Capturing the Essence of the Wound Evaluation
May 12, 2008 | Leave a Comment
Pam Unger PT, CWS; Caroline Fife, MD, FAAFP, CWS; and Dot Weir, RN, CWON, CWS
ocumentation in wound care is critical for reimbursement. To ensure payment, a comprehensive individualized plan, indicating the wound problem and goal of treatment must be in the medical record. The American Physical Therapy Association’s (APTA) “Guide to Physical Therapist Practice” recommends the five-stage management system; examination, evaluation, diagnosis, prognosis, and intervention.
Wound care is usually best performed by a team of experts. Your team may consist of any combination of diabetic educators, dieticians, nurses, nurse practitioners, occupational therapists, orthotists, pedorthists, physical therapists, physicians, physician assistants, and podiatrists. The physician or advanced practice nurse will function as the coordinator of care, utilizing the expertise of other team members to accomplish the wound care goals. The team members conduct evaluations within their specific scope of clinical practice.
The examination phase of a wound consultation is assumed to be the most important aspect, particularly identifying any pre-existing signs or symptoms, relevant systems review and tests and measures. It is very important to identify all risk factors.
Crucial to the evaluation of the wound is identifying the cause of the wound to establish a diagnosis and prognosis. This allows the clinician to identify the class and severity of the wound by stage, thickness, or colors. In broad terms, wounds are lesions caused by trauma or surgical interventions, and all other lesions would fall into some sort of ulcer classification. However, the ICD-9 diagnosis coding system is a poor one when it comes to proper coding of ulcerations. Using ICD-9, it is not possible to properly designate mixed arterial/venous or inflammatory ulcerations, for example. In addition, a lesion, which began traumatically but persists in a non-healing state for many months, could be classified as a chronic ulcer. Medicare provides no guidance as to how to deal with these issues. For the rest of this article, the term wound to refer generically to all skin lesions, whether they would be classified as a wound or an ulcer in the ICD-9 coding system. Ironically, using the term wound and ulcer interchangeably in clinic notes can be cause of confusion and even lead to coding errors and should be avoided in clinic documentation.
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InStruction Article
Compression Therapy: Inside the Wrap
March 17, 2008 | Leave a Comment
Words of wisdom: Get a leg up on compression systems
Val Sullivan, PT, MS, CWS; and Dot Weir, RN, CWON, CWS
Mr. RU Swollen is referred to your clinic from his primary care provider. He walks into the clinic with an antalgic gait then rests in the waiting room. On examination, both lower extremities are edematous, the left greater than the right. He has purulent draining ulcers over the left foot and leg as well as the right leg. Pedal pulses are weakly palpable and his blood glucose level is 196 mg/dL. Should this patient receive compression for his lower extremities?
Compression therapy is considered a standard of care for chronic venous insufficiency (CVI) patients. A wound care practitioner’s instinctive response is to compress the edematous leg in an effort to control the cause of the wound rather than to simply dress the ulcer. Knowing when to apply compression, what compression or support to utilize, and how to safely compress are critical in the care of these patients.
The Overall Picture
Assessment. The bedrock of the treatment plan must be a comprehensive patient assessment. Through appropriate clinical testing, the root cause of the edema must be determined. Does the patient have lymphedema, CVI, or a combination of the two? Is the patient experiencing an acute flare or episode related to another diagnosis such as deep vein thrombosis or congestive heart failure (CHF) exacerbation? A thorough history and exam should rule out disease processes (eg, arterial occlusive disease) that would put the limb at greater risk with the addition of a compression therapy. If arterial patency is in question, comprehensive arterial studies should be done before compression therapy is applied. Special consideration and precaution should be given to diabetic patients who may have a deceptively elevated ankle/brachial index (ABI) secondary to disease related atherosclerotic changes and calcification of vessels.
If it has been established that the patient’s lower extremity arterial system is adequate and compression would be of benefit, the source of the swelling (ie, edema or lymphedema) must be determined. Patients with lymphedema ideally should have been seen and treated by a clinician trained in manual lymphatic drainage (MLD) and complete decongestive therapy (CDT), a certified CLT-LANA therapist. Although edema and lymphedema patients both are treated with compression therapy, the lymphedema therapy regimen may be quite different from the management of edema resulting from CVI.
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WHAT YOU CAN EXPECT FROM YOUR MANAGEMENT COMPANY
October 31, 2007 | Leave a Comment
PAT HUDSON, RN, BSN, CWCN;
SHERRILL A. WHITE; TERRY;
BEARD, RN, RRT, CHT, ACHRN
From conception to recognition as centers of excellence, wound care clinics must make education a priority. Management companies understand the importance of a knowledgeable team and have spent years refining and perfecting the education process. Not all managed companies are alike — hospital and wound clinic decision makers must understand what type of knowledge and support will be provided by the management company before partnering with them. Ultimately, the hospital should seek an accredited, comprehensive approach to education that includes all staff involved in the care and support of a wound center patient.The instruction provided should address key areas of clinic operation: wound care and hyperbaric medicine, clinical practice guidelines, advanced wound management, program operations, clinical coordination, safety, database outcomes management, quality improvement and accountability, reimbursement, patient education, marketing, and community education. The following article details what a hospital should expect from a management company in terms of education support of its wound clinic.
Staff Education: Independent versus Managed Facility
October 31, 2007 | Leave a Comment
Education is a never-ending process of acquiring knowledge and skills and developing powers of reason and judgment. In an independent wound clinic, educational responsibilities are handled in-house. The following discussion offers insights into the way one independent wound clinic, the Archbold Center for Wound Management, Thomasville, Ga, addresses staff educational and training needs.
Background. Our wound care program consists of an outpatient clinic where patients are seen both for MD appointments as well as regularly scheduled wound care.We also consult on acute care patients with complex wounds and provide any advanced wound care required during the hospitalization. Additionally, we oversee the wound management practices and round on complex cases at our four affiliate hospitals and four nursing homes.
