Elizabeth A. Ayello

Special considerations in wound bed preparation 2011: an update

PURPOSE: To enhance the learners knowledge and competence in wound bed preparation. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After participating in this educational activity, the participant should be better able to: Assess wounds to classify them and determine prognosis. Apply evolving evidence regarding effective wound bed preparation and recommend patient-specific therapy. This article builds and expands upon the concept of wound bed preparation introduced by Sibbald et al 2000 as a holistic approach to wound diagnosis and treatment of the cause and patient-centered concerns such as pain management, optimizing the components of local wound care: Debridement, Infection and persistent Inflammation, along with Moisture balance before Edge effect for healable but stalled chronic wounds.

Diabetic foot ulcers: Part II. Management.

The management of diabetic foot ulcers can be optimized by using an interdisciplinary team approach addressing the correctable risk factors (ie, poor vascular supply, infection control and treatment, and plantar pressure redistribution) along with optimizing local wound care. Dermatologists can initiate diabetic foot care. The first step is recognizing that a loss of skin integrity (ie, a callus, blister, or ulcer) considerably increases the risk of preventable amputations. A holistic approach to wound assessment is required. Early detection and effective management of these ulcers can reduce complications, including preventable amputations and possible mortality.

Assessing peristomal skin changes in ostomy patients: validation of the Ostomy Skin Tool

Background  Peristomal skin problems are common and are treated by a variety of health professionals. Clear and consistent communication among these professionals is therefore particularly important. The Ostomy Skin Tool (OST) is a new assessment instrument for the extent and severity of peristomal skin conditions. Formal tests of reliability and validity are necessary for its use in clinical practice, research, and education.

New opportunities to improve pressure ulcer prevention and treatment: implications of the CMS inpatient hospital care Present on Admission (POA) indicators/hospital-acquired conditions (HAC) policy. A consensus paper from the International Expert Wound Care Advisory Panel.

As part of the Deficit Reduction Act of 2005, the Centers for Medicare & Medicaid Services (CMS) initially identified eight preventable adverse events on August 1, 2007, with nine more conditions proposed on April 14, 2008.1,2 They have introduced a plan to help contain costs by rejecting payment of the higher diagnostic category when such events occur as a secondary diagnosis in acute care facilities. This policy, which began a phased rollout in the acute-care setting in October 2007 (culminating in October 2008), has created some logistical and implementation concerns in the clinical community. The financial implications for pressure ulcers will be determined by the Present on Admission Indicator (POA). The POA Indicator identifies if a patient has a pressure ulcer at the time the order for admission occurs. Now there is a renewed urgency and heightened focus on prevention because beginning in October of 2008, the hospital will not receive additional reimbursement to care for a patient who has acquired the pressure ulcer while under the hospital’s care. Like any groundbreaking policy, this provides impetus for change. We view this payment provision as challenging, but one that provides all clinicians and particularly wound care specialists with an opportunity to assume leadership in important preventive healthcare strategies. Pressure ulcers represent the possibility to implement best practices to improve outcomes. In FY 2007, CMS reported 257,412 cases of preventable pressure ulcers as secondary diagnoses.2,3 The average cost per case in which pressure ulcers were listed as a secondary diagnosis is estimated to be

MDS 3.0 section M: Skin Conditions: what the medical director needs to know.

43,180 per hospital stay.2,3 The incidence of new pressure ulcers in acute-care patients is around 7 percent, with wide variability among institutions.4 The Medicare program’s hospital inpatient prospective payment system (PPS), as currently set forth, will no longer assign a higher DRG for facility-acquired pressure ulcers effective October 1, 2008.5 Physician/provider* determination and documentation during the hospitalization that J Wound Ostomy Continence Nurs. 2008;35(5):485-492. Published by Lippincott Williams & Wilkins

Pressure ulcer prevention and treatment: use of prophylactic dressings

The Centers for Medicare and Medicaid Services has released the new Resident Assessment Instrument version 3.0, which went into effect October 1, 2010. The intention of the revised Resident Assessment Instrument is to improve health-related quality of life and care planning, and incorporate evolving standards of terminology, assessment, and technology. To reach this goal, Section M: Skin Conditions has been greatly expanded and will alter the process of pressure ulcer assessment in all long-term care facilities across America. Details of this assessment instrument include upgraded criteria for risk factors, staging, identification, tracking, and evolution of pressure ulcers. The medical director can and should assume a leadership role in education and collaboration with primary care physicians and wound clinicians to accommodate changes in revised Section M. Integrating the medical director into the facilitys wound care program will improve the quality of care for residents of long-term care facilities.

Perioperative use of bispectral (BIS) monitor for a pressure ulcer patient with locked-in syndrome (LIS).

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Diabetic foot ulcers: Part I. Pathophysiology and prevention

The bispectral (BIS) monitor uses brain electroencephalographic data to measure the depth of sedation and pharmacological response during anaesthetic procedures. In this case, the BIS monitor was used for another purpose, to demonstrate postoperatively to the nursing staff that a patient with history of locked‐in syndrome (LIS), who underwent pressure ulcer debridement, had periods of wakefulness and apparent sensation, even with his eyes closed. Furthermore, as patients with LIS can feel pain, despite being unable to move, local block or general anaesthesia should be provided for sharp surgical debridement and other painful procedures. This use of the BIS has shown that as a general rule, the staff should treat the patient as though he might be awake and sensate even if he does not open his eyes or move his limbs. The goal of this study was to continuously monitor pain level and communicate these findings to the entire wound team, i.e. anaesthesiologists, surgeons and nurses.