; trauma-free removal, absorptive, comfortable; q3- 5d changes Not for minimal draining wounds, eschar; may macerate periwound

Treating the Wound

Generic ic Category Description Indic icat ations ns Advant antages Disad advant antag ages Ca Alginate Nonwoven composite of fibers; comes from brown seaweed; forms soft gel when mixed with wound fluid Pressure ulcers; moderate to heavy draining wounds; sinus tracts, tunnels, cavities Highly absorbent; hemostatic properties for minor bleeding; QD-QOD changes; available in sheets, ropes Contraindicated for dry eschar, 3rd degree burns, heavy bleeding; gel may have odor during dressing change; can dessicate wound bed Hydrofiber Na carboxymethylce llulose that interacts with wound exudate to form gel Pressure ulcers; donor sites; sinus tracts, tunnels, cavities; dehiscence Highly absorbent; trauma-free removal; available in sheets/ribbons Contraindicated for dry eschar, nonexudating wounds, heavy bleeding

Treating the wound

Generic ic Category Description Indica cation Advant antage Disad advant antag age Enzymatic debriders Proteolytic, chemical agent that breaks down devitalized tissue Debridement of necrotic wounds Nonsurgical method; QD changes Inactivated by soaps, detergents, acidic solutions, and metallic ions (silver) Collagen Protein; stimulates cellular migrations and contributes to new tissue development partial/full thickness wounds, Stage III, dermal ulcers, surgical wounds Absorbent, nonadherent, biodegradable gel; Q1-3d change, daily if infection present Contraindicated for 3rd degree burns and sensitivities to collagen/bovine; not for necrotic wounds; may require rehydration

McIntosh and Galvan – taken from their table in Wound Care Essentials by S. Baranoski and E. Ayello, pg161-169

So, let’s chat…

■ Mentor: dive deep before discussing treatment ■ Homeostasis: Co-morbids, age of patient, medications, current state of health, history, advanced directives, circulation, mobility level, continence, nutrition ■ Identify the focus and realistic goal setting – Healing? – Bioburden/infection risk – Wound edge – Causative factors (pressure, shear, etc..)

■ Can the factors that are tipping the scale of homeostasis be mitigated? Discuss goal setting and primary focus ■ Mobility? Shearing? Tone? Contracture? ■ Any other factors impeding healing- Nutrition? Osteo? Circulation/edema? ■ Now onto the wound treatment: – Keep focus and goals in mind – Moisture management – Wound Edge – Necrotic tissues/debridement options

To get more info

■ ABWMcertified.org ■ NNACM ■ NPUAP ■ WOCN

References

■ Nursing Home Compare website: https://www.medicare.gov/nursinghomecompare/search.html ■ WOUND TABLE: McIntosh and Galvan – taken from their table in Wound Care Essentials by

• S. Baranoski and E. Ayello, pg161-169

■ Biofilms: Gürgen, Marcus. (2014). Excess use of antibiotics in patients with non-healing

• ulcers. EWMA Journal (EWMA J), 14 (1): 17-22.

■ Biofilms: Alhede, Maria and Morten Alhede.(2014). The Biofilm Challenge. EWMA Journal (EWMA J), 14 (1): 54-8. ■ Wound healing: Morrison, C., & Lee, S. 2013. Initial Wound Assessment and

• Communication. In P. Brown (4th Ed), Quick Reference to Wound Care: Palliative, home, and

clinical practices (pp.3-5) Burlington, MA: Jones & Bartlett Learning ■ Wound healing: Hewish, Julie.(2014). 'I' for Infection: Preventing local wound bed infection: A holistic approach to nursing assessment and management. Dermatological nursing. 3(4) 10-18

References

■ National Pressure Ulcer Advisory Panel 2014 International Pressure Ulcer Prevention and treatment Guidelines. Available at http://www.npuap.org/resources/educational-and- clinical-resources/ ■ Robert E. Burke MD, MS, Emily A. Whitfield PhD, David Hittle PhD c,Sung-joon Min PhD, Cari Levy MD, PhD, Allan V. Prochazka MD. JAMDA, Readmission From Post-Acute Care Facilities: Risk Factors, timing and Outcomes. 17(2016)249e255 ■ Brem, H; Maggi, J; Nierman, D; Rolnitzky, L; Bell, David; Rennert, R; Golinko, M; Yan, A; Lyder, C; Vladeck, B. The American Journal of Surgery, High Cost of Stage IV Pressure Ulcers. October 2010Volume 200, Issue 4, Pages 473–477