Focus On…Pressure Relief & Wound Care
| focuson Pressure Relief & Wound Ca re|
Implementing the new CMS guidelines for wound care
Areas for potential citations are explained by Jeffrey M. Levine, MD, AGSF, CMD; Marilyn Pete rson, RNC, MSN; and Fay Savino, RN, BSN, MA
| The Centers for Medicare & Medicaid Services’ (CMS) new pressure ulcer guidelines for surve yors have arrived. 1 Federal Tag 314 (F314) is replaced completely by a 40-page document that vastly expands protocols for investigating pressure ulcers (see tables 1 and 2 for F-tags applicable prior to and in the new CMS guidelines). 2 In addition, surveyors are directed to consider other F-tags during inves tigations for compliance. The volume of detail written into the new F314 is extraordinary and essentially amoun ts to a “clinical practice guideline” for wound care directed to both facility staff and surveyors. Along with the Quality Measures posted on CMS’s Nursing Home Compare Web site (www.medicare.gov/nhcompare/home.asp), these guidelines increase the incentive for f acilities to strengthen their wound care programs.|
We suggest that facilities first become familiar with the guidelines, and then completely review their internal systems for wound care, including the policy and pro cedure (P&P) manual. Good wound care is dependent on many aspects of the care process, and this is reflected in the new CMS guidelines, which include emphasis on resident assessment and care planning. New citations are add ed for lack of physician and medical director involvement with wound care, as described below. Since emphasis i s added on physician notification and the correct use of products, internal review should include the responsiv eness and effectiveness of physician services. Remember that wound care is interdisciplinary and includes not o nly medicine and nursing but also nutrition, rehabilitative services, and social work.
Accuracy is critical when performing a risk assessment. When the medical record is reviewed by a surveyor, each subscale should corr espond accurately to the patient’s condition at that time. Therefore, in-services on use of the assessment scal e are important components of the wound care program. Conduct in-services for all nurse managers and other indi viduals delegated the task of completing the scale. Quality assurance (QA) review is recommended to ensure accu rate determination of the subscales.
The system for documentation of risk requires facility-wide review, beginning with review and revision of the P&P manual and the charting system’s organization. An important cons ideration is the construction of the medical record for ease of review. Risk-assessment results should be congr egated in a separate section, thereby allowing for ease of retrospective review of documentation timeliness and accuracy by QA and survey personnel. An alternative method is to place the risk-assessment documentation withi n the interdisciplinary notes in a clearly marked entry.
The Prevention Plan
Several resident characteristics affect the ease of enforcing a turning schedule. Residents with feeding tubes or those on ventilators, for example, ma y not be turned in the same manner as those not attached to life support. Residents with contractures can be tu rned but may need specially positioned pillows or cushions to maintain proper pressure relief. Thus, an individ ualized care plan can provide a guide to pressure-relief management.
Mobilization strategies are always a component of pressure-sore prevention. These include physical therapy and occupational therapy involvement fo r body strength improvement, balance training, and adaptive equipment. These therapists often are able to provi de suggestions for proper seat cushions and positioning devices. A speech therapy consult is helpful when deter mining ability to swallow and the need for special diets and therapies.
An individualized care plan shou ld be constructed for each resident deemed at risk by the risk-assessment scale. This care plan should take int o consideration factors that interfere with pressure relief, such as the life-support modalities mentioned abov e, and should address pressure-relief devices currently in use. Incontinence management for relief of moisture and fecal contamination is a must in any skin-management plan. In addition, the care plan should address nutrit ion and refer to the appropriate section of the medical record that covers this. It is important for QA efforts to review the appropriateness as well as the timeliness of care plan interventions.
Ulcer Documentation and Treatm ent
A pressure sore’s location can sometimes assist in pinpointing system problems that require intervention. For example, bilateral ischial ulcers frequently res ult from improper seating. Ulcers on the perineum that are surrounded by dermatitis may indicate fungal infecti on or inadequate continence care.
The first step in proper wound documentation is determining the correc t diagnosis. The new CMS guidelines specifically mention arterial/ischemic ulcers, venous insufficiency ulcers (formerly known as the stasis ulcer), and diabetic neuropathic ulcers. It is critical that the diagnosis be mad e as early as possible and that the diagnostic process be carried forth with all disciplines, not only for surv eyors and QA, but also for risk-management purposes. We therefore advise obtaining a physician consultation for assistance with diagnosing lower extremity ulcers and for clarification of ulcer type. Noninvasive vascular st udies can be of crucial assistance in documenting ulcers associated with peripheral vascular disease. Consisten cy of documentation is important: If an ulcer is designated a pressure ulcer in one place and an arterial/ische mic ulcer elsewhere, this may spell trouble when a surveyor investigates the resident.
For documentation purposes, simply stating the stage of the ulcer is insufficient. Description of the wound should be accompanie d by measurements of length, width, and depth, as well as notation of odor and presence of drainage. The new CM S guidelines contain specific definitions of tunneling, sinus tract, undermining, eschar, slough, exudate, and granulation tissue. These definitions, as well as the staging system, need to be understood by staff entering w ound documentation into the medical record. The best documentation contains not only stage and measurements, bu t also a narrative description of the wound, current treatment, and response to treatment. It is helpful to doc ument the treatment in progress and the rationale for that treatment (i.e., absorbs drainage, treats infection, protects surrounding skin, debrides eschar, etc.).
Documentation in the medical record should be organi zed to facilitate QA and/or surveyor review. As with the risk-assessment results discussed above, we recommend congregating the wound care flow sheets and documentation in a separate section. This, however, does not elimin ate the need to discuss wound prevention and care in the narrative nursing notes.
The presence of pain i s an important consideration when caring for wounds, and this is indeed reflected in the new CMS guidelines. Pa in can result from the wound itself or can be a consequence of prevention measures or treatment. 6 T urning and positioning a frail resident with arthritis and contractures can be painful for him/her. Dressing ch anges can induce pain, with positioning of the resident and removal of adhesives. Pain should be assessed and d escribed in the wound documentation note and addressed in the care plan and physician record.
Photograph s can provide excellent supplementary documentation of wounds but should never take the place of written descri ptions. Each facility must decide whether photographs should be part of its wound care documentation program. T his decision should not be taken lightly, as the incorporation of photographs into wound care documentation is a decision that will require new P&Ps, staff training, expenses for a camera and printing, and incorporation of the photographs into the charting system.
Physician Involvement and Wound Care Formula ry
The medical director is delegated the task of supervising the primary care physicians in thei r wound assessment and documentation. All too often, primary care physicians rely on the nursing staff to perfo rm wound assessments and decide on treatment modalities. The physician assessment should reflect the presence a nd location of the wound, as well as treatment and response to care. The medical documentation also should disc uss conditions such as diabetes mellitus, peripheral vascular disease, weight loss, and stroke, which may adver sely affect response to treatment.
Primary care physicians should be familiar with advanced wound care m odalities and their proper use. The new CMS guidelines state, “[N]ot all products are appropriate for all press ure ulcers. Wound characteristics should be assessed throughout the healing process to assure that the treatmen ts and dressings being used are appropriate to the nature of the wound.” The facility should review its formula ry for wound care products and make sure that the products are used properly. To accomplish this goal, a restri cted formulary may be advantageous, with in-services for physicians and nurses on appropriate use. Efforts shou ld be made to keep these products in stock to avoid delays when treatments are needed.
Was the Ulcer Avoidable?
For ulcers that develop or worsen within the facility, we recommend a comprehensive narrative note that summarizes what was done to prevent the ulcer and/or what was done to stop it from getting worse. This note preferably should be written by the medical director and should incorporate in formation regarding the resident’s underlying medical condition, nutritional status, and advance directives. To facilitate the surveyor’s review, this note should refer to specific dates that interventions were performed a nd where the information can be found.
Reverse Staging and the PUSH Tool
NPUAP has advocated the use of the PUSH Tool, which offers the advantage of calculating a s ingle numeric value for an ulcer, combining scores for length, width, exudate, and presence of eschar. 7 This tool does not supplant regular staging, measurement, and a narrative description of the wound. The PU SH Tool is optional and will require additional flow sheets, education, and training; revision of wound care P& Ps; and QA activities to ensure that the tool is being used correctly. Facilities should carefully consider thi s tool and determine whether it fits with their wound care program.
Nutrition and Hydrat ion
Resident Choice and Advance Directives
The guidelines also contain instructions that care must be delivered in accordance with residents’ wishes as expressed in valid advance directives. There is a sp ecific notation that a do not resuscitate order is limited only to resuscitative measures and is not applicable to other treatments and services. The incorporation of resident choice and advance directives into the CMS gui delines for wound care strengthen the mandate for resident and family education and inclusion in care plan meet ings. Given the cognitive debility of many residents with pressure ulcers, as well as the complexity of end-of- life care decisions, the role of the social worker in wound care must be emphasized. The social worker is the t eam member who usually invites families to meetings and takes care of advance directives.
Jeffrey M. Levine, MD, AGSF, CMD, practices medicine in New York Ci ty at the Cabrini Medical Center. He is a Certified Wound Care Specialist, and he has served as a consulting ex pert on elder care to the U.S. Department of Justice, the New York State Office of Professional Medical Conduct , and the Centers for Medicare & Medicaid Services.
Marilyn Peterson, RNC, MSN, is certified by the Ame rican Nursing Association in gerontological nursing. As a former director of nursing and assistant director of education in long-term care, she has a reputation as a leader and clinician with expertise in wound care, speci alized care for dementia, and continuous quality improvement.
Fay Savino, RN, BSN, MA, has been active i n healthcare since 1965, holding positions in direct care, nursing management, and regulatory compliance as a f ormer New York State surveyor. She has been an LTC consultant since 1992.
For more information, contact Dr. Levine at (212) 253-5601. To send comments to the authors and editors, e-mail email@example.com. To order reprints in quantities of 100 or more, call (866) 377-6454.
| Wound Management Certification|
The American Academy of Wound Management (AAWM) is a voluntary, not-for-profit organization established for cre dentialing multidisciplinary practitioners in the field of wound management. AAWM is dedicated to the multidisc iplinary team approach in promoting the science of prevention, care, and treatment of acute and chronic wounds. Its primary function is to establish and monitor a national certification process, recognize competency, promo te education and research, and elevate the standard of care across the continuum of wound management. AAWM offe rs four levels of certification: Diplomat, Fellow, Clinical Associate, and Research Associate.
| Elbo w and Heel Pads|
Hatch® ShearStop Elbow and Heel Pads with LiquiCell® technology help prevent bedsores b y reducing both pressure and shear stress (the primary causes of decubitus ulcers) through constant liquid flot ation and soft foam padding. The pads are compact, lightweight, and comfortable to wear.
By using a comb ination of low-viscosity fluid and strategically placed baffles that control the flow, the LiquiCell inserts re duce tissue shear stress and pressure, and absorb shock. Constructed of a lightweight urethane membrane, the Li quiCell inserts will not burst or freeze. Hatch ShearStop Elbow and Knee Pads are machine washable.
Hatch Corporation (Armor Holdings), 800-347-1200
| Mattress Program|
The Bio Clinic® Therapeutic Foam Mattress Program from Sunrise Medical offers more flexibility to meet specific care needs, as well as solutions to help meet entrapme nt guidelines. All of the mattresses in the program-Imprint, BodyWrap®, Turnstyle, Bio Core®, and DermaTech- are constructed using a high-density foam core designed to address the areas of the body most susceptible to sk in breakdown. Used in conjunction with an effective wound care management program, Bio Clinic mattresses can he lp prevent and treat pressure sores.
To provide protection against entrapment, the mattresses are availa ble in a sidewall or perimeter construction.
| Skin Care System|
SECURA, from Smith & Nephew, uses high-q uality ingredients that make the difference between basic and proactive skin care. The SECURA product line is u ser-friendly and supports a four-step, preventive skin care system: cleanse, protect, moisturize, and treat.
With easy-to-use color-coded packaging and skin-friendly ingredients, the SECURA skin care system can be a dded to a facility’s prevention program.
| Pressure-Reducing Mattress|
The CARE FLEX® PHPFP mattress from Chestnut Ridge Foam, Inc., features a soft heel pad to help maximize targeted wound c are therapy. All foam densities are selected for trouble-free service and firmness. The PHPFP also features fir mer side-perimeter cushioning for increased support and stability.
Chestnut Ridge Foam manufactures a co mplete family of pressure-reduction mattresses that combine quality, durability, and comfort.
| Wound Management Software|
Net Health Systems’ WoundExpert software lets users monitor up-to-the-minut e high-risk rosters, administer risk assessments, and view in-house acquired pressure ulcer statistics for any period.
WoundExpert is a detection, prevention, and treatment tool designed to reduce risk, decrease the incidence of in-house acquired pressure ulcers, and improve healing times.
A point-and-click interface makes bedside charting simple, and the reporting suite makes viewing information easy.
| Heel Suspension Boots |
Heelift Original and Heelift Smooth Suspension Boots from DM Systems, Inc., assist facilities in complying with federal regulations for the prevention of pressure ulcers as outlined in Medicare F-tag 314.
Heelif t and Heelift Smooth can be used in the treatment and prevention of heel pressure ulcers. Heelift eliminates pr essure by lifting the heel with an elevation pad and suspending it in a protective space. Pressure is transferr ed from the heel to the lower leg.
| Folding Wheelchair|
The Alco Comfort Classic® Folding Solid-Seat Wheelchair features a 4″-thick Memory Foam cushion, which eliminates sling-seat hammocking. It is more comfortable for residents r estricted to a wheelchair for long periods of time and is especially helpful to rehabilitation/therapy patients . The Visco foam cushion is temperature sensitive and molds to the patient to decrease pressure and increase co mfort. The fluidproof, low-shear seat cushion cover prevents skin-damaging friction.
| Heel Support fo r Recliners|
Intensive Therapeutics, Inc., has introduced a new version of the popular HeelZup Heel Elev ating Cushion, specifically designed for use on a reclining chair. It exceeds AHRQ and NPUAP guidelines; elevat es heels a minimum of 1″ off the leg rest while supporting the lower leg; avoids hyperextension of the knee; ha s raised side bolsters that stabilize legs; adapts quickly to virtually any recliner without using straps or Ve lcro®; has a friction and shear reducing nylon cover; is made from hypoallergenic and latex-free foam; and incr eases compliance and decreases incidence.
| Pressure-Reduction Boot|
The redesigned Posey Deluxe Podus Boot (M odel 6147) offers comfort and protection against heel ulcers and plantar flexion at an affordable price. Availa ble in two sizes, the Posey Podus Boot is made with moisture-wicking Orthowick® material to help keep feet dry. The contours of the inner shell isolate the heel to prevent/treat heel ulcers and accommodate up to a 45° plan tar flexion contracture.
Standard features include a padded, detachable toe post; two anchors to prevent unwanted rotation; a sturdy, adjustable antirotation bar; and larger foot securement straps. The Model 6148 is available with an easy-mount, sure-grip ambulation sole for in-room transfers.
Smith & Nephew has introd uced its newest antimicrobial barrier dressing, ACTICOAT Moisture Control, which complements the company’s exi sting ACTICOAT line. It delivers antibacterial protection in a highly absorbent, easy-to-use dressing.
< center>Karen Panozzo (Williams Labadie-agency), Smith & Nephew, Inc. Acticoat, 312-222-5800, firstname.lastname@example.org
| Air Therapy Surface|
Span-America Medical Systems, Inc., introduces the Pressu reGuard® APM2 “Safety Supreme” that was designed to address fall and entrapment prevention, fire saf ety, and skin integrity.
The “Safety Supreme” features air support cylinders inside an engineered foam shell. It offers the options of alternating pressure or lateral rotation via a built-in toggle switch.
T o help prevent falls and entrapment, the mattress incorporates the patented, raised perimeter found in the Geo- Mattress with Wings®. The system is also outfitted with an inner fire barrier for maximum flammability protecti on.
| Viscoelastic Products|
Tempur-Pedic Medical, Inc. provides products for comfort, pressur e, and pain management using TEMPUR® viscoelastic material. TEMPUR displaces to allow a resident to immerse int o it and distributes pressure, reducing the number of pressure peaks.
Tempur-Pedic Medical provides nonp owered and powered mattresses for standard and bariatric use, wheelchair cushions, specialty pads, pillows, and positioning cushions.
| Bariatric Wheelchair Cushion|
The WAFFLE Bariatric Wheelchair Cushion from EHOB, Inc., i s recommended for residents up to 700 lbs who need additional comfort and pressure ulcer prevention and treatme nt. Pressure, friction, and shear decrease with the low-profile, WAFFLE static-air technology. It is shipped in flated.
| Waterproof Heel Device Cover|
The new waterproof cover for Global Medical Foam’s Conformin g Comfort® patented Heel/Arterial Device can be easily cleaned and used from resident to resident. This monolit hic fluidproof cover is machine washable and dryable. The cover fabric is antifungal, antibacterial, cleanable, waterproof, and latex-free. It meets Cal 117 requirements and AHRQ guidelines.
| Nonpowered Support Surface|
Th e AkrosAir from Graham-Field Products is a nonpowered, self-adjusting support surface that provides low-pressu re therapy. It is suitable for the prevention and treatment of all stages of pressure ulcers, saving time and m oney. Delivered ready to use, it has no pumps or power cords and is easy to use.
The AkrosAir, which req uires no maintenance, has a 500-lb maximum capacity and comes with a five-year, non-prorated warranty.
| Self-Adhesive Dressing|
ALLEVYN Thin, from Smith & Nephew, is a self-a dhesive polyurethane dressing for surface wounds with low to moderate exudate. It’s flexible and conformable, m aking it easy to shape and fit awkward areas and maintain a moist wound-healing environment. ALLEVYN Thin stick s well to dry, intact skin, but does not adhere to the wound, eliminating the need for a second dressing and mi nimizing the risk for maceration.
| Positioning Cushions|
Crest Heal thcare Supply’s affordable Alevio cushions feature Visco Memory Foam that conforms to the user for added suppo rt and comfort. Alevio cushions use Recovery 5 high polyurethane covers that are incontinent-proof, antibacter ial, latex-free, antifungal, flame retardant, and machine washable.
Four chair configurations are availa ble: Zero Elevation, Wedge, Gel Pac, and 4-Chamber Gel Pac. The 4-Chamber Gel Pac keeps the gel in place under the ischials. It prevents gel migration while reducing heat and pressure. The double layer foam construction in cludes a top layer of Visco Memory Foam that molds to bony prominences and a bottom layer that
An Alevio Back Cushion for use in a sling-seat wheelchair is also available.
Heidi Burg, Crest HealthCare Supply, 320-275-3382, hburg@cresth ealthcare.com
| Low-Air-Lo ss Mattress|
Mason Medical’s LS9900 Low-Air-Loss mattress system enables the use of a bedpan without comp romising resident comfort or safety. It is configured into three adjustable pressure-relief zones: head, torso, and legs. The torso section can be deflated by disconnecting the one-way valve, allowing easy placement of the bedpan. Each zone is preprogrammed but the caregiver does have the ability to adjust each zone’s pressure on t he digital control panel based on personal preference.
The LS9900 has audible and visible low-pressure a larms, a waterproof cover, and a 450-lb weight capacity. It comes complete with mattress and high-flow pump.
| Wound Therapy|
The quiet Verstile 1® Wound Vacuum System from BlueSky Medical offers value , new technology, and durability. The Versatile 1, when used with the Chariker-Jeter Wound Sealing Kit®, helps to promote wound healing. BlueSky Medical has a variety of accessory kits available. The Versatile 1 Wound Vacu um System provides wound healing with minimal patient discomfort at a minimal cost.
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