March 2013 by HMP Communications, LLC

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Today’s

Contemporary Approaches to Wound Clinic Management

Managing Diabetes in the Wound Clinic Effective Screening Modalities The ‘Heart’ of DFUs

Also in This Issue: Diabetes & ICD-10 Business Briefs

March 2013

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Today’s

Volume 7, Number 2, March 2013 • www.todayswoundclinic.com

Table of Contents • Feature Articles 12

Diabetic Foot: The Heart of The Matter

Diabetic Wound Healing Through Nutrition and Glycemic Control

The importance of taking into account the cardiovascular status of diabetic foot patients is paramount for all wound care clinicians. The highest priority must be given to avoiding potentially fatal events such as myocardial infarctions and cerebrovascular accidents.

Wound care providers have the power to help reduce the huge economic burden and life-threatening complications of diabetes by implementing timely interventions such as comprehensive diet and nutrition management. This article explains how uncontrolled blood sugar impairs wound healing and offers nutritional recommendations and guidelines that promote healing, as well as suggestions to prevent further complications.

Cornelius A. Davis III, MD

Nancy Collins, PhD, RD, LD/N, FAPWCA & Colleen Sloan, RD, LD/N

Identifying New ICD-10-CM ‘Buzzwords’ in Diabetes Terminology Conversion from ICD-9-CM diagnosis coding to ICD-10CM will become effective Oct. 1, 2014.This article focuses on important documentation issues for wound care practitioners to consider while preparing for this system change. Donna J. Cartwright, MPA, RHIA, CCS, RAC, FAHIMA

Monitoring Blood Glucose Values in the Wound Clinic: An Aggressive Approach to Diabetes Management

In this exclusive article, Today’s Wound Clinic shares one nurse’s struggle to earn advanced diabetes education.

When wound care providers at one Georgia-based wound clinic repeatedly saw chronically high glucose values among their patients living with diabetes, they took it upon themselves to become part of the solution—not the problem.Take an inside look at the screen protocol at the Archbold Center for Wound Management with Today’s Wound Clinic editorial board member Tere Sigler and learn how her staff reversed this trend through education and proper monitoring.

Jill Henneberg, BSN, RN

Tere Sigler, PT, CWS, CLT-LANA

Raising the Debate on Wound Care and Diabetes Education

TODAY’S WOUND CLINIC® (ISSN 1938-6311), is published by HMP Communications, 83 General Warren Boulevard, Suite 100, Malvern, PA 19355. TODAY’S WOUND CLINIC® website, www.todayswoundclinic.com, is registered with all major Internet search engines. Full content is available online to TODAY’S WOUND CLINIC print subscribers. Subscriptions: TODAY’S WOUND CLINIC® annual rates for US subscriptions: $99.00 annual; single copies, $39.00. Single or replacement copies of TODAY’S WOUND CLINIC® are subject to availability. To subscribe to TODAY’S WOUND CLINIC®, call (800) 237-7285, ext. 221, write to TODAY’S WOUND CLINIC®, Circulation Department, HMP Communications, 83 General Warren Boulevard, Suite 100, Malvern, PA 19355, or visit us online at www.todayswoundclinic.com. Reprints: Bulk professional-quality reprints (minimum quantity 100) of articles may be purchased. Contact the Managing Editor at (610) 560-0500 for information.

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Editorial Staff

Today’s

Clinical Editors and Founding Board Caroline E. Fife, MD, FAAFP, CWS Dot Weir, RN, CWON, CWS

Founding Editorial Board Kathleen Schaum, MS Christopher Morrison, MD Val Sullivan, PT, MS, CWS

Volume 7, Number 2, March 2013 • www.todayswoundclinic.com

Managing Editor Joe Darrah jdarrah@hmpcommunications.com

Table of Contents

Web Editor Samantha Alleman salleman@hmpcommunications.com

6 In Memoriam A Tribute to Morris David Kerstein, MD, FACS

Business Staff

Laura Bolton, PhD

Executive Vice President Peter Norris pnorris@hmpcommunications.com

Departments 4

VP/Group publisher Jeremy Bowden jbowden@hmpcommunications.com

From the Editor

Publisher Kristen J. Membrino kmembrino@hmpcommunications.com

Caroline Fife, MD, FAAFP, CWS

7 Business Briefs Understanding Medicare Payment Changes

Sales Associate Brian Hill bhill@hmpcommunications.com

for HOPDs and Physicians in 2013

Classified Sales Associate Jenn Ratcliffe jratcliffe@hmpcommunications.com

Kathleen D. Schaum, MS

Wound Care Provider Profile

Conference Connection SAWC Spring/WHS 2013

Controller Meredith Cymbor-Jones

TWC News Update

Vice President, Special Projects Jeff Hall

HMP Communications, LLC

An interview with Desmond Bell, DPM, CWS

PRESIDENT BIll Norton

Spotlight on diabetes; Report seeks end to fee-for-service

Ask The Board

Kathleen D. Schaum, MS

Marketing Manager Stephanie Manzo Creative Director Vic Geanopulos vgeanopulos@hmpcommunications.com Art Director Bernadette Zeminski bzeminski@hmpcommunications.com Senior Production Manager Andrea Steiger asteiger@hmpcommunications.com

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MEETING PLANNER Cynthia Noonan

Top online visits from Feb. 1-28 1) Measuring Quality in Wound Care 2) The Changing Face of Wound Care: Measuring Quality 3) Facility in Focus Photo Slideshow: Washington (PA) Health System

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83 General Warren Boulevard, Suite 100, Malvern, PA 19355 Editorial Correspondence should be addressed to Managing Editor, Today’s Wound Clinic®, HMP Communications, 83 General Warren Boulevard, Suite 100, Malvern, PA 19355. Telephone: (800) 237-7285 or (610) 560-0500 /Fax: (610) 560-0502. Editorial policy: TODAY’S WOUND CLINIC® seeks to provide practical, timely insight into clinical and operational issues inherent to the success of an outpatient wound center. Program Directors, Medical Directors, and Clinical Managers (including Nurse Practitioners and other professional wound care providers across multiple disciplines) will benefit from the interactive nature of feature articles and regular departments that address medical and practice management options and perspectives affecting fiscal and, most importantly, patient outcomes of wound clinics. Articles from knowledgeable, experienced practitioners are invited and will be subject to Editorial Board review. , LLC

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fromtheeditor

s I think about the national epidemic of diabetes and my own struggles in caring for these patients, I’m convinced this is an example of the emerging theory of “simplexity” — a concept that considers a potential relationship between complexity and simplicity that’s the subject of a 2008 book by Time magazine’s Jeffrey Kluger. In the book, Kluger explores this phenomenon with a variety of examples, including how an apparently simple house plant can be more complicated than a modern industrial Caroline Fife plant and how 90 percent of money that’s donated to help Co-Editor of TWC cure the world’s diseases is only given to research supporting 10 percent of those diseases. Consider: Adult-onset diabetes (responsible for most cases in the US) is caused primarily by obesity and poor lifestyle choices. Diabetes, which can be “cured” by diet and exercise, will kill more people in the US than AIDS will. (If AIDS could be cured in this manner, what type of initiatives would we see across the US?) Diabetes leads to diabetic foot ulcers (DFUs), nearly 85 percent of which can be treated by offloading, a relatively simple treatment that is poorly reimbursed and unlikely to be properly implemented at even the most sophisticated wound centers. Diabetes leads to peripheral vascular disease (PVD), a primary cause of lower extremity limb loss. However, for the past 10 years, every randomized controlled trial to prove the efficacy of a new DFU treatment has excluded patients with PVD.There are virtually no new treatments on the horizon for PVD, with the exception of some vascular growth factor trials that are far from commercialization. However, diabetic patients whose blood sugars are under control are more likely to heal their ulcers and are less likely to have end-organ disease like PVD. Still, reimbursement for diabetic education is poor and almost no wound centers offer this service. We know what needs to be done in order to manage this disease – eat right, lose weight, exercise, offload, control blood sugar, and screen for vascular disease. This may all seem simple in scope; however, care delivery is actually very complex.

A CLOSER LOOK This edition of TWC features an article by Cornelius Davis A. Davis III, MD (with whom I had the privilege of collaborating for many years), that deals with the link between DFUs and heart health and offers an insider perspective from TWC board member Tere Sigler, PT, CWS, CLT-LANA, on diabetes screening in place at her Georgia wound clinic; an expert review of diabetes nutritional guidelines by Nancy Collins, PhD, RD, LD/N, FAPWCA and Colleen Sloan, RD, LD/N; and an intriguing piece on the difficulties wound care clinicians may face when seeking continued diabetes education by wound nurse Jill Henneberg, BSN, RN. Additionally, TWC board member Donna Cartwright, MPA, RHIA, CCS, RAC, FAHIMA, provides us with a primer on diabetes documentation “buzzwords” that will soon become familiar as ICD-10-CM approaches (revealing that there really doesn’t seem to be a “simple” part at all to the payment side related to diabetes care) and popular columnist and fellow TWC founding board member Kathleen Schaum, MS, continues her 2013 “Business Briefs” update with an article on Medicare payment changes for HOPDs and physicians. As you read the articles, see if you find them to be examples of simplexity in action. Noted professor Peter Wipperman has suggested that as the complexity of our world continues to grow, we will have to stop striving to make “optimal” decisions and instead concentrate on making judgments that are “just good enough.” Somehow, that doesn’t seem an adequate way to approach the care of our patients.We hope this issue of TWC offers more insight. n

Today’s

Editorial Board Founding Editorial Board Members Co-Editor of Today’s Wound Clinic Caroline Fife, MD, FAAFP, CWS Co-Editor of Today’s Wound Clinic Dot Weir, RN, CWON, CWS Christopher A. Morrison, MD, FACHM, FCCWS Valerie Sullivan, PT, MS, CWS Kathleen D. Schaum, MS

Editorial Board Members Andrew J. Applewhite, MD, CWS, UHM Leah Amir, MS, MHA Desmond Bell, DPM, CWS Trisha Carlson, MSN, MBA-HCM, RN, CWCN Donna J. Cartwright, MPA, RHA, CCS, RAC, FAHIMA Moira Hayes, MHA, RRT, CHT Cathy Thomas Hess, BSN, RN, CWOCN Harriet Jones, MD, BSN, FAPWCA Robert S. Kirsner, MD, PhD Trisha Markowitz, MSN, MBA-HCM, RN, CWCN, DAPWCA Pamela Scarborough, PT, DPT, MS, CDE, CWS Susie Seaman, NP, MSN, CWOCN Tere Sigler, PT, CWS, CLT-LANA Pamela G. Unger, PT, CWS, FCCWS Randall Wolcott, MD, CWS

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83 General Warren Boulevard, Suite 100, Malvern, PA 19355 © 2013, HMP Communications, LLC. All rights reserved. Reproduction in whole or in part prohibited. Opinions expressed by authors, contributors, and advertisers are their own and not necessarily those of HMP Communications, LLC, the editorial staff, or any member of the editorial advisory board. HMP Communications, LLC is not responsible for accuracy of dosages given in articles printed herein. The appearance of advertisements in this journal is not a warranty, endorsement or approval of the products or services advertised or of their effectiveness, quality or safety. HMP Communications, LLC disclaims responsibility for any injury to persons or property resulting from any ideas or products referred to in the articles or advertisements. Content may not be reproduced in any form without written permission. Reprints of articles are available. Contact HMP Communications, LLC for information.HMP Communications, LLC (HMP) is the authoritative source for comprehensive information and education serving healthcare professionals. HMP’s products include peer-reviewed and non-peer-reviewed medical journals, national trade shows and conferences, online programs and customized clinical programs. HMP is wholly owned subsidiary of HMP Communications Holdings LLC. Discover more about HMP’s products and services at www.hmpcommunications.com.

Caroline Fife, MD, FAAFP, CWS, co-editor of TWC, chief medical officer at Intellicure Inc. 4

March 2013 Today’s Wound Clinic®

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www.todayswoundclinic.com

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inmemoriam A Tribute to Morris David Kerstein, MD, FACS Jan. 13, 1938 – Feb. 1, 2013 Laura Bolton, PhD

ometimes, life allows us to learn from a person so gifted and gracious his presence remains even after he leaves the room … or the planet. That was Morris Kerstein. As one of the world’s pre-eminent vascular surgeons, his legacy to medical practice included more than 800 manuscripts published in peer-reviewed journals, 18 books, and 90 book chapters. His reach extended around the world as a “doctor without borders”; his influence in the wound care arena was meaningful, deep, and far-reaching. During his distinguished academic and surgical career, he mentored countless medical students and colleagues with patience, humor, and a penetrating appreciation of human nature. Dr. Kerstein found new ways to improve clinical outcomes wherever opportunities arose. His career in the US Navy began in 1963 and took him to Vietnam for two years as a trauma surgeon where he learned methods to combat heat stress; his validated guideline, published in 1982, is still used to help military personnel thrive in hot environments.While he continued his active clinical academic service in the US Naval Reserve, he also served as a medical military strategist in Beirut and during Operation Desert Storm, never failing to answer the call to help “wounded warriors” and those who serve them. Lia van Rijswijk, clinical editor of Today’s Wound Clinic sister publication Ostomy Wound Management, said, “His experience led him to value the importance of multi- and interdisciplinary care on patient outcomes long before scientific data proved him correct. And he practiced what he preached. Among his publications was evidence of the importance and cost effectiveness of moist wound healing in optimizing acute, surgical, and chronic wound outcomes.” Dr. Kerstein also served wound care patients and professionals in several capacities through his involvement with the Association for the Advancement of Wound Care (AAWC): He was a physician board member (1996–98), president (1998–2000), and past-president (2000–01). He used his leadership skills to enhance the value of membership in the AAWC and to help the association develop into the world’s largest multidisciplinary global wound care organization. AAWC executive

director Tina Thomas noted, “Dr. Kerstein was the first president I worked with when I was hired in 1999. He was always very kind and patient as I learned the ropes of my position.” Thomas reminisced about the way he acknowledged people who worked hard, an attribute that inspired those around him to give their all. “He had such a burning passion for wound

Sometimes, life allows us to learn from a person so gifted and gracious his presence remains even after he leaves the room ... or the planet. care, and he continuously counseled our board members on ‘doing what is right,’” Thomas said. “That certainly left a distinct impression on me — one that, along with other sage advice he provided through the years, made me appreciate my own passion for my position as the association’s director.” Thomas also mentioned how a statement from John Macdonald, MD, FACS, another AAWC president, applies to Dr. Kerstein: “Wound care specialists are the ones who rise to the top … They see patients so terribly wounded that others have given up on and no one else wants to see.” Coincidentally, the AAWC recently launched a new category of membership that offers significantly reduced dues for those on active military duty and military civilian healthcare workers.With this in mind,Thomas said,“Given Dr. Kerstein’s military service, followed by all of his years of selfless work to educate, I bet he’s smiling down at us right now for ‘doing the right thing.’” n

Visit www.aawconline.org to become a “military” member of the AAWC.

March 2013 Today’s Wound Clinic®

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www.todayswoundclinic.com

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businessbriefs

Understanding Medicare Payment Changes for HOPDs and Physicians in 2013 Kathleen D. Schaum, MS Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure the accuracy of the information. However, HMP Communications and the author do not represent, guarantee, or warranty that the coding, coverage, and payment information is error-free and/or that payment will be received.The ultimate responsibility for verifying coding, coverage, and payment information accuracy lies with the reader.

n March 2012, we described the physician as an “orchestra leader” and the staff of the hospital-based outpatient wound care department (HOPD) as an “orchestra” that work together to implement a unique plan of care for each patient living with a chronic wound.1 In fact, the staff of the HOPD cannot care for patients if a physician is not immediately available to provide direct supervision in the HOPD. Last month, we discussed the new 2013 codes that should be integrated into encounter forms, Charge Description Masters, and billing systems (if the physician orders those services, procedures, and/or products for their patients).2 The next logical 2013 topic is the 2013 Medicare payment rates for codes that are relevant to wound care professionals. When a physician provides care to wound

patients in the HOPD, the patients receive two bills — one from the physician and one from the HOPD. This article will review the 2013 Medicare payment rates for both physicians and HOPDs. NOTE: Medicare payment rates in tables 1 (below), 2 (page 7), and 3 (page 7) are national average payment rates. HOPDs and physicians should verify their own unique Medicare payment rates.

E&M Services/Clinic Visits If the physician provides evaluation and management (E&M) services in the HOPD, the physician selects the appropriate code based on the 1995 OR the 1997 E&M guidelines that are published by the American Medical Association. The Medicare payment rates for E&M services and all other services and procedures are released each year in the Medicare Physician Fee Schedule (MPFS) Final Rule: www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/ PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1590FC.html. For the past few years, the Centers for Medicare & Medicaid Services (CMS) has been increasing the payment rates for E&M services provided by physi-

TABLE 1. 2012 vs. 2013 MPFS and HOPD National Average Medicare Rates for E&M Services E&M Codes 2012 MPFS 2013 MPFS 2012 HOPD $

2013 HOPD

New Patient Visits 99201

25.87

25.86

53.79

56.77

99202

49.01

48.99

72.12

73.68

99203

74.88

118.20

95.12

96.96

99204

126.96

128.27

130.41

128.48

99205

162.70

164.67

176.51

175.79

Established Patient Visits 99211

9.19

8.85

53.79

56.77

99212

25.19

24.50

72.12

73.68

99213

49.69

49.67

72.12

73.68

99214

76.24

76.55

95.12

96.96

99215

107.22

107.85

130.41

128.48

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cians. Table 1 shows a blend of payment increases and decreases for physicians when they perform E&M services in the HOPD. The payment increases for new patient E&M levels III, IV, and V continue to provide additional financial incentives for physicians to take the time to carefully diagnose new patients. HOPDs borrow the 10 new and established patient E&M codes, but are required by CMS to create their own mapping system as well as policy and procedure for affiliating resources used in the HOPD during a clinic visit with the new patient and established patient clinic-visit codes. The Medicare payment rates for these and all other services,procedures,and separately billable products are determined by CMS: They assign the HOPD clinic visit codes to ambulatory payment classification (APC) groups with services that require similar HOPD resources. Medicare releases APC group assignments and their affiliated Outpatient Prospective Payment System (OPPS) rates every year in the OPPS Final Rule: www.cms. gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/ Hospital-Outpatient-Regulations-andNotices-Items/CMS-1589-FC.html. As Table 1 reveals, CMS pays the HOPD more for a clinic visit than it pays the physician because the HOPD incurs the practice expenses such as the cost of surgical dressings. The 2013 OPPS payment rates for E&M services have very slight increases and decreases.

Debridements: Surgical, Selective, and Non-Selective The 2013 MPFS payment rates for debridements performed by physicians in HOPDs increased/decreased ever so Today’s Wound Clinic®

March 2013

3/8/13 5:21 PM

businessbriefs TABLE 2. 2012 vs. 2013 MPFS and HOPD National Average Medicare Rates for Debridement Debridement Codes 2012 MPFS 2013 MPFS 2012 HOPD

2013 HOPD

Surgical Debridement 11042

59.57

62.26

193.02

209.65

11043

158.27

157.87

193.02

209.65

11044

236.56

234.76

578.84

583.61

11045

26.89

27.56

193.02

209.65

11046

55.14

56.14

193.02

209.65

11047

97.69

99.35

578.84

336.38

Selective Debridement 97597

23.83

23.48

104.86

106.96

97598

11.23

104.86

106.96

Non-Selective Debridement 97602

61.45

71.54

TABLE 3. 2012 vs. 2013 MPFS and HOPD National Average Medicare Rates for Advanced Technologies Advanced Technology Codes 2012 MPFS 2013 MPFS 2012 HOPD

2013 HOPD

Application of Cellular- and/or TissueBased Products for Wounds 15271

87.82

86.76

227.80

251.48

15272

17.36

17.01

83.55

85.75

15273

209.33

194.95

347.63

393.38

15274

44.25

41.51

227.80

251.48

15275

101.77

104.79

227.80

251.48

15276

24.85

25.86

83.55

85.75

15277

216.14

217.75

347.63

393.38

15278

54.80

52.40

227.80

251.48

Application of Compression 29445

106.45

106.49

179.55

189.14

29580

35.74

36.06

78.88

94.54

29581

12.59

78.88

94.54

29582

15.32

15.31

78.88

53.93

29583

11.23

78.88

53.93

29584

15.32

15.31

78.88

53.93

Application of Negative Pressure G0456

Carrier Priced

209.65

G0457

Carrier Priced

209.65

97605

26.89

26.20

61.45

71.54

97606

29.61

29.26

104.86

106.96

Hyperbaric Oxygen Therapy C1300

104.74

109.75

99183

119.47

119.76

Wound Ultrasound 0183T

Carrier Priced

104.86

71.54

slightly. (See Table 2.) Physicians should continue to select the appropriate debridement codes based on the depth of tissue removed and the size of the wound surface area that was debrided. The 2013 OPPS payment rates for debridements increased for all debridement codes except for the add-on code for surgical debridement of bone. This decrease occurred because CMS moved 11047 from APC Group 20 to lowerpaying APC Group 19. (See Table 2.) Like physicians, HOPDs should continue to select the appropriate debride8

ment codes based on the depth of tissue removed and the size of the wound surface area debrided.

Advanced Technology Procedures Cellular- and/or Tissue-based Products for Wounds (CTPs): The 2013 Medicare payment rates for the application of CTPs codes increased/decreased slightly for physicians, but increased for HOPDs. (See Table 3.) Compression: Similarly, 2013 MPFS rates for the application of various forms of compression nearly mirror 2012 payment rates.The 2013 HOPD payment rates increased for the application of rigid leg casts,

March 2013 Today’s Wound Clinic®

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Unna’s boots, and multilayer compression to the lower leg, but decreased for the application of multilayer compression to the upper leg, upper arm, and arm/hand because CMS moved these three codes to a lower-paying APC group that requires fewer resources. (See Table 3.) Negative PressureWoundTherapy (NPWT): The 2013 MPFS payment rates for physicians who apply NPWT pumps decreased by pennies while the Medicare payment to HOPDs increased for that work. A Medicare payment rate for the new code (NPWT using a mechanically powered device) has been posted for HOPDs, but is carrier priced for physicians. (See Table 3.) Hyperbaric Oxygen Therapy (HBO): Physicians who supervise HBO received a very slight increase in Medicare payment while HOPDs received about $20 more for every 120 minutes of HBO therapy provided. (See Table 3.) Wound Ultrasound: MPFS payment for wound ultrasound is carrier priced in 2013, just as it was in 2012. HOPDs received a sizeable Medicare payment decrease for this procedure because CMS moved the code to a lower-paying APC Group. (See Table 3.) Now that we have reviewed the major changes that will affect wound care’s “orchestra leaders” and “orchestras” in 2013, physicians and HOPDs should make any necessary adjustments to their charges and billing systems. All wound care professionals should pay close attention to any Medicare payment changes that may be implemented due to the across-the-board government spending cuts known as “sequestration” that took effect March 1. n Kathleen Schaum is president and founder of Kathleen D. Schaum & Associates Inc., Lake Worth, FL. She can be reached for questions and consultations at 561-964-2470 and kathleendschaum@bellsouth.net. References 1. Schaum, K. The business of wound care: the physician’s perspective. Today’s Wound Clinic. 2012;6(2):6-8. 2. Schaum, K. Integrating new/updated codes into your business for 2013. Today’s Wound Clinic. 2013; 7(1):6-8. www.todayswoundclinic.com

3/8/13 5:21 PM

Diabetic Foot:

The Heart of The Matter Wound care providers must appreciate the cardiologic impact of diabetes in order to truly manage DFUs effectively. Cornelius A. Davis III, MD

roviding wound care to patients who live with diabetes is further complicated by the admixture of other conditions commonly present with this chronic disease. However, the significance of these comorbid complications is only evident once the astounding rates of death and disability are appreciated. Among Medicare beneficiaries between 2006 and 2008, the one-year death and major adverse cardiovascular event (MACE) rate among those experiencing diabetic foot ulcers (DFUs) was 11%.1 Moderate-to-severe peripheral artery disease (PAD) typically contributes to this wounding, and critical PAD with wounding (without the presence of diabetes) is attended by a one-year, 25% cardiovascular mortality rate.2 The subset of patients who live with both critical PAD and diabetes has even worse outcomes. As such, the im-

portance of taking into account the cardiovascular status of all DFU patients is paramount for all wound care clinicians. The highest priority must be given to avoiding potentially fatal events such as myocardial infarctions and cerebrovascular accidents.

Honing in on the Heart

It’s very tempting (and maybe even expedient in a sense) for wound care clinicians to focus on the wound-impacted limb alone when caring for their patients. However, a narrow-focused approach that does not invoke true wholistic care will only exacerbate the chance for heart attack and/or stroke at a near-incalculable rate. While never unavoidable, gauging the likelihood of a cardiovascular incident can be better anticipated without unnecessary testing when there’s a full appreciation

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of where the patient stands at the first point of care. This assessment begins by comprehensively reviewing the patient’s cardiovascular history, including previous surgeries. These procedures can directly impact one’s wound care. Coronary bypass procedures often involve the use of the saphenous vein and could lead to the creation of wounds to the leg, which can further impact revascularization attempts within the limb (lack of autologous vein for bypass procedures). They can also result in a chronically edematous limb and create “zones” of relative hypoperfusion at the scar sites. The presence of an automatic implantable cardioverter defibrillator (AICD) or pacemaker must also be accounted for if electrocautery will be used during wound debridement or if MRI is desired for osteomyelitis evaluation. Ad-

Today’s Wound Clinic® March 2013

3/8/13 4:51 PM

diabetesmanagement ditionally, an AICD reveals the presence of a dysrhythmia and the likelihood that prescribed medications will affect future medication choices for moderate sedation procedures. Existing prescriptions can also create drug conflicts (ie, metoprolol and ketorolac or sotolol and ciprofloxacin, etc). The practitioner is better equipped with this information up front as opposed to trying to determine what is occurring during an unexpected cardiovascular event. The presence of an AICD also informs the practitioner of the likelihood of depressed cardiac function, possible prior heart failure, and, in all probability, an ejection fraction of less than 30%. This wealth of event-preventative information should arise from collecting the patient’s medical history; meanwhile, a social history can reveal the probability of unreported COPD due to heavy tobacco abuse (an additional major risk factor for coronary and cerebrovascular events). It may be possible and worthwhile for the wound care clinician to assess whether patients are currently under the care of a cardiovascular specialist who may be capable of producing results from recent electrocardiograms, echocardiograms, stress tests, cardiac catheterizations, and/or carotid Doppler exams. Fellow practitioners who may have cared for the patient prior and have intimate knowledge of cardiovascular status can share opinions related to patient care and serve as resources for questions regarding possible change in health status while reassuring the wound care provider of related risk factors of office-based procedures. The DFU patient may appear to have a poorly controlled cardiovascular status with elevated blood pressure or resting tachycardia; however, this may have been controlled prior to the pain or infection. This should not be simply assumed, however, as some patients have poorly controlled hypertension at baseline and can experience dangerous elevations in blood pressure with minimal bedside debridements.

Further Assessments

After discussing the presentation of the wounded extremity, the conversa-

tion should turn toward the patient’s cardiovascular status. One helpful line of questioning involves tolerance to exertion. For example, assessing one’s habits at a supermarket or large store can provide valuable insight. Can the patient walk to and from his/her car without stopping, or must he/she lean on a cart throughout (or is a motorized cart needed)? Can the patient walk a flight of stairs without stopping? What limits does the patient have — overall fatigue, shortness of breath, leg pain, etc? Each of these clues has different implications. Overall fatigue can be due to deconditioning, heart failure, COPD, etc. Shortness of breath is similar, but with pulmonary causes increasing and cardiac causes also present. If leg pain is the limiting factor, claudication, lower back pain, or low cardiac output may all be participating in the patient’s difficulties, which should specifically be probed at night, as heart failure may cause nocturnal dyspnea or difficulty breathing when lying flat. If the patient needs several pillows or has to sleep sitting up, many caution flags should start to wave regarding the severe degree of cardiac impairment that exists. The decision to repeat or obtain new cardiac assessment tests is dependent on the information provided by the patient and on how much time has passed since tests were obtained. If symptoms have not changed in the last six months, testing during this time is likely sufficient. Determining tests that are sufficient to reassure the wound care practitioner should be based on the intensity of therapy needed. If only dressing changes are required (far less impact than debridements or resections), then less proof of cardiovascular competence is necessary. It is straightforward to appreciate that if the patient reports new chest pain, pressure, or constriction (or an increase in one of these is found) that immediate referral to a cardiovascular specialist is indicated for full workup. If the patient has an increased respiratory rate and is pursing his/her lips with each breath, then referral or return visit to a pulmonologist may be appropriate. Avoiding cardiovascular

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events requires attention to detail and a brief yet thorough line of questioning. Routinely ordering electrocardiograms or echocardiograms in asymptomatic patients who can tolerate exertion is likely of low yield. On the other extreme, ignoring changing symptoms and new complaints is hazardous and invites complications. In all, the most important goal is being able to recognize that an undisclosed problem exists and that a referral to the proper practitioner is necessary. Additionally, caution is heightened once the severity of a cardiovascular condition is defined. This form of care is cost effective, protective for the patient, and avoids events where a practitioner’s insight could be called into question. One’s clinical acumen will also be hailed by patients when a condition such as a carotid artery bruit that signaled a potential pending stroke is identified, even if the patient expected the primary focus to be on the existing DFU. n Cornelius A. Davis, III is a physician at Genesis Heart Institute, Genesis Medical Center, Davenport, IA. References 1. M argolis DJ, Malay DS, Hoffstad OJ, et al. Incidence of diabetic foot ulcer and lower extremity amputation among Medicare beneficiaries, 2006 to 2008: Data Points #2. 2011 Feb. 17. In: Data Points Publication Series [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2011-. Accessed online: www. ncbi.nlm.nih.gov/books/NBK65149 2. H irsch AT, et al. ACC/AHA 2005 practice guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients with Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation. 2006; 113(11): e463-654.

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Diabetic Wound Healing Through businessbriefs Nutrition and Glycemic Control In order to facilitate positive wound outcomes, providers must first help patients manage blood sugar through a healthy diet. Nancy Collins, PhD, RD, LD/N, FAPWCA & Colleen Sloan, RD, LD/N

iabetes has quickly become one of the most complex health challenges of the 21st century. In 2010, a total of 10.9 million US residents ages 65 years and older were reported to be living with diabetes.1 Currently, it is the seventhleading cause of death in the US, totaling 4.6 million deaths in 2011 (with healthcare expenditures reaching more than $471 billion.)2 A condition that increases one’s risk for heart disease and stroke, diabetes is also the leading cause of kidney failure, new cases of blindness among adults, and non-traumatic lower-limb amputations. Approximately 15% of individuals who live with diabetes develop a foot ulcer, and 84% of this population will end up with lower-leg amputations.3 Several factors can disrupt wound healing. Without proper nutrition, a normal wound can rapidly become a chronic, infected wound. However, it is possible for wound care providers to reduce the huge economic burden and life-threatening complications of diabetes by implementing timely, easy-to-use interventions. Comprehensive diet and nutrition management have been shown to promote optimal glycemic control and facilitate wound prevention and healing. As such, all healthcare professionals should know how to adequately manage blood glucose levels to support wound healing in patients living with diabetes. This article explains how uncontrolled blood sugar impairs wound healing and offers practical nutrition recommendations and guidelines that promote healing, as well

as simple suggestions to prevent further complications and comorbidities.

EFFECT OF DIABETES

Diabetes often causes slow-healing wounds that can worsen rapidly — with elevated blood glucose levels serving as the initial barrier to healing. Thus, achieving optimal glycemic control is imperative. Hyperglycemia stiffens arteries, causes cell walls to become rigid, and makes blood vessels become narrow. As a result, red blood cell permeability and flow is reduced, causing oxygen and nutrient deficits in the wound.Without oxygen, macrophage mobility is diminished and granulation tissue growth is limited, which causes a prolonged inflammatory phase.4 Impaired cell migration, inadequate leukocyte function, and insufficient collagen synthesis are the main causes for poor or delayed wound healing.5 Persistent hyperglycemia lowers the efficiency of the immune system, decreases sensory nerve function, and increases the development of infections. When blood glucose levels are persistently elevated, the process by which white cells are attracted to the site of an infection (chemotaxis) and the ingestion of bacteria by white cells (phagocytosis) are compromised.6 Protein-calorie malnutrition and the consequent body composition changes are additional considerations in wound healing, as are patient weight and nutritional status. Whether overweight (eg, sarcopenic obesity) or malnourished, adequate nutrition is vital to healing. Targeting the underlying cause of de-

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layed healing is as important in promoting optimal outcomes as is treating the wound topically. Proper nutrition plays a key role in managing blood glucose levels and wound healing. The role of the registered dietitian (RD) is to evaluate patient nutritional needs and provide an individualized diet that strives to achieve glycemic, lipid, and blood pressure control. The following suggestions aim to provide the basics of a carbohydrate-controlled diet designed to control glucose levels and weight while minimizing the risk of other comorbidities: 1. PROVIDING ADEQUATE CALORIES The process of wound healing is very energy-demanding. Energy needs are increased to support the immune response and regeneration of new tissue. If patients have an existing nutritional deficiency, wound care interventions may become less effective, making it important to address and optimize nutrition early on. Malnutrition is linked to more complications and infections, resulting in increased duration and frequency of hospital admissions. Individual energy needs depend on a variety of factors, making it necessary to adjust according to age, gender, nutritional status, comorbid conditions, activity level, severity of the wound, and stage in the healing process. Currently no evidencedbased recommendations exist for energy requirements. However, the European Pressure Ulcer Advisory Panel (EPUAP) and the National Pressure Ulcer Advisory Panel (NPUAP) recommend a minimum www.todayswoundclinic.com

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diabetesmanagement of 30–35 kcal/kg/day.7 Patients who are losing weight or are underweight may benefit from additional calories to ensure adequate wound healing and halt further weight loss. A well-balanced diet that incorporates the macronutrients — carbohydrates, protein, and fat — provides the energy needed. 2. ENCOURAGING WEIGHT LOSS (AS NEEDED) In order to maintain A1c levels below 7%, changes to diet and physical activity levels are recommended to facilitate weight loss, which is a proven means to improve glycemic control and reduce complications.8 If patients are willing and ready to make dietary changes, encourage them to eat at regular times every day. Suggest they cut calories from beverages by drinking water, unsweetened tea, artificially sweetened drinks such as Crystal Light,® or seltzer water with lemon or lime juice. Discuss appropriate snacking throughout the day. Snacking on the right foods can keep blood sugar stable and prevent overeating at the next meal. Think of snacking as an opportunity to optimize nutritional intake and increase energy levels. Some good snacks include ½ c. almonds or other nuts, 3 c. lite popcorn, five whole wheat crackers with one piece of string cheese, or celery sticks with 1 tbsp. peanut butter. 3. FUELING WITH CARBOHYDRATES Carbohydrates are the main and first source of cellular energy during wound healing. A diet with sufficient carbohydrate calories prevents the oxidation of protein for energy. An inadequate supply of carbohydrates can lead to muscle wasting, loss of subcutaneous tissue, and poor wound healing. Distribute carbohydrates evenly throughout the day to prevent fluctuations in blood sugar.Whole grains, fruits, and vegetables with complex carbohydrates are the preferred source. With the help of an RD, patients can become familiar with the various types of carbohydrates and how many they should consume daily.

4. HEALING WITH PROTEIN Protein provides the foundation for tissue growth, cell renewal, and repair resulting from a wound. Insufficient dietary protein can slow the rate and quality of wound healing. The preferred source is complete proteins, such as meat, poultry, fish, eggs, milk products, and soybeans. The EPUAP and the NPUAP recommend 1.25–1.5 g/kg/ day.7 For a 150-lb male, this equates to 85–102 g of protein/day.To put this into perspective, a 6-oz steak has roughly 54 g protein, one egg has 7 g protein, and 1 cup of milk has 8 g protein. Use caution when recommending excessive amounts of protein (>2 g/kg/day) for individuals with pre-existing renal or hepatic conditions. 5. SUPPLEMENTING (AS NEEDED) Encourage whole, fresh foods — they offer all of the required nutrients for wound healing, along with the additional benefits of phytonutrients and antioxidants. However, if patients are unable to consume adequate calories, a readyto-drink high-calorie/high-protein oral nutritional supplement (eg, Glucerna®) can fill the nutritional gaps. Add milk or cheese to foods to enrich daily meals and increase protein and energy intake. Consider a daily multivitamin for patients who live with comorbid diabetes and chronic or nonhealing wounds. Additional supplementation of vitamin A, vitamin C, and zinc is typically only warranted in the presence of a deficiency. 6. DEVISING AN ACTION PLAN Diabetes and wounds sometimes become a dangerous combination. A lack of glucose control combined with a poor diet can lead to nonhealing wounds and eventual amputation. However, with appropriate nutritional interventions, it is possible to have wounds heal properly while helping to prevent future wounds. Healthcare professionals should closely monitor dietary patterns to ensure increased protein and energy needs are met. With frequent meals and “smart snacking,” blood glucose levels can be controlled to

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promote normal wound healing. It is imperative to identify malnutrition early and implement appropriate strategies for correcting any nutritional deficits. If patients would benefit from weight loss, recommend appropriate lifestyle modifications. If patients require a more individualized plan, consult an RD, who can provide dietary counseling and guidance. Encourage well-balanced meals and frequent blood sugar monitoring to help prevent patients from becoming another diabetic statistic. n Nancy Collins is founder and executive director of Nutrition411.com and Wounds411. com (NCtheRD@aol.com). Colleen Sloan is a clinical dietitian at JFK Medical Center, Atlantis, FL, and nutrition expert at community-based workshops and food demonstrations. References 1. National diabetes statistics, 2011. National Diabetes Information Clearinghouse. Accessed online: http://diabetes.niddk.nih.gov/ dm/pubs/statistics/#allages. 2. Diabetes and impaired glucose tolerance — global burden: prevalence and projections, 2010 and 2030. International Diabetes Federation. Accessed online: www.idf.org/diabetesatlas/diabetes-and-impaired-glucose-tolerance. 3. McLennan SV, McGill M, Twigg SM,Yue DK. Improving wound-healing outcomes in diabetic foot ulcers. Expert Rev Endocrinol Metab. 2007;2(2):205-213. 4. Blakytny R, Jude E. The molecular biology of chronic wounds and delayed healing in diabetes. Diabet Med. 2006;23(6):594–608. 5. Kane DP. Surgical repair in advanced wound caring. In: Krasner DL, Rodeheaver GT, Sibbald RG. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. 3rd ed. Wayne, PA: HMP Communications; 2001:404. 6. Kenshole AB. Wholistic care of the person with diabetes. In: Krasner DL, Rodeheaver GT, Sibbald RG. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. 3rd ed. Wayne, PA: HMP Communications; 2001:584. 7. Pressure ulcer treatment: quick reference guide. European Pressure Ulcer Advisory Panel, National Pressure Ulcer Advisory Panel. Accessed online: www.epuap.org/guidelines/ Final_Quick_Treatment.pdf. 8. McAndrew LM, Napolitano MA, Pogach LM, et al. The impact of self-monitoring of blood glucose on a behavioral weight loss intervention for patients with type 2 diabetes. Diabetes Educ. 2012; June 26 [Epub ahead of print]. Accessed online: http://tde.sagepub.com/content/early/2012/06/26/0145721712449434. Today’s Wound Clinic®

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businessbriefs

250.5 — Diabetes with ophthalmic manifestation 250.6 — Diabetes with neurological manifestation 250.7 — Diabetes with peripheral circulatory disorder 250.8 — Diabetes with other specified manifestation 250.9 — Diabetes with unspecified complication.

Identifying New ICD-10-CM

‘Buzzwords’ in Diabetes Terminology As part of this comprehensive diabetes management issue of Today’s Wound Clinic, we offer wound care clinicians a critical look into diabetes documentation in preparation for ICD-10-CM. Donna J. Cartwright, MPA, RHIA, CCS, RAC, FAHIMA

he diagnosis of diabetes (and its related complications) is one of the most common diagnoses that occurs in wound care clinics. As many may have already heard, the US will convert from the current ICD-9-CM coding for diagnoses to the new ICD-10-CM system effective Oct. 1, 2014. This article focuses on important documentation issues for wound care practitioners to consider while preparing for the conversion to the new diagnosis coding system.

Quick Review of ICD-9-CM

Let’s take a moment to review the current “buzzwords” used in ICD-9CM. In the ICD-9-CM coding system, 14

diabetes is found in the 250 category of codes and are five digits in length. The coding instructions found in ICD9-CM for conditions due to diabetes are to code both the underlying cause (diabetes) and the manifestation (ulcer). There are 10 subcategories for coding diabetes with the appropriate current manifestation in the 250 category: 250.0 — Diabetes without mention of complication 250.1 — Diabetes with ketoacidosis 250.2 — Diabetes with hyperosmolarity 250.3 — Diabetes with other coma 250.4 — Diabetes with renal manifestation

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When assigning these codes, the diabetes (underlying cause) is sequenced first when reporting these types of conditions. The coding system then directs that the specific code for the manifestation be used as the second code. An example might be a diabetic foot ulcer that would be coded to 250.8X and then a category 707 code for the diabetic ulcer.The codes listed above all require a fifth digit indicating whether the patient is type 1 or 2 and if the diabetes is controlled or uncontrolled. If a patient has secondary diabetes from a disease or drug/chemical, a code is selected from category 249 in the code book.To summarize, the current buzzwords associated with diabetes are: • Clearly defining the manifestation for accurate assignment of the diabetic code subcategories • Type 1 or type 2 diabetes • Insulin dependent or non-insulin dependent • Controlled or uncontrolled • Secondary diabetes due to another condition or drug. Diabetes coding also comes with issues related to the sequencing of the codes for purposes of medical necessity. Some payers require the manifestation be coded in the first position as it is most related to the treatment. Even though the coding rules clearly state that the underlying cause is coded first (then the manifestation), payers may mandate that the manifestation be coded first. The best example of this is for diabetic ulcers. Payers may require the ulcer code be sequenced first, followed by the appropriate 250 category code for the underlying diabetes. Refer to www.todayswoundclinic.com

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diabetesmanagement your Local Coverage Determinations to see if there are specific instructions for codes proving medical necessity for certain treatments.

Introduction to ICD-10-CM

The wound care industry will gain many benefits when ICD-10-CM is implemented, so let’s focus on those benefits surrounding diagnosis codes for diabetes. The new codes will be very granular, which means the level of specificity will greatly improve. The new ICD-10-CM diagnosis codes for diabetes have their own subchapter in the endocrine, nutritional, and metabolic diseases chapter.The categories for diabetes in ICD-10-CM are: E08 — Diabetes mellitus due to underlying condition E09 — Drug- or chemicalinduced diabetes mellitus E10 — Type 1 diabetes mellitus E11 — Type 2 diabetes mellitus E13 — Other specified diabetes mellitus. These categories are further subdivided and can contain up to six characters. The higher the number of characters, the more specific the codes are. The new diabetes codes are combination codes that include the type of diabetes, the body system affected, and the complications affecting that system. It is important to remember that providers can assign as many codes as necessary to fully describe the patient’s diabetic conditions. Here’s an example of a comparison between ICD-9-CM and ICD10-CM diagnosis codes: ICD-9-CM 250.40 — Diabetes with renal manifestation type 2 not stated as uncontrolled 583.81 — Nephritis and nephropathy not specified as acute or chronic in disease classified elsewhere ICD-10-CM E11.21 — Type 2 diabetes with diabetic nephropathy.

ICD-9/10 TABLE. Below is a summary of some major differences and similarities between the two systems: ICD-9-CM

ICD-10-CM

Controlled vs. uncontrolled diabetes

Eliminated and replaced with hyperglycemia to indicate uncontrolled diabetes.

Etiology and manifestation/ complication coded separately

Underlying cause and manifestation/complication combined. In some instances may need to use additional codes to add specificity. (Use additional code instruction.)

Etiology sequenced first (See codefirst instructions.)

Usually the same. Some conditions require the manifestation to be coded first. As a reminder, the reason for the encounter is always listed in the first position.

The reason for the encounter is the diagnosis that should be sequenced first. (This is important for medical necessity purposes). If the type of diabetes is not documented in the record, coders are instructed to default to type 2 diabetes mellitus. Also, if the documentation does not indicate the patient uses insulin, use the type 2 diabetes codes. There is a code (Z79.4) that is to be used when the patient has long-term current use of insulin. This code should not be used if the patient is using insulin on a temporary basis. Secondary diabetes due to other diseases or drugs is most likely a secondary code using the underlying disease or drug/chemical first as an adverse event or a poisoning or sequelae of poisoning. Controlled versus uncontrolled diabetes has been eliminated and replaced with coding hyperglycemia. Detailed documentation will be necessary for appropriate code assignment. For review, the buzzwords in ICD-10-CM diabetes coding documentation are: • Type of diabetes • Body system affected • Insulin use • Any complications associated with diabetes • Any manifestation of diabetes • If secondary diabetes, provide the disease or drug/chemical causing the secondary diabetes. NOTE: Additional codes in other chapters may have specific combination codes when coding with diabetes. For example, when coding skin ulcers, the ulcer codes require additional specificity of documentation, such as:

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• Laterality (right or left), skin breakdown, fat exposed, muscle necrosis, bone necrosis, or unspecified severity • Pressure ulcers require the documentation of the specific ulcer stages. There are differences between old diabetes buzzwords and new ones for ICD10-CM. A few have been outlined in this article. To get started, evaluate current documentation by running a report of the most common diabetic conditions seen. Then, pull some of the medical records to see how well both the etiology and manifestation codes are documented. Review the records to ensure the main reason for the encounter is documented properly. For example, if the reason for the encounter is a wound infection, that should be in the first position for that particular encounter. Now is the time to highlight any needs for documentation improvement and educate to ensure use of accurate and specific etiology and manifestation codes for diabetes. The appropriate documentation will assist in the justification of medical necessity for many treatments. Stay tuned for more ICD-10-CM updates in Today’s Wound Clinic. n Donna J. Cartwright is senior director of strategic reimbursement services with Integra LifeSciences Corp., Plainsboro, NJ. Resources Centers for Medicare and Medicaid Services. 2013 ICD-10-CM and GEMs. Accessed online: www.cms.gov. National Center for Health Statistics. ICD-10CM Official Guidelines for Coding and Reporting 2013. Accessed online: www.cdc.gov/nchs. Cartwright D, Schaum K. ICD-10-CM for Wound Care Workshop. Today’s Wound Clinic®

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businessbriefs Monitoring Blood Glucose Values in the Wound Clinic: An Aggressive Approach to Diabetes Management By becoming more invested in care management, one wound clinic learns that it can make major impacts in the lives of its patients. Tere Sigler, PT, CWS, CLT-LANA

s a physical therapist, my initial experience in wound care was limited to hospital rehabilitation departments, where blood glucose monitoring is generally not available. I had always discussed the relationship between wound healing and blood glucose levels with my patients; however, I was dependent on them to report to me any issues they were having with their blood glucose levels. So, when I was given the opportunity to develop a multidisciplinary outpatient wound center at Archbold Medical Center in Thomasville, GA, in 1999, I was very excited about the opportuni-

ty to utilize finger stick blood glucose values as an additional assessment tool for all of my patients. As a clearly defined component of the protocol at our wound clinic from the day our doors opened, we made it routine to check finger stick blood glucose at each visit for any patient with a known history of diabetes or who reported having been diagnosed with diabetes. This practice was made a formality to catch elevations that might indicate a developing infection. Much to my surprise, the majority of our patients were found to be living with chronically high glucose

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values. Our initial plan to reverse this trend had been to educate our patients about the negative effects that elevated glucose poses to wound healing and to encourage them to follow up with their primary care physician (PCP) about proper monitoring. As one might suspect, this resulted in very little change. However, our collection of objective evidence for elevated blood glucose levels across our patient population did accomplish justifying the need to recruit a certified diabetes educator (CDE) for the clinic. While some patients declined their opportunities to www.todayswoundclinic.com

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diabetesmanagement meet with a dietician, many of them were receptive to this option — and those who participated experienced positive outcomes including lower hemoglobin A1c levels and reduced visits to the emergency department for blood glucose-related problems. The CDE was additionally successful in facilitating placement of insulin pumps among appropriate patients, which, to nobody’s amazement, resulted in improved wound healing outcomes. However, our ability to offer this great CDE resource to our patients was short-lived (she would relocate to another area after about two years). Without another CDE employed within the health system and the always-tightening budget constraints faced by administration, we lost the funding needed to keep the position filled. Although our dietary department’s staff members have given us support over the subsequent years whenever possible, the sporadic nature of their availability has made it hard to be as effective as we were when we had a dedicated CDE, which allowed us the “luxury” of more narrowly focusing our education.

Dealing With The Adjustment

Despite the lack of a certified CDE, we continued to finger stick each patient during all visits. While we were able to appropriately manage those who recorded low levels (as well as those with levels “too high to read”), we weren’t as successful when it came to patients whose blood glucose was chronically in the 200s or even 300s. Having known many of these patients for several years, we had become accustomed to sharing their finger stick values with their PCPs and becoming complacent when we never noticed much change. As providers, when patients come into your clinic 2-3 times per week for negative pressure wound therapy or compression bandaging, it can become all too convenient to accept high glucose as “normal” for those patients. Admittedly, we had become part of the problem. How many of our patients were walking out of the

clinic with the idea that their elevated blood glucose was “OK” because we had failed to say it wasn’t? Were we passively reinforcing their lack of concern? In an effort to stop this trend, we made a decision to actively engage patients in a discussion regarding any out-of-range blood glucose during each visit. Today, if a patient attributes their high blood sugar to having “just eaten lunch,” our clinicians will question them about what they had for lunch, what they ate for breakfast and what was planned for dinner. By investigating in this manner, we find that we can often focus on particular bad habits and spark a conversation to promote change. Common traits like drinking sweet tea or soda throughout the day, eating potatoes at every meal, or skipping breakfast are easy starting points. Additionally, to help patients and providers visualize their care, we keep “vital sign flow sheets” on each of them and use them to track particular issues being discussed. We send copies of the flow sheets to the PCP when we know patients have follow-up appointments to allow the physician to also see how the patient’s blood glucose has been running.

Addressing ‘Compliancy’

Many patients who live with diabetes get labeled as “noncompliant” when the reality may be they don’t understand what they’re being educated on. This is a patient population that is typically given a wealth of instruction over a short period of time with long periods between follow-up appointments. The high frequency at which we see our patients allows us to conduct timely clarification. One recent patient of ours returned to the clinic three days after having met with a dietician and his blood glucose was higher than usual. He said he had followed his dietician’s recommendations to “add more fruit to his diet” — claiming he had eaten four strawberry pastries that day. There was definitely some clarification needed. We’ve also uncovered other obstacles that our patients face in managing their diabetes

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through our more aggressive screening tactics. We have had patients who bring their meters in to us for one-onone instructions on their usage. We’ve seen patients with meters who’ve said they couldn’t afford strips, only to discover that their insurance covers them. Patients who weren’t regularly taking their medication because they “couldn’t afford it” are now discussing less costly medications and/or are being connected to the health department because we engaged their PCP in related conversations. Our greatest success story from an education perspective may be the phone call we received from a patient who took the time in a grocery store to ask us for advice on a food purchase. Still, we’ve also learned that taking a more inquisitive interest in our patients can actually lead to negative outcomes on occasion. One patient decided to quit coming to the clinic because he felt he was being “nagged” about his blood glucose. Another patient stopped coming after she was asked on several visits to bring in a food diary she had agreed to keep. We later discovered that she was hiding the fact that she couldn’t write. While not all patients are interested in the education we offer, many have embraced the opportunity to learn at their individual pace. Overall, we have seen chronically high glucose levels become lowered and remain down. We have embraced our roles as advocates for patients who are trying to make changes in their lives but need assistance in making the adjustments. Is cutting sweet tea out of the diet of someone who typically has a blood glucose higher than 300 going to bring it to a normal range? No, but neither will ignoring it. And by asking more questions than we make assumptions, we’ve put ourselves in a unique position to help our patients make small, albeit meaningful, changes toward better control of their diabetes. n Tere Sigler is the clinical director of the Archbold Center for Wound Management at Archbold Memorial Hospital, Thomasville, GA. Today’s Wound Clinic® March 2013

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Raising the Debate businessbriefs

on Wound Care and Diabetes Education After pursuing her CDE, a wound care nurse can’t help but wonder — are wound care and diabetes education a “certifiable” match? Jill Henneberg, BSN, RN

he No. 1 cause of non-traumatic lower limb amputations and the seventh-leading cause of death in the US,1 diabetes has a large presence in the majority of wound care clinics. This is where comprehensively educated, trained, and credentialed wound care staff members can prove invaluable to patients, especially in those centers where there is an established interdisciplinary team that includes a certified diabetes educator (CDE). While having a CDE is more likely a common trait of larger clinics, smaller centers are considered lucky to have access to a regular, devoted CDE. But what about those individual wound care providers who would like to earn their CDE certification in an effort to bolster their clinical acumen and improve patient care outcomes? Unfortunately, many may find it very challenging (or in some cases relatively impossible) to achieve these initials behind their name due to eligibility requirements.2 For patients, this often means making a separate appointment to a CDE at another location (and sometimes being charged another copay). For wound care providers, this often means relying on the services of another clinician outside their respective clinics to effectively collaborate with the patient’s wound care (and possibly having nothing more than hope that the patient will follow through with the necessary educational appointments). How should the wound care industry and individual wound care clinics best

handle this conundrum? Apparently, there are no easy answers.

Does CDE Fit Wound Care?

According to the CDC, the number of people who have been diagnosed with diabetes in the US is almost 21 million (or approximately 8% of the total population).1, 3 In my personal experience of managing diabetes and wound care, the average patient is seen in the clinic weekly for approximately 30 minutes. While some patients may feel “forced” to listen to any education we provide, others may actually be more receptive to what their wound care providers have to say due to fear of developing future wounds. Regardless, the provider should view the opportunity as a chance to change someone’s life by providing needed information while possibly improving the patient’s future healthcare through prevention (not to mention reducing their related healthcare costs). After roughly two years of working as a wound care nurse, I began to personally feel as if the education I had been giving my patients was too repetitive and not individually focused, so I decided to pursue a CDE. My pursuit to become credentialed, as it turned out, was not a lengthy one because I apparently do not qualify to provide accredited education in my current role as a staff nurse in an outpatient wound clinic. According to the National Certification Board of Diabetes Educators’ eligibility requirements, one

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must earn a minimum of 1,000 hours in diabetes self-management education (DSME) within an accredited center, with the hours being accrued in no more than five years time and a minimum of 40% of those hours (400 hours) being accrued in the year preceding application. Furthermore, wound care nurses who work in an outpatient setting do not qualify for the credential on their own merits because “… it is not for those who may perform some diabetes-related functions as part of or in the course of other usual and customary occupational duties …”.2 The definition of DSME is quite extensive.4 Although I can certainly agree with the requirements being strict, I still sought answers as to why I didn’t qualify for this opportunity as an experienced, licensed wound care provider. “Part of the reason it’s so difficult to become a CDE is that the criteria is set up to protect the public and ensure people are being taught diabetes education according to the current standards of care for diabetes management and education,” said Pamela Scarborough, PT, DPT, MS, CDE, CWS, a wound care provider with experience in acute and long-term care, outpatient services, and home health who earned her educator credential nearly 20 years ago. “What one does as a wound care specialist when educating people living with diabetes and wounds or a diabetic foot issue does not count toward the hours needed to be eligible to sit for www.todayswoundclinic.com

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diabetesmanagement CDE examination.” Though she values the prestige that is inherent with the CDE and stands by the increased knowledge one gains through earning the credential, Scarborough admits the challenge to obtain the CDE today may be more than the requirements intend them to be. “It is a problem,” said Scarborough, who has been able to maintain her previously acquired certification through one of the mandated processes for renewal, which includes passing the board certification exam and acquiring 75 hours of continuing education related to diabetes management and education every five years. “If I had to get my CDE today, I don’t know how I would do it because I don’t want to be a fulltime diabetes educator — I want to do clinical wound care and teach wound prevention, wound care, and diabetes management, especially in the context of chronic, nonhealing wounds, to my colleagues who are proving care. One of the big drawbacks for wound clinicians trying to attain this credential is the fact that it’s very difficult to find a setting that will allow them the opportunity to accrue the required 1,000 hours. So, here we are in this diabetes epidemic and the CDE credential has become more difficult to acquire.” With the requirements for CDE unlikely to significantly change any time soon, Scarborough said any possible solutions to this dilemma aren’t on the near horizon. “What we really need, and I’ve been saying this for years, is another credential related to diabetes care competency for clinicians who have an interest in elevating their diabetes-care practices, regardless of the kind of clinical care one provides,” she continued. “Wound care clinicians need to be knowledgeable and competent in both diabetes-care practices and have a working knowledge of DSME to be able to provide quality wound care and communicate with their wound care patients. This clinical diabetes credential that I’m fantasizing about should be across the disciplines, where you can say that you have advanced training in diabetes care, yet you’re not a CDE or an endocrinologist. The question is, 22

‘How do we fix this without offending people like endocrinologists, other physician disciplines, or diabetes educators?’ How the industry will do something like this, I don’t know, but providers need some advanced training in general diabetes management beyond what we get in school.”

The Mission Continues

All wound care clinicians are in a unique position to provide consistent, ongoing, and relevant education to a rather captive audience. But what real information do we have for our patients? While there is readily available research on the prevalence of diabetic foot ulcers, the data regarding the association between other types of chronic wounds and diabetes is scarce. Even more difficult to find are data related to the education of patients regarding their diabetes as given by their wound care providers. Not to be deterred in my desire to strengthen my knowledge base and become more equipped to share patientfocused education, I decided to take a different avenue and look at specific wound care certification related to diabetes. According to the Wound Care Education Institute and the National Alliance of Wound Care, the week-long Diabetic Wound Certified (DWC) certification class focuses on “… overall diabetic wound care and promotion of an optimal wound healing environment including prevention, therapeutic, and rehabilitative interventions …”.5,6 Additionally, the definition for DWC scope of practice aligns with the wound care provider: “The DWC provides direct patient care, necessary patient education, and prevention measures through comprehensive assessment, referrals, and continuing evaluation of high-risk diabetic patients and all types of diabetic wounds.”6 This is not a blind endorsement of any program, as I am still undecided on how I will move forward. It falls heavily on all providers to do their own research regarding available resources; however, if there is ever a push in the wound care community regarding the importance of diabetes education due to the obvious opportunity

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wound care clinicians have to provide it, the change can begin to be made toward more education and certification in this area by those providers who chose to investigate available options. While Scarborough admits the time commitment needed to earn the CDE can be very daunting to many wound care clinicians, she insists the CDE benefits are evident. “Anyone who has certification by an accredited board knows what that means,” she said. “Part of the quality that you have as a CDE is the problem-solving component for people with glucose issues. If a person comes into my clinic in the morning with a blood glucose of 175 after eight hours of sleep when their glucose was 125 at bedtime, I know their medication is not covering them through the night for their gluconeogenesis and that they need to go back to their primary care physician. Also, in order to get reimbursed by Medicare and many insurance companies for diabetes education, the patient has to have been educated by a CDE in a recognized diabetes self-management education program.” Regardless of the path taken, it would seem that wounds and diabetes education could one day become a standard pairing. n Jill Henneberg is on staff at St. Mary’s Hospital, Grand Junction, CO. Joe Darrah, managing editor of TWC, contributed to this article. References 1. National Diabetes Fact Sheet, 2011. CDC. Accessed online: www.cdc.gov/diabetes/ pubs/pdf/ndfs_2011.pdf. 2. Eligibility Requirements. National Certification Board of Diabetes Educators. Accessed online: www.ncbde.org/certification_info/ eligibility-requirements. 3. Diabetes Report Card 2012. CDC. Accessed online: www.cdc.gov/diabetes/pubs/pdf/ DiabetesReportCard.pdf. 4. Professional Practice Experience. National Certification Board of Diabetes Educators. Accessed online: www.ncbde.org/certification_info/professional-practice-experience. 5. Diabetic Wound Management Course Information. Wound Care Education Institute. Accessed online: www.wcei.net/dwc_courseinfo. 6. DWC Certification. National Alliance of Wound Care. Accessed online: www.nawccb. org/page.asp?id=95. www.todayswoundclinic.com

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providerprofile Desmond Bell, DPM, CWS Editor’s Note: Desmond Bell is a member of the Today’s Wound Clinic editorial board and co-founder/executive director of the Save A Leg, Save A Life Foundation, Jacksonville, FL. This interview originally published in the journal Ostomy Wound Management.

Today’s Wound Clinic (TWC): Please describe the education, training, and work experiences that prepared you for your current position as the co-founder and executive director of the Save a Leg, Save a Life (SALSAL) Foundation. Desmond Bell (DB): I am a graduate of Tulane University (New Orleans, LA) with a bachelor’s degree in psychology. I received my DPM degree from the Temple University School of Podiatric Medicine (Philadelphia, PA). My first year of residency was at the Department of Veterans Affairs Medical Center in Philadelphia, which was the pivotal year in my career as it led me to recognize the importance of wound care and limb preservation. An additional year of surgical training in Langhorne, PA, at DelawareValley Medical Center and then a move to Florida in 1997 allowed me to further pursue my passion in wound care. I established my private practice that evolved into a freestanding wound center. Writing, lecturing, and immersing myself in the wound care community have allowed me to meet so many talented and kindred spirits who share the desire to continually improve outcomes and quality of life for our patients.

TWC: What should our readers know first and foremost about SALSAL? DB: We are a nonprofit, grassroots organization whose core principles are education, intervention, and advocacy.

We are comprised solely of volunteers. Our goals are to improve wound healing outcomes and reduce lower extremity amputations at the community as well as the national level. We also are trying to connect the dots between diabetesrelated complications such as diabetic foot ulcers (DFUs), peripheral arterial disease, and catastrophic events such as heart attack and stroke. A DFU on the bottom of a foot is a symptom of far more serious underlying conditions. Improved awareness on the part of the public can help patients be their own advocates and proactive in their own well-being.

TWC: How were you introduced to the arena of wound care? Why do you enjoy working in this arena? DB: I was a teenager, working as an orderly in a hospital in northern New Jersey. A patient on one of the med/ surg floors was treated for a stage IV sacral wound, and I would often assist the nurses during dressing changes. Dressing changes for this unfortunate patient were typically performed every shift, and the patient remained in the same hospital for more than one year before he finally died. I immensely enjoy providing wound care, and my favorite aspects include giving hope where previously there has been frustration and pain. Seeing someone regain independence and quality of life is a great reward, especially when am-

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putation of a foot or leg was previously the only option offered.

TWC: What are some of the organization’s biggest accomplishments thus far? What are some of your key products and/or functions? DB: We have grown from an informal Jacksonville “lunch and learn” group created initially to help educate home health nurses about advanced wound care into an international nonprofit foundation with 60 chapters that keeps growing. We have received endorsements from the mayors of four American cities: Detroit, MI; Greenville, SC; Jacksonville, FL; and Oklahoma City, OK; via proclamations that Sept. 25 be declared “Save A Leg, Save A Life” Day. We plan for more cities to follow, as well as recognition by the minister of health in the Bahamas that our model can be instrumental in the fight against diabetes-related lower extremity amputation. We have begun reaching the people who need education the most, that being the general population, by way of community screenings, meetings, and a weekly radio show based out of Jacksonville and heard via the Internet and podcasts. One of our goals has always been to make Save A Leg, Save A Life a recog-

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providerprofile nized name in every household and, in essence, to become the “pink ribbon” of limb preservation.

TWC: Please describe the mission/vision of your organization and how your personal vision fits with the company’s goals. DB: The SALSAL Foundation Mission Statement: “To reduce the number of lower extremity amputations and improve the quality of life of our fellow citizens who are afflicted with wounds and complications from diabetes and peripheral arterial disease. We will accomplish these goals by using advanced, evidence-based methods by educating fellow practitioners and patients through community outreach and patient advocacy.” I developed this statement, as well as the name of our foundation, while sitting at my kitchen table. In one of those moments of clarity, I wrote the words “Save A Leg, Save A Life” on a napkin, and the mission statement came flowing right after that. I don’t know if it was divine intervention, but here we are, six-plus years later, no longer under the radar and capturing people’s imaginations as to all the good we can achieve. My experiences as a clinician have inspired the vision of SALSAL. It really is quite simple — many of the terrible things we all see our patients endure are enough incentive to do better. We have been hearing about the team approach to wound healing for quite some time now, but many providers have no idea how to engage a team or how to join one if one already exists in their community. We are a community-based and driven solution for a community-based problem at the most basic level. Communication where politics are put aside in the best interest of patients facilitates better outcomes. When someone joins a local chapter of SALSAL, we ask that they put egos aside and work together to share information and establish relationships with fellow like-minded individuals as the way to optimize the team approach. Personally, I have been work24

ing hard to create a foundation that will endure long after I am gone. I am energized by the number of extremely talented and incredibly bright people from all areas we are attracting to our organization. The problems we are trying to address are not going away any time soon, especially with the perfect storm of the aging of our population and the pandemic of diabetes.

TWC: Please explain what must take

place on a daily basis at SALSAL in order to accommodate patients, clinicians, and healthcare facilities.

DB: As I alluded to, communication without hidden agendas is the way to achieve the goals of expedited wound healing and limb preservation. This cannot be selective and must be an ongoing, shared effort within a community. Hospital administrators must understand the reality that their facilities may not have the best wound healing outcomes and limb-preservation rates. You cannot promote your facility as having “advanced wound care” or “limb salvage” if this is nothing more than a marketing tool and until you have the data to support your claims. This goes for physicians and all other providers. The SALSAL model is based on sharing information and education within a community. There is nothing more satisfying than hearing from providers how SALSAL has positively impacted their community. On more than one occasion, I have heard similar stories that before a local SALSAL chapter was established, “vascular surgeons and podiatrists never used to communicate, but are now working together on the same patients.” This is exciting and shows the potential of our model.

TWC: Looking ahead, what are some

incentives or products the organization is working on?

DB: In addition to regularly held chapter meetings throughout the year, we are working on our upcoming SALSAL National Conference, (to be held

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at the Disney Yacht and Beach Club, Orlando, FL, May 9–11). Our conference is designed to bring our members together in a town-hall type atmosphere with a goal of not only sharing information, but giving our members ideas and additional support to take home and maintain the momentum with their fellow chapter members. We also inadvertently have created a network where people are finding us through our website and social media to seek answers and help. We are contacted on a regular basis by patients or their family members who are seeking resources or local assistance when facing either a chronic, nonhealing wound or the prospect of an amputation. It is rewarding to be able to make referrals to our members around the country when the occasion arises. We expect to continue creating amputee support groups in SALSAL communities where none exist. We were surprised to learn that Jacksonville had no amputee support groups, so we created one two years ago that is now called “A Leg Up.” Members of “A Leg Up” are inspiring, and they have also become part of our local chapter. They have fun and meet monthly, and I expect we will see other “A Leg Up” groups organize throughout the country. Our social media sites (Facebook and Twitter especially) and the radio program (heard Sundays at noon on WOKV 690 AM/106.5 FM Jacksonville and on www.wokv.com) are helping us spread the word among those in the “SALSAL Nation” and beyond. We are planning a continued presence at various events and festivals throughout the year to provide educational screenings. We also have created the “SALSAL Ribbon,” which we will be unveiling this year, as well as something we are tentatively calling the “White Sock Campaign” to create greater awareness of lower extremity amputation. Stay tuned! To nominate someone to participate in a Wound Care Provider Profile, contact Joe Darrah at jdarrah@hmpcommunications.com.

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conferenceconnection 2013 SAWC Spring/WHS Abstract Award Winners Announced for SAWC 2013 Officials with HMP Communications Holdings, LLC, Malvern, PA, have announced the abstract award winners for the upcoming Symposium on Advanced Wound Care (SAWC) Spring/Wound Healing Society conference to be held May 1-5 in Denver, CO. Abstracts were selected from more than 350 submissions and blind-scored by a panel of 24 judges, all of whom are experts in wound care. The 2013 abstract winners are:

Highest Scoring Oral Abstracts (first authors listed only) • 1st place – Inflammation in Diabetic Foot Ulcers, Nanjin Park, DPM • 2nd place – Debridement of Venous Leg Ulcers with Low Frequency, High Intensity, Contact Ultrasound: Results

SAWC Spring/WHS 2013 Supports Wounded US Soldiers Thousands of US soldiers who have been injured in the line of duty will benefit from the continued support of those who organize, host, and attend the annual Symposium on Advanced Wound Care (SAWC) Spring and Wound Healing Society (WHS) conference to be held May 1-5 at the Colorado Convention Center in Denver. Proceeds from the SAWC’s “Gives Back” Program, an initiative launched in conjunction with HMP Communications Holdings, LLC companies North American Center for Continuing Medical Education, LLC and HMP Communications, LLC (publisher of Today’s Wound Clinic) in 2012 to honor the work and dedication of some of the industry’s most exceptional wound care clinicians, will be donated to the Wounded Warrior Project™ (WWP), a nonprofit organization that provides support to injured US service members. More than 47,000 servicemen and women have been injured in recent military conflicts, according to WWP officials. In addition to their physical wounds, it is estimated as many as 400,000 service members live with the “invisible” wounds of war including combat-related stress,major depression,and posttraumatic stress disorder.Another 320,000 are believed to have experienced a traumatic brain injury while on deployment. WWP’s 18 programs and services are uniquely structured to nurture the mind and body and encourage economic empowerment and engagement for US soldiers in need. Helping this worthy cause is as easy as registering for the event. Nearly 2,500 wound care providers are expected to attend SAWC Spring/WHS 2013, SAWC officials said. For more information on theWWP,visit www.woundedwarriorproject.org. 26

of a Randomized Clinical Outcome Trial, Martin Wendelken, DPM, RN • 3rd place – Re-amputation After Minor Foot Amputation in Diabetic Patients: Risk Factors Leading to Limb Loss, Vincent Nerone, DPM PGY-III.

Young Investigators • Nanjin Park, DPM • Edwin P. Monroy, PT, DPT, CLT, SCI/D • Claudia Chavez-Munoz, MD, PhD

Highest Scoring Poster in Category (first authors listed only) • Case Study – Use of Cyanoacrylate-Based Skin Barrier in Protection of Skin Around Tracheostomy, Martha Fjelde Ondrejko, BSN, RN, CWOCN • Laboratory Research – Modular Biocompatible In-vivo Bioreactor for Tissue Engineering, Claudia ChavezMunoz, PhD, MD • Information/Educational Report – Barriers and Facilitators to Evidence-based Pressure Ulcer Prevention and Treatment for Hospital Inpatients, Toba Miller, RN, MScN, MHA, GNC(C), CETN(C) • Clinical Research – An Assessment of Sacral Pressures in Two Seated Positions, Stephannie Miller, BA. HMP Communications Holdings is a collaborative formed by HMP Communications, LLC and North American Center for Continuing Medical Education, LLC. n

‘Gives Back’ Program Grants New Scholarships

The North American Center for Continuing Medical Education, LLC, the continuing education sponsor of the Symposium on Advanced Wound Care (SAWC) Spring/Wound Healing Society conference, will honor six new scholarship recipients as part of the SAWC’s “Gives Back” program in Denver, CO, May 1-5. Launched in April 2012 in conjunction with SAWC and HMP Communications, LLC (publisher of Today’s Wound Clinic), the program has honored nine previous winners who are selected by prominent wound care groups such as the Association for the Advancement of Wound Care, the American Podiatric Association, and the American Physical Therapy Association’s Clinical Electrophysiology & Wound Management Section (APTA-CEWM).The SAWC scholarship program now honors candidates in six categories.The 2013 spring scholarship winners are: • Wound Healing Research – Susan R. Opalenik, PhD • Wound Healing Fellow – Devn Frandsen, DO

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conferenceconnection • Wound Care Physician – Humberto J. Villalvazo, MD • Wound Care Nursing – Jessica Browning, LPN • Wound Care Therapist – Stephanie Woelfel-Dyess PT, MPT, CWS, FACCWS • Wound Care Podiatrist – Andrew Belpedio, DPM. “The SAWC scholarship program is a way to thank the many clinical specialists, their societies, and associations who advocate for optimal care and treatments for patients with wounds,” said Jeremy Bowden, vice president/group publisher of the Wound Care Division at HMP Communications. The winners will be recognized at SAWC’s annual spring VIP party on May 2 at the Denver Convention Center. n

SAWC Spring/WHS Offers Industry-Supported Symposia Each year, the Symposium on Advanced Wound Care (SAWC) and Wound Healing Society (WHS) meeting offers attendees the opportunity attend industry-supported symposia that complement and enhance the information being presented throughout the main symposium. The following is a list of symposia, both accredited and non-accredited (times and event info are subject to change): Non-Accredited May 1 (Dinner: 6 p.m.–7:30 p.m.) The Role of Collagenase SANTYL Ointment in Wound Bed Preparation May 2 (Lunch: 12:30 p.m.–2 p.m.) 1) The Future of Tissue Regeneration: Scientific and Clinical Evidence Supporting the Use of Dehydrated Amniotic Membrane in Wound Healing 2) Biofilm and Wound Care: Understanding Biofilm’s Impact on Chronic Nonhealing Wounds May 3 (Breakfast: 7:30 a.m.–9 a.m.) Dermagraft® for the Treatment of Nonhealing Diabetic Foot Ulcers May 4 (Breakfast: 7:30 a.m.–9 a.m.) OASIS® Matrix Wound Management – A Sophisticated Structure for Challenging Wounds

Additionally, SAWC Spring/WHS 2013 will feature industry-supported, complimentary, accredited educational programs that take place during the main symposium. These educational activities are open to all SAWC attendees and pre-registration is not required: May 3 (Interactive Educational Session: 4:45 p.m.-5:45 p.m.) Patient-Centered Approaches to Managing Nonhealing, Chronic Wounds: Novel Uses of Mechanically Powered NPWT Systems May 4 (Interactive Educational Session: 3:30 p.m.-4:30 p.m.) Today’s Science is Tomorrow’s New Treatment Option: Emerging Cell-Based Therapy for Difficult-to-Heal Wounds. For more information, visit www.sawcspring.com. n

2nd Annual AAWC Celebration To be Held at SAWC The Association For The Advancement of Wound Care (AAWC) is planning its second annual membership meeting and auction at the Symposium on Advanced Wound Care (SAWC) Spring/Wound Healing Society conference May 1–5 in Denver, CO. The celebration is scheduled for May 3 from 5 p.m.-7 p.m. All auction proceeds will benefit the AAWC’s scholarship fund. The event will include a live auction complete with auctioneer, as well as a silent auction. Attendees are invited to participate in the planning by donating items or reaching out to contacts and local businesses for contributions.Themed gift baskets are also welcome, as are product/service donations from industry representatives and tax-deductible cash donations. AAWC members will receive a special gift for attending the celebration, along with a chance to win valuable door prizes. For more information, contact Lyn Donze at ldonze@aawconline. org. Donations to the silent auction are needed by March 31. n

Accredited May 2 (Lunch: 12:30 p.m.–1 p.m.; Educational Session: 1 p.m.-2 p.m.) 1) Demystifying Debridement Modalities: An Interdisciplinary Panel Perspective 2) Patient-Centered Approaches to Managing Diabetic Foot Ulcers May 3 (Breakfast: 7:30 a.m.-8 a.m.; Educational Session: 8 a.m.-9 a.m.) 1) An Interactive Case-Based Model to Managing Diabetic Foot Ulcers:The Role of Platelet-Derived Growth Factor 2) A Multi-Faceted Expert’s Approach to Managing Venous Disease and Venous Leg Ulcers May 4 (Breakfast: 7:30 a.m.-8 a.m.; Educational Session: 8 a.m.-9 a.m.) Clinical Implications of Un-modulated pH Within the Wound Environment and the Effects of Active Leptospermum Honey on Surface pH of Chronic Wounds www.todayswoundclinic.com

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Plans Released For SAWC Fall 2013 Wound care providers interested in attending the annual SAWC Fall conference can begin to make their travel arrangements for the next event. SAWC Fall 2013 will be held Sept. 27-29 at Bally’s Las Vegas in Nevada and offer up to 40 new clinical sessions as well as a major exhibition of products and services for wound care professionals. SAWC officials said they remain committed to providing the highest level of clinical education and information to physicians, podiatrists, nurses, physical therapists, and allied health professionals dedicated to the advancement of wound care and healing. On the heels of the successes that the four annual fall meetings have shown, the fifth conference is also expected to be remembered for its ability to connect providers of various healthcare settings, members of government agencies that regulate care, and multiple overarching organizations working toward a common goal to decrease the number and severity of chronic wounds. For more information, visit www.sawcfall.com.

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TWCnewsupdate Spotlight On: Diabetes Children’s Hospital Nets $5 Million for Diabetes Center A $5 million donation from the Lift a Life Foundation has helped fund the launch of a $12 million comprehensive diabetes center at Kosair Children’s Hospital, Louisville, KY. A celebration to mark the building’s establishment was held March 6. According to a report by Business First, the center offers diabetes care and education, particularly for those living with type 1 diabetes. An inpatient portion of the center is reportedly set to open later this year, with an outpatient center to be established in the coming years. Collectively, the facilities will be called the Wendy L. Novak Diabetes Center at Kosair Children’s Hospital.The gift will also support the hiring of additional staff, including a physician, diabetes educators, and nurse practitioner specialists. Funding will help enhance medical, educational, and technology resources as well as programs available to families and to improve inpatient and outpatient care facilities. n

HHS Grant to Fund Diabetes Research A federal grant of more than $333,000 has been awarded to the University of Tennessee Health Science Center in Memphis for diabetes, endocrinology, and metabolic research. According to the Associated Press, US Rep. Steve Cohen said the grant by the US Department of Health and Human Services will be distributed by the National Institute of Diabetes and Digestive and Kidney Diseases and is expected to give researchers the tools needed to help people in Memphis and across the country reduce risk factors, improve diabetes management, and increase quality of life. n

New York Physicians Noted for Diabetes Care Two physicians on staff at Lake Erie Regional Health System of New York, Dunkirk, NY, are being honored nationally for providing quality diabetes care and meeting recognized standards. According to the Dunkirk Observer, Ronald Greco, MD, and Joel Yoviene, MD, have received honors from the National Committee for Quality Assurance and the American Diabetes Association. The recognition is reportedly valid for three years. Greco provides services at Forestville Primary Care Center, Gowanda Medical Center, and Conewango Valley Medical Center.Yoviene is on staff at Forestville and Gowanda. To receive recognition, data from the physicians were submitted that demonstrate performance that meets key diabetes-care measures, including eye exams, blood pressure tests, nutrition therapy, and patient satisfaction, among others. n 28

Georgia Hospital Opens Wound Care & Hyperbaric Center Piedmont Newnan Hospital, Newnan, GA, has opened its Wound Care and Hyperbaric Center, which provides a variety of services including hyperbaric oxygen therapy, debridement, vascular testing, compression therapy, negative pressure, and the use of the most advanced dressing technology, according to hospital officials. “The new center is a tremendous resource to the Coweta community,” said Michael Bass, president and CEO. “It offers the latest tools in both wound care and hyperbaric treatments, partnered with the excellent quality care our wound care and hyperbaric center team has always provided to its patients.” n

NEED TO KNOW: In 2012, the growing toll of diabetes cost the nation a record $245 billion, a 41% increase from $174 billion in 2007, according to “Economic Costs of Diabetes in the U.S. in 2012,” a study commissioned by the American Diabetes Association.

Report Seeks to End Physician Fee-For-Service A recent report released by the National Commission on Physician Payment Reform calls for the elimination of feefor-service payments to physicians by the end of this decade, according to MedPage Today. The commission was convened by the Society of General Internal Medicine in March 2012. The report, published March 4, suggests replacing standalone fee-for-service with a blended payment system based on new delivery and reimbursement models. A number of recommendations to change the way doctors are paid and discourage incentives that may lead to higher cost as well as higher volumes of care were outlined. “The commission concluded that our nation cannot control runaway medical spending without fundamentally changing how physicians are paid, including the inherent incentives built into the current fee-for-service pay system,” reads the 24-page report. Among the listed considerations: • Including evaluation and management diagnostic codes, which are currently undervalued, in annual updates • Eliminating higher payments for facility-based services that can be performed in a lower-cost setting • Incorporating quality metrics into negotiated reimbursement rates of fee-for-service contracts • Forming virtual relationships between small practices to share resources • Including fixed payments where significant potential

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TWCnewsupdate for cost savings exists, such as care for people living with multiple chronic conditions and in-hospital procedures and their follow-up • Ensuring access to high-quality care and physician commitment for fixed-payment models. The report also named several factors that are driving healthcare costs, including reliance on technology and expensive care, high ratio of specialists to primary care physicians, and paying more for the same service when done in a hospital rather than outpatient setting. The commission also calls for eliminating Medicare’s sustainable growth rate (SGR) formula and suggests that an SGR repeal to be paid for with cost savings from the Medicare program, including physician payments and reductions in inappropriately used services. The commission’s work was reportedly funded by the Robert Wood Johnson Foundation and the California HealthCare Foundation. n

asktheboard In this exclusive column, Today’s Wound Clinic (TWC) offers readers the chance to ask industry-related questions to our expert editorial board members. This month’s questions come from multiple sources. Kathleen D. Schaum, MS

Q: “How much attention should physicians pay to ICD-9CM codes listed in Medicare Local Coverage Determinations (LCDs)?”

A: BY KATHLEEN D. SCHAUM, MS This month, the TWC board received several questions regarding the ICD-9-CM codes that are listed in most Medicare LCDs. These wound care professionals asked: 1) If the physician did not use the specific ICD-9-CM codes listed in the LCD, would the service, procedure, and/or product be covered? 2) Is the sequence of ICD-9-CM codes on the claim form important? Here’s what you need to know: 1) If the Medicare Contractor provides a list of ICD-9-CM codes that are covered in the LCD, those are typically the only covered diagnoses for that service, procedure, and/ or product. • If the patient has one of the covered diagnoses, but the physician uses one of the non-specific ICD-9CM codes, the physician may want to break that bad habit and begin using the most specific ICD-9CM code(s) that pertain(s) to the patient. • If the patient does not have one of the covered diagnoses, the physician should provide the patient with an Advanced Beneficiary Notice of Non-Coverage (ABN). The ABN will inform the patient: a) that the service, procedure, and/

Sanford Health Opens Limb-Preservation Center A new limb-preservation program has been launched in Sioux Falls, SD, by Sanford Health. The Sanford Health Limb Preservation Center specializes in treating lower extremity wounds in patients at high risk of amputation and compromised leg and toe function, particularly those with diabetes and peripheral arterial disease, according to officials. Led by a team of fellowship-trained, board-certified vascular surgeons and an advanced-trained podiatrist, the facility coordinates multidisciplinary care with other Sanford specialties, including infectious disease, endocrinology, cardiology, nephrology, plastic surgery, orthopedics, wound care, and rehabilitation, the center reportedly houses the region’s only comprehensive limb-preservation program. n

or product will most likely not be covered by Medicare and b) about the cost that the patient will incur to receive the non-covered service, procedure, and/or product. The patient will then have the choice of denying or accepting/paying for the service, procedure, and/or product. 2) If the LCD states the expected sequence of covered ICD9-CM codes, the diagnosis codes should be listed on the claim form in that sequence. For example: One physician was upset that her claim for application of a cellularand/or tissue-based product for wounds was denied for a diabetic foot ulcer. The physician knew the LCD listed the exact ICD-9-CM codes that were on the claim form. Unfortunately, the LCD stated the ulcer ICD-9CM code was to be listed as the primary diagnosis and the diabetes ICD-9-CM code was to be listed as the secondary diagnosis. You guessed it, the physician’s claim form listed diabetes as the primary diagnosis and the ulcer as the secondary diagnosis! The claim was denied because the procedure and product are not treatments for diabetes — they are treatments for an ulcer that is a result of diabetes. Some LCDs also describe ICD-9-CM codes that must be used in pairs.Wound care professionals should pay close attention to the required code pairs. These code pairs must be documented in the medical record by the physician and must be placed in the correct sequence on the claim form in order to receive payment for the service, procedure, and/or product and to keep your payment upon an audit. Kathleen D. Schaum can be reached for questions and consultations by calling 561-964-2470 or at kathleendschaum@bellsouth.net. For a full disclaimer related to the information in this column, please refer to Business Briefs on page 7. n

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Apligraf® Essential Prescribing Information Numbers in parentheses ( ) refer to sections in the main part of the product labeling. Device Description: Apligraf is supplied as a living, bi-layered skin substitute manufactured from cells processed under aseptic conditions using neonatal foreskin-derived keratinocytes and fibroblasts with bovine Type I collagen. (1) Intended Use/Indications: Apligraf is indicated for use with standard therapeutic compression in the treatment of uninfected partial and/or full-thickness skin loss ulcers due to venous insufficiency of greater than 1 month duration and which have not adequately responded to conventional ulcer therapy. (2) Apligraf is indicated for use with standard diabetic foot ulcer care for the treatment of full-thickness foot ulcers of neuropathic etiology of at least three weeks duration, which have not adequately responded to conventional ulcer therapy and extend through the dermis but without tendon, muscle, capsule or bone exposure. (2) Contraindications: Apligraf is contraindicated for use on clinically infected wounds and in patients with known allergies to bovine collagen or hypersensitivity to the components of the shipping medium. (3, 4, 5, 8) Warnings and Precautions: If the expiration date or product pH (6.8-7.7) is not within the acceptable range DO NOT OPEN AND DO NOT USE the product. A clinical determination of wound infection should be made based on all of the signs and symptoms of infection. (4, 5) Adverse Events: All reported adverse events, which occurred at an incidence of greater than 1% in the clinical studies are listed in Table 1, Table 2 and Table 3. These tables list adverse events both attributed and not attributed to treatment. (6) Maintaining Device Effectiveness: Apligraf has been processed under aseptic conditions and should be handled observing sterile technique. It should be kept in its tray on the medium in the sealed bag under controlled temperature 68°F-73°F (20°C-23°C) until ready for use. Apligraf should be placed on the wound bed within 15 minutes of opening the package. Handling before application to the wound site should be minimal. If there is any question that Apligraf may be contaminated or compromised, it should not be used. Apligraf should not be used beyond the listed expiration date. (9) Use in Specific Populations: The safety and effectiveness of Apligraf have not been established in pregnant women, acute wounds, burns and ulcers caused by pressure. Patient Counseling Information: VLU patients should be counseled regarding the importance of complying with compression therapy or other treatment, which may be prescribed in conjunction with Apligraf. DFU patients should be counseled that Apligraf is used in combination with good ulcer care including a non-weight bearing regimen and optimal metabolic control and nutrition. Once an ulcer has healed, ulcer prevention practices should be implemented including regular visits to appropriate medical providers. Treatment of Diabetes: Apligraf does not address the underlying pathophysiology of neuropathic diabetic foot ulcers. Management of the patient’s diabetes should be according to standard medical practice. How Supplied: Apligraf is supplied sealed in a heavy gauge polyethylene bag with a 10% CO2/air atmosphere and agarose nutrient medium. Each Apligraf is supplied ready for use and intended for application on a single patient. To maintain cell viability, Apligraf should be kept in the sealed bag at 68°F-73°F (20°C-23°C) until use. Apligraf is supplied as a circular disk approximately 75 mm in diameter and 0.75 mm thick. (8) Patent Number: 5,536,656 Manufactured and distributed by: Organogenesis Inc. Canton, MA 02021 REV: December 2010 300-111-8 References: 1. Veves A, Falanga V, Armstrong DG, Sabolinski ML; Apligraf Diabetic Foot Ulcer Study. Graftskin, a human skin equivalent, is effective in the management of noninfected neuropathic diabetic foot ulcers: a prospective randomized multicenter clinical trial. Diabetes Care. 2001;24(2):290-295. 2. Data on file, Organogenesis Inc. 3. Apligraf® [package insert]. Canton, MA: Organogenesis Inc; 2010.

classified Wound Care Clinic Supervisor

Responsible for the supervision and coordination of the clinical activities of the wound care program evaluating, implementing and providing care as it relates to the age and specific needs of patients. Minimum five (5) years clinical experience; ambulatory experience highly desired. Minimum of two years of prior supervisory or health care management experience preferred. Wound experience preferred. WCC required or obtain within 6 months after employment. Bachelor's degree preferred. Graduate of an approved school of nursing with NLN accreditation. Current CA RN License in good standing. BLS certified. Organogenesis_PI_0211.indd 1 St. Mary’s Medical Center San Francisco is a full-service acute care facility with more than 575 physicians and 1,100 employees who provide high-quality and affordable health care services to the Bay Area community.

Advertiser’s Index ConvaTec (Aquacel Foam).............................................. 5 Derma Sciences (TCC-EZ)...................................Cover 2 KCI (V.A.C.).................................................................. 11 Medela (Invia) .................................................................3 Net Health Systems (WoundExpert) ....................Cover 3 2/1/11 2:41 PM

Organogenesis (Apligraf)...............................Cover 4, 32 Sechrist Industries Inc. (HBOT) ................................... 21

For additional information visit www.dignityhealthcareers.org.

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