A: A 2014 analysis of Medicare spending found between $28.1 billion and $96.8 billion per year was spent on wound care in the US. 

Limited data was available for costs specific to post-acute or long-term care settings, but wound care is undoubtedly expensive. Wound care standards require that the initial assessment of a patient at every skilled nursing facility must include a head-to-toe skin assessment. Staff must also complete an assessment to determine if risk factors for skin breakdown are high, moderate or low. Post surgical and diabetic wounds require rigorous observation and care since they are at higher risk of complication. 

Unfortunately, scrutiny is severe at nursing facilities compared to hospital settings. Wound experts at the hospital are mostly part-time contractors, while many SNFs have wound experts visiting the location weekly to provide hands-on education during the wound rounds. 

There is no comparison of one location versus another in terms of patient care, though often nursing facilities have restricted treatment options due to Medicare or Medicaid reimbursements. 

It is important to understand the barriers to efficient wound care management. Often providers feel uncomfortable handling wounds and leave the matter to the rounding wound experts who come into the facility once a week. This trickles down to the nursing team who are required to assess the wound with every wound care treatment. It is reminiscent of a famous saying: “We are the enemy of what we don’t know.”

It is important to have adequate knowledge and expertise in wound care for improved patient care and cost efficiency. After all, as another famous saying goes, “An ounce of prevention is worth a pound of cure.”

As a leader, you are in charge of financial stability, quality standards and patient care. After 11 months of hard work, you take vacation for 10 days. Upon return, you find out there was survey with an F-Tag 314 for an in-house Stage IV pressure ulcer. 

The surveyor interviewed then observed the nurse performing the wound dressing and reviewed the wound documentation. The wound nurse in your facility comes every Tuesday, and the surveyors came on Wednesday. The regular nurse got anxious and was not able to answer questions and missed the Braden Scale assessment.

Documentation showed skin assessment was missed at the time of admission, and the wound was discovered when it was stage II. Secondary to the patient’s immobility and recent back surgery, the wound progressed to stage IV quickly. No one documented a wound description, risk factors or the unavoidable status of the skin injury. Late detection, inadequate risk assessment and poor documentation lead to this citation.  

Long-term care can be a punitive environment. No matter how many boxes you check, something may be missed. But  this may not be the case if we develop a system of accountability.  For example, in the above case, simple steps like conducting a Braden  assessment at admission, performing a  weekly skin assessment, providing nurse education, ensuring diligence to accurate risk assessment and better documentation could have prevented the F-Tag. 

The F-Tag was given to the facility secondary to the lack of assessment and documentations at the time of admission. For providers to have knowledge regarding skin injury, risk factor and the possibility of healing or non-healing are empowering for the patient and the staff. Every patient deserves respect with empathy and should not be treated as “just a number.”

A: Not necessarily! 

Extensive work is done in assessment, identification and treatment of a pressure ulcer to understand the patient‘s needs and avoid F-Tag 314.

The key to success is to have the skin assessment at the initial assessment. It is a good practice to use standardized tools, such as the Braden Scale, to assess the nutritional status, cognitive status, swallowing difficulties, dental status, medications, comorbidities and immobility that could prevent wound healing. 

Many patients have venous, arterial or neuropathic diseases that may affect the circulation in the lower extremities, consequently leading to ulcers. Patient history also should be acquired. Ballet dancers and soldiers may end up with undesired foot problems due to prolonged standing or uncomfortable footwear use in the past.

 Another key factor is that older adults may not have access to fresh fruits or vegetables, which can lead to nutritional deficiencies and avoidable skin breakdown. That can occur in areas of previously healed ulcers due to decreased tensile strength of scars. 

The location of the wound with associated symptoms is an important aspect of initial assessment. For example, arterial ulcers are punched out and circular with mild drainage, while venous ulcers are shallow with ragged edges and profuse drainage. Neuropathic ulcers are painless for the most part, though they may have associated neuropathic symptoms in other parts of the body. Frequently, there are multiple factors that lead to wound formation. While a few may be modifiable, many are not. 

In conclusion, it is essential to know the medical, cultural, economic, educational and psychosocial background of one’s patient. This will allow a thorough person-centered understanding and therapeutic healing with the patients.

Please send your wound care-related questions to Dr. Naqvi at ltcnews@mcknights.com.

A: What is the best treatment option for necrotic wounds — collagenase or manuka honey?  Though collagenase is often suggested for pressure ulcers, it is both costly and not easily accessible.

Let’s review a few details regarding these treatment options. Collagenase is the only agent that functions as an enzymatic debridement. Collagenase formulation is an enzyme derived from the fermentation by clostridium histolyticum. It has the ability to digest collagen in necrotic tissue.

Santyl is the only FDA-approved enzymatic debrider. It is indicated for debriding chronic dermal ulcers (diabetic foot ulcers and pressure ulcers) and severely burnt areas. Ointment is applied once a day or as needed. Antibiotics are applied prior to the application of collagenase if a local infection is present. Treatment can last for a few weeks until debridement is complete or granulation tissue is established. 

Manuka honey is a monofloral honey derived from manuka tree (leptospermum scoparium). Its chemical composition is suggested to have antioxidant and antibacterial activity and can help maintain a moist wound environment. It has pro- and anti-inflammatory effects leading to absorption of the devitalized and necrotic tissue as autolytic debridement agent, which promotes healing by better re-epithelializing and decreasing the bioburden on the wound bed. 

Most of the research is expert opinion or meta-analyses that may involve bias.  This makes it difficult to find conclusive evidence. Whatever treatment is chosen, review wound progress daily and weekly, or with every dressing change. There may be many local or systemic factors leading to the maceration of the skin around the wound, worsening infection, or compromised circulation that can stall the wound healing.

A:  A punitive environment can be minimized with a proactive approach of care and by maintaining standards of practices. The F-tag F 686 is for skin failure and includes F 483.25 (b) for skin integrity and F 483.25 (b) (1)for pressure ulcers. 

The intent from the Centers for Medicare & Medicaid Services is that a resident does not develop pressure ulcers or skin injury unless it is clinically unavoidable, and the facility provides care services that maintain the professional standards of care. 

Multiple risk factors including age, dry skin, previous sun exposure, multiple medications and systemic factors including co-morbidities, can make skin injury unavoidable. As we age, subcutaneous fat decreases, and elasticity of the skin, vascularity, Langerhans cells (the fighter cells in the skin), sweat glands, and thermoregulation are all altered. This leads to weaker skin. Dry skin is one of the most common factors for skin breakdown, and excessive moisture and sweat can cause skin excoriation. 

The history of sun exposure can lead to photoaging. Signs include hyperpigmented skin, fine veins on the surface of sun exposed skin, freckles (melasma), and actinic or seborrheic keratosis. Medications, including some diuretics, antibiotics and local or systemic steroids, also can cause photosensitivity and skin reactions. 

Other risk factors, such as excessive adipose deposition, chronic conditions, acute systemic infections and even stress (which leads to an increase in steroid hormones) can lead to skin damage with the slightest risk for skin integrity. 

 A proactive approach including assessment for risk factors of unavoidable skin breakdown, as well as timely and comprehensive documentation, are the first steps for standards of practice.

Fatima Naqvi, MD, CMD, is medical director of AMDA – The Society for Post-Acute and Long-Term Care Medicine. Send her your wounds-related questions at ltcnews@mcknights.com.

A: Literature and research supports the use of antibiotics when deemed appropriate, though unnecessary use can lead to antibiotic resistance and development of MRSA and VRE. Where  does one draw the line in post-surgical wound care for older adults when the risk of infection is higher,  compared to younger individuals with fewer comorbidities?

The situation can be more complex when leaders are striving to maintain Quality Assurance and Performance Improvement standards for antibiotic usage.

It’s critical to understand each patient’s individual infection risks. 

Factors that predispose a person to develop infection include patient characteristics such as uncontrolled diabetes, smoking status, excessive deposition of adipose tissue, and autoimmune disorders that can lead to immune deficiency. Pre-operative risk factors also can factor in, such as when a patient with uncontrolled diabetes or hypertension needs an emergency hip replacement.

Then there is a suboptimal aseptic environment caused by  improper hand hygiene or skin preparation prior to the surgery. Post surgical risk factors may involve all of the above and the inability to mobilize early, excessive moisture or dryness, improper wound care and the inability to differentiate between inflammation during the healing process and development of infection.

Standards of care practices guide us toward initiation of the antibiotics when appropriate with the duration of the therapy.

Key factors for early detection and prompt intervention are to know your patient as a person, and to assess and examine them and their wounds at the time of admission. Timely follow-up with accurate documentation is doing the right thing at the right time. 

A: It is important to know what outcome to expect when a patient with a wound is being discharged from a rehabilitation facility. Will the wound heal or maintain its status quo or is it non-healing? As many efforts are made to heal any wound, one needs to know the key factors that will guide care.

The first priority is to assess the healing ability of the wound. Factors that foster wound healing include a correctable cause and adequate blood supply. Non-healing wounds, on the other hand, do not have a correctable cause or adequate blood supply. 

Wounds often persist though they may have the capability to heal. Both patient-related factors and healthcare factors can impair healing. Administrators, nurses and others should understand whether a patient can help care for himself or herself and how the patient perceives the wound. 

Also, ask if the patient is able to access and afford necessary wound care products. Does the patient or a caregiver know how to care for wound care equipment? Often, these inquiries are made but missed at discharge, resulting in wound deterioration, infections and recurrent hospitalization. Person-centered care may take extra time but can lead to much better outcomes. 

Documentation of these assessments are an important part of resident care. Litigation and liability risks amplify if such care is not documented. The documentation of initial assessment, daily monitoring and weekly assessment is the minimal expectation by the Centers for Medicare & Medicaid Services. Excellent patient care and timely documentation saves the residents and the facilities from unwarranted frustrations and litigation. After all, what is not documented is not done!

Please send your wound care-related questions to Fatima Naqvi at ltcnews@mcknights.com.

A: In post-acute and long-term care facilities,  older adults with lower extremity  wounds may have unknown ulcer etiology. Is it arterial, venous or both? Does it have associated neuropathy? Diabetics with arterial vascular disease may not manifest pain.

In some facilities, staff opt for the in-house audible handheld Doppler ultrasound (AHHD), which can provide bedside testing. Information from an AHHD can benefit the patient, but it does not supersede the importance of history taking and examination. 

Arterial ulcers are often painful unless patients have severe neuropathies. Such patients suffer with claudication pain. It may be a stabbing, burning sharp and/or achy pain associated with ambulation. It is relieved with rest. With disease progression,  pain becomes persistent and gnawing. It often causes severe sleep disturbances. For a patient with any wounds, it is also helpful to explore whether the ulcer is healable. 

Noninvasive bedside testing is ideal for older patients in post-acute or long-term care settings. It can allow the wound care expert to rule out peripheral arterial disease. However, it may be falsely high in diabetics (80%) and older adults (20%). A Doppler with 8-MHz or more yields the best results. Just placing the Doppler on the lower extremity vascular system is not enough. Also perform a procedure to check for the ankle-brachial pressure index (ABPI)..

As of today, the arteriogram remains the gold standard for arterial testing and is done when a bypass or arterial dilation procedure is required. 

It may not be a big deal whether or not you have AHHD in your facility, but what is more important is how the healthcare team provides person-centered care. It is best to strive for healthy habits and healing, regardless of the patient.

Q: How do pain management and wound care intersect?

A: In the US, the crisis of opioid abuse, dependency, overdose and death continues. Controlling the dispensing process in response to the addiction epidemic may have slowed it, but it did not eliminate it.

Mortality data shows that in 2018 approximately 67,000 people died from drug overdose, down from 70,000-plus in 2017. But what do these numbers mean for older adults living with chronic medical conditions in long-term care facilities?

How should I manage the wound pain of a 65-year-old patient who has multiple complex comorbidities versus a 90-year-old male with minimal comorbidities, who still walks three miles every day? Does it matter if the older adult has used recreational drugs in the past?

Pain is not just a subjective finding. It is well known as a biopsychosocial phenomenon that involves physical, mental, emotional and psychosocial components. Often, the main risk factors that predispose one to opioid misuse or addiction are past or current substance abuse, untreated psychiatric disorders, younger age and social or family environments that encourage these behaviors.

The post-acute environment is highly regulated and controlled with the supervision of nursing staff and leaders who monitor controlled substance count, supply, usage and proper disposal, which often minimizes drug diversions and abuse potential.

Pain management in older adults requires a thorough understanding of their age-related physiological changes, comorbidities, polypharmacy, and patient related factors in the particular condition of the wound, be it acute or chronic. Let’s decide together, and treat every patient as a unique individual requiring person-specific care.

Q: Why should diabetic wounds be taken more seriously than non-diabetic wounds?

A: Diabetic foot complications are one of the most common complications that lead to hospitalization. In the United States, the lifetime risk of developing diabetes is approximately 40%.

As of 2014, approximately 29.1 million (9.3%) of Americans were said to have diabetes. It is the leading cause of cardiovascular morbidity and mortality, renal failure, blindness and amputation. Prognosis of a foot ulcer is changed dramatically due to the presence of diabetes, because the underlying pathology is not reversible.

Some of the complexities of diabetic wounds are as follows: Previous foot ulcers, non-healing wounds, recurrent infections, previous or pending amputation, recurrent hospitalization, financial burden, and compromised social, psychological or mental health.

Prevention with early detection is the best initial strategy. Risk factors for developing a foot ulcer in patients with Diabetes (Type I and Type II) include: uncontrolled diabetes, smoking history, presence of neuropathy; or its signs and symptoms, previous foot ulcer or amputation, signs of toenail fungal infection or inflammation, dry skin, and other skin abnormality of the foot (e.g., toe webs, bottom of the foot). For example, psoriasis, corns, calluses, blisters and dermatitis can predispose to skin ulcers, presence of bony abnormality, foot/ankle edema (swelling), arterial disease, absence of foot pulses and venous disease.

Perform an appropriate history and physical exam with risk assessment upon admission. Patient-centered standards of practice for foot ulcers, along with early prevention and optimal treatment, are crucial for preventing complications.