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Practical Issues in Wound, Skin and Ostomy Management
By Carrie Carls, BSN, RN, CWOCN, CHRN, and Sherry Clayton, RHIA
In an atmosphere of changing reimbursement, it’s important to understand indications and utilization guidelines for healthcare services. Otherwise, facilities won’t receive appropriate reimbursement for provided services. This article focuses on Medicare reimbursement for hyperbaric oxygen therapy (HBOT). (See What is hyperbaric oxygen therapy?)
Indications and documentation requirements
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By Kulbir Dhillon, MSN, FNP, APNP, WCC
Venous disease, which encompasses all conditions caused by or related to diseased or abnormal veins, affects about 15% of adults. When mild, it rarely poses a problem, but as it worsens, it can become crippling and chronic.
Chronic venous disease often is overlooked by primary and cardiovascular care providers, who underestimate its magnitude and impact. Chronic venous insufficiency (CVI) causes hypertension in the venous system of the legs, leading to various pathologies that involve pain, swelling, edema, skin changes, stasis dermatitis, and ulcers. An estimated 1% of the U.S. population suffers from venous stasis ulcers (VSUs). Causes of VSUs include inflammatory processes resulting in leukocyte activation, endothelial damage, platelet aggregation, and intracellular edema. Preventing VSUs is the most important aspect of CVI management. (more…)
Read MorePerformance scores for rates of hospital-acquired pressure ulcers might not be appropriate for comparing hospitals, according to a study in the Annals of Internal Medicine.
“Hospital report cards for hospital-acquired pressure ulcers: How good are the grades?,” funded by the Agency for Healthcare Research and Quality, analyzed 2 million all-payer administrative records from 448 California hospitals and quarterly hospital surveillance data from 213 hospitals from the Collaborative Alliance for Nursing Outcomes. (more…)
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By Jeri Lundgren, BSN, RN, PHN, CWS, CWCN
Navigating through the thousands of wound care products can be overwhelming and confusing. I suspect that if you checked your supply rooms and treatment carts today, you would find stacks of unused products. You also would probably find that many products were past their expiration dates and that you have duplicate products in the same category, but with different brand names. Many clinicians order a product by brand name, not realizing that plenty of the product is already in stock under a different brand name. (more…)
Read MoreBy Nancy Chatham, RN, MSN, ANP-BC, CCNS, CWOCN, CWS, and Lori Thomas, MS, OTR/L, CLT-LANA
An estimated 7 million people in the United States have venous disease, which can cause leg edema and ulcers. Approximately 2 to 3 million Americans suffer from secondary lymphedema. Marked by abnormal accumulation of protein-rich fluid in the interstitium, secondary lymphedema eventually can cause fibrosis and other tissue and skin changes. (more…)
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With so much focus on dressing choices, it’s easy to forget the importance of wound cleansing. Cleaning a wound removes loose debris and planktonic (free-floating) bacteria, provides protection to promote an optimal environment for healing, and facilitates wound assessment by optimizing visualization of the wound. You should clean a wound every time you change a dressing, unless it’s contraindicated.
Here’s a review of how to choose and use a wound cleanser so you can see if your practice is up to date. (more…)
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To begin appropriate treatment for chronic venous insufficiency (CVI), clinicians must be able to make the correct diagnosis. Part 1 (published in the March-April edition) described CVI and its presentation. This article provides details of the CVI diagnosis (including the differential diagnosis from other diseases), disease classification to help assess the extent of CVI, diagnostic studies used to diagnose CVI, and various treatment options to “rescue” the patient from CVI. (more…)
Read MoreOne of the worst fears of a wound care clinician is inadvertently compressing a leg with critical limb ischemia—a condition marked by barely enough blood flow to sustain tissue life. Compression (as well as infection or injury) could lead to necrosis, the need for amputation, or even death. The gold standard of practice is to obtain an ankle-brachial index (ABI) before applying compression. However, recent research and expert opinion indicate an elevated or normal ABI is deceptive in patients with advanced diabetes. What’s worse, in the diabetic foot, skin may die from chronic capillary ischemia even when total blood perfusion is normal. For information on how to perform an ABI and interpret results, click on this link. (more…)
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Digital cameras have many helpful features, but the most important considerations for choosing a camera are hardware features. Focus on the following when choosing a camera:
Resolution. The resolution determines picture quality. The National Pressure Ulcer Advisory Panel recommends using a digital camera with a minimum of 3 megapixels
for wound photography. A megapixel is 1 million pixels. The more pixels used to produce a photo, the less grainy it will appear and the clearer any enlargements made from it will be. In essence, the more megapixels a camera produces, the clearer and more detailed the photograph will be. (more…)
Clinical practice guidelines help ensure we are applying the latest knowledge and expertise when we’re caring for patients. Here are a few recent guidelines that you may find useful.
An American Heart Association scientific statement, “Measurement and interpretation of the ankle-brachial index (ABI),” published in Circulation, outlines the use of ABI, terminology, how to calculate the value, training, standards, and suggestions for future research.
Recommendations for obtaining an ABI measurement include:
• Use the Doppler method to determine the systolic blood pressure in each arm and each ankle.
• Use the appropriate cuff size, with a width of at least 40% of the limb circumference.
• Place the ankle cuff just above the malleoli with the straight wrapping method.
• Cover open lesions with the potential for contamination with an impermeable dressing.
• Avoid using a cuff over a distal bypass.
The article also recommends measurement and interpretation of ABI be part of the standard curriculum for nursing and medical students. For more information about ABI, read “Bedside ankle-brachial index testing: Time-saving tips” in this issue of Wound Care Advisor.
http://circ.ahajournals.org/content/126/24/2890
Childhood obesity continues to be a significant problem in the United States, requiring innovative approaches for prevention and management. Those who are obese run the risk of poorer wound healing.
“Approaches to the prevention and management of childhood obesity: The role of social networks and the use of social media and related electronic technologies: A scientific statement from the American Heart Association,” published in Circulation, evaluates the role of social networks and social media in relation to childhood obesity and presents five steps for using social networks:
1 Define the goal of the intervention.
2 Identify the social network.
3 Develop and pilot test the intervention.
4 Implement the intervention.
5 Spread the intervention.
The guidelines conclude that social media holds promise as a tool, but more research is needed.
http://circ.ahajournals.org/content/early/2012/12/03/CIR.0b013e3182756d8e
Many patients with wound or ostomy needs have comorbid heart disease. Be sure you are aware of the most current information for managing these patients by accessing “2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease,” published in Circulation.
The guidelines acknowledge the vital importance of shared decision making between the healthcare provider and the patient. The information is divided into four sections with supporting algorithms:
• approaches to diagnosis
• risk assessment
• treatment
• follow-up.
Access the top 10 things to know and the executive summary.
http://circ.ahajournals.org/content/126/25/e354
The Agency for Healthcare Research and Quality (AHRQ) has made it easier to compare guidelines for managing pressure ulcers by publishing two guideline syntheses:
• Management of pressure ulcers
• Prevention of pressure ulcers
In each case, the synthesis includes information in the following categories:
• areas of agreement and difference
• comparison of recommendations
• strength of evidence and recommendation grading schemes
• methodology
• source(s) of funding
• benefits and harms
• abbreviations
• status.
Access these and other guideline syntheses from AHRQ.
Free, one-time registration is required to view the entire video and all other
content on the Medscape website.
Patients have a right to make their own decisions, but what happens when a decision is so painful for staff that it affects morale? Arthur Caplan, PhD, Division of Medical Ethics at the NYU Langone Medical Center in New York, discusses such a case: “Patients have the right to choose death from bedsores.”
Read MoreA hot flush of embarrassment creates a bead of sweat on my forehead. “I’ve got to get this measurement,” I plead to myself. One glance at the clock tells me this bedside ankle-brachial index (ABI) procedure has already taken more than 30 minutes. My stomach sinks as I realize I’ll have to abandon the test as inconclusive. (more…)
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There’s an app for that! Here are a variety of medical apps that you might want to try. You can download them in the iTunes store, and the basic service is free.
More than 1.4 million healthcare professionals use this app from WebMD, which includes:
• medical news
• clinical reference information, such as drugs and diseases
• medical calculators (not available for iPad).
The app is available for Android, iPad, and iPhone/iPod touch devices.
Use this app to take a photo of a wound. The app segments the image into red, yellow, and black to help with ulcer classification. You can also use the app to track changes in the wound over time. The app is available for iPad and iPhone/iPod touch devices. Note: This is free for a limited time.
The ePSS (Electronic Preventive Services Selector) app allows you to search and browse the U.S. Preventive Services Task Force recommendations on the Web or a mobile device. The app is from the U.S. Department of Health & Human Services and is available for Android, iPad, and iPhone/iPod touch devices.
This app from the University of Michigan Health System allows users to complete and store photographs of the skin. Features include:
• guidance on performing a skin cancer self-exam and full-body photographic survey
• tracking of detected skin lesions and moles for changes over time
• notifications/reminders to perform self-exams on a routine basis
• storage of photos for baseline comparisons during routine follow-up self-
exams
• informational videos and literature on skin cancer prevention and healthy skin as well as a skin cancer risk calculator function.
The app is available for iPad and iPhone/iPod touch devices.
This data storage utility app is perfect for your patients with diabetes who want all their information in one place. Users can manually enter their glucose results, carbohydrate consumption, insulin dosages, and activities, and then view the data in a free glucosebuddy.com online account. Another option is the ability to set reminders for when it’s time to check blood glucose.
The app is available for Android, iPad, and iPhone/iPod touch devices.
Use this app to learn more about pressure ulcer staging. It includes information about 3M pressure ulcer products.
The app is available for iPad and iPhone/iPod touch devices.
This evidence-based tool is helpful for assessing and classifying peristomal skin lesions. Click here for more information about the SACS Instrument.
The app is available for iPad and iPhone/iPod touch devices.