Advancing Wound Care Through Compliancy with F314

1
Advancing Wound Care Through Compliancy with F314

• A survival guide for LTC

2
Intent of F314

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

3
Actual Harm

• Failure to heal existing wounds
• Preventable Pressure Ulcers, including Stage I
• Failure to provide standard of care treatments

4
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 residents
  overall clinical condition should be re-assessed

5
Avoidable- Preventable

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

6
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

7
Stage I indicators

• Indicators present after 30-45 minutes of
  removing pressure to the site
• Observable, pressure related alteration of intact
  skin
• Indicators include
• Skin temperature changes
• Tissue consistency
• Sensation
• Defined area of persistent redness, blue or
  purple hues

8
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

9
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

10
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

11
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

12
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

13
Pressure Ulcers

• any lesion caused by unrelieved pressure that
  results in damage to underlying tissues.

14
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)

15
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

16
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

17
Venous Hypertension

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

18
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

19
Perineal Dermatitis

• Rash due to reaction from incontinence, not
  pressure related.
• Residents skin is at greater risk for pressure
  breakdown

20
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
• Location
• Local perfusion
• Host immunocompetency
• and type of microbial bodies
• Presence of necrosis

21
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

22
Best PracticesInfection 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.

23
Best Practices Infection Control

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

24
Non-Cytotoxic Topical Antimicrobials

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

25
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
  facilitys policies and procedures as developed
  with the medical directors review and approval.

26
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.

27
Surveyor Instruction inPain 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

28
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

29
Pressure
Relief
30
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)

31
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.

32
Debridement Options

• Types
• Autolytic
• Enzymatic
• Mechanical
• Sharp or surgical
• Bio-debridement
• Polyacrylate

• Consider
• Condition of resident
• Condition of wound
• Goals of resident
• Location of wound
• Viability of wound
• Underlying conditions
• Anticoagulants
• Arterial status
• Bioburden

33
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

34
Enzymes Derived from

• Plant Derived (Papaya) Papain and Urea
• Accuzyme
• Gladase
• Ethezyme
• Ziox
• Copper Chlorophyll
• Panafil
• Gladase C
• Ziox

• Biologically Engineered
• Collagenase
• Painless, may be appropriate for maintenance
  therapy and used in conjunction with sharp
  debridement.

Painless
Aggressive
less Papain, less aggressive
35
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)

36
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

37
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 30-45 minutes.
• Some reports of pain
• Yuck factor

38
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

39
Avoidable vs. Unavoidable

• Must be addressed in the case of
• New Pressure Ulcer
• Non-healing Ulcer
• Wound pain
• Infection

40
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.