Wound Email - October 10, 2008

Wound Care Information Network

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October 10, 2008

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I work for Utah Medicaid policy. We are in the process of looking at our policy and criteria related to wounds and care. We have recently met and voted to not cover negative pressure wound therapy after January 1, 2009. We need any evidence -based articles or a statement of your support for wound vacs and why you support it. Darlene, R.N,, B.S.N., C.C.M. Bureau of Coverage Reimbursement Policy	I don’t work in Utah but surely use wound vacs on patients. I have no research articles for you but can give a testimonial for their use. They have cut healing times by days and weeks therefore cutting cost for wound treatment. I am surprised that research is not more readily available. I will look into that. Heidi, MSPT ---- Oh my gosh if we did not have a wound vac my mother would never get out of bed. The wound vac is the only treatment that has cleared up her wounds completely. We have struggled for months with the regular bandaging and tried different products but until she was admitted to the hospital for heart problems and they put her on the wound vac, did her wounds clear up. The Dr.s are always hesitant to order them for her but they really do work! Unsigned
Is a blood blister coded the same as a blister? (stage ll). Thanks Logan	It depends on what you mean by "coding." For the NPUAP pressure ulcer staging system, serous fluid blisters are a stage II, if due to pressure/friction/shear. Blood blisters are staged as deep tissue injury (DTI). You can find more information at www.NPUAP.org. If you meant coding for reimbursement issues, it depends on your setting to some extent. Medicare/CMS does not recognize DTIs at this time. Renee C, PT, PhD(c), MSPT, MPH, CWS ---- No, blood blister is staged as DTI (deep tissue injury) unsigned ---- i would call it suspected deep tissue injury if it is maroon in color and not elevated based on the new classification of pressure sore. but if it like a serum filled blister filled with blood i would stage it as II. that's my opinion- mel, PT ---- No, a fluid filled blister is staged as II. A blood filled blister is staged as a DTI, Deep tissue injury. Glenda Hall LPN WCC
What test can be used to check the drainage of an abdominal wound for fecal content? Would a culture be enough, or is there something more specific? Thanks, Ellen S.	You can you use one of the stool for occult blood cards. It doesn't know if there is stool on it but does show if blood is present. Less expensive than a culture which will not show blood only bacteria. Marie RN
I hope you will be able to advise me about my wound care. I am 61 yrs. Old. Not diabetic. Have M.S. and hypertension. I slipped off a wooden chair 8 wks ago and waited too long for stitches in E.R. At present the wound is almost closed but for a very small area at the corner of its V shape. It drains copious serous fluid requiring several dsg changed per day. Two days ago the P.A. in my doc’s office inserted a syringe into the opening and pushed in 2-3cc.’s of Alcolol into the wound. The pain was awful and bloody material squirted out all over me and him and the floor. This was done twice and since then the wound continues to drain but is now feeling like a severe burn. My question is this: is this appropriate protocol? I am a retired nurse and have never heard of alcolol being used as other than topical antiseptic. Thank you Barbara	Just because they have the word "physician" in their name does not mean they know the best way to treat wounds. Alcohol is the worst thing to irrigate with!! I would recommend a loose packing with a saline moistened gauze strip into the wound daily and change the external gauze daily. You could also try and alginate packing that can be left in the wound several days. This will absorb the drainage. If the wound continues to drain, there may be a reason. You may need to have the wound reopened. Choose another physician and Good Luck! KJ ---- I've been in wound care for over 20 years and have never heard of the use of alcohol for irrigation purposes (topical only!!) If I were you, I'd see a vascular doctor before you have any further trouble. Unsigned --- Alcohol will certainly burn the tissue. Can you see a wound care specialist? Marie RN ---- I am an Orthopaedic PA and work and have a wound care practice within our group. I have never heard nor have ever used alcohol in that manner. I would suggest that you have the wound cultured and cared for by a wound specialist. It is difficult to advise you on the care of your wound without seeing it, however you need to know why the wound is draining so much and have the appropriate dressing applied. Unsigned
Hello and thank you for the opportunity to ask a question about debridement in the hospital based outpatient setting. We read many publications about debridement guidelines, but find conflicting information about whether a service is non-selective debridement or just a dressing change. Our wound clinic nurses want to select the most appropriate code for their services. We are trying to determine the guidelines for coding non-selective debridement, CPT 97602. We have found only one article which states "Removal of non tissue-integrated fibrin exudates, crusts, biofilms or other materials from a wound without removal of tissue does not meet the definition of any debridement code and may not be reported as such". If this statement is correct, is it appropriate to select a facility Evaluation & Management CPT code to bill for this service? We hope you can help with our question. Thank you so much. Sue R.N. CPC	Sorry, but there were no replies.
My 94 year old mother is an invalid and desperately needs some more foam booties to protect her feet from ulcers. I cannot find any more like the ones she has. They come almost up to her knees and have a heel lift in them but are completely foam. This is the only one she can wear. Can you please help me. The home health care nurses cannot find them any more for me. Please let me hear from you. Thank you, Saundra	The foam boot ones I know about are HeelLift from DM Systems and the DeRoyal Heel Suspension Boot. Keep in mind that products change a lot, and the one you liked might not be made anymore. Is there any kind of a tag or label in the ones she has now? You could look for it by name on-line or with a vendor. Renee C, PT, PhD(c), MSPT, MPH, CWS --- I believe I know what product you are looking for. it is called HEEL LIFT suspension boot. Try www.alimed.com. You may want to take it to you local medial supply store or do a wider search for cost comparison. Hope its the one you were looking for! Michelle PT, CWS --- Saundra, There is a wonderful professional rehab catalog called Sammons Preston that you can probably find those type boots. I have ordered some like you’ve described for a patient in the past. Good luck! --- Look online google : heel lift booties and you will find them In the meanwhile, elevate her feet on pillows with no pressure to the heels --- We have had good pressure relief for the heels with pressure-relieving orthotic (PRAFO) boots. you can also find some ideas at the following websites: www.sageproducts.com www.liberatomedical.com www.colonialmedical.com good luck, let us know what you choose and how it works for you, Marie RN
Hi, I am Suresh from India. I met with an accident, & suffered with a broken big toe & an open wound. Surgery was done with K-Wire implant, & the wire has removed a couple of days back. Now the open wound is healing but it is still soggy & wet. Can anyone advice me what is the treament & how normally many more days would it take for the soogy & wet wound to heal. Look forward for you response. Regards, S.Suresh	You have not given any details of the number of days or weeks the K-wire was in place. Also you have not said anything about how you are managing the wound at present? You have not mentioned your age and if you have any other medical problems such as diabetes, hypertension etc. Also are you a smoker? Anyway with the limited information that you have provided, I would suggest that you wash the wound and the entire foot daily or even twice a day and then dress it either with an 'antibiotic' powder if the wound is discharging and with a cream or ointment it it is dry and forming a scab. kumkum
Hello, I am a dialysis nurse back in school and have been tasked with a project on wound care products. If there is a clinical person I can ask his/her opinions on the following questions? Thank you in advance. 1. What would you consider the top four most widely used dressing products? 2. What dressing product is underutilized? 3. What dressing products are saturated (me too) in the wound market today? 4. What type of dressing would you like to see that is not currently used? Shelly RN	Practice varies so much that you will probably have different answers from every person who responds. Everyone has their own preferences. Some people are very attached to a specific treatment or product for a number of reasons, sometimes to the exclusion of other very beneficial products. There's no single answer to your question. Renee C, PT, PhD(c), MSPT, MPH, CWS
My husband has had a venous ulcer since March. He has gone to his Pcp., a vascular dr., sees a nurse at the vascular office once a week for wraps, and was referred to a dermetologist for a biopsy which he did today. The dermetologist said the wound should not have been covered. THat it needed air and that he shouldn't be going to a vascular Dr. at all. We are lost at this time and don't know what to do. He has been sponge bathing since May, and now doesn't even know about that. He was told by her to take a week off work which he has not missed thus far, and recieved 2 prescriptions, one topical and one oral which are both new to us from the other meds.up to this point. What should we do? He is so disscuted and so am I for him. There has to be someone that specializes in wound care in our area of Pittsburgh, PA. Our ins. doesn't seem to have anyone on the list for this type of specialty. Help us with some advice, PLEASE Contact me at this email glophin@yahoo.com I should also mention that he works at a hospital on his feet all day and had a bleed-out at work last weekend. It seems that no one at this facility could help or has offered any advice. In fact after his shift he must catch a shuttle bus and another pat authority bus to go to another area hospital once a week to have this wound tended to. Can this get any harder for him?	The dermatologist clearly is not current in wound care. Leaving it open to air is definitely not the best thing. And, standing on his feet all day makes it harder for this kind of wound to heal. If it is a pure venous ulcer, without significant arterial problems, then he needs compression therapy. I recommend you go to www.wocn.org or www.aawm.org and find someone near you who is specialized in wound care. It's not a medical specialty you'll see on your insurance list. But, you can find someone, maybe a dermatologist, vascular surgeon, surgeon, internal medicine physician, podiatrist, physical therapist, or nurse, who has gone through additional training and a certification exam with these website. Also, look for wound clinics in your area. Renee C, PT, PhD(c), MSPT, MPH, CWS ---- Have your husband have an ABI and doppler study. If arterial involvemment is ruled out, he should continue with moist healing and compression wraps. I've found the Coban 2 layer wrap to be most comfortable, definately do not leave the wound open to air. That is very POOR advice!!! You leave the wound open to infection. If he doesn't have a fever, increase pain, redness and warmth around the wound, he probably should not be on antibiotics. Treatment for venous ulcers is compression for life (even after the wound has healed he will need to wear compression stockings) SCohenRN --- Can you furnish some more details: 1. exact site of the ulcer in relation to the ankle 2. size of the ulcer 3. appearance of the ulcer -- yellow areas, red areas, black hard areas etc. 4.the surrounding skin -- angry red, small pin-point ulcers, eczematous, dry scaly etc. Is he using a compression bandage when he is on the move? Does he elevate his leg whenever possible? He should be washing the ulcer with a mild soap during a bath. Thereafter he must tackle the surrounding skin and the ulcer depending on situation. if the surrounding skin is dry -- apply a moisturizer or baby oil if it is oozy -- use a powder on the ulcer there are various applications available having different effects. Saline soaked gauze is the safest I can suggest as you have not described the ulcer. kumkum
I have a 72 year old bariatric CVA resident whi has chronic perineal/buttocks excoriation/open areas that we cannot heal. He has a hx of MRSA, but presently is not infected. He has a suprapubic catheter, so he is usually dry other than perspiration. He is incontinent of stool. His open areas are scattered throughout the perineal/buttocks/scrotal/penis area. We get one healed and another develops. They are stage 2, with occasional tan drainage. We have used zinc oxide, A & D, petrolatum, Calmoseptine, and Bag Balm. We have used hydrocolloid pads, Allevyn, plain protective dressings. It is a difficult area to make dressings adhere. He has a gel cushion on his wheelchair, and an air mattress in bed. He wears an adult brief. When in bed, he does not want to lay on his side as he cannot breathe and is not comfortable. He cannot reposition himself without assistance. Nutritionally he is good, he eats most all of his meals, he takes a multivitamin and protein supplements, and vitamin C. His hydration is good. His pressure areas have been chronic for several years. Any suggestions of new or old treatments we can use? Thank you for your consideration! Carla Engle, RN Unit Coordinator	You've tried a lot of different moisture barriers. I'd ask if they're being used correctly. You really need a good layer on there. If you can see the skin, so can the stool. And, many of them don't need to be fully removed with cleaning. Being that thorough can be rough on the skin. Often you can remove the top layer and then apply more. Also, remember moisture isn't just urine and perspiration. Bowel incontinence is a real problem. Rather than briefs, try an absorbent wicking underpad. Briefs will hold the stool tight against the skin. An underpad will allow much of the stool to fall away from him instead of squishing up and creating a warm moist greenhouse-type effect. Lastly, it sounds like it's more incontienence-associated skin breakdown than pressure ulcer. They are different etiologies. Renee C, PT, PhD(c), MSPT, MPH, CWS --- Carla: I cared for my father for little over a year and I found the best ointment is Allanderm T. This stuff is great. Had we found it sooner, my dad may have survived. We used it for six months and we were able to start to get his heel healed, healed his ear, his knee and a 2 inch long 1 inch deep sore on his calve. Unfortunately, the backside was so bad that there just was not enough ointment to cover. Please try this. You will love it. Unfortunately, most insurance companies will not cover but it is well worth it. Gabby

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