Advancing Wound Care Advancing Wound Care Through Compliancy with Through Compliancy with

F314 F314

A survival guide for LTC A survival guide for LTC

Intent of F314Intent of F314

The facility must ensure that a wound The facility must ensure that a wound demonstrates: demonstrates: Optimal improvement, orOptimal improvement, or Does not deteriorateDoes not deteriorate

• Within the limits of:Within the limits of: Residents right to refuse treatmentsResidents right to refuse treatments Recognized pathologyRecognized pathology Normal aging processNormal aging process

Actual HarmActual Harm

Failure to heal existing wounds Failure to heal existing wounds Preventable Pressure Ulcers, including Preventable Pressure Ulcers, including

Stage IStage I Failure to provide ‘standard of care’ Failure to provide ‘standard of care’

treatmentstreatments

CMS Expectation for HealingCMS Expectation for Healing

““a clean pressure ulcer with adequate a clean pressure ulcer with adequate blood supply and innervation should show blood supply and innervation should show evidence of stabilization or some healing evidence of stabilization or some healing within 2-4 weekswithin 2-4 weeks” CMS F314” CMS F314

““If a pressure ulcer fails to show some If a pressure ulcer fails to show some evidence of progress within 2-4 weeks, the evidence of progress within 2-4 weeks, the resident’s overall clinical condition should resident’s overall clinical condition should be re-assessedbe re-assessed””

Avoidable- Preventable Avoidable- Preventable

A Pressure Ulcer (any stage) is acquired A Pressure Ulcer (any stage) is acquired and the facility failed to do one or more:and the facility failed to do one or more: Evaluate resident’s clinical conditionEvaluate resident’s clinical condition Evaluate resident’s risk factorsEvaluate resident’s risk factors Define and implement interventions that are Define and implement interventions that are

consistent with individual needs, goals, and consistent with individual needs, goals, and standards of practicestandards of practice

Monitor and revise interventions as neededMonitor and revise interventions as needed

Deep Tissue InjuryDeep Tissue Injury

““This damage can lead to an unavoidable This damage can lead to an unavoidable stage III or IVstage III or IV,” or,” or

““The progression of a Stage I to an ulcer The progression of a Stage I to an ulcer with eschar or exudate within days after with eschar or exudate within days after admissionadmission.”.”

Indicators:Indicators: Purple or very dark area with profound Purple or very dark area with profound

redness, edema, or indurationredness, edema, or induration

Stage I indicatorsStage I indicators

Indicators present after 30-45 minutes of Indicators present after 30-45 minutes of removing pressure to the siteremoving pressure to the site

Observable, pressure related alteration of intact Observable, pressure related alteration of intact skinskin

Indicators include:Indicators include: Skin temperature changesSkin temperature changes Tissue consistencyTissue consistency SensationSensation Defined area of persistent redness, blue or purple Defined area of persistent redness, blue or purple

hueshues

Standard of CareStandard of Care Assessing RiskAssessing Risk Classifying wound types to provide specific Classifying wound types to provide specific

interventionsinterventions Moist Wound Healing techniquesMoist Wound Healing techniques Pain ManagementPain Management Infection controlInfection control Appropriate InterventionsAppropriate Interventions Debridement as appropriateDebridement as appropriate Nutritional InterventionsNutritional Interventions Continence managementContinence management

Risk AssessmentRisk Assessment

Pressure Ulcers can develop in 2-6 hoursPressure Ulcers can develop in 2-6 hours In LTC, most pressure ulcers occur within the In LTC, most pressure ulcers occur within the

first 4 weeks after admission, or with acute first 4 weeks after admission, or with acute illness illness

Comprehensive Assessment evaluates risk Comprehensive Assessment evaluates risk factors for developing ulcers, and/or for causing factors for developing ulcers, and/or for causing delay in healing of existing ulcersdelay in healing of existing ulcers

Assessment should identify factors that can be Assessment should identify factors that can be removed, modified, or stabilizedremoved, modified, or stabilized

Risk AssessmentRisk Assessment

RAIRAI Risk tool on admission, weekly x 4, Risk tool on admission, weekly x 4,

quarterly and with change in conditionquarterly and with change in condition Do not focus on scores, focus on actual Do not focus on scores, focus on actual

categoriescategories Risk Factors, pressure points, nutrition, Risk Factors, pressure points, nutrition,

hydration, moisture, mobilityhydration, moisture, mobility **Refusals, End of Life and Multi Organ **Refusals, End of Life and Multi Organ

Failure**Failure**

Classification of WoundsClassification of Wounds

Clinicians are expected to document Clinicians are expected to document clinical basis to permit classification, clinical basis to permit classification, especially if the ulcer has characteristics of especially if the ulcer has characteristics of pressure, but is determined Not to be pressure, but is determined Not to be pressure.pressure.

Surveyors provided with description of Surveyors provided with description of common wound types: Venous, Arterial, common wound types: Venous, Arterial, Diabetic, Perineal DermatitisDiabetic, Perineal Dermatitis

Expected Documentation of Wound Expected Documentation of Wound Characteristics to support DxCharacteristics to support Dx

Underlying condition contributing to ulcerUnderlying condition contributing to ulcer Ulcer edgesUlcer edges Wound bedWound bed LocationLocation SizeSize Condition of surrounding tissuesCondition of surrounding tissues ExudateExudate PainPain

Pressure UlcersPressure Ulcers

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

Arterial UlcerArterial Ulcer

Result of Arterial occlusive disease Result of Arterial occlusive disease When When non-pressure related disruption or non-pressure related disruption or blockage of the arterial flow to an area blockage of the arterial flow to an area causes tissue necrosis.causes tissue necrosis.

Intermittent claudicationIntermittent claudication Mod-severe PVDMod-severe PVD ArteriosclerosisArteriosclerosis Inflammatory or autoimmune disordersInflammatory or autoimmune disorders Significant vascular disease (CVA, MI)Significant vascular disease (CVA, MI)

Arterial Ulcer CharacteristicsArterial Ulcer Characteristics Location: distal part of Location: distal part of

lower extremitylower extremity Wound Bed: dry and pale Wound Bed: dry and pale

with minimal to no exudatewith minimal to no exudate Diminished or absent Diminished or absent

pulsespulses Coolness to touchCoolness to touch Increased pain with Increased pain with

exercise or elevationexercise or elevation Delayed capillary refillDelayed capillary refill LE hair lossLE hair loss Toenail thickeningToenail thickening

Diabetic Neuropathic UlcerDiabetic Neuropathic Ulcer

Must have Diagnosis Must have Diagnosis of Diabetesof Diabetes

Must have peripheral Must have peripheral neuropathyneuropathy

Ulcer on foot: mid-Ulcer on foot: mid-foot, ball of foot, top foot, ball of foot, top of toes, also with of toes, also with Charcot deformityCharcot deformity

Venous HypertensionVenous Hypertension

Due to one or many factorsDue to one or many factors Loss of or compromised valve functionLoss of or compromised valve function Vein obstruction (DVT, Obesity, malignancy)Vein obstruction (DVT, Obesity, malignancy) Failure of the calf muscle to pumpFailure of the calf muscle to pump

* Leads to edema, induration, hemosiderin * Leads to edema, induration, hemosiderin staining, dermatitis, ulcerationstaining, dermatitis, ulceration

Venous Ulcer characteristicsVenous Ulcer characteristics

Location: Medial Ankle- Location: Medial Ankle- Pretibial areaPretibial area

Most common Lower Most common Lower extremity woundextremity wound

May occur off and on for May occur off and on for yearsyears

Moist wound baseMoist wound base May be superficialMay be superficial Minimal to copious Minimal to copious

drainagedrainage Increased pain with Increased pain with

dependencydependency

Perineal DermatitisPerineal Dermatitis

Rash due to reaction Rash due to reaction from incontinence, not from incontinence, not pressure related.pressure related.

Resident’s skin is at Resident’s skin is at greater risk for greater risk for pressure breakdownpressure breakdown

Infection ControlInfection Control All chronic ulcers are colonizedAll chronic ulcers are colonized Avoiding infection is vital to healingAvoiding infection is vital to healing Infected wounds delay healing and increase Infected wounds delay healing and increase

chance of cross-contaminationchance of cross-contamination Factors that increase infection: Factors that increase infection:

Size of ulcerSize of ulcer LocationLocation Local perfusionLocal perfusion Host immunocompetencyHost immunocompetency # and type of microbial bodies# and type of microbial bodies Presence of necrosisPresence of necrosis

Best Practices to Decrease Best Practices to Decrease BioburdenBioburden

Select dressings that offer bacterial barrier Select dressings that offer bacterial barrier properties and minimize airborne distribution properties and minimize airborne distribution with dressing changes (hydrocolloids)with dressing changes (hydrocolloids)

Avoid dressings that do not (gauze)Avoid dressings that do not (gauze) Systemic Antibiotics are considered essential for Systemic Antibiotics are considered essential for

acute, advancing, infection in chronic woundsacute, advancing, infection in chronic wounds Topical Antibiotics are not justified or Topical Antibiotics are not justified or

recommendedrecommended

Best PracticesBest PracticesInfection ControlInfection Control

Antiseptic solutions for cleansing should Antiseptic solutions for cleansing should be avoided be avoided

If selecting Antiseptic solutions for wound If selecting Antiseptic solutions for wound treatments, like Dakins, clinician must treatments, like Dakins, clinician must weigh benefits vs risks. It is currently not weigh benefits vs risks. It is currently not accepted as standard practice among accepted as standard practice among most wound care experts.most wound care experts.

Best PracticesBest Practices Infection Control Infection Control

Cadexomer Iodine: time released, Cadexomer Iodine: time released, effective against MRSA, safe and effective against MRSA, safe and effective. Wound must be moist.effective. Wound must be moist.

Time released SilversTime released Silvers Broad spectrum AntimicrobialsBroad spectrum Antimicrobials Safe and effectiveSafe and effective Non toxic to fibroblastsNon toxic to fibroblasts Allows for moist wound healingAllows for moist wound healing

Non-Cytotoxic Topical Non-Cytotoxic Topical AntimicrobialsAntimicrobials

Consider Cadexomer iodine or Time Consider Cadexomer iodine or Time released Silvers for the following released Silvers for the following indications: indications: 1 or more signs of infection are present1 or more signs of infection are present If less obvious signs, like increased exudate If less obvious signs, like increased exudate

or friable base, are notedor friable base, are noted Increased local wound painIncreased local wound pain Delayed healedDelayed healed

Treatment SelectionTreatment Selection

““A facility should be able to show that its A facility should be able to show that its treatment protocols are based upon treatment protocols are based upon current standards of practice and are in current standards of practice and are in accord with facility’s policies and accord with facility’s policies and procedures as developed with the medical procedures as developed with the medical director’s review and approval.”director’s review and approval.”

Expectations with TreatmentsExpectations with Treatments

Stage III and IV ulcers must be coveredStage III and IV ulcers must be covered No Particular dressing promotes healing of No Particular dressing promotes healing of

all ulcersall ulcers Balance to maintain a moist wound bed, Balance to maintain a moist wound bed,

and a dry peri area is required for optimal and a dry peri area is required for optimal resultsresults

Stable eschar on foot/ heel area should Stable eschar on foot/ heel area should not be debrided unless infection or not be debrided unless infection or instability are detected.instability are detected.

Surveyor Instruction inSurveyor Instruction inPain ManagementPain Management

Goal: eliminate wound painGoal: eliminate wound pain Stage III and IV ulcers can be as painful Stage III and IV ulcers can be as painful

as a Stage I or IIas a Stage I or II Inappropriate dressings and trauma during Inappropriate dressings and trauma during

treatment can be route of paintreatment can be route of pain

Pain ManagementPain Management

Most wound pain occurs with dressing Most wound pain occurs with dressing change due to: dried dressing, desiccated change due to: dried dressing, desiccated wound base, strong adhesives and poor wound base, strong adhesives and poor exudate control.exudate control.

Selecting appropriate product to allow for Selecting appropriate product to allow for moist wound healing will significantly moist wound healing will significantly decrease pain decrease pain

Avoid gauze and wet-dry treatmentsAvoid gauze and wet-dry treatments Pre-medicate prior to dressing changePre-medicate prior to dressing change

Expected InterventionsExpected Interventions

Reposition in chair every hour, minimumReposition in chair every hour, minimum Reposition in bed every 2 hours, minimumReposition in bed every 2 hours, minimum Teachable residents reposition every 15 Teachable residents reposition every 15

minutesminutes No one should sit in a wheel chair for No one should sit in a wheel chair for

prolonged periods of time (time for a meal) prolonged periods of time (time for a meal) without modifications to chair (seat without modifications to chair (seat cushions)cushions)

Appropriate InterventionsAppropriate Interventions

Static surfaces (gel, foam): may be Static surfaces (gel, foam): may be appropriate for prevention, or healing, if appropriate for prevention, or healing, if resident can position off wound site.resident can position off wound site.

Dynamic (air): consider for non-healing Dynamic (air): consider for non-healing wounds, or if resident can not assume a wounds, or if resident can not assume a variety of positionsvariety of positions

Repositioning is still required, heel floating Repositioning is still required, heel floating is still required. is still required.

Debridement OptionsDebridement Options

Types:Types: AutolyticAutolytic EnzymaticEnzymatic MechanicalMechanical Sharp or surgical Sharp or surgical Bio-debridementBio-debridement PolyacrylatePolyacrylate

Consider:Consider: Condition of residentCondition of resident Condition of woundCondition of wound Goals of resident Goals of resident Location of woundLocation of wound Viability of woundViability of wound Underlying conditionsUnderlying conditions AnticoagulantsAnticoagulants Arterial statusArterial status Bioburden Bioburden

AutolyticAutolytic

Defined: use of moisture retentive Defined: use of moisture retentive dressing to allow devitalized tissue to self-dressing to allow devitalized tissue to self-digest by the action of enzymes in wound digest by the action of enzymes in wound fluidsfluids

Pro: pain-free, decreased frequency of Pro: pain-free, decreased frequency of dressing changedressing change

Con: slower, requires adequate circulation, Con: slower, requires adequate circulation, can not be used with infected woundscan not be used with infected wounds

Enzymes Derived from:Enzymes Derived from:

Plant Derived (Papaya) Plant Derived (Papaya) Papain and UreaPapain and Urea

AccuzymeAccuzyme GladaseGladase EthezymeEthezyme ZioxZiox

Copper ChlorophyllCopper Chlorophyll Panafil: Panafil: Gladase CGladase C ZioxZiox

Biologically EngineeredBiologically Engineered CollagenaseCollagenase

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

MechanicalMechanical

Each must be considered carefully and Each must be considered carefully and performed by a professional performed by a professional knowledgeable about Pros, Cons, knowledgeable about Pros, Cons, Indications and Contraindications. Indications and Contraindications.

WhirlpoolWhirlpool Pulse LavagePulse Lavage Wet-dry (not wet-moist)Wet-dry (not wet-moist)

Sharp or SurgicalSharp or Surgical

Immediate removal of devitalized tissueImmediate removal of devitalized tissue SurgicalSurgical Often necessary in the case of Often necessary in the case of

infected, necrotic woundinfected, necrotic wound SharpSharp may be performed at bedside: must may be performed at bedside: must

consider wound location, viability, consider wound location, viability, circulation, use of anticoagulants, pain circulation, use of anticoagulants, pain management, skilled clinician availabilitymanagement, skilled clinician availability

Bio-DebridementBio-Debridement

Selective debridement of necrotic tissues Selective debridement of necrotic tissues by sterile maggotsby sterile maggots

Decreasing bacteria and infection in Decreasing bacteria and infection in wound tissueswound tissues

Requires skilled clinicians to apply Requires skilled clinicians to apply ‘retention’ dressing that takes ‘retention’ dressing that takes approximately 30-45 minutes.approximately 30-45 minutes.

Some reports of painSome reports of pain ‘‘Yuck’ factorYuck’ factor

PolyacrylatePolyacrylate

Polyacrylate pad moistened with ringers Polyacrylate pad moistened with ringers solutionsolution

Draw necrosis out of wound while Draw necrosis out of wound while maintaining a moist wound bedmaintaining a moist wound bed

Debrides at a rate of 38% Debrides at a rate of 38% No discomfortNo discomfort

Avoidable vs. UnavoidableAvoidable vs. Unavoidable

Must be addressed in the case of:Must be addressed in the case of: New Pressure UlcerNew Pressure Ulcer Non-healing UlcerNon-healing Ulcer Wound painWound pain InfectionInfection

Successful LTC CentersSuccessful LTC Centers

Internal policies and procedures are in Internal policies and procedures are in harmony with Best Practice and CMS harmony with Best Practice and CMS regulatory requirementsregulatory requirements

Understand that Non-compliance is more Understand that Non-compliance is more expensive than Compliance.expensive than Compliance.