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Surgical Wounds: A little clarity

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Hi Everyone,

This past week I received a question in my email:

“I had the pleasure of watching one of your wound videos this weekend and have a question for you about MO 1342.  What are the current guidelines.  I have been talking with some of our nurses and we used to answer either Newly Epithelialized or NOT healing/not healed.  I remember talking with Dorothy Doughty about this question and she just laughed at me and said that ten people lined up will give ten different answers…so pick the one that shows progress at the end of the cert period..she admitted she was being silly but that’s how silly the questions is.  Still and all it is what we, in home health have to work with. ”

Indeed, OASIS is what we in home health have to work with.

M1342 has always been a source of great consternation. As I have said before, if the wound is healing by primary intention, you have two answer choices, and you probably won’t like either of them.

The item is:

(M1342) Status of Most Problematic (Observable) Surgical Wound:

0-Newly epithelialized

1-Fully Granulating

2-Early/partial granulation

3-Not healing

As you know, wounds healing by primary intention don’t granulate. That leaves only 0 or 3 as possible choices. The dilema is, as nurses, we can assess that a surgical wound is healing beautifully, but if it is not fully epithelialized, we are forced to choose response 3, Not healing. It just doesn’t feel right, does it? But, go ahead, choose it. It is what we have to work with in home health. You can describe the wound better in your documentation.

And what about scabs? That is always another problem. Do they mean you automatically choose 3-Not healing?

Well, the latest guidance from CMS finally does address scabs. They say “The presence of a scab does not automatically equate to a “not healing” response. The clinician must first assess if the wound is healing entirely by primary intention (complete closure with no openings), or if there is a portion healing by secondary intention, due to dehiscence or interruption of the incision.”

The scab question comes up with wounds healing by primary intention. CMS goes on to say, “If there is not full epithelial resurfacing such as in the case of a scab adhering to underlying tissue, the correct response would be ‘Not healing’ for the wound healing by primary intention.”

So, is the scab adhering to underlying tissue? How do we know? Well, one way to find out is to pick it off and see if it bleeds (that was a joke. Please don’t do that.) I would say, if you cleanse the wound and the scab is solidly attached, it is adhering to underlying tissue, therefore, choose 3-Not healing as your response. (Don’t even argue with yourself that the wound is healing beautifully, etc. Just choose it.)

I hope this is helpful.

I am standing with you for quality patient care.

Sue

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Wound and Formulary Management Plan

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The Basic Basics

  • If there is infection, treat it.
  • If it’s wet, absorb it.
  • If it’s dry, hydrate it.
  • If there is a hole, fill it.
  • If there is necrotic tissue, remove it.
  • If there is healthy tissue, protect it.

Use this grid to make wound dressing decisions based on wound characteristics. These are the basics.

Wound Type Shallow Deep
Wet Foam Alginate
Dry HydrocolloidTransparent Film Hydrogel

Special Dressings for Special Situations:

Infection Prevention (eg. immunosupression, diabetes, poor home hygiene) –PHMB Kerlix and gauze

 

Rolled Edges – HydroferaBlue

Odor – Silver dressings (and/or metronidazole gel or crushed tabs)

Hypergranulation –HydroferaBlue

Clean wound bed with no granulation tissue – collagen powder (if wet, add hydrogel or use SilvaKollagen)

Need to use enzyme debriding agent with antimicrobial dressing – HydroferaBlue

Infection – Silver dressing appropriate for wound (see above), HydroferaBlue, PHMB gauze

Arterial Ulcer – SilvaKollagen

Eschar, Dry – Hypergel

Eschar, Wet – Mesalt

Getting Wound Care Under Control

 

When you look in your supply closet, do you have a little bit of many unused products? Does your purchaser go crazy trying to fill orders for all different kinds of dressings because the doctor’s orders call for them? Do you think dressings are not being used properly, because no one can keep up with all the different choices out there?

 

Here are the steps to follow to get control.

 

 

1. For most wound care, get orders using CATEGORIES, not brand names. Use the Basic Basics of wound care and the Grid to select the correct category. If you order by category, you can use any brand of that category, so you can use the less expensive ones that you keep in your formulary (hopefully purchased from this website :-) ). You won’t need to have 4 different kinds of foam around and 6 different brands of alginate. You will have your formulary of what you use.

 

2. Identify special situations — suggested ones are listed above — and know in advance what you use for those situations and have those products on hand (a little to get started) and have them as part of your formulary, so you know what to recommend when those situations arise. Don’t just take the shotgun approach — let’s try this. Oh, that didn’t work. Let’s try this. Etc. Get those wounds out of their ruts, then you can go back to the less expensive supplies listed in the grid.

 

 

3. Be proactive with doctors. Make a basic basics list and a grid and a special situations list, like the ones above, and take them to the offices of the doctors you deal with the most. I recommend you give the list to the NURSE or MA so it doesn’t get lost. Tell them that this is what you use. You could also make a list of the categories and specific products in your formulary, so the doctors know what to order. As you know, most of them want help with selection wound care for their patients. Give it to them. You will also be giving them the confidence that your agency knows what they are doing, when it comes to wound care.

 

4. Work with doctors and wound clinics that don’t want to work from your formulary. Develop a reputation of being agreeable to work with. In the meantime, find out what those doctors and wound clinics use routinely, and add those products to your formulary BUT separate them from the rest of the wound care products. Designate areas as Dr. Soandso’s wound products, or XYZ Clinic’s wound care. If you can’t beat them join them, and you will get their referrals. If there is a wound clinic in your area, find out what THEIR formulary is. Find out what products are on THEIR carepaths, and add them to your formulary and make a special place for them. Then, when they order a treatment, then change it in two weeks, you are ready for them. You will lower your own stress level, and gain a great reputation.

 

5. Finally, learn to use your products correctly. There is a lot of information out there. For example don’t use two expensive products that counteract each other. For example, don’t use a hydrogel with an alginate or a foam. They do opposite things! That is a waste of money. Just learn to use things correctly, and you will save money.

 

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Practical Wound Formulary Help!

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I have not been writing very often lately, because I have been working on a class for Beacon Health on cost effective wound care in home health, and working at my job, of course.

While working on the Beacon class, I have been thinking a lot about wound formulary management. I keep thinking “If they would just do it MY way!”  And the more I thought about it, the more I thought I should make a new website,

SO I DID!

It is Sue’s Wound Formulary of course! I did it MY way!

Yes, I am selling the products in my formulary, but I am well aware most of you already have contracts with big companies, so you won’t be buying from me, but don’t let that stop you from visiting the site!

The front page has a complete wound care plan and wound formulary management plan on it!

There is a ton of very practical information there that you can use today.

Of course, I hope some agencies will decide to purchase advanced wound care products from me, and work with me as their CWOCN, but the front page is for all of you to use.

So, take a look at Sue’s Wound Formulary and make use of everything you can.

I am standing with you for quality patient care!

Sue

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Nutrition Assessment?

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Hello Everyone,

I recently read an article in Wound Source, by Mary Ellen Posthauer RD, CE, LD, on the significance of the patient’s serum albumin and pre-albumin. This is an article that will change my practice!

I was taught that those lab levels indicate the nutritional status of the pt. over the short term and the long term. Were you?

My habit has been to look at those levels as an indication of nutrition status, and at the CBC to see if the cells needed for healing are present.

Well, what does the research indicate?

Here is a quote from Mary Ellen’s article:

“Multiple studies, either randomized, interventional, or prospective cohort studies, fail to demonstrate a relationship between nutritional status and serum protein levels. Declining intake does not correlate with declining serum protein levels, nor does increased nutritional intake result in improved values. Low levels of albumin and pre-albumin are indicators of morbidity and mortality, and increased levels may reflect the improvement in the overall clinical status of the individual.”

In other words, those labs do not indicate nutritional status, but rather, the general condition of the patient.

So, how do we assess nutritional status?

Just the way we already know how. We look at the patient. What is the weight related to the height? Has there been recent weight loss? Is nutritional food difficult for the patient to access? Is the patient dependent on someone else to cook and provide food for him? Has the patient had a loss of appetite? Can the patient feed herself? What is the patient actually eating? This is the place for food diaries.

So, we can look at serum albumin and pre-albumin to assess improvement or decline in the general condition of the patient, but not nutritional status.

Who knew?

I’m standing with you for quality patient care!

Sue

PS– If you struggle with wound formulary management, I am working on a website that addresses just that. I will keep you posted.

Posthauer, ME, (2011). Albumin and pre-albumin: Are they markers of nutritional status in wound management? Retrieved 7/8/11 from http://www.woundsource.com/blog/albumin-and-pre-albumin-are-they-markers-nutritional-status-wound-management

You don’t have to be an incontinence expert to help your home health patients improve incontinence, and improve your incontinence scores. Read more HERE.

 

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Wound Care in a Nutshell

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Here are the basic basics. I don’t think I can boil it down much more than this.

  • If there is infection, treat it.
  • If it’s wet, absorb it.
  • If it’s dry, hydrate it.
  • If there is a hole, fill it.
  • If there is necrotic tissue, remove it.
  • If there is healthy tissue, protect it.

There is nothing more for me to say!

I’m standing with you for quality patient care.

Sue

sue@woundconsultations.com

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Struggling With Infection Definitions?

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Do you have an infection prevention program that includes monitoring wound infections? Are you having trouble deciding which wounds are infected? Are you using cumbersome wound infection definitions that are intended for hospitals and are difficult to implement in home health?

If so, you REALLY need to read this article from the website of the Association of Professionals in Infection Control and Epidemiology (APIC). It is specifically written for home health, and it addresses other infections besides just wound infections.

When you read these definitions, remember that you must look at each individual infection reported by your staff to see if it meets the case definitions. If it doesn’t, it doesn’t count as an infection — even if the physician has ordered an antibiotic! (Unless you specifically add that to the case definitions specific to your facility).

The article is here.  I hope this is helpful for you.

I’m standing with you for quality patient care.

Sue

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Chemical/Enzyme Debridement

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In all wounds, your first consideration is infection, followed closely by debridement, if there is non-viable tissue (slough or eschar).

Sometimes, the thing to do is send the patient to the doctor for sharp debridement, but at other times, that is not possible or desirable, and enzyme debridement is implemented.

There are two main types of enzyme preparations used: collagenase (Santyl ointment) and papain/urea (Panafil, Accuzyme). While it is true that each works best on specific types of necrotic tissue, it is very difficult to tell what type of tissue you are working with, so decisions about which type to use are usually based on availability, cost, ease, frequency of application and familiarity with the product (Bryant & Nix, 2007).

As clinicians, we want to know how to use the stuff! Right? There always seem to be questions about moist or dry, how to protect the edges, etc. One reason why these questions are out there is that there is no clear consensus on what really is the best procedure! (Don’t you just love science?)

So, here is what I do.

If there is thick eschar, I crosshatch it with a scalpel. That is, I make VERY SHALLOW cuts in th eschar so the ointment can get into the eschar. You need training to do this, and it has to be within your scope of practice. It might be wise for your agency to have one or two nurses trained to do this.

Then I apply skin prep around the wound, or a barrier ointment or cream. This is to protect from excess moisture.

Then I apply a thin coat of enzyme ointment to the non-viable tissue.

I cover that with damp (wetted and wrung out well) gauze.

If there is a caregiver who is willing and able, I like to have the dressing changed twice a day. In that case, I use gauze of ABD as a secondary dressing.

If the best we can do is daily dressing changes (Ugh!), then I use something that will retain the moisture better, such as a composite dressing (Like Coversite of similar). If there is more drainage I use foam.

Keep in mind that heavy metals inactivate enzymes. That includes silver and zinc. Also, many wound cleansers inactivate enzymes.

As the non-viable tissue breaks down, expect increased drainage.

Just FYI, the antimicrobials in Hydrofera Blue are not inactivated by the enzymes, and the enzymes do not inactivat the HF Blue.

Once the wound is cleaned up, it is time to change the wound care to something appropriate for the wound.

I’m standing with you for quality patient care.

Sue

sue@woundconsultations.com

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Scab vs Eschar

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Do you and your nurses know the difference between scabs and eschar? Here it it:

A scab is made up of dried blood and exudate. It sits on the surface of the skin.

Eschar is dead tissue within the wound.

Short one, huh?

I’m standing with you for quality patient care.

Sue

sue@homeline360.com

Wound Healing Partners

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Blister Management

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Today I am going to give you an idea you will love!

What do you do with a blister? You know the problem. You discover a blister. If you don’t do anything, it will probably unroof and be open and vulnerable by the time you go back for a follow up visit.

If you put a transparent film on it, there will be a puddle of fluid in the dressing that will either leak or cause maceration and further skin breakdown.

What to do??

Here is what I do:  Cleanse the area well with saline or wound cleanser. Allow to dry well. Place a piece of alginate over the blister, then cover that with a transparent film dressing. That’s it!

Now, if the blister stays intact, great. If the blister opens up, the alginate will absorb the fluid and provide the wound bed with a moist wound environment, ready for you to assess when you make your visit.

While we are on the topic of blisters, remember, a serum-filled blister is a stage II. A blood-filled blister is a suspected deep tissue injury.

I’m standing with you for quality patient care.

Sue

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#5 Interventions for PU Treatment

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Here’s what usually happens. Risk assessment, check. Skin assessment, check. Patient has a pressure ulcer. Nurse says, “What should I put on this?”

Whoa! Let’s back up a little!

The first principle of wound management is, eliminate the cause (if possible). So, with a pressure ulcer it isn’t a question of putting something ON the ulcer, but rather, taking something OFF the ulcer. That is, the patient!

That is not always as easy as it sounds. But you all knew that, right?

For example: You have a patient with a stage III PU on her coccyx, probably caused by pressure and shear, because she has CHF and has to have the head of her bed up to breathe.

You will not be able to save the day by telling her, or her caregivers, to put the head of the bed down. Sometimes you have to be creative.

For one thing, in this case, she needs a pressure redistributing surface, such as a 4″ foam overlay, or a low air loss overlay, or even a low air loss mattress.  Another thing to consider would be having her sit, upright, in a chair for meals. The under appreciated chair does relieve pressure from the coccyx/sacral area (and trochanters and heels, by the way). However, it does place pressure on the ischial tuberosities, so she can’t stay in the chair too long.

Once the cause, pressure, has been addressed, the rest of the patient needs to be addressed. What else is going on that is slowing healing? Is there infection? Does he have diabetes that is not well controlled? Does she eat only corn chips all day long? Does he remove his oxygen giving him O2 sats of 89% consistently? Is there fecal and/or urinary incontinence?

Look at the whole patient. Not just the wound.

Once you have done those two things (and dealing with infection is included in those things), you may, FINALLY, think about what to put on the ulcer. By the time you reach this stage, it is like other wound care. You evaluate the characteristics of the wound, and you use dressings that will provide a moist wound healing environment. Not dripping wet. Moist.

So, if the wound is dry, you would add moisture with a hydrogel, or a hydrocolloid (Hydrocolloids are for shallow wounds only).  If the wound is dry and deep, you can put hydrogel in the wound, then put gauze in with the hydrogel to fill the dead space.

If the wound has drainage making it too wet, you would want to manage that drainage with alginate and/or foam dressings. In deep wounds, alginate or cavity foam can go in the wound. A foam or just ABDs can cover the wound. In a wet wound, make sure you protect the periwound skin with a skin prep.

If the wound has slough or eschar, the wound needs to be debrided first (repeat: first). This can be achieved with sharp debridement by a physician, or by using an enzyme debriding agent. (I would like to mention here that, if a pressure ulcer is surgically debrided in the OR, it remains a pressure ulcer. It does not become a surgical wound for OASIS-C).

Another way to debride a wound is with autolytic debridement. That is, providing an environment for the body to debride the wound. This can be done by covering the wound with a transparent film and allowing the moisture to accumulate. This has to be checked every day, and it is slow. I don’t use it often, because I think the patient is at a higher risk of infection the longer the non-viable tissue is there. This also won’t work with an immunosuppressed patient, because they won’t have the white cells necessary to break down the tissue.

Mechanical debridement, eg. wet to dry dressings or whirlpool, are not recommended, because they are non-selective. They harm the good, new tissue along with removing the non-viable tissue.

So, basically, you think in this order:

Remove the cause, evaluate the whole patient to discover contributing factors including infection, treat infection, remove non-viable tissue, provide a moist wound healing environment based on the wound characteristics.

I have covered a LOT of territory here in a short space. Please feel free to ask question and make comments. I know you all have ideas to add!

I hope this series has been helpful, and I hope you will give me ideas for other series or single posts.

I’m standing with you for quality patient care.

Sue

sue@woundconsultations.com

PS I am working on a class, on CD, that is in 15 minute modules that goes much more in depth on wound care. It is called Wound Care for Home Health Nurses. I know that people who have been with me a while are wondering what is taking me so long with this class! Anyway, here is a clip from the class, so you can see what it is like. I will let you know when it is ready.

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