Exit Poll Surveys
May 13, 2008 | Leave a Comment
Dear Today’s Wound Clinic subscriber,
To entice wound care professionals to complete Today’s Wound Clinic online surveys, HMP Communications, publisher of Today’s Wound Clinic, is offering four chances to win a complimentary autographed copy of the latest edition of Chronic Wound Care, and a new Grand Prize opportunity for those that complete all four surveys. Read more
Pneumatic Compression Pump Therapy:
March 17, 2008 | Leave a Comment
An Evidence-based Approach to the Treatment of
Chronic Vascular Disorders
Teresa Conner-Kerr, PT, PhD, CWS, CLT
The importance of compression therapy in treating tissue swelling associated with lymphedema and venous insufficiency is well recognized by wound management practitioners. Compression therapy is delivered by a variety of methods with differing levels of evidence to support the use of specific compression modalities. Treatment algorithms prepared by experts from a variety of disciplines using original research are available that provide evidence ratings for particular compression modalities.1,2
In The Venous Ulcer Guideline developed by the Government and Regulatory Task Force of the Association for the Advancement of Wound Care, an “A” level of evidence was assigned to eight different compression therapy options.2 One of the eight therapeutic modalities receiving an “A” level rating was intermittent pneumatic compression.
Pneumatic compression pumps have been in use since the 1960s for the treatment of limb swelling due to both acute and chronic conditions. Pneumatic compression pumps consist of an electric pneumatic pump that is used to push compressed room air into an inflatable garment or sleeve either continuously or intermittently depending on inflation and deflation times. Most pneumatic compression pumps today use intermittent compression cycles with inflation and deflation cycles either preset or programmable by the clinician. The sleeve or garment may have a single chamber design with one port or a multiple chamber design with one port per chamber. Pressure may be graded with the highest pressures in distal chamber segments. Depending on the specific manufacturer, compression cycles, treatment times, and compression levels may be either preset or programmable. Multichamber sequential compression pumps typically provide the greatest programming flexibility. Newer compression pump technology such as the Lympha-pants™ (LymphaCare, New York, NY) employs large multi-segment chambers that cover bilateral limbs and the lower or upper trunk simultaneously so that a comprehensive treatment may be delivered in a more efficient manner. The sequential inflation of chambers from distal to proximal in these devices is also thought to more naturally mimic lymph return.
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InTech
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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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Houston’s Healers: Approaching 20 Years of Wound Care
March 17, 2008 | 1 Comment
The Memorial Hermann Wound and Lymphedema Center
Houston, Texas
The Memorial Hermann Wound and Lymphedema Center Houston, Tex, will soon mark its 20th anniversary. Opened as the Hermann Center for Hyperbaric Medicine in 1989 with one nurse and a technical staff, it evolved in response to the needs of patients and the changing field of wound care. Wound healing (which includes a venous stasis clinic) and lymphedema divisions were added to the center’s operations in response to the lack of facilities available for patient referrals requiring chronic wound care.
The center has met many challenges from educating the staff to integrating computer technology, operating with a small advertising budget, and adjusting to changes in Medicare.
TWC asked Vonda Wall, Administrative Director Outpatient Diagnostic and Procedural Services for Memorial Hermann Hospital, to fill in some of the details of the center’s operations.
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InCentive
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The Frustrating 15: What’s Missing?
March 17, 2008 | Leave a Comment
Dot Weir, RN, CWON, CWS
Caroline Fifes’s commentary on the state of healing of venous leg ulcers over the years evoked several questions. She described the “frustrating 15%,” describing the relatively small change in healing rates of this population of patients through the years. This begs the question, how can this be? Our diagnostic skills regarding recognition of atypical ulcers that masquerade as venous ulcers have improved and we have many more advanced and “active” topical approaches in our treatment armamentarium. As Caroline more than adequately noted, wound care professionals know and understand the necessity of adequate compression and many sophisticated options for providing that compression are available.
What is missing in the care of that frustrating population (the 15%) of refractory ulcers? Although the following ideas might not change outcome statistics, at least five factors must be understood in order to impact refractory ulcerations:
1. Patient participation
2. Recognition of the impact of bacteria
3. Recognition of atypical ulcers
4. Use of advanced treatments
5. Defining closure versus healing.
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InPerspective
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Bringing Wound Care Back To The Future
March 17, 2008 | Leave a Comment
A 20-year perspective on Venous Ulcer management
Caroline Fife, MD
The majority of patients afflicted with chronic wounds suffer from lower extremity ulcers caused by chronic venous insufficiency (CVI) that affects approximately 2.5 million people in the US. It has been estimated that approximately 600,000 people seek treatment for venous leg ulcers on an annual basis and given the relationship between age and venous ulceration that number most likely will continue to grow as the population ages. Tremendous effort has been expended by many organizations to define the standard of care for venous ulcerations.
Data show that following guidelines improves patient outcomes. With regard to venous ulceration, guidelines are focused on the provision of appropriate compression. Margolis1,2 reported that appropriate limb compression resulted in healing rates of 30% to 60% at 24 weeks and 70% to 85% at 1 year. In a 2006 study of wound healing trajectories in 232 patients conducted in eight trials over 10 years, Steed3 showed that 60% of patients were healed on average at 20 weeks. Thus, when appropriate compression is applied, the overall healing rate in venous ulcers approaches 80% and has remained unchanged for the past 20 years.
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The Clinician’s Role in Compression
March 17, 2008 | Leave a Comment
Susan Gallagher Camden, RN, MSN, WOCN, PhD
Tere Sigler, PT, CWS, CLT
Lymphedema, a disorder of the lymphatic system, affects at least 3 million Americans.1 The lymphatic system plays a role in both immune function and circulation. The system is comprised of lymphatic vessels located just under the skin and lymph nodes in areas around the neck, axilla, and groin. As the vessels transport fluid away from the tissues, waste products, bacteria, and large protein molecules are collected. The fluid is carried to the lymph nodes where the water products are degraded and eliminated, while the remaining protein-rich fluid is transported to the heart and back into circulation.2
When the normal lymphatic channels are disrupted, abnormal amounts of protein-rich lymphatic fluid collects in the interstitial tissue and causes swelling, most often in the arm and/or legs, and occasionally in other parts of the body. When the disruption becomes profound, the volume of lymphatic fluid exceeds the lymphatic transport capacity, leading to lymphedema.
Primary lymphedema is caused by connatal malformations of the lymphatic system, such as missing or impaired lymphatic vessels. This can affect any or all parts of the body but is usually seen in the legs. Secondary lymphedema, sometimes referred to as acquired lymphedema, occurs when lymphatic vessels are damaged or lymph nodes are removed. The lymphatic vessels can become damaged as a result of trauma, surgery, radiation, severe chronic venous insufficiency, morbid obesity, or infection. Without appropriate intervention, the protein-rich fluid increases the size and number of the tissue channels. This contributes to a reduction in the oxygen availability in the transport system, which interferes with wound healing and provides a culture medium for bacteria. This increased bacterial load can result in lymphangitis. When lymphedema continues unchecked, the protein-rich fluid continues to accumulate, swelling increases, and tissue becomes fibrotic. Untreated lymphedema can lead to a decrease or loss of limb function, skin breakdown, or chronic infections.
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The Clinician’s Role In Compression
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Coding and Medicare Coverage Review
March 17, 2008 | Leave a Comment
Unna Boot and Multilayered, Sustained,
Graduated High Compression Systems
Kathleen D. Schaum, MS
Hospital-owned outpatient wound care departments (HOPDs) must routinely check their Medicare contractors’ websites for updates to their Local Coverage Determinations (LCDs) and Articles that pertain to the application of compression systems. All of the Medicare contractors seem to agree that CPT® code 29580 is the appropriate code to use when applying a zinc paste Unna Boot. However, there is great disparity among the Medicare contractors regarding the appropriate CPT® code for the application of multilayered, sustained, graduated high compression systems. This author reviewed all the available LCDs and Articles on this topic (see Table 1).
(Please note: Medicare contractors may write new and/or change existing LCDs and Articles at any time. The information in Table 1 was only accurate on the day the author drafted this column. Any or all of the Medicare contractors could have released new policies while this column was awaiting publication. Therefore, providers should assign someone to monitor all pertinent changes that are released by their Medicare contractor.)
When the HOPD program directors and physicians review the compression guidelines that pertain to them, they should ascertain the:
• Description of product applications covered by the CPT® code 29580
• Alternative CPT® code(s) recommended for non-zinc paste compression systems
• Professionals who are covered to apply the various compression systems
• Diagnoses that support medical necessity of application of the various compression systems.
Some Medicare contractors followed the American Medical Association’s coding guidelines; some followed the American Hospital Association Coding Clinic guidelines; and others chose to discount both sets of guidelines and wrote their own opposing guidelines. If providers disagree with their Medicare contractor’s LCD, they should take advantage of Medicare’s Reconsideration Process. This is a formal process to request updates to LCDs by providing clinical evidence to the contractor’s medical director. The exact steps in the Reconsideration Process are outlined on each Medicare contractor’s website. Providers also should enlist assistance from their professional society’s representative to the Carrier Advisory Committee (CAC).
The author suggests noting that the Reconsideration Process is applicable only to LCDs. It is not applicable to Articles released by the Medicare contractors. Therefore, if your Medicare contractor only wrote an Article regarding this issue, providers cannot challenge the Article. However, providers can request that their Medicare contractor create an LCD.
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InBusiness
Confident In Our Content
March 17, 2008 | Leave a Comment
As VP, Group Publisher/Wound Care, Podiatry and Dermatology Division of HMP Communications, I have had the pleasure of meeting many of you and learning about your individual needs and goals as wound care providers.
After a very successful launch last year of Today’s Wound Clinic, our staff, Editorial Board, and advertisers are excited to offer four quarterly issues in 2008.
Starting with this issue, TWC is moving to a paid subscription format. We are confident the content we have produced for this issue and the content we are planning for the future are worthy of the subscription price and can only result in a greater product for the readers. Everyone who works in a wound care clinic should invest in their careers by subscribing to TWC, most valuable tool on the market.
According to Advanced Medical Technologies, an online source for medical information, current estimates put the total annual cases of chronic wounds at almost 9 million worldwide. An aging population of Americans is greatly contributing to this growth. Also, there are approximately 177 million cases of diabetes worldwide resulting in 10% to 15% of diabetic patients developing ulcers at some point.
It is imperative for wound care professionals, at every level of the industry, to understand this growth, the causes behind it, and how to properly handle it once it quickly becomes a reality.
This journal will offer you the complete package of key information, insight, and expert advice that can only advance your career in the wound care industry while giving your patients the best possible care.
We have expanded our page count for this issue to an impressive 56 pages. We are aggressively gathering information on the wound care industry with four in depth online surveys this year and will be providing a concrete outlook of the industry to our paid subscribers.
We also have revamped the TWC website so that in the future all of the information we provide to print subscribers also will be available exclusively for them online.
If you still are undecided about paying for a subscription to the journal, please take a few seconds to visit our website and research the experience and knowledge of the following individuals, (www.todayswoundclinic.com):
Kathleen Schaum, MS
Dot Weir RN, CWON, CWS
Christopher Morrison, MD
Caroline Fife, MD, FAAFP, CWS
Val Sullivan, PT, MS, CWS
These talented professionals comprise our Editorial Board and will be your guides to advancing your careers in wound care. I welcome your comments and suggestions on what you need from TWC as a print and online resource. I look forward to hearing from you and wish you a prosperous new year.
Jeremy Bowden
VP/Group Publisher
jbowden@hmpcommunications.com
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Publisher’s Message
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A Brand New World
March 17, 2008 | Leave a Comment
Welcome to the first 2008 issue of Today’s Wound Clinic. Hopefully, you found the two 2007 issues relevant and meaningful and are ready to embark on a new year of sharing clinical and practical information.
The four quarterly issues of TWC this year focus on topics that present multifaceted, clinical, reimbursement, and management challenges. Chris Morrison will introduce a new online feature “Exit Polls” that comprises a quarterly survey — results to be published in subsequent issues with a culminating detailed analysis available in an article or supplement at the end of the year. These results also will be available online to subscribers.
The current issue highlights the patient with lower extremity edema, both venous and lymphatic (ie, lymphedema). Our cover story by Susan Gallagher Camden and Tere Sigler examines the unique clinical challenges related to obesity and lymphedema, compares lymphedema and lipedema, and offers suggestions for safe handling of the obese patient in the clinic setting. Commentary on the state of the art management of venous stasis ulcers, a historical perspective, usual healing rates, and what might be going on with the “non-healers” also is provided. In the InBusiness section, Kathleen Schaum discusses the disparity among Medicare contractors regarding the appropriate CPT® code for the application of multilayered, sustainted, graduated high compression systems. After researching all the available Medicare LCDs and Articles regarding the disparate coverage for these compression systems, she shares her research via a comprehensive table. InStruction offers information from Val Sullivan and Dot Weir on different categories of and how to handle some of the pitfalls of compression. InTech presents Teresa Conner-Kerr’s examination of the role of compression pumps. InCentive spotlights The Memorial Hermann Wound and Lymphedema Center and its upcoming 20th anniversary.
Today’s Wound Clinic has gained tremendous momentum by presenting important and timely topics related to our very specialized practice. We hope you enjoy this issue. Share it with your colleagues, make it a topic of discussion at your staff meetings, and send us feedback. Let us help you improve your wound care practice.
Dot Weir, RN, CWON, CWS
Caroline Fife, MD, CWS
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Editor’s Note
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