TWC November/December 2013

, LLC

™

an HMP Communications Holdings Company

TODAY’S

®

Contemporary Approaches to Wound Clinic Management

THE

AGING WOUND CARE PATIENT

WOUND HEALING IN THE GERIATRIC POPULATION COLLABORATION BETWEEN LTC AND OUTPATIENT CLINICS NUTRITIONAL CONSIDERATIONS

ALSO IN THIS ISSUE: Business Briefs ICD-10 Prep Tool SAWCSPRING November/December 2013 www.todayswoundclinic.com

00_TWC_NovDec_CVR.indd 1

the symposium on advanced wound care

www.sawcspring.com

12/6/13 12:50 PM

TODAY’S

®

Volume 7, Number 9, November/December 2013 • www.todayswoundclinic.com

Table of Contents • Feature Articles 11

14

Wound Healing in the Geriatric Patient

Building Collaboration Between the Outpatient Wound Clinic and Long-Term Care

Among the most impacted arenas of healthcare as the US population gets older and medicine allows people to live longer with comorbid conditions will be outpatient wound centers.

Providers need to possess an increased understanding of basic principles related to aging, particularly with skin care.

Nonhealing chronic wounds among LTC residents continue to be a concern. With the strict regulations faced by CMS, clinicians in this environment rely on wound care providers to help meet their residents’ needs when collaborating with the outpatient clinic. Maximizing these relationships is key.

Jeffrey M. Levine, MD, AGSF & Michael Cioroiu, MD, FACS

Les Kiemele, PA-C & Paul Takahashi, MD, CMD

20

28

Nutrition & Wound Healing in the Older Adult: Considerations for Wound Clinics

ICD-10-CM Column: Diagnosis Coding Documentation Tips for Skin Neoplasms

The aging population is especially dependent on proper nutrition to aid wound closure, but many outpatient wound clinics don’t have protocols in place for evaluating nutritional status and implementing appropriate interventions. What does the wound care provider need to know?

In the second installment of our special column on ICD-10CM implementation, we provide tips for the category C43-C44, neoplasms.This keepsake chart is meant to serve as a constant reminder for your wound clinic and can be used as a teaching tool among your clinic staff.

Liz Friedrich, MPH, RD, CSG, LDN & Nancy Collins, PhD, RD, LD/N, FAPWCA

Donna J. Cartwright, MPA, RHIA, CCS, RAC, FAHIMA

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.

01-02_TWC_NovDec_TOC.indd 1

ADVERTISING QUERIES should be addressed to Jeremy Bowden, Publisher, Today’s Wound Clinic®, HMP Communi­cations, 83 General Warren Boulevard, Suite 100, Malvern, PA 19355. Telephone: (800) 237-7285 or (610) 560-4154 Fax: (610) 560-0501. Email: jbowden@hmpcommunications.com DISPLAY AND CLASSIFIED ADVERTISING: HMP Communications, 83 General Warren Boulevard, Suite 100, Malvern, PA 19355, Phone: (800) 237-7285 or (610) 560-0500 x259 CORPORATE OFFICES HMP Communications, LLC 83 General Warren Boulevard Suite 100 Malvern, PA 19355 Phone: (610) 560-0500 or (800) 237-7285 Fax: (610) 560-0502

, LLC

™

an HMP Communications Holdings Company

12/6/13 12:51 PM

EDITORIAL STAFF

TODAY’S

CLINICAL EDITORS AND FOUNDING BOARD Caroline E. Fife, MD, FAAFP, CWS Dot Weir, RN, CWON, CWS

®

Volume 7, Number 9, November/December 2013 • www.todayswoundclinic.com

FOUNDING EDITORIAL BOARD Kathleen Schaum, MS Christopher Morrison, MD Val Sullivan, PT, MS, CWS MANAGING EDITOR Joe Darrah jdarrah@hmpcommunications.com WEB EDITOR Samantha Alleman salleman@hmpcommunications.com

Table of Contents

BUSINESS STAFF

Departments 4

6

EXECUTIVE VICE PRESIDENT Peter Norris pnorris@hmpcommunications.com VP/GROUP PUBLISHER Jeremy Bowden jbowden@hmpcommunications.com

From the Editor: Guest Editorial

PUBLISHER Kristen J. Membrino kmembrino@hmpcommunications.com

Jeffrey M. Levine, MD, AGSF

SALES ASSOCIATE Brian Hill bhill@hmpcommunications.com

Business Briefs

CLASSIFIED SALES ASSOCIATE Michael Deleo mdeleo@hmpcommunications.com

HOPDs: Prepare for ‘Payment Packaging’ Kathleen D. Schaum, MS

HMP COMMUNICATIONS, LLC PRESIDENT BIll Norton

24

TWC News Update

alifornia hospital performs pressure ulcer pilot study; C Wound care nurse helps form ostomy algorithm

32

Advertiser’s Index

VICE PRESIDENT, SPECIAL PROJECTS Jeff Hall CREATIVE DIRECTOR Vic Geanopulos vgeanopulos@hmpcommunications.com ART DIRECTOR Karen Copestakes kcopestakes@hmpcommunications.com PRODUCTION MANAGER Elizabeth Vasil evasil@hmpcommunications.com

TWC Online

Find us on Facebook @ www.facebook.com/todayswoundclinic

www.todayswoundclinic.com

Follow us on Twitter: @TWCjournal

www.twcjournal.wordpress.com

PRODUCTION/ CIRCULATION DIRECTOR Kathy Murphy kmurphy@hmpcommunications.com AUDIENCE DEVELOPMENT MANAGER Bill Malriat MEETING PLANNER Cynthia Noonan

Online Exclusive:

MEETING PLANNER Trisha Keppler

Non-Accredited Education Webcast: 2014 Medicare Reimbursement

Information for Implementation: By Qualified Healthcare Professionals, Hospital-Based Outpatient Wound Care Departments, and Ambulatory Surgery Centers

HMP COMMUNICATIONS HOLDINGS, LLC CHAIRMAN & CHIEF EXECUTIVE OFFICER Jeff Hennessy CHIEF FINANCIAL OFFICER Dan Rice SENIOR VICE PRESIDENT Anthony Mancini

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

an HMP Communications Holdings Company

01-02_TWC_NovDec_TOC.indd 2

™

CONTROLLER Meredith Cymbor-Jones DIRECTOR OF E-MEDIA AND TECHNOLOGY Tim Shaw SENIOR DIRECTOR OF MARKETING Corey Krejcik SR. MANAGER, IT Ken Roberts

12/6/13 12:51 PM

Invia Wound Therapy True NPWT ®

™

The innovative design of the Medela Invia Liberty NPWT System delivers user friendly functionality with a simple set-up and easy operation for the clinician and patient.

The Invia Liberty System can be used in a hospital, home or long term care setting.

Motion

™

Invia Motion is a personal pump which enables patients to participate in their normal daily activities while providing True NPWT throughout the period of treatment. Invia Motion is an all case setting pump designed with patient dignity and hygiene in mind.

Wound Therapy Dressing Kits are available either with Avance ® Foam Dressing Kits or Antimicrobial Gauze offering flexiblity to manage your wounds.

1547741 C 0313 © 2013

Liberty

Federal law restricts this device to sale or rental by or on the order of a physician. Avance Dressing Kits distributed by Medela, Inc. Medela, True NPWT and Invia are registered trademarks of Medela Holding AG. Liberty and Motion are trademarks of Medela, Inc. Avance is a registered trademark of Mölnlycke Health Care AB. Medela, Inc. 1101 Corporate Drive, McHenry, IL 60050, USA Phone: 1 877 735 1626 Fax: 1 815 307 8942 suction@medela.com www.medelasuction.com

®

Precious life – Progressive care

Medela_Invia_0413.indd 2

3/19/13 2:48 PM

fromtheeditor: guest editorial Editor’s Note: For this issue of Today’s Wound Clinic, Jeffrey M. Levine, MD, AGSF, serves as guest editorial consultant.

I

developed an interest in wound care during my geriatric fellowship in the 1980s, and I’ve had the privilege of being part of the field as it has evolved in knowledge, technology, and stature.

In my current position as an attending physician for the wound care center at Beth Israel Medical Center in New York’s Mount Sinai Health System, I’ve also come to realize that our practice has an historic opportunity to meet the needs of the community Jeffrey M. Levine, MD, AGSF by embracing trends in healthcare reform. However, we cannot succeed without understanding the needs of the aging population and the imperative to manage multiple coexisting chronic diseases within an increasingly complex system.

The geriatric patient is often overwhelmed by a system of specialists. I recently saw an elderly woman who was referred for leg ulcers. She’s intelligent and active in her lifestyle, but her retinue of doctors included an oncologist, a vascular surgeon, a cardiologist, an infectious disease specialist, a podiatrist, and a dermatologist. After spending some time taking a history, I removed her bandages and was surprised to find venous stasis wounds that were malodorous and neglected. None of these specialists, including her primary care provider, had the knowledge or expertise offered by my wound center to care for this serious problem.

Chronic, nonhealing wounds do not exist in a vacuum. In order to understand and facilitate healing, caregivers must understand and take into consideration the complex biology, physiology, and psychosocial aspects of our patients. As wound care clinicians, our task is to facilitate the body’s healing, but the aging patient brings special challenges that must be considered beyond choices of debridement techniques and products. Teamwork, communication, and collaboration are key to successful wound healing.

For example, nearly half of persons aged 85 an older live with Alzheimer’s disease. The issues of informed consent and complex treatment prescriptions become complicated in a wound care patient with advanced cognitive deficits, and treatment involves collaborating and communicating with family members and other providers on the team. Malnutrition is commonly associated with frailty in old age, and the wound care clinician must take this into consideration when offering interventions that increase metabolic demand such as sharp debridement. Communication and collaboration with the nutritionist and speech therapist is important in decision-making. Issues at the intersection of wound care and geriatrics are many, and this issue of Today’s Wound Clinic serves only as an introduction.

In this issue we present an article co-authored by myself and Michael Cioroiu, MD, FACS, that reviews changes in aging skin, discusses comorbidities of aging that impact wound healing, and gives an introduction to the geriatric approach.We also present an excellent review article

by Les Kiemele, PA-C, and Paul Takahashi, MD, CMD, that discusses special considerations when caring for patients in long-term care settings. Liz Friedrich, MPH, RD, CSG, LDN, and Nancy Collins, PhD, RD, LD/N, FAPWCA, also offer an important perspective on incorporating nutritional strategies for elderly wound care patients. Of course, other TWC staples such as Business Briefs and the new ICD-10-CM keepsake can also be found in this issue.

Embracing the Future The 21st century has brought the outpatient wound clinic to a crossroad that can improve value in healthcare by facilitating savings and improving outcomes, but only if we understand the tasks at hand and work toward making our contribution. To accomplish this we need to enhance the continuum of care with teamwork and apply our unique expertise and knowledge to keep patients out of the hospital. To meet the challenges we face, we must embrace change and collaborate across specialties while understanding the needs of the population we serve. n Jeffrey M. Levine, MD, AGSF, is attending physician in the Center for Advanced Wound Care at Beth Israel Medical Center, Mount Sinai Health System, NY. 4

November/December 2013 Today’s Wound Clinic®

XX_TWC_NovDec_Editor.indd 4

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 Donna J. Cartwright, MPA, RHIA, 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 GUEST EDITORIAL CONSULTANT Jeffrey M. Levine, MD, AGSF

, LLC

™

an HMP Communications Holdings Company

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.

www.todayswoundclinic.com

12/6/13 12:47 PM

Untitled-2 2

12/5/13 12:36 PM

businessbriefs HOPDs: Prepare for ‘Payment Packaging’ 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. HMP Communications and the authors do not represent, guarantee, or warranty that the coding, coverage, and payment information is error-free and/or that payment will be received.

The responsibility for verifying information accuracy lies with the reader.

N

ormally, the Centers for Medicare & Medicaid Services (CMS) release the Outpatient Prospective Payment System (OPPS) Final Rule for the upcoming calendar year around Nov. 1.That timeline allows staff within hospital-based outpatient wound care departments (HOPDs) approximately 60 days to read, interpret, implement, and train their entire department regarding any Medicare payment changes that will take place Jan. 1. Unfortunately, this year’s government shutdown forced a delay of the 2014 OPPS Final Rule, which was released nearly 4 weeks late at the close of business Nov.

27. HOPDs across the country will now have only a few weeks to digest and implement several major Medicare payment changes that will significantly impact their wound care business. In fact, there are too many changes to discuss in a single “Business Briefs” column. Therefore, we will discuss more of the 2014 OPPS changes in the next issue. In this edition, in honor of the holiday season and that many readers are busy wrapping “packages” for their family and friends, I thought it was appropriate to first discuss the “payment packaging” portions of the 2014 OPPS Final Rule: payment packaging of addon codes and of cellular and/or tissuebased products for wounds (CTPs) [old term “skin substitutes”].

Medicare Packaged Payment of Add-On Codes Several years ago, the CPT® editorial panel revised the surgical debridement codes, the application of skin substitute codes,and the active wound management

codes. Many of these chronic wound procedures have primary codes (which represent the work that is performed on the first 20, 25, or 100 sq cm) and add-on codes (which represent the work that is performed on each additional 20, 25, or 100 sq cm, or part thereof).

Let’s look at an example of reporting a primary code and an add-on code on the same insurance claim in 2013 vs. 2014: The medical director of an HOPD debrides 35 sq cm of subcutaneous tissue from a diabetic foot ulcer: He/she should submit a claim, which includes two codes to Medicare: 11042 for debridement of the first 20 sq cm of subcutaneous tissue.

11045 for debridement of the additional 20 sq cm, or part thereof, of subcutaneous tissue.

In 2013, the national average Medicare allowable is $62.26 for 11042 and $27.56 for 11045.Therefore,the total Medicare allowable for the medical director’s work is $89.82.

Medicare will pay 80% ($71.86) of the allowable and the medical director should collect

TABLE 1. 2013 vs. 2014 Average Medicare Allowable Rates for HOPDs When Debridement is Performed

6

CPT Code

2013 APC Group

2013 Allowable

2013 Coinsurance

2014 APC Group

2014 Allowable

2014 Coinsurance

11042

0016

$209.65

$41.93

0016

$274.81

$54.97

+11045

0016

$209.65

$41.93

Packaged

11043

0016

$209.65

$41.93

0016

$274.81

$54.97

+11046

0016

$209.65

$41.93

Packaged

11044

0020

$583.61

$116.73

0020

$640.91

$128.19

+11047

0019

$336.38

$67.28

Packaged

97597

0015

$106.96

$21.40

0015

$147.39

$29.48

+97598

0015

$106.96

$21.40

Packaged

97602

0013

$71.54

$14.31

0013

$83.73

$16.75

November/December 2013 Today’s Wound Clinic®

XX-XX_TWC_NovDec_Business.indd 6

www.todayswoundclinic.com

12/6/13 12:55 PM

businessbriefs the remaining 20% ($17.96) of the allowable from the patient.

Because the patient received this subcutaneous debridement in an HOPD, the HOPD should also submit a claim to Medicare. The claim should include the same pair of codes that were billed by the medical director. In 2013, both the primary and add-on debridement codes are in the ambulatory payment classification (APC) group 0016.The 2013 national average Medicare allowable is $209.65 for 11042 and 50% of $209.65 for 11042.

Therefore, the total Medicare allowable for the HOPD’s work is $314.48. Medicare will pay 80% ($251.58) of the allowable and the HOPD should collect the remaining 20% ($62.90) of the allowable from the patient.

In 2014, qualified healthcare professionals (QHPs) will continue to be paid separately for the primary procedure code and the add-on code. The only items that may change the 2013 Medicare payment rates for QHPs are the relative value units (RVUs), which are assigned to the procedure codes and the add-on codes, and the conversion factor that converts RVUs into Medicare allowable rates.

Effective Jan. 1, HOPDs will no longer receive separate payment for any add-on codes. CMS has unconditionally packaged all procedures described as add-on codes. HOPDs will now receive 1 packaged payment for surgical and medical debridement regardless of the wound surface area debrided. See Table 1 on page 6 for a comparison of the 2013 vs. 2014 national average Medicare allowable rates when debridement is performed in HOPDs. Now, let’s return to our example to see how the packaged payment for add-on codes affects the HOPD’s Medicare payment: As you can see from Table 1, CMS did not change the APC groups for the primary debridement procedure 11042. However, CMS did package the payment for the 11045 add-on code into the payment for 11042. Therefore, the total Medicare allowable for the HOPD’s work is $274.81. Medicare will pay 80% ($219.84) of the allowable and the HOPD should collect the remaining 20% ($54.97) from the patient. This 2014 packaged paywww.todayswoundclinic.com

XX-XX_TWC_NovDec_Business.indd 7

TABLE 2. Low-Cost CTPs Packaged in HOPDs ALLOPATCH HD™

MatriStem® Burn Matrix

AlloSkin™

MatriStem Wound Matrix

AminoExcel

Matrix™ HD

Architect™

Mediskin®

BioDExCel™

NEOX®

BioDfence™

OASIS® Ultra Tri-Layer Matrix

BioDfence™ Dry Flex

OASIS Wound Matrix

FlexHD

Repriza®

™

®

GammaGraft®

Surgimed, Fetal

Hyalomatrix

Surgimed, Neonatal

INTEGRA Bilayer Matrix Wound Dressing

TenSIX™

INTEGRA Dermal Regeneration Template

TheraSkin

INTEGRA Matrix

Unite® Biomatrix

INTEGRA Meshed Bilayer Wound Matrix

XCM Biologic Tissue Matrix

®

™

TABLE 3. High-Cost CTPs Packaged in HOPDs

TABLE 4. CTPs With PassThrough Codes in HOPDs

AlloDerm®

hMatrix®

DermACELL®

Apligraf®

InteguPLY

ArthroFlex

®

MemoDerm

Dermagraft®

PriMatrix

DermaSpan™

TranZgraft®

Graftjacket®

EpiFix® ™

Grafix® Core Grafix Prime Talymed®

-----------

ment is less than the HOPD was paid in 2013 for wounds that are > 20 sq cm. However, the HOPD will receive the same packaged payment rate when QHPs debride subcutaneous tissue from wounds that are < 20 sq cm: $274.81 in 2014 vs. $209.65 in 2013.

Medicare Packaged Payment of CTPs The 2014 OPPS Final Rule explains that CMS packaged 2 different items into the primary code for the application of CTPs. Just like the debridement codes, CMS packaged the payment for the add-on codes into the payment for the primary procedure. In addition, CMS packaged the payment for the CTP products into the payment for the primary procedure. In order to accommodate the

various CTPs with widely different costs, CMS divided the CTPs into 3 packaged payment groups: 1. Low-cost CTPs (See Table 2 above) 2.High-cost CTPs (See Table 3 above) 3. CTPs with “pass-through” codes (See Table 4 above).

For your convenience, the CTPs that are underlined in Tables 2, 3, and 4 are currently covered in 1 or more Medicare Local Coverage Determinations.

CMS packaged the payment for the high-cost products (Table 3) into the payment for the existing CPT codes 1527115278 (Table 5 on page 8). Nevertheless, HOPDs should continue to separately bill for the appropriate CTP with the correct number of units purchased and with

Today’s Wound Clinic® November/December 2013

7

12/6/13 12:55 PM

businessbriefs TABLE 5. 2013 vs. 2014 National Average Medicare APC Allowable Rates for HOPDs When High-Cost CTPs Are Applied CPT Code

2013 Allowable

2013 Coinsurance

2014 Allowable

2014 Coinsurance

15271

$251.48

$50.30

$1,371.19

$274.24

+15272

$85.75

$17.15

Packaged

Packaged

15275

$251.48

$50.30

$1,371.19

$274.24

+15276

$85.75

$17.15

Packaged

Packaged

15273

$393.38

$78.68

$2,260.46

$452.09

+15274

$251.48

$50.30

Packaged

Packaged

15277

$393.38

$78.68

$1,371.19

$274.24

+15278

$251.48

$50.30

Packaged

Packaged

TABLE 6. 2013 vs. 2014 National Average Medicare APC Allowable Rates for HOPDs When Low-Cost CTPs Are Applied CPT Code

2013 Allowable

2013 Coinsurance

2014 Allowable

2014 Coinsurance

C5271

$251.48

$50.30

$409.41

$81.88

+C5272

$85.75

$17.15

Packaged

Packaged

C5275

$251.48

$50.30

$409.41

$81.88

+C5276

$85.75

$17.15

Packaged

Packaged

C5273

$393.38

$78.68

$1,371.19

$274.24

+C5274

$251.48

$50.30

Packaged

Packaged

C5277

$393.38

$78.68

$409.41

$81.88

+C5278

$251.48

$50.30

Packaged

Packaged

their current charge that correctly reflects their current cost.As you review the packaged payment rates for high-cost CTPs in Table 5, you will see the 2014 packaged payment rate is $1371.19 for the procedure, add-on code, and high-cost CTPs applied to wounds < 100 sq cm.

CMS created new Healthcare Common Procedure Coding System codes (Table 6 above) in which to package the payment for the low-cost CTPs (Table 2). Therefore, HOPDs must immediately add the new codes C5271- C5278 (Table 6) to their charge description master (CDM), to their billing and coding systems,and to their electronic medical records.This has to be accomplished before Jan. 1 in order to be prepared to submit claims for the application of lowcost CTPs. HOPDs should also continue to separately bill for the appropriate CTP with the correct number of units purchased and with the HOPD’s cur8

rent charge that correctly reflects their current cost. As you review the packaged payment rates for low-cost CTPs in Table 6, you will see the 2014 packaged payment rate is $409.41 for the procedure, add-on codes, and low-cost CTPs applied to wounds < 100 sq cm.

Finally, let’s discuss how CTPs that have been assigned temporary passthrough codes will be handled in this new packaged payment methodology.

New CTPs may be assigned temporary pass-through codes for 2-3 years.

NOTE: Each brand’s temporary passthrough code will terminate at different times. Once the temporary pass-through code is removed by CMS, these products will be packaged by CMS into either the high-cost or low-cost groups. As of the publication of this article, the CTPs in Table 4 have temporary passthrough codes for use by HOPDs. The 2014 OPPS Final Rule directs HOPDs

November/December 2013 Today’s Wound Clinic®

XX-XX_TWC_NovDec_Business.indd 8

to report the application of these products with the CPT codes 15271-15278 for high-cost products. HOPDs should continue to separately bill for the appropriate CTP with the correct number of units purchased and their current charge that correctly reflects their current cost.

As long as the CTP has a pass-through code, CMS will continue to pay for the CTP separately, at the average sales price plus 6% minus the device offset amount that is packaged into the procedure code.

Next Steps for HOPDs As HOPDs review the 2014 OPPS packaged payments for CTPs, their application, and their add-on codes, HOPDs may find that some CTPs cost more than Medicare’s packaged payment allowable. CMS intends for the packaged procedure payment rate to represent the average cost of purchasing and applying all the CTPs in the highwww.todayswoundclinic.com

12/6/13 12:55 PM

WCB2014 WOUND CLINIC BUSINESS Our thanks to the hundreds of Wound Clinic Revenue TEAM members who attended the 2013 Wound Clinic Business meetings.

Earlybird and group discount pricing will be available for 2014 meetings!

It takes a TEAM to manage the wound care & HBOT revenue cycles.

The meeting evaluations overwhelmingly stated that the teams who attended were extremely satisfied with their experience.

LOOK FOR 2014 WOUND CLINIC BUSINESS DATES & LOCATIONS IN THESE 10 CITIES NEXT YEAR n March 14 Dallas, TX

n June 13

Chicago, IL

n April 11

Philadelphia, PA

n September 5

Houston, TX

n April 23

Orlando, FL

n September 12 Columbus, OH

n May 30

Atlanta, GA

n September 19 Los Angeles, CA

n June 6

Boston, MA

n October 15

Las Vegas, NV

Notes: Dates and locations subject to change.

Please visit www.woundclinicbusiness.com for updates and additional information.

Thanks to our 2013 sponsors

速 速

This program is produced and managed by

WCB2013-THANKS+2014dates.indd 1

, LLC

TM

an HMP Communications Holdings Company

12/6/13 9:10 AM

businessbriefs cost and low-cost category. CMS used several pieces of data to calculate the dollar value that is packaged into the procedure payment (eg, average sales price submitted by the manufacturers and claims submitted by HOPDs).

Therefore, HOPDs should be very careful that their claims for the application of CTPs actually report the correct number of sq cm purchased for each application and the correct charge per sq cm. The only way HOPDs can verify the accuracy of their claims is to actually review the submitted claims.

Many auditors have reported finding the following CTP claim errors: • HOPDs billed for 1 unit (which represents only 1 sq cm) rather than

billing for the total number of sq cm in the piece.

• HOPDs billed for only the number of sq cm used and failed to also bill for the number of sq cm wasted.

• HOPDs failed to load the correct cost per sq cm into the CDM. To prevent large losses of reimbursement and to provide correct data to CMS about the costs of CTPs, HOPD staff should check the CDM and billing programs to be sure claims are correctly reporting the total number of sq cm purchased for each application and the correct charge.

While the HOPD staff members are working with the CDM, they should make any needed changes to the charges for the primary and add-on debride-

ment codes and to the charges for the primary and add-on codes for the application of the CTPs. Most importantly, HOPDs must add C5271-C5278 to their CDM in order to bill for the packaged payment of the low-cost CTPs. Remember, all of these changes to your CDM must be accomplished by Jan. 1. Have a happy holiday season! Look for more information about Medicare payment changes in the next “Business Briefs” column in the January/February edition of Today’s Wound Clinic. n Kathleen D. Schaum is president and founder of Kathleen D. Schaum & Associates Inc., LakeWorth, FL. She may be reached for questions and consultations at 561-9642470 or kathleendschaum@bellsouth.net.

SAWC on-demand Miss any sessions?

Do you want to review them?

Now you can experience the content from the 2013 SAWC Fall meeting when and where you want ON-DEMAND right from your computer.

TOTAL ACCESS View the conference sessions online, on-demand.

Get 24/7 access to comprehensive sessions from the 2013 SAWC Fall meeting with video and synchronized presentation slides.

Have the ability to start, pause, and restart sessions on your time.

10

November/December 2013 Today’s Wound Clinic®

XX-XX_TWC_NovDec_Business.indd 10

Order Today For more information or to order your SAWC On-Demand sessions visit

www.sawcondemand.com

www.todayswoundclinic.com

12/6/13 12:40 PM

WOUND HEALING IN THE

GERIATRIC PATIENT The aging US population won’t make it any easier on wound care providers to repair skin.

Understanding the implications of one’s age on wound closure is a must.

Jeffrey M. Levine, MD, AGSF & Michael Cioroiu, MD, FACS Editor’s Note: There are no financial disclosures related to this article.

www.todayswoundclinic.com

XX-XX_TWC_NovDec_GeriatricWoundHealing.indd 11

Today’s Wound Clinic® November/December 2013

11

12/6/13 12:01 PM

theagingpatient

T

he US is in the midst of a profound demographic change with the rapid aging of its population — a steep increase reflected by the estimated 75 million baby boomers who will move into the ranks of the geriatric healthcare population during the next 20 years. This demographic change is having a major impact on the organization and delivery of healthcare itself, particularly in the shift from acute to chronic illnesses that require healthcare providers to have an increased understanding of basic principles related to aging.

Among the most impacted arenas of healthcare as the population gets older and medicine allows people to live longer with comorbid conditions will be outpatient wound centers. Chronic wounds have great impact on quality of life, and experts have estimated the cost of their care to be in excess of $25 billion.1 In order to provide the highest quality of care and cost-effective treatment with this patient population, wound care clinicians must consider the biologic and psychosocial complexities of aging. Because many nonhealing wounds are the consequence of functional changes and diseases that accompany aging, it is of paramount importance that outpatient wound centers be equipped with the knowledge and infrastructure to meet this challenge and take a comprehensive, multidisciplinary approach to care. This article will provide guidance related to changes associated with aging skin as well as altered physiology and comorbidities that impact wound healing.

INTRINSIC & EXTRINSIC CAUSES OF AGING SKIN

Normal skin serves the human body with several critical functions, most notably providing barrier protection against physical and chemical insults.

Adipose cells in subcutaneous tissue in concert with capillaries, arterioles, and vasodilatation controlled by autonomic nerves provide thermoregulation. Skin and specialized sweat glands provide regulation of water loss while 12

Langerhans cells, mast cells, and T- and B-cells provide protection from microorganisms. Specialized nerve cells provide sensation and give us signals about our environment. Vitamin D3 is produced in the skin, and sebaceous glands are important in testosterone metabolism.

Changes that occur to human skin as it ages are classified as intrinsic and extrinsic. Intrinsic refers to physiologic changes taking place in the aging process and is most evident in sun-protected areas, while extrinsic refers to environmental influences. It is sometimes difficult to separate intrinsic from extrinsic factors due to the pervasive impact of diet and lifestyle, but there are profound genetic and ethnic differences in the body’s response to both.

One major factor impacting both intrinsic and extrinsic aging is oxidative stress leading to macromolecular damage and cell senescence. Changes of aging depend largely upon homeostasis between free radical production and the proper working of repair systems. The term reactive oxygen species (ROS) refers to free radicals and non-radicals that contain an oxygen atom. ROS are byproducts of cell respiration that takes place in mitochondria during oxidative phosphorylation, but are generated by other cellular structures such as peroxisomes and endoplasmic reticulum.2 Not only does ROS increase with age, but aging is accompanied by reduced antioxidant activity and decreased DNA repair capability.

Extrinsic causes of aging skin are also mediated by oxidative stress and ROS. The most important cause of aging skin is ultraviolet (UV) light from the sun, which is divided into UVA and UVB. UVA is considered more damaging because of its deeper penetration into the dermis. Other environmental factors recognized as extrinsic causes of aging include cigarette smoke, ozone, and airborne particulate matter with adsorbed polycyclic aromatic hydrocarbons. 3 These extrinsic factors generate free radicals and ROS that overwhelm

November/December 2013 Today’s Wound Clinic®

XX-XX_TWC_NovDec_GeriatricWoundHealing.indd 12

the body’s natural antioxidant defenses and stimulate lipid proxidation reaction cascade, which in turn releases pro-inflammatory mediators that include matrix metalloproteinases (MMPs). Mitochondrial DNA mutations resulting from ROS leads to defective electron transfer activity and oxidative phosphorylation. Telomere shortening is a known result of oxidative insults resulting from environmental factors and is associated with psychological stress. 4 Telomeres are repetitive DNA sequences at the end of linear DNA that shorten each time a cell divides and ultimately leads to cessation of cell division and apoptosis, or programmed cell death.

Polycyclic aromatic hydrocarbons adsorbed to airborne particulate matter induce xenobiotic metabolism that releases ROS and MMPs that accelerate aging. Xenobiotic metabolism refers to the metabolic pathways the body uses to eliminate environmental toxins such as polycyclic aromatic hydrocarbons that are adsorbed to airborne particulate matter.

CHANGES IN AGING SKIN

There are numerous changes in aging skin that impair the adaptive and homeostatic capacity and leads to increased susceptibility to environmental and internal stresses that lead to impaired wound healing and chronic wounds. These are discussed as follows: In the epidermis there is reduced keratinocyte proliferation and turnover time, and surface pH is less acidic. Desquamation is less effective and lipid biosynthesis in the stratum corneum is impaired. There are decreased melanocytes that protect from UV radiation and decreased Langerhans cells that process microbial antigens and present them to other immune system cells.

This is accompanied by altered T- and B-cell function and a general pro-inflammatory environment that is now an accepted component of the aging process. The dermal-epidermal junction is flattened with smoothing of the rete ridges and decreased adhesion of this critical mechanical defense barrier. www.todayswoundclinic.com

12/6/13 12:01 PM

theagingpatient The dermis becomes atrophic with reduced numbers of fibroblasts and mast cells, and collagen becomes disorganized with change in synthesis from type 1 to type 3. There is decreased synthesis of elastin and elastic tissue is degraded with overall loss of elasticity.

Decreased mechanoreceptors including Meissner and Pacinian corpuscles result in diminished sensation to light, touch, pressure, and vibration.

There are decreased pilosebaceous units, which are composed of hairs, sebaceous glands, and arrector pili muscles that contribute to decreased sebum production. Impaired thermoregulation results from loss of subcutaneous fat, decreased autonomic nerves from the sympathetic nervous system, and decreased dermal vascularity. Loss of sweat glands also contributes to impaired thermoregulation as well as decreased ability to manage water balance in response to anti-diuretic hormone.

COMORBIDITIES OF AGING THAT IMPACT WOUNDS

Along with the accumulation of deleterious changes in aging skin, pathologic changes add to the risk for development of chronic wounds and impair the body’s ability to heal. Changes in aging physiology decrease the body’s reserve when stressed — a phenomenon known as homeostenosis. The aging body is more susceptible to injuries related to shearing forces, ischemia, pressure, and other forms of trauma. Alterations in barrier function, vascularity, and immune function make aging skin more susceptible to infection, both fungal and bacterial.

Disorders of the vascular system present common underlying factors in development of wounds and delayed wound healing, and arterial and venous ulcers are commonly seen in wound clinics. Venous insufficiency with increased venous pressure is a common result of post-thrombotic syndrome,

with risk factors including obesity, pregnancy, inactivity, and gender. Atherosclerotic arterial disease reduces perfusion to the skin and results in suboptimal delivery of oxygen and nutrients. Risk factors for atherosclerosis include hypertension, smoking, hyperlipidemia, and diabetes mellitus.

Approximately 25% of people ages 65 and older are currently living with diabetes mellitus, according to the Centers for Disease Control and Prevention, and common sequelae include neuropathy, microvascular disease, dysfunctional leukocytes, and altered inflammatory pathways.5 The rising rates of obesity with the known association with type 2 diabetes will continue to have a great impact on public health and the prevalence of chronic wounds.

Other endocrine imbalances that accompany aging potentially impact wound healing. Hypothyroidism is common in geriatric patients, and a feature of this disease is dry skin from continued on page 31

WWW.NOPRESSUREULCERS.COM

SKIN CARE -

A QUALITY, DOCUMENTATION AND FISCAL ISSUE

N

ow in its third edition, the Pocket Guide to Pressure Ulcers, is designed to help clinicians accurately identify, stage and document pressure ulcers. The guide contains photos and descriptions, as well as expanded information for reporting requirements for all provider types.

Created by wound care experts Drs. Jeffrey Levine and Elizabeth Ayello, it’s a must-have resource for your entire team. Affordably priced at $12.99, the guide is available as a laminated spiral-bound book or can be downloaded to your iPad or iPhone (available for download in English or Spanish.)

Visit www.nopressureulcers.com to place your order; discounts available for large quantity orders.

www.todayswoundclinic.com

XX-XX_TWC_NovDec_GeriatricWoundHealing.indd 13

Today’s Wound Clinic® November/December 2013

13

12/6/13 12:01 PM

BUILDING COLLABORATION BETWEEN THE

OUTPATIENT WOUND CLINIC AND LONG-TERM CARE The US government is paying more attention to pressure ulcer prevalence in nursing homes. What can outpatient clinics do to help heal wounds more quickly and cost-effectively?

Les Kiemele, PA-C & Paul Takahashi, MD, CMD

14

November/December 2013 Today’s Wound Clinic®

XX-XX_TWC_NovDec_WoundCareLTC.indd 14

www.todayswoundclinic.com

12/6/13 12:18 PM

theagingpatient

N

onhealing chronic wounds among long-term care (LTC) residents continue to be a concern in the US. Up to 11% of patients in this setting are living with pressure ulcers, according to the National Nursing Home Survey.

LTC remains a common environment for wounds due to populations of older residents who are often ill, functionally disabled, and/or at the end stages of disease states. According to the National Center for Health Statistics, prevalence of pressure ulcers in LTC can range from 2-28%.1 Many of these patients will require repeated visits to the outpatient wound clinic in order to achieve wound closure. This places outpatient wound centers in the unique position of playing key roles to the LTC treatment overview because many wounds do not heal with conservative measures.

Additionally, the federal government uses pressure ulcers as a quality indicator in the LTC environment and nursing homes are required to report the presence or development of pressure ulcers through the Minimum Data Set 3.0,2 further increasing the likelihood of transfers as a method of best practice.

With strict regulations by the Centers for Medicare & Medicaid Services (CMS) placing more emphasis on quality of care in LTC, those clinicians in this area of healthcare rely on outpatient wound care specialists to meet each resident’s medical needs and assist in adhering to governmental mandates. Wound care providers are also required to remain compliant with the government’s regulations regarding wound documentation and adherence to quality standards of care while patients are in the clinic. As a result of the regulatory issues, associated costs, and patient needs, LTC facilities will often turn to wound care centers for consultation on complex wounds. While the financial burden of wound care may be felt by residents, families, private insurance, CMS, and state Medicaid programs, LTC facilities must also strive to heal wounds at lower cost and nursing time. Wound care providers can assist in this goal by fostering collaboration with residents, families, and LTC staff. www.todayswoundclinic.com

XX-XX_TWC_NovDec_WoundCareLTC.indd 15

CARING FOR THE LTC POPULATION

LTC residents referred to wound clinics present unique challenges. The wound care physician, nurse practitioner, or physician’s assistant (hereafter called qualified healthcare professional [QHP]) must remember that the body — and not the dressings — actually heals wounds. This is particularly true of LTC residents, who often represent two very distinct groups: short-term rehabilitation patients who have an expectation of returning home after a short LTC stay and LTC residents who live in the facility for extended periods, often life.

The wound care management of shortterm patients is similar in many respects to hospital inpatients. This article will focus on the LTC resident.

These residents often have functional debility with impairment of 2-3 activities of daily living such as ambulation, transferring, bathing, toileting, dressing, and eating.3 They often live with dementia, urinary and/or fecal incontinence, and are wheelchair-bound.

All these physical and cognitive disabilities dramatically impact the history and physical examination within the wound clinic, so QHPs must be prepared to deal with difficult transfers for debilitated patients. QHPs must also accept indirect historical information, as the patient often cannot provide an accurate wound history. Specifically, nutritional history, mobility, and pressure ulcer information may be challenging to obtain directly from the patient; often QHPs rely upon written notes from the facility. The challenges of diagnosis and determining the needs of the cognitively impaired patient also apply to compliance with the wound care plan. Informed consent for procedures and acceptance of a treatment plan often requires the aid of the healthcare power of attorney or an accepted spokesperson for the patient.

QHPs caring for LTC residents have additional challenges beyond standard wound management. Providing highquality wound care to the LTC population requires a systematic approach that addresses the wound (diagnosis and treatment) as well as the overall

health of the resident. Systemic pathology such as diabetes, heart failure, and cancer are common in older LTC residents and can impair wound healing. The QHP must encourage wound healing via standard techniques such as debridement, infection control, and hydrating wound environment while addressing other risk factors that impede wound healing such as ongoing pressure, ischemia, or edema in many LTC residents.4 QHPs must also understand the nutritional aspects of wound care and should address the nutritional status. This assessment may require labs (albumin, cholesterol, prealbumin) in addition to weight and body mass index (BMI). In patients with tube feedings, the adequacy of fluid should be assessed as well as caloric and protein intake through the tube feedings.

COLLABORATING WITH LTC

Chronic wounds require a comprehensive, multidisciplinary approach that includes patient and caregiver education in order to adequately address all patient needs, eliminate duplication of services, enhance patient compliance, and increase patient satisfaction.5 One critical component of the wound specialist in relation to LTC residents is the prognosis and possibility of wound healing.

Providing an honest opinion on the potential of wound healing is important to the patient, family, and the LTC facility.6 Wound clinics may have diagnostic and therapeutic options that may not be available to LTC facilities such as specialized testing (ie, non-invasive arterial testing), hyperbaric oxygen, and ultrasonic mist therapy.7,8 The ability to conduct specific evaluations helps with the diagnosis of and prognosis for LTC residents. Another fundamental advantage of wound clinics is the ability to perform surgical debridement by skilled QHPs.9 LTC facilities are working aggressively to reduce hospital readmissions,10 and part of this approach involves effective wound care. A dedicated nursing home/wound care relationship may produce further advantages that are not available in the LTC setting. The onsite wound team

Today’s Wound Clinic® November/December 2013

15

12/6/13 12:18 PM

theagingpatient can evaluate residents in its own environment with a reduction in patient stress and expense while providing ongoing education to the nursing staff, patients, and families face-to-face. The QHP can also observe implementation of the treatment plan on a more consistent basis. The need to communicate directly with nursing staff at the LTC center is especially critical with those patients who live with dementia or other cognitive disorders.

Key elements to ensure safe transfer of care should focus on patient-centered care, communication, and safety. Improved communication leads to enhanced patient safety, better outcomes, greater patient and family satisfaction, and reduced length of stay.11 The communication to the LTC facility should include specific documentation of the wound, treatment plan, and prognosis.

For documentation, accurate staging of pressure ulcers is a key part of LTC communication and is critical for quality measures within LTC. One uniform provider staging the pressure ulcer is ideal for consistency. Wound plans to LTC should include specific nursing orders (such as turning protocol) with frequency as well as specific wound care dressings, amount (if needed), and end date (if needed). A prognosis helps the LTC staff communicate with the resident and family about the progress of the wound. In particular, if the QHP believes the wound will not heal, discussing palliative wound options is appropriate and encouraged. Nutritional support is another important issue for

many LTC wound care patients, as nutritional deficiencies are common when patients become frail and require LTC stays. Awareness of potential nutritional deficiency should be a concern for any LTC patient in the outpatient clinic, and QHPs should comment and document nutritional status when a resident is evaluated. Ideally, all patients are weighed and have BMI documented at each visit to evaluate weight changes.

The use of supplements often remains a challenge in LTC, as some residents will not drink supplements. Working with dietary support staff within the facility may improve compliance with nutritional intake. A summary of issues faced by many LTC residents is in the Table below.

THE REIMBURSEMENT PIECE

Payment restrictions often limit wound treatment options in LTC. Administrators are often forced to tightly manage resources for wound care, including nursing time and wound products. QHPs in the outpatient center should take time to communicate with LTC staff and help them understand that lowest-cost products may not produce the lowest total cost of care, the best outcomes, and/ or the greatest patient satisfaction. LTC payment often involves Medicare Part A insurance for short-term residents, which is a per-diem prospective payment system. This one payment includes all resident costs including wound supplies and nursing time. Restricting wound care formularies is one method of controlling costs; thus, expensive wound options like

TABLE: Clinical Overview of LTC Residents in the Outpatient Wound Clinic Issue

Action and Outcome

Patients display marked physical disability

May need specialized equipment to help with transfers or to visualize the wound.

Patients live with dementia

Communication with clinicians in the facility through written or oral communication is critical for wound plan implementation.

Patients experiencing nutritional deficiency

Assess and treat nutritional issues when seen in the wound clinic.

Patients experience nonhealing wound despite initial wound care

Expertise in diagnosis and access to better diagnostic equipment and advanced treatment options, including debridement, may be helpful.

Patients may be at end stages of illness

Higher potential for nonhealing wounds and palliative wound care.

Facilities have restricted wound care formularies

Adjusting wound care plans or working with medical or nursing leadership at the facility.

18

November/December 2013 Today’s Wound Clinic®

XX-XX_TWC_NovDec_WoundCareLTC.indd 18

silver-based therapies may not be available. LTC facilities also limit advanced wound technologies because of staffing, patient volumes, and economics. Thus, outpatient clinics must be aware that facilities are mindful of costs. If a QHP feels strongly that a wound treatment plan requires an out-of-formulary exception, it might be best to work with the director of nursing at the facility or the medical director. n Les Kiemele and Paul Takahashi are on staff at the Mayo Clinic College of Medicine, Rochester, MN. References 1. Park-Lee E, Caffrey C. Pressure ulcers among nursing home residents: United States, 2004.

NCHS Data Brief. Feb 2009(14):1-8.

2. Levine JM, Ayello EA. MDS 3.0 section M: Skin Conditions: what the medical director needs to know. Journal of the American Medical Directors Association. Mar 2011;12(3):179-183.

3. Gill TM, Gahbauer EA, Han L, Allore HG. Functional trajectories in older persons admitted to a nursing home with disability after an acute hospitalization. Journal of the American Geriatrics Society. Feb 2009;57(2):195-201.

4. Takahashi PY, Kiemele LJ, Jones JP, Jr. Wound care for elderly patients: advances and clinical applications for practicing physicians. Mayo Clinic Proceedings. Feb 2004;79(2):260-267.

5. Bogie KM, Ho CH. Multidisciplinary approaches to the pressure ulcer problem. Ostomy Wound Management. Oct 2007;53(10):26-32.

6. Jaul E. Non-healing wounds: the geriatric approach. Archives of Gerontology and Geriatrics.

Sep-Oct 2009;49(2):224-226.

7. Kranke P, Bennett MH, Martyn-St James M, Schnabel A, Debus SE. Hyperbaric oxygen therapy for chronic wounds. The Cochrane Database of Systematic Reviews.

2012;4:CD004123.

8. Ennis WJ, Foremann P, Mozen N, Massey J, Conner-Kerr T, Meneses P. Ultrasound therapy for recalcitrant diabetic foot ulcers: results of a randomized, double-blind, controlled, multicenter study. Ostomy Wound Management.

Aug 2005;51(8):24-39.

9. Levine SM, Sinno S, Levine JP, Saadeh PB. An evidence-based approach to the surgical management of pressure ulcers. Ann Plast Surg. Oct 2012;69(4):482-484.

10. Ouslander JG, Lamb G, Tappen R, et al.

Interventions to reduce hospitalizations from nursing homes: evaluation of the INTERACT II collaborative quality improvement project. Journal of the American Geriatrics Society. Apr 2011;59(4):745-753.

11. Cioroiu M, Levine JM. Improving Communication in the Wound Clinic. Today’s Wound Clinic. 2013;7(3). www.todayswoundclinic.com

12/6/13 12:18 PM

Simple solutions to complex problems Graftjacket® regenerative tissue matrix and Graftjacket® Xpress flowable soft tissue scaffold for wounds, brought to you by KCI. • Graftjacket® RTM – a 12-week, prospective, randomized, controlled diabetic foot ulcer study of 86 patients demonstrated that 69.6% of patients achieved complete healing* vs. 46.2% of patients receiving standard-of-care wound management.1 • Graftjacket® Xpress FSTS – an innovative, flowable treatment that fills deep tunneling wounds. In a retrospective, 12-week study of 12 patients with deep tunneling wounds, a 50% reduction of wound depth was observed within the first 14 days post-treatment for all patients.**,2

Initial presentation of wound bed

Graftjacket® RTM sutured into wound

Wound epithelialized with healthy plantar skin within 6 weeks.

Case images courtesy of Lee C. Rogers, DPM; used by permission.

As with any case study, the results and outcomes should not be interpreted as a guarantee or warranty of similar results. Individual results may vary depending on the patient’s circumstances and condition.

Learn more at www.graftjacketbykci.com *Complete healing defined as 100% epithelialization without drainage **in a case study series2 References: 1. Reyzelman A, Crews RT, Moore JC, et al. Clinical effectiveness of an acellular dermal regenerative tissue matrix compared to standard wound management in healing diabetic foot ulcers: a prospective, randomised, multicentre study. Int Wound J. 2009;6(3):196-208. 2. Brigido S, Schwartz E. Use of an Acellular Flowable Dermal Replacement Scaffold on Lower Extremity Sinus Tract Wounds: A Retrospective Series. Foot Ankle Spec. 2009;2:67.

Every patient is different and patient results may vary. Before use, physicians must review all risk information and essential prescribing information which can be found in the Graftjacket® regenerative tissue matrix Instructions for Use. Rx only. ©2013 KCI Licensing, Inc. All rights reserved. Graftjacket is a trademark of Wright Medical Technology, Inc. All other trademarks designated herein are proprietary to KCI Licensing, Inc., its affiliates and/or licensors. For US use only. Products processed by LifeCell Corporation for KCI. DSL#13-0291.US.TWC (6/13)

KCI_GraftJacket_0613.indd 2

5/28/13 4:28 PM

NUTRITION & WOUND HEALING IN THE OLDER ADULT: CONSIDERATIONS FOR WOUND CLINICS The aging population is especially dependent on proper nutrition to aid wound closure. What does the outpatient clinic need to know?

Liz Friedrich, MPH, RD, CSG, LDN & Nancy Collins, PhD, RD, LD/N, FAPWCA

20

November/December 2013 Today’s Wound Clinic®

XX-XX_TWC_NovDec_GeriatricNutrition.indd 20

www.todayswoundclinic.com

12/6/13 12:35 PM

theagingpatient

W

ound care providers know that a patient’s nutritional status can have a profound effect on wound healing. Unfortunately, research has provided few definite answers as to exactly which nutritional interventions are most effective.

Nutrition assessment, diagnosis, intervention, monitoring, and evaluation are commonplace for patients within hospitals and long-term care (LTC) facilities. Unfortunately, most outpatient wound clinics don’t have protocols in place for evaluating a patient’s nutritional status and implementing timely nutritional interventions. This can be a cause for concern in instances when patients are being seen conjunctively by an outpatient wound clinic and an LTC facility. Wound care clinicians may be unfamiliar with the criteria used to determine whether nutritional status is compromised and may be unsure of which interventions are most useful if ongoing communication with LTC staff is not occurring. Additionally, many wound clinics don’t have access to a registered dietitian (RD) whose expertise is needed in evaluating and treating patients living with chronic wounds. Each patient that presents to the wound clinic will have unique nutritional needs, so clinical judgment is critical when making nutritional recommendations for all patients living with chronic wounds — particularly older adults. Comprehensive nutritional assessment can identify those needs, and regular monitoring and evaluation of weight and food intake can help determine if changes in the nutritional plan of care are needed to help facilitate wound healing.

This article will discuss how to evaluate nutritional status, review nutritional needs for wound healing, and provide practical information on how to maximize nutritional status in older adults who are living with chronic wounds.

EVALUATING NUTRITIONAL STATUS

Improving a patient’s nutritional status begins with the identification of underlying problems such as malnutrition.

Pressure ulcers are frequently connected to malnutrition, but its diagnosis is not www.todayswoundclinic.com

XX-XX_TWC_NovDec_GeriatricNutrition.indd 21

Figure: USDA Recommendations

as simple as requesting an albumin and prealbumin level. Evidence now shows that serum hepatic proteins are not the “gold standard” nutritional assessment tool.1,2 Rather, low serum albumin and prealbumin are indicators of underlying inflammation related to acute or chronic illness.1 Although this information has been in the literature for at least 10 years, it has been slow to trickle down to clinicians, who often still request serum hepatic proteins and identify a patient as malnourished on these lab results.

So how is malnutrition identified? In May 2013 the Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition published a consensus statement on the subject. The paper suggests malnutrition be diagnosed using a set of criteria that includes energy (caloric) intake, weight loss, loss of muscle mass, loss of subcutaneous fat, localized or generalized fluid accumulation that might mask weight loss, and diminished functional status as measured by hand-grip strength.1 The consensus statement emphasizes that comprehensive assessment is needed to evaluate malnutrition. Changing the paradigm in healthcare facilities to use

the suggested criteria is a dynamic work in progress that will take time to incorporate into facility protocols.

RDs in LTC facilities and hospitals typically use weight history and meal intake to help identify compromised nutritional status. That information can be difficult to obtain in an outpatient setting, but can still serve as a basis for identifying nutritional problems. Patients should be weighed at each clinic visit and weight history should be collected from medical records. Significant weight loss (defined as > 5% of body weight in 30 days or 10% in 180 days) and slow losses over time can both be indicators of changes in food intake and/or underlying medical problems. It is also important to learn about patients’ food and fluid intake by asking simple questions about what they eat. The US Department of Agriculture (USDA; reference www.choosemyplate.gov; see Figure above) recommends consuming a minimum of 5-6 oz of sources of protein, 2-3 servings of dairy, 2 c of fruits, at least 6 servings of grain products, and 2.5 c of vegetables daily. Specific meal patterns for various calorie levels

Today’s Wound Clinic® November/December 2013

21

12/6/13 12:35 PM

theagingpatient are also available (http://choosemyplate.gov/supertracker-tools/dailyfood-plans.html). It is important to understand that a patient’s intake can be suboptimal for many reasons. In the aging population, difficulty with driving, shopping, or food preparation can play a major role in the quality of the diet. Evaluating a patient’s weight over time and gathering information about his/her normal food intake can provide clues as to whether nutritional status is compromised. Knowledge of a patient’s normal intake and barriers to eating a nutritious diet can help wound care providers develop appropriate care plans.

NUTRITIONAL NEEDS FOR WOUND HEALING Energy, Protein, & Fluid The process of wound healing often results in a hypermetabolic state, meaning it requires energy above and beyond what is needed for daily activities.3 There are several ways to estimate calorie needs, but the National Pressure Ulcer Advisory Panel (NPUAP) clinical practice guidelines recommend 3035 calories per kg of body weight per day for individuals under stress with a pressure ulcer.2 Caloric requirements should be individualized and may vary depending on a patient’s medical condition, ability to ambulate, and age.

A patient with a pressure ulcer or chronic wound needs to eat enough protein to maintain positive nitrogen balance. When protein intake is not adequate, the body can break down lean body mass (LBM) to help meet its calorie needs. Preventing this process is critical because loss of LBM will impede wound healing.3 Research on protein needs for wound care patients is limited, but NPUAP recommends 1.25-1.5 g of protein per kg of body weight per day.2 To meet those needs, some patients will need more protein foods than is recommended by USDA. Renal status may change protein recommendations; those with chronic kidney disease may need less protein to prevent a decline in kidney function. Fluid intake is particularly important for older adults, who

TABLE: M ifflin-St. Jeor Formula to Estimate Resting Metabolic Rate (RMR) Men: RMR = (9.99 x weight) + (6.25 x height) – (4.92 x age) + 5 Women: RMR = (9.99 x weight) + (6.25 x height) – (4.92 x age) – 161 Equations use weight in kg and height in cm.

Source: Academy of Nutrition and Dietetics Nutrition Care Manual.

may not feel thirsty and as a result not drink enough to meet their needs. Dietitians have several ways to estimate fluid needs, but 30 mL of fluid per kg of body weight per day is a quick and easy estimation. More fluid may be needed if a wound has significant drainage or the patient uses an air-fluidized mattress.

Less may be needed for those with conditions such as heart or renal failure.

Vitamins & Minerals In the past, multivitamins and supplements such as vitamin C and zinc (nutrients thought to be important to wound healing) have been routinely ordered for wound healing. Some facility protocols still recommend these nutrients in amounts above the upper limits of the Dietary Reference Intakes established by the USDA. NPUAP guidelines suggest vitamin and/or mineral supplements should be offered to a patient with a pressure ulcer only when dietary intake is poor or a deficiency is confirmed or suspected.2 If a patient is taking a multivitamin, the addition of supplemental zinc could contribute to mineral overload. Most nutrition experts agree that eating a variety of nutrientrich foods as recommended by USDA is generally the best strategy for meeting nutrient needs, with supplements added only if they appear necessary.

STRATEGIES TO PROMOTE WOUND HEALING

Nutritious food is the first intervention for a patient with a healthy appetite. Patients should strive to eat a diet that provides enough protein, calories, vitamins, and minerals to meet their unique nutritional needs using USDA

recommendations as a general guideline. Because both calorie and protein needs are elevated in wound care patients, it often makes sense to suggest high-calorie, high-protein meals and snacks such as meats, eggs, milk, cheese, yogurt, dried beans, and nuts and seeds (including peanut butter). Recommendations should take into account a patient’s cultural background, food preferences, lifestyle, and economic limitations.Those who are on restrictive therapeutic diets might benefit from individualizing the diet and discontinuing restrictions, especially if the change increases nutrient intake and prevents unintended weight loss.2 If a patient tires easily when preparing food, wants a quick snack, or has a poor appetite at meal times, oral nutrition supplements (ONS) are convenient sources of calories and protein. Research supports the use of ONS for wound healing if needed because of poor intake.2 Various types of supplements are available, including milkshake-type beverages, clear beverages, bars, and puddings. Finding the form of supplement that a patient will consume is one key to the success of a nutritional intervention.

TARGETED NUTRITION THERAPY

Arginine and glutamine are two amino acids that are considered conditionally essential, meaning they may be needed during periods of stress, such as during wound healing. β-hydroxy-βmethyl buterate (HMB), a metabolite of the amino acid leucine, is thought to promote tissue-building and to help maintain muscle mass. Oral nutrition supplements containing arginine, glutamine, and/or HMB are available as adcontinued on page 30

22

November/December 2013 Today’s Wound Clinic®

XX-XX_TWC_NovDec_GeriatricNutrition.indd 22

www.todayswoundclinic.com

12/6/13 12:35 PM

MEDICARE PAYMENT FOR AUTOLOGEL INCREASES IN 2014 Natural healing from within.

Closing a wound can be a life-changing experience.

For more information, visit www.autologel.com.

Or call 866.CYTOMED (866.298.6633).

Warning

Patients known to be sensitive to components and/or materials of bovine origin are contraindicated. See instructions for use. AutoloGel is produced with the use of bovine thrombin.

You know the challenge—and frustration—of closing a non-healing wound. But when a wound starts healing, it can dramatically transform your patient’s life.

AutoloGel PRP Gel kick-starts the natural healing process to help speed wound closure in many wound types of all severities.

AutoloGel consists of a fibrin matrix of activated platelets derived from the patient’s blood that may assist in the regeneration of tissue deep within the wound bed.

91% of long-term stalled wounds responded to AutoloGel treatment with a 64% reduction in volume in 15 days or less.1* By reducing wound area and volume in days, not weeks, AutoloGel may reduce the need for further treatment.

Foot ulcer before AutoloGel treatment

After treatment with AutoloGel

1. de Leon JM, Driver VR, Fylling CP, et al. The clinical relevance of treating chronic wounds with an enhanced near-physiological concentration of platelet-rich plasma gel. Adv Skin Wound Care. 2011;24(8):357-368. *Observational study of 285 wounds of 337 days’ average previous duration.

© 2013 Cytomedix, Inc.

All rights reserved.

MKG010164 Rev 02

Cytomedix_1213.indd AutoloGel Journ.Ad.TWClinic.hirez.mechanical.indd 2 1

12/5/13 12/3/13 1:03 9:19 PM AM

TWCnewsupdate Physician Suggests Re-evaluation Of Pressure Ulcer Treatments A physician who specializes in geriatric medicine believes more research is needed regarding pressure ulcer prevention and treatment. According to a report by McKnight’s, David Thomas, MD, FACP, AGSF, GSAF, CMD, professor at the Saint Louis University School of Medicine, is also urging for the adoption of more evidence-based approaches to pressure ulcer care as it relates to certain types of dressings, nutritional supplements, negative pressure therapy, and turning protocols for those in the long-term care (LTC) environment.

“We don’t know as much as we think we know,” Thomas said. “What we have been facing in the care of pressure ulcers in nursing home is dogma. We desper-

ately need people in nursing homes to do clinical research.”

When it comes to dressings, Thomas voices concern over what he considers no evidence that options work better than others. He also stressed unreliability in choosing mattresses.

“What should you use, nobody knows,” he said, adding that there’s no evidence that zinc paste is effective, no difference between gold leaf or aluminum foil versus gauze, and no “clear evidence” that silver works. He also questions whether debridement is effective in LTC. He points to the fact that only 51 papers on pressure ulcers in world literature exist for his raised concern, further suggesting that more leaders in the field conduct pressure ulcer research trials. n

California Hospital Performs Pressure Ulcer Pilot Study In an effort to prevent pressure ulcers, staff members at El Camino Hospital, Mountain View, CA, are partnering with Leaf Healthcare Inc., Newark, CA, to test a product that wirelessly monitors inpatients to track their positioning, movement, and activity.

“Like all hospitals across the country, El Camino Hospital is focused on decreasing the incidence of pressure ulcers among our inpatients; and while we’ve made great strides, we are always looking for new ways to help our staff manage this complex condition,” said Tomi Ryba, president and chief executive officer (CEO) of El Camino Hospital.

“Participating in this pilot program will allow us to couple our process and protocols with this innovative monitoring technology to help our staff more effectively manage our most at-risk patients.”

The pilot program utilizes the Leaf Patient Monitor, a small, lightweight, wearable patient sensor that electronically monitors an individual’s position and movements. Data collected by the

24

sensor is then communicated wirelessly to central monitoring stations or mobile devices so that patient position and movement status can easily be viewed.

The system also alerts staff when movement deviates from individual turnmanagement protocols. The device has been FDA cleared.

“This system provides caregivers with accurate information regarding a patient’s position and movement over time, thus enabling easy identification of which patients are turning adequately on their own and which patients are in need of a greater assistance,” said Mark Weckwerth, CEO of Leaf Healthcare.

“The result is that all patients are repositioned per their prescribed protocol, which is an integral component of successful pressure ulcer prevention programs. Partnering with El Camino Hospital on this pilot provides us and them with critical information and data that we hope can be applied across their organization – and shared with other healthcare organizations, as well.” n

November/December 2013 Today’s Wound Clinic®

XX-XX_TWC_NovDec_News.indd 24

Elder Care Organization Celebrates 500 Member Milestone Officials with the Nurses Improving Care for Healthsystem Elders (NICHE) recently hosted a reception to celebrate reaching 500 members for its network of healthcare organizations that have implemented its geriatrics program.

The NICHE hospital member designation signals a resolve to provide specialized and patient-centered care for older adults. Through participation, NICHE hospitals and their associated healthcare facilities are able to offer evidence-based, interdisciplinary approaches that promote better outcomes, positive experiences, and improved care for older adults. This leads to greater satisfaction rates for patients, their families, and staff.

“Our network is now 500 strong and growing,” said Elizabeth Capezuti, PhD, RN, FAAN, NICHE director, John W. Rowe professor in Successful Aging, New York University College of Nursing. “These hospitals, located throughout North America, have made the vital commitment to help meet one of the most critical challenges of our times: quality care of older adults.”

The vision of NICHE is for all patients ages 65 and older to be given sensitive and exemplary care. The mission of NICHE is to provide principles and tools to stimulate a change in the culture of healthcare facilities to achieve patient-centered care for older adults. NICHE, based at New York University College of Nursing, consists of more than 500 hospitals and healthcare facilities throughout North America. For more information visit www.nicheprogram.org. n

www.todayswoundclinic.com

12/6/13 12:05 PM

TWCnewsupdate NYU Nurse Receives Leader in Aging Award Elizabeth Capezuti, PhD, RN, FAAN, a faculty member of New York University College of Nursing (NYUCN) has been named the American Academy of Nursing (AAN) and Elizabeth Capezuti, Hartford Foundation’s Nurse Leader in PhD, RN, FAAN Aging Award winner for 2013. Specifically, she’s being recognized for her research and leadership in gerontological nursing as well as her promotion of education, community outreach, and service.

“Her publications and teaching demonstrate an extraordinary commitment to her students, many of whom are coauthors on her papers and who are now respected scholars themselves,” said Eileen Sullivan-Marx, dean of NYUCN. “Dr. Capezuti is adding immeasurably to our understanding of aging and gerontological nursing, especially in the field of frail elders in hospitals and nursing homes. Dr. Capezuti is indeed a leader, with the stature and record of achievement worthy of the AAN and Hartford Foundation’s Nurse Leader in Aging Award.”

Established in 2006 by the AAN and the John A. Hartford Foundation, the award represents superior leadership, achievements, contributions, productivity, and influence on gerontological nursing and meeting the healthcare needs of the US population.

“I am deeply honored to have been selected for this award, and am so happy that it recognizes the importance of quality nursing care for older adults,” said Capezuti, the John W. Rowe professor in Successful Aging at NYUCN and director of Nurses Improving Care for Healthsystem Elders (NICHE), an international program designed to help hospitals improve the care of older adults. Her work focuses on care of older adults in hospitals and nursing homes with studies highlighting the injuries and falls due to restraints including side rails. In her role as the director of NICHE, Capezuti has led the development of NICHE into a financially sustainable model fostering geriatric excellence in 500 hospitals and healthcare organizations. n

Wound Care Nurse Helps Form Ostomy Algorithm Janice Beitz, PhD, RN, CS, CNOR, CWOCN, CRNP, APN, C, MAPWCA, a professor at Rutgers School of Nursing–Camden (NJ), recently served as a member of a research team Janice Beitz, PhD, RN, CS, CNOR, that developed the ostomy algorithm CWOCN, CRNP, for a new tool that reportedly provides APN, C, MAPWCA wound care professionals with a comprehensive guide to optimizing ostomy management and enhancing patient safety. www.todayswoundclinic.com

XX-XX_TWC_NovDec_News.indd 25

According to officials at Rutgers, the algorithm consists of 11 assessments, beginning with the type of ostomy, and provides a pathway that leads to the selection of the best ostomy management option.

“It helps guide [providers] through what they need to think about when they’re taking care of a patient,” Beitz said.

Beitz said given the aging population, more people are developing medical conditions that require an ostomy.

“It’s our role as care providers to give them the best care possible,” she continued. “We want to create the blueprint for choosing the safest and best product.”

At Rutgers–Camden, Beitz oversees the state’s first graduate certificate program in wound, ostomy, and continence nursing. She was inducted as an American Academy of Nursing fellow in October, joining a distinguished group of more than 2,000 academy fellows — including three other Rutgers–Camden nursing scholars — as leaders in nursing education, management, practice and research.

Beitz has co-authored numerous research articles and coauthored multiple book chapters as well as one book. A research study and algorithm on pressure ulcer prevention was recently published in Ostomy Wound Management.

“The majority of ostomy care is provided by non-specialized clinicians or caregivers and family members who do not have ostomy care expertise,” Beitz said. “There is a clear need for evidence-based guidelines in this area.”

A Cherry Hill, NJ, resident who specializes in acute and chronic wound, ostomy, and continence care, Beitz is also part of a team that is developing an interactive online version of the algorithm for use on computers and mobile devices. n

MiMedx Releases Results of DFU Follow-Up Study Officials at MiMedx Group Inc., Marietta, GA, have announced the results of a long-term follow-up study from a previously completed randomized controlled trial (RCT) involving patients living with diabetic foot ulcers (DFUs). For the follow up, patients whose DFUs healed after treatment with EpiFix® in the initial RCT and the subsequent crossover study were examined.

Eighteen of 22 eligible patients returned for follow-up examination, which was conducted 9-12 months after primary wound closure with EpiFix, according to officials. Of the 18 patients studied, only 1 patient had recurrent DFU during the follow-up period, while 17 (94.4%) remained fully healed.

These findings support the long-term effectiveness of dehydrated human amnion/chorion membrane (dHACM) for treatment of DFUs, officials claim. The study concluded that dHACM is a clinically viable and economically feasible treatment option that should be considered by clinicians who treat diabetic pedal ulcers.

“The identification and implementation of an ideal treatment regimen for DFUs is an increasingly common issue faced Today’s Wound Clinic® November/December 2013

25

12/6/13 12:05 PM

TWCnewsupdate by clinicians,” said Parker H. “Pete” Petit, chairman and chief executive officer of MiMedx. “Therapies that promote rapid and complete healing, thus reducing the risk for infection and amputation, can substantially improve quality of life while decreasing financial burdens. An optimal treatment for DFUs would be one that supports both rapid and long-term healing.

With 94.4% of DFUs remaining healed approximately one year after treatment, we believe our EpiFix allograft is a clinically effective and economic solution to these needs.” n

Wound Care Education Expert Appointed By McCord Research McCord Research has hired a new expert in the wound care education field as part of its goal to expanded its research and development division to pursue innovative healing, officials said.

Michelle Moore RN, MSN, WCC, CWCMS, has been named vice president of clinical affairs for McCord Research. Moore’s background includes holding the position of chief clinical officer with Links Medical Products, director of clinical at Gulf South Medical Supply, and director of clinical and vendor relations for Wound Care Education Institute. Her skills have aided in the design and development of several advanced wound care products that are currently in the field today, according to officials.

“My skills will assist in bringing training and education to the clinical personnel that will utilize our products as well as the patients who will benefit from the superior line,” said Moore, who will reportedly be working exclusively on a new, innovative wound care brand being launched later this year by McCord. “My goals are to empower the industry and get the field staff excited about how they can prevent wounds from occurring.” n

Potential Breakthrough With MRSA Treatment for Seniors A new method to increase the effects of antibiotics to treat deadly bacterial diseases in the elderly population has reportedly been uncovered by researchers. According to staff at the University of California-Irvine, the answer could lie through the use of inhibitor compounds that have been developed by structural biologists and chemists at the university. Researchers say they paired the inhibitor compounds with currently used antibiotics to see if they could increase the drugs’ effectiveness. The discovery adds to previous work conducted by university physician Thomas Poulos, PhD, and Northwestern University’s Richard Silverman, PhD, who created the compounds, according to the report. The compound combinations could mute neurodegenerative diseases by blocking overproduction of cell-killing nitric oxide within neurons.

26

November/December 2013 Today’s Wound Clinic®

XX-XX_TWC_NovDec_News.indd 26

“We found that NOS inhibitors were extremely successful at inhibiting neurodegeneration in an animal model, and if they could be successful combatting other diseases, we wanted to identify that as quickly as possible to help other people,” Poulos said in a prepared release.

The researchers reportedly tested the compounds on Bacillus subtilis, a nonpathogenic bacteria similar to Staphylococcus aureus. The bacteria treated with an antibiotic and NOS inhibitors were killed more efficiently than those treated with just an antibiotic, researchers said.

“Now that we know which region of the NOS to target, we should be able to develop compounds that selectively bind to bacterial NOS,” Poulos added. n

Wound Care Nurses Earn DAISY Awards Leslie Moore, RN, director of the Wound Clinic at Eastside Medical Center - South Campus, Snellville, GA, and Lisa Freeman, RN, a wound care nurse at Carroll Hospital Center, Westminster, MD, have been honored with the DAISY Award for Extraordinary Nurses at their respective facilities.

The award is given as part of the Glen Ellen, CA-based nonprofit DAISY Foundation’s program to recognize the extraordinary efforts of nurses. The organization was established by family members in memory of the late J. Patrick Barnes and the care he and his family received from nurses while he was ill as a means of thanking nurses for their roles in the lives of patients and their families.

“I was so surprised and appreciative to receive the DAISY Award,” Moore told the Gwinnett Daily Post. “I am honored to wear the DAISY Pin and thank everyone for their support.”

Both nurses were reportedly nominated for the awards by their patients.

“Lisa is an extraordinary nurse who truly exemplifies our hospital’s SPIRIT values,” Stephanie Reid, BSN, RN, MBA, vice president of quality and chief nursing officer at Carroll Hospital, said in a prepared statement. “Her great personality, warm smile, and kindheartedness lifted this patient’s spirits at a time when she needed it most.” n

KCI Earns FDA Clearance for NPWT Officials at Kinetic Concepts Inc., San Antonio, TX, have announced FDA clearance for the V.A.C. ®Via, the company’s next-generation negative pressure wound therapy (NPWT) device. The 510(k) clearance also reportedly brings with it plans to secure market placement in early December.

A portable wound care system that features a diaphragm pump for faster draw down, longer battery life, and a higher leak rate threshold, the V.A.C.Via provides streamlined access to NPWT and is ideal for low-exudating (<80 mL/day) www.todayswoundclinic.com

12/6/13 12:05 PM

TWCnewsupdate wounds, small-to-medium-sized wounds (up to 250 cm3), split-thickness skin grafts, and immediate discharges from the acute care setting (while unit is on home V.A.C. Therapy authorization and delivery).

“We’ve listened to the feedback from our customers and patients and have taken our original system and enhanced it to better meet their needs,” said senior vice president Jim Cunniff. “The V.A.C.Via therapy unit is designed to help patients return to their normal lifestyle, while receiving up to seven days of negative pressure wound therapy in a compact, portable unit.” n

Connecticut Hospital Opens New Wound Clinic Western Connecticut Health Network has opened a new wound care clinic at its New Milford Hospital location. The new center complements and augments ser-

vices provided at the Robert J. and Pamela Morganti Center for Wound Care and Hyperbaric Medicine at Danbury Hospital.

“We are thrilled to be able to expand this important service to residents in the Greater New Milford area,” said David Charash, DO, medical director at both hospitals’ wound care centers. “The newly opened location at New Milford Hospital allows us to provide the most advanced wound care treatments and therapies, and increases accessibility to these much-needed services for the Network’s patients in the northwestern reaches of Connecticut and bordering areas of New York.”

The Robert J. and Pamela Morganti Center recently achieved accreditation by the Undersea and Hyperbaric Medical Society (UHMS) and is one of only four facilities in Connecticut to have received the designation, according to officials. UHMS awarded the accreditation of the hospital’s clinical hyperbaric facility for the demonstration of its commitment to patient care and facility safety. n

Classified

www.todayswoundclinic.com

XX-XX_TWC_NovDec_News.indd 27

Today’s Wound Clinic® November/December 2013

27

12/6/13 12:05 PM

ICD-10-CM ICD-10-CM DIAGNOSIS CODING DOCUMENTATION TIPS FOR SKIN NEOPLASMS NEOPLASMS (C43-C44)

T

he arrival of ICD-10-CM is on the horizon, and it will soon be essential for all wound care practitioners to refine their documentation skills in preparation for the new coding format. In an effort to assist our readers as they transition from ICD-9-CM, Today’s Wound Clinic will feature an assortment of ICD-10-CM documentation tools in the coming months on particular disease states or conditions that have been developed to help improve one’s documentation habits, which will be vital to the success of wound clinics in the ICD-10-CM environment. The tools may also contain information on coding guidelines when appropriate. This month’s tool covers the category of neoplasms. (Refer to our October 2013 issue for our tool on infectious diseases and an overview of our ICD-10-CM agenda.) n ICD-10-CM Diagnosis Coding Documentation Tips for Skin Neoplasms (C43-C44 Category) Topic

ICD-10-CM Code Ranges

Documentation Tips/Guidelines

Malignant Neoplasm of the Skin (Primary and Secondary)

C43-C44 (Primary) C79.2 (Secondary or Metastatic Site)

Document exact site of malignancy and type of malignant neoplasm, such as basal cell, squamous, or melanoma. The alphabetic index in ICD-10-CM will enable you to look up the type of tumor and refer you to the proper category on the neoplasm table.

If skin malignancy is metastatic, document the primary and secondary site.

Treatment for Malignancy

C43-C44 (Primary) C79.2 (Secondary or Metastatic Site)

If the encounter is for treatment of a complication of surgical treatment, specify what the complication is, such as postoperative wound infection or dehiscence, and use the complication code as the first-listed diagnosis code.

Surgical Complications

Primary Malignancy Previously Excised

Z85 Category – Personal History of Malignancy

Be sure to document primary sites that have been excised previously and are currently showing no evidence of the disease. If further treatment is directed to the previously excised site such as surgery, radiation, or chemotherapy, use the primary site code instead of the personal history code.

Document whether the multiple neoplasms are primary or secondary for each neoplasm site.

Malignancy in 2 or More Contiguous Sites

Other Neoplasms

If treatment is directed at the primary skin malignancy, it should be the first-listed diagnosis. If treatment is directed toward the metastatic site or secondary site, the secondary site should be used as the first-listed diagnosis.

D04 Category (Carcinoma in situ) D23 Category (Benign) D48 Category (Uncertain) D49 Category (Unspecified Behavior)

Document exact location of the neoplasm as well as the type, such as adenoma, lipoma, etc.

As with malignancies, the alphabetic listing shows all tumor types and directs you to the appropriate column on the neoplasm table.

RESOURCE: 2014 ICD-10-CM Official Guidelines for Coding and Reporting 2014-National Center for Health Statistics: www.cdc.gov/nchs/icd/icd10cm.htm

28

November/December 2013 Today’s Wound Clinic®

XX_TWC_NovDec_ICD-10.indd 28

!

As a reminder, please refer to the original ICD-10-CM article in the October 2013 issue of Today’s Wound Clinic for instructions on how to properly use the above grid to begin your documentation improvement program. Pointers: Remember to have any pathology reports readily available as well as documentation regarding results of any treatments rendered. Stay tuned for our next topic on pressure ulcers! www.todayswoundclinic.com

12/6/13 12:06 PM

NUTRITION & WOUND HEALING IN THE OLDER ADULT: CONSIDERATIONS FOR WOUND CLINICS The aging population is especially dependent on proper nutrition to aid wound closure. What does the outpatient clinic need to know?

Liz Friedrich, MPH, RD, CSG, LDN & Nancy Collins, PhD, RD, LD/N, FAPWCA

20

November/December 2013 Today’s Wound Clinic®

XX-XX_TWC_NovDec_GeriatricNutrition.indd 20

www.todayswoundclinic.com

12/6/13 2:51 PM

theagingpatient

W

ound care providers know that a patient’s nutritional status can have a profound effect on wound healing. Unfortunately, research has provided few definite answers as to exactly which nutritional interventions are most effective.

Nutrition assessment, diagnosis, intervention, monitoring, and evaluation are commonplace for patients within hospitals and long-term care (LTC) facilities. Unfortunately, most outpatient wound clinics don’t have protocols in place for evaluating a patient’s nutritional status and implementing timely nutritional interventions. This can be a cause for concern in instances when patients are being seen conjunctively by an outpatient wound clinic and an LTC facility. Wound care clinicians may be unfamiliar with the criteria used to determine whether nutritional status is compromised and may be unsure of which interventions are most useful if ongoing communication with LTC staff is not occurring. Additionally, many wound clinics don’t have access to a registered dietitian (RD) whose expertise is needed in evaluating and treating patients living with chronic wounds. Each patient that presents to the wound clinic will have unique nutritional needs, so clinical judgment is critical when making nutritional recommendations for all patients living with chronic wounds — particularly older adults. Comprehensive nutritional assessment can identify those needs, and regular monitoring and evaluation of weight and food intake can help determine if changes in the nutritional plan of care are needed to help facilitate wound healing.

This article will discuss how to evaluate nutritional status, review nutritional needs for wound healing, and provide practical information on how to maximize nutritional status in older adults who are living with chronic wounds.

EVALUATING NUTRITIONAL STATUS

Improving a patient’s nutritional status begins with the identification of underlying problems such as malnutrition.

Pressure ulcers are frequently connected to malnutrition, but its diagnosis is not www.todayswoundclinic.com

XX-XX_TWC_NovDec_GeriatricNutrition.indd 21

Figure: USDA Recommendations

as simple as requesting an albumin and prealbumin level. Evidence now shows that serum hepatic proteins are not the “gold standard” nutritional assessment tool.1,2 Rather, low serum albumin and prealbumin are indicators of underlying inflammation related to acute or chronic illness.1 Although this information has been in the literature for at least 10 years, it has been slow to trickle down to clinicians, who often still request serum hepatic proteins and identify a patient as malnourished on these lab results.

So how is malnutrition identified? In May 2013 the Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition published a consensus statement on the subject. The paper suggests malnutrition be diagnosed using a set of criteria that includes energy (caloric) intake, weight loss, loss of muscle mass, loss of subcutaneous fat, localized or generalized fluid accumulation that might mask weight loss, and diminished functional status as measured by hand-grip strength.1 The consensus statement emphasizes that comprehensive assessment is needed to evaluate malnutrition. Changing the paradigm in healthcare facilities to use

the suggested criteria is a dynamic work in progress that will take time to incorporate into facility protocols.

RDs in LTC facilities and hospitals typically use weight history and meal intake to help identify compromised nutritional status. That information can be difficult to obtain in an outpatient setting, but can still serve as a basis for identifying nutritional problems. Patients should be weighed at each clinic visit and weight history should be collected from medical records. Significant weight loss (defined as > 5% of body weight in 30 days or 10% in 180 days) and slow losses over time can both be indicators of changes in food intake and/or underlying medical problems. It is also important to learn about patients’ food and fluid intake by asking simple questions about what they eat. The US Department of Agriculture (USDA; reference www.choosemyplate.gov; see Figure above) recommends consuming a minimum of 5-6 oz of sources of protein, 2-3 servings of dairy, 2 c of fruits, at least 6 servings of grain products, and 2.5 c of vegetables daily. Specific meal patterns for various calorie levels

Today’s Wound Clinic® November/December 2013

21

12/6/13 2:51 PM

theagingpatient are also available (http://choosemyplate.gov/supertracker-tools/dailyfood-plans.html). It is important to understand that a patient’s intake can be suboptimal for many reasons. In the aging population, difficulty with driving, shopping, or food preparation can play a major role in the quality of the diet. Evaluating a patient’s weight over time and gathering information about his/her normal food intake can provide clues as to whether nutritional status is compromised. Knowledge of a patient’s normal intake and barriers to eating a nutritious diet can help wound care providers develop appropriate care plans.

NUTRITIONAL NEEDS FOR WOUND HEALING Energy, Protein, & Fluid The process of wound healing often results in a hypermetabolic state, meaning it requires energy above and beyond what is needed for daily activities.3 There are several ways to estimate calorie needs, but the National Pressure Ulcer Advisory Panel (NPUAP) clinical practice guidelines recommend 3035 calories per kg of body weight per day for individuals under stress with a pressure ulcer.2 Caloric requirements should be individualized and may vary depending on a patient’s medical condition, ability to ambulate, and age.

A patient with a pressure ulcer or chronic wound needs to eat enough protein to maintain positive nitrogen balance. When protein intake is not adequate, the body can break down lean body mass (LBM) to help meet its calorie needs. Preventing this process is critical because loss of LBM will impede wound healing.3 Research on protein needs for wound care patients is limited, but NPUAP recommends 1.25-1.5 g of protein per kg of body weight per day.2 To meet those needs, some patients will need more protein foods than is recommended by USDA. Renal status may change protein recommendations; those with chronic kidney disease may need less protein to prevent a decline in kidney function. Fluid intake is particularly important for older adults, who

TABLE: M ifflin-St. Jeor Formula to Estimate Resting Metabolic Rate (RMR) Men: RMR = (9.99 x weight) + (6.25 x height) – (4.92 x age) + 5 Women: RMR = (9.99 x weight) + (6.25 x height) – (4.92 x age) – 161 Equations use weight in kg and height in cm.

Source: Academy of Nutrition and Dietetics Nutrition Care Manual.

may not feel thirsty and as a result not drink enough to meet their needs. Dietitians have several ways to estimate fluid needs, but 30 mL of fluid per kg of body weight per day is a quick and easy estimation. More fluid may be needed if a wound has significant drainage or the patient uses an air-fluidized mattress.

Less may be needed for those with conditions such as heart or renal failure.

Vitamins & Minerals In the past, multivitamins and supplements such as vitamin C and zinc (nutrients thought to be important to wound healing) have been routinely ordered for wound healing. Some facility protocols still recommend these nutrients in amounts above the upper limits of the Dietary Reference Intakes established by the USDA. NPUAP guidelines suggest vitamin and/or mineral supplements should be offered to a patient with a pressure ulcer only when dietary intake is poor or a deficiency is confirmed or suspected.2 If a patient is taking a multivitamin, the addition of supplemental zinc could contribute to mineral overload. Most nutrition experts agree that eating a variety of nutrientrich foods as recommended by USDA is generally the best strategy for meeting nutrient needs, with supplements added only if they appear necessary.

STRATEGIES TO PROMOTE WOUND HEALING

Nutritious food is the first intervention for a patient with a healthy appetite. Patients should strive to eat a diet that provides enough protein, calories, vitamins, and minerals to meet their unique nutritional needs using USDA

recommendations as a general guideline. Because both calorie and protein needs are elevated in wound care patients, it often makes sense to suggest high-calorie, high-protein meals and snacks such as meats, eggs, milk, cheese, yogurt, dried beans, and nuts and seeds (including peanut butter). Recommendations should take into account a patient’s cultural background, food preferences, lifestyle, and economic limitations.Those who are on restrictive therapeutic diets might benefit from individualizing the diet and discontinuing restrictions, especially if the change increases nutrient intake and prevents unintended weight loss.2 If a patient tires easily when preparing food, wants a quick snack, or has a poor appetite at meal times, oral nutrition supplements (ONS) are convenient sources of calories and protein. Research supports the use of ONS for wound healing if needed because of poor intake.2 Various types of supplements are available, including milkshake-type beverages, clear beverages, bars, and puddings. Finding the form of supplement that a patient will consume is one key to the success of a nutritional intervention.

TARGETED NUTRITION THERAPY

Arginine and glutamine are two amino acids that are considered conditionally essential, meaning they may be needed during periods of stress, such as during wound healing. β-hydroxy-βmethyl buterate (HMB), a metabolite of the amino acid leucine, is thought to promote tissue-building and to help maintain muscle mass. Oral nutrition supplements containing arginine, glutamine, and/or HMB are available as adcontinued on page 30

22

November/December 2013 Today’s Wound Clinic®

XX-XX_TWC_NovDec_GeriatricNutrition.indd 22

www.todayswoundclinic.com

12/6/13 2:51 PM

theagingpatient continued from page 22

juncts to other ONS for tissue-building and wound healing. Research on these products is ongoing and evidence-based recommendations are not available.2 However, they are frequently used to treat pressure ulcers and chronic wounds with anecdotal success reported.

CONDITIONS THAT AFFECT NUTRITIONAL RECOMMENDATIONS Obesity Obese patients (those with a BMI≥30) and morbidly obese patients (BMI≥40) living with wounds present a challenge to clinicians. Dietitians use the Mifflin St. Jeor formula to estimate the resting metabolic rate of obese patients, (see Table on page 22) using patients’ actual body weight, even if it is well above their ideal body weight for their height.4 This formula usually results in different calorie estimates from the formula that is recommended by the NPUAP. Assessment of protein and fluid needs is complicated in obese patients; some clinicians use patients’ actual body weight and others use an adjusted body weight.

Research is not clear as to which method is most accurate. What is clear is that adding protein to the diet will also add calories, which could contribute to unwanted weight gain in an already obese patient. If a patient’s wound is healing, weight is stable, and there are no signs or symptoms of dehydration, his/her protein, calorie, and fluid needs are most likely being met. Although it might seem counterintuitive, drastic cuts in calories are not usually recommended in obese wound care patients. Reducing calories to promote weight loss could compromise wound healing by breaking down lean body mass and/or result in a diet that is compromised in nutrients. For that reason, in most cases, wound healing should take precedence over weight loss.

Diabetes Blood sugar control is important to all patients living with diabetes, but especially those with wounds. High blood glucose can lead to defective white blood cell function and make a diabetic wound susceptible to infection.

30

In the aging population, however, blood glucose goals may be relaxed based on expected life span and comorbidities.5 Food choices, including the timing and carbohydrate content of meals and snacks, can have an impact on glycemic control and any form of carbohydrate can affect blood sugars eaten in excess.

For that reason, portion control of all carbohydrates is important. Choosing whole-grain breads and cereals over refined grains will provide added fiber, vitamins, and minerals. Patients should be taught to choose appropriate carbohydrate portions and balance food with oral medication and insu-

Most outpatient clinics don’t have protocols for evaluating nutritional status. lin to help optimize glycemic control.

Patients living with diabetes should be counseled on the relationship between high blood sugars and wound healing and be encouraged to make healthy choices, but some patients will resist adhering to nutritional recommendations. Providers who work with the elderly know and respect the fact that for many older adults, quality of life takes precedence over blood sugar control. Rather than provide a restrictive diet, one key to managing blood sugars in many older adults with limited life spans is to adjust timing and/ or doses of medication to match meal consumption.5

TUBE FEEDING & WOUND HEALING

Patients with a poor intake and/or unintended weight loss may be candidates for tube feeding if it is consistent with the patient’s wishes.

Studies have not supported improved outcomes for pressure ulcers in those

November/December 2013 Today’s Wound Clinic®

XX-XX_TWC_NovDec_GeriatricNutrition.indd 30

receiving enteral support.2 The decision to place a tube ultimately lies with a patient and/or responsible party after the healthcare professional has presented the risks and benefits. Tube-fed patients with new wounds may need their feeding adjusted to meet elevated protein and calorie needs. This can usually be achieved by increasing the volume or duration of the current feeding.

Specialized formulas high in protein or designed to enhance immune function may benefit wound healing. Physicians should consult the RD to select the most appropriate tube feeding formula and determine the total volume, infusion rate, and additional water flushes to meet the patient’s needs. Tube feeding should be assessed periodically to assure the feeding is being delivered correctly and that it meets the patient’s protein, calorie, and fluid needs. n Nancy Collins is a registered dietitian and founder and executive director of Nutrition411.com. Correspondence may be sent to NCtheRD@aol.com. Liz Friedrich is associate director of Nutrition411.com and president of Friedrich Nutrition Consulting, Salisbury, NC. References 1. White JV, Guenter P, Jensen G, Malone A, Schofield M. Consensus Statement of the Academy of Nutrition and Dietetics/ American Society for Parenteral and Enteral Nutrition: Characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). J Acad Nut Diet. 2012;112: 730-738.

2. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel.

Prevention and treatment of pressure ulcers: Clinical practice guidelines. Washington, DC. National Pressure Ulcer Advisory Panel, 2009.

3. Demling R. Nutrition, anabolism, and the wound healing process: An overview. Eplasty.

2009; 9: e9. 2009 Feb 3. Accessed online: www.ncbi.nlm.nih.gov/pmc/articles/ PMC2642618/ 4. Academy of Nutrition and Dietetics Evidence Analysis Library. Adult weight management (AWM): Determination of resting metabolic rate. Accessed online: http://andevidencelibrary.com/template. cfm?template=guide_summary&key=621.

5. American Medical Directors Association.

Diabetes management in the long-term care setting clinical practice guideline. Columbia, MD: AMDA 2008, revised 2010;13,3. www.todayswoundclinic.com

12/6/13 2:51 PM

theagingpatient

continued from page 13

decreased sebum production and eccrine gland secretion. Thyroid hormone accelerates barrier function by increasing enzymes in the cholesterol sulfate cycle, and an evolving literature suggests this hormone is integral to cutaneous physiology.6 Reduced estrogen levels in post-menopausal women disturb tissue regeneration through impaired cytokine transduction.7 The anabolic process of protein synthesis requires anabolic hormones that decrease with age such as testosterone, insulin-like growth factor 1, and human growth hormone. The decrease in normal anabolic hormone activity, along with an increase in catabolic hormones, occurs with aging and chronic illness and results in decreased lean body mass and impairment of the wound healing process.8 Physiologic and pathologic changes that decrease delivery of oxygen and nutrients to the skin will adversely impact wound healing. These include anemia, hypoxia, and low cardiac output states. Anemia of chronic disease is common in chronically ill elders and hypoxia results from chronic lung diseases such as COPD. Common causes of edema include congestive heart failure, venous insufficiency, and hypoalbuminemia leading to anasarca. The anatomic and biochemical changes associated with lymphedema also impair wound healing.

Nutritional depletion and altered functional status can contribute to skin fragility and impair wound healing as well. Urinary and fecal incontinence affects a large number of elderly patients. When left untreated, the skin becomes macerated and inflamed and leads to folliculitis, cellulitis, fungal dermatitis, and loss of integrity that can result in pressure ulceration. The wound clinic provider must recognize these factors and provide interventions in the form of patient and family education, discussions with nursing staff and other primary care providers, pressure-relieving interventions, and referrals to dietitians or rehabilitation specialists.

Elderly persons have often been exwww.todayswoundclinic.com

XX-XX_TWC_NovDec_GeriatricWoundHealing.indd 31

posed to pharmacologic agents that impair skin integrity or compromise the immune system, and this can additionally impact wound healing.

Agents include chemotherapeutic drugs administered for malignancies and immunomodulators for diseases such as rheumatoid arthritis. Systemic corticosteroids and overuse of topical corticosteroids cause thinning and atrophy of the skin because of the suppressive action on cell proliferation and inhibition of collagen synthesis.

THE GERIATRIC APPROACH

The proper approach to caring for the geriatric patient living with a nonhealing wound is to take a comprehensive and multidisciplinary perspective,9 including consideration of social support systems while taking into account religious and ethical beliefs as well as quality of life. Nutritional status and assessment of comorbidities should be a component of every initial visit and addressed in an ongoing fashion. Although healing is always the best outcome, palliation with symptom control and avoiding infectious complications may be an acceptable outcome.

The social worker assists in psychosocial evaluation, entitlement assessment, placement, advance directives, and supporting the patient and family emotionally. Rehabilitation specialists such as occupational, physical, and speech therapists assist with maximizing mobility and feeding abilities. The nutritionist can assist with optimal protein and caloric intake as well as hydration. Nursing staff is critical for dressing changes, choice of dressing, and reporting changes in wound status. Home attendants spend the most time with patients and often are the best frontline resources for information on intake, functional status, and changes in condition.

Recognizing the palliative wound and educating the patient and family on reasonable and realistic treatment choices is a major role of the wound clinic provider.10 Palliative care is different from hospice and is not necessarily directed toward people who are actively dying. A palliative care ap-

proach to a nonhealing wound begins with education of the patient and family regarding rational choices followed by ongoing counseling and psychological support. Similar to a geriatric approach, the values, culture, and lifestyle of the patient must be taken into consideration when setting treatment goals. Feelings of guilt or failure among caregivers must be anticipated and dealt with in a proactive fashion.

Treatment involves symptom control for pain, malodor, and exudate with stabilization of existing wounds while preventing additional wounds and infectious complications if possible. n Jeffrey M. Levine is attending physician and Michael Cioroiu is a medical director at the Center for Advanced Wound Care at Beth Israel Medical Center and the Mount Sinai Health System, Manhattan, NY. References 1. Sen CK, Gordillo GM, Roy S, et al. Human skin wounds. A major snowballing threat to public health and the economy. Wound Repair Regen. 17 (6): 763-771; 2009.

2. Poljšak B, Dahmane RG, Godi´c A. Intrinsic skin aging: The role of oxidative stress. Acta Dermatovenerologica. 21: 33-36, 2012.

3. Vierkötter A, Krutmann J. Environmental influences on skin aging and ethnic-specific manifestations. Dermato-Endocrinology. 4:3, 227-231; 2012.

4. Epel ES, Blackburn EH, Lin J et al. Accelerated telomere shortening in response to life stress. Proceedings of the National Academy of Sciences. 101 (49), 17312–17315; 2004.

5. Sentell TL, Ahn HJ, Juarez DT, et al. Comparison of potentially preventable hospitalizations related to diabetes among native Hawaiian, Chinese, Filipino, and Japanese elderly compared to whites. Prevention Chronic Dis. 10: 120340, 2013.

6. Safer JD. Thyroid hormone and wound healing. Journal of Thyroid Research.

2013;2013:124538. Epub.

7. Zouboulis CC, Makrantonaki E. Hormonal therapy of intrinsic aging. Rejuvenation Research. 15(3) 302-312; 2012.

8. Demling RH. The role of anabolic hormones for wound healing in catabolic states. Journal of Burns and Wounds. 2005 Jan 17;4:e2.

9. Jaul E. Non-healing wounds: The geriatric approach. Arch Gerontol Geriat. 49, 224226; 2009.

10. Hughes RG, Bakos AD, O’Mara A, Kovner CT. Palliative wound care at the end of life.

Home Health Care Management & Practice. 17 (3): 196-202; 2005.

Today’s Wound Clinic® November/December 2013

31

12/6/13 12:01 PM

Advertiser’s Index Cytomedix (AutoGel System)..................................................................................................23 Derma Sciences (Medihoney)........................................................................................ Cover 2 Healthcare Business Solutions (Pocket Guide to Pressure Ulcers)........................................13 KCI (Graftjacket)......................................................................................................................19 Medela (Invia)............................................................................................................................3 Net Health (WoundExpert)............................................................................................. Cover 3 Organogenesis (Apligraf)......................................................................................... Cover 4, 32 Sechrist Industries (HBOT Chambers)......................................................................................5 Smith & Nephew (Cochrane)....................................................................................... Cover Tip

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

Please see complete prescribing information at www.Apligraf.com © 2013 Organogenesis Inc. OI-A1112 All rights reserved. Printed in U.S.A. 4/13 Apligraf is a registered trademark of Novartis.

32

November/December 2013 Today’s Wound Clinic®

16-00211D_APL_R4_TurnHealingOn Journal Ad_CommonSize.indd 2 XX_TWC_NovDec_AdIndex.indd 32

www.todayswoundclinic.com

4/29/13 9:37 AM 12/6/13 1:49 PM

ADVERTISEMENT

The Cochrane Collaboration analyzed 25 clinical studies that evaluated the use of honey in acute and chronic wounds 1

A 2013 COCHRANE REVIEW CONCLUDED THAT HONEY DRESSINGS1: Do not significantly increase rates of healing in venous leg ulcers when used as an adjuvant to compression May delay healing in partial- and full-thickness burns in comparison to early excision and grafting, and may also delay healing in cutaneous leishmaniasis when used as an adjuvant with meglumine antimoniate Might be superior to some conventional dressings, but there is considerable uncertainty about the replicability and applicability of this evidence

â&#x20AC;&#x153;There is insufficient evidence to guide clinical practice in other areas, and health services may wish to consider avoiding routine use of honey dressings until sufficient evidence of effect is available.â&#x20AC;?

Print the full review at honeystudy.com/TWC TWC_cover tip_A1113.indd 1

11/4/13 1:44 PM

TREATMENT DECISIONS SHOULD BE BASED ON THE HIGHEST LEVEL OF EVIDENCE AVAILABLE

EVIDENCE-BASED MEDICINE PYRAMID2

Systematic reviews

Strongest evidence

Cochrane Reviews

Study reports and meta-analyses Evidence guidelines Evidence summaries Randomized controlled trials, case cohorts, control studies Clinical research critiques Other reviews of literature Case reports, case series, practice guidelines Weakest evidence

Clinical reference texts

Evidence-based medicine uses the best available published evidence with a clinician’s expertise and a patient’s values and preferences according to the US Department of Health and Human Services, Agency for Healthcare Research and Quality3 The Cochrane Collaboration is an international network of more than 28,000 dedicated people from more than 100 countries who create systematic reviews of primary research investigating the effects of intervention for diagnosis, prevention, treatment, and rehabilitation The Cochrane Collaboration is an independent, not-for-profit organization that does not accept commercial or conflicted funding from organizations such as pharmaceutical companies Cochrane Reviews are internationally recognized as the highest standard in evidence-based medicine

References: 1. Jull AB, Walker N, Deshpande S. Honey as a topical treatment for wounds. The Cochrane Library. 2013;6:1-90. 2. Adapted from the evidence-based medicine pyramid, Fox Chase Cancer Center: Talbot Research Library. Available at: http://libguides.fccc.edu/content.php?pid=232226&sid=1921302. Accessed June 17, 2013. 3. US Department of Health and Human Services, Agency for Healthcare Research and Quality. Evidence-based decision making. Available at: http://www.ahrq.gov/professionals/prevention-chronic-care/decision/index.html. Accessed June 14, 2013.

To obtain a copy of the Cochrane Review of honey dressings, visit honeystudy.com/TWC ©2013 Smith & Nephew, Inc. TM1618-1013

TWC_cover tip_B1113.indd 1

11/4/13 1:44 PM

®

MEDIHONEY Dressings: A Smart Choice for Promoting Autolytic Debridement Through to Healing

High Osmolarity Week 1

Low pH

Week 9*

Week 16*

(*The only change in protocol was the addition of MEDIHONEY®. Individual results may vary.)

MEDIHONEY®, with Active Leptospermum Honey (ALH), has been shown to promote autolytic debridement1, 2, and support the healing of stalled wounds3-5 through two mechanisms of action (high osmolarity and low pH): • High osmolarity helps to pull additional fluid from within the wound bed, creating an optimally moist environment and aiding the body’s natural processes to cleanse debris and necrotic tissue from the wound.

Gel

HCS

• Low pH, Medihoney® helps to lower the ph within the wound environment, which has been shown to have wound healing benefits.6, 7

www.dermasciences.com or call 800.445.7627

Honeycolloid

Calcium Alginate

(Hydrogel Colloidal Sheet)

with Active Leptospermum Honey

Prepare. Promote. Progress.

1. Gethin G, Cowman S. Manuka honey vs. hydrogel - a prospective, open label, multicentre, randomised controlled trial to compare desloughing efficacy and healing outcomesvenous ulcers. J of Clinical Nursing 2008;18(3):466-474. 2. Acton C, Dunwoody G. The use of medical grade honey in clinical practice. British J Nursing 2008;17(20): S38-S44. 3. Regulski M. A novel wound care dressing for chronic venous leg ulcerations. Podiatry Management 2008; Nov/Dec:235-246. 4. Simon A, Sofka K, Wiszniewsky G, Blaser G, Bode U, Fleischhack G. Wound care with MEDIHONEY in pediatric hematology-oncology. Supportive Care in Cancer 2006;14(1): 91-7. 5. Gethin G, Cowman S. Case series of use of Manuka honey in leg ulceration. International Wound Journal 2005;2(1):10–15. 6. Gethin G, Cowman S. The impact of Manuka honey dressings on the surface pH of chronic wounds. International Wound Journal 2008;5:185-194. 7. Gethin G. Understanding the significance of surface pH in chronic wounds. Wounds UK 2007;3 (30): 52-54). Disclaimer: Results may vary. Photos represent one patient’s outcome. For more examples of clinical case outcomes using MEDIHONEY®, visit our website. PHOTOS COURTESY OF NANCY CHAIKEN, ANP-C, CWOCN. MEDIHONEY® is a trademark of Comvita New Zealand Ltd and is used with permission by Derma Sciences, Inc. © 2013 Derma Sciences, Inc. All rights reserved.

Untitled-1 2

11/25/13 3:57 PM

The right fit can be enlightening.

With a bird’s eye view on facility performance, it’s easy to see achievements and areas to improve. That’s why we’ve created new WoundExpert services and products to empower your facility with tools for wise decision-making. We’re here to help with the most extensive benchmarking reports, the largest wound care database, and tailored analytics. We’re the enlightening solution that gives a hoot.

Fitting, don’t you think?

Sign up for a free Wound Care Industry Report Webinar on Dec. 19 or Jan. 14 at nhsinc.com.

nhsinc.com The Art of the Right Fit™ © 2013 Net Health Systems, Inc. All Rights Reserved.

Net Health_1213.indd Health Ad.indd 1 2 Net

12/3/13 12:55 11:15 PM AM 12/5/13

Think Apligraf® FIRST after FOUR weeks of failed conventional therapy.

WITH THE POWER OF LIVING CELLS

Dermal Fibroblasts

Keratinocyte Stem Cells

Differentiated Keratinocytes

Recent evidence has demonstrated the presence of living keratinocyte stem cells in Apligraf.1 The only bioengineered, bilayered, living cell–based product with FDA approval for healing both diabetic foot ulcers and venous leg ulcers.2 Now, turn healing on and transform lives.

For information on support programs and tools available from Organogenesis Inc., call 1.888.HEAL.2.DAY (1.888.432.5232–Option 3).

Please see accompanying essential prescribing information, or visit www.apligraf.com for complete prescribing information.

References: 1. Carlson M, Faria K, Shamis Y, Leman J, Ronfard V, Garlick J. Epidermal stem cells are preserved during commercial-scale manufacture of a bilayered, living cellular construct (Apligraf®). Tissue Eng Part A. 2011;17(3-4):487-493. 2. Apligraf® [package insert]. Canton, MA: Organogenesis Inc.; 2010.

Organogenesis_Apligraf-1andhalf_0513.indd 2

4/29/13 10:23 AM