Solving the Compliance Riddle with Compression Garments

Transcription

1 Solving the Compliance Riddle with Compression Garments Jeffrey D. Lehrman, DPM, FASPS, MAPWCA Editorial Advisory Board, WOUNDS Consulting Editor, Podiatry Management APMA Coding Committee Expert Panelist, Codingline APMA MACRA Task Force Fellow, American Academy of Podiatric Practice Management Board of Directors, ASPS Board of Directors, APWCA FACTS: CHRONIC VENOUS ULCERS Venous Ulcers account for 60-90% of leg ulcers More common in women: 3X Difficult to heal: 50% > 9 months/20% > 2 years High rate of reccurrence: Up to 69% Advances in Skin & Wound Care: August Volume 22 - Issue 8 - p 384 VASCULAR MECHANICS DEEP VEINS SUPERFICIAL VEINS COMMUNICATING VEINS (PERFORATORS) VALVES CALF PUMP Hegarty M,: Am Overview of Compression Therapy. Today s Wound Clinic vol 4 issue 10-Oct

2 DEEP VEINS SUPERFICIAL VEINS PERFORATORS NORMAL ANATOMY VENOUS SYSTEM Semin Intervent Radiol. Sep 2005; 22(3): ARTERY PROVIDES OXYGENATED BLOOD TO THE LIMB IS A FACTOR IN VENOUS DISEASE 20% OF THE TIME 2

3 Hypoxia in areas of venous congestion Growth factors get trapped VENOUS PRESSURE = EDEMA Ambulatory Venous Hypertension: The elevated pressure in the leg vein during walking Partsch, H; compression therapy of venous ulcers;, Hemodynamic effects depend on interface pressure and stiffness; EWMA Journal 2006, vol 6 NO2. ANATOMICAL FAILURE Venous Wall Physical Properties: Reduced Strength Venous Valves Primary Venous Disease: degenerative damage Secondary Venous Disease: DVT Calf Pump 90% of venous return is through these 3 Fletcher, Moffatt, Partsch, Vowden, Vowden: Principles of Compression in venous disease, a practitioner's guide to treatment and prevention of venous leg ulcers; Wounds International:

4 LYMPHEDEMA An abnormal collection of excessive tissue proteins, edema, chronic inflammation and fibrosis in the interstitial space. Blockage in the lymphatic system CHRONIC PROBLEM LYMPHATICS Pre Lymphedema High Protein Edema Sub-Acute Edema MEM:Manual Edema Mobilization EDEMA AND WOUND HEALING Inflammation Fibrosis Induration Elevated Proteases Ischemia 4

5 Elevated MMP 1 in Venous Ulcers Beidler et al, Multiplexed analysis of matrix metalloproteinases in leg ulcer tissue of patients with chronic venous insufficiency before and after compression therapy. Wound Rep Regen 16: , ORGANIZED APPROACH TO WOUND CARE Disease Process Controlled Patient Centered Pain Wound Moisture Balance Advanced Modal ities Edema Offloading BioBurden Debridement Blood Flow 1. Is there adequate perfusion and/or oxygenation? 2. Is non-viable tissue present? 3. Are signs/symptoms of infection and/or inflammation present? 4. Is offloading or pressure relief appropriate? 5. Is edema controlled? 6. Is tissue growth optimized? 7. Is the wound microenvironment conducive to healing? 8. Is pain controlled? 9. Are host factors optimized? COUNTERACT GRAVITY TREATMENTS EXERCISE THERAPY COMPRESSION SURGERY 5

6 Exercise RCT 12 weeks progressive resistance exercise program + compression versus only compression Significantly greater improvements in ejection fraction of the calf muscle in the exercise group The prepare pilot RCT of home based progressive resistance exercises for venous leg ulcers. Jull A, Parag V, Walker N, Maddison R, Kerse N, Johns T J Wound Care Dec; 18(12): Elevation Prospective longitudinal study At least an hour of leg elevation associated with lesser number of recurrences Relationships between preventive activities, psychosocial factors and recurrence of venous leg ulcers: A prospective study. Finlayson K, Edwards H, Courtney M. J Adv Nurs. 2011;67: Surgery Sub facial endoscopic venous surgery Saphenous vein stripping Percutaneous ligation of varicose veins Valvoplasty 6

7 Surgery Superficial venous surgery: Similar rates of ulcerhealing to compression alone The role of superficial venous surgery in the management of venous ulcers: a systematic review. Howard DP, Howard A, Kothari A, Wales L, Guest M, Davies AH Eur J Vasc Endovasc Surg Oct; 36(4): Ultrasound Guided Foam Sclerotherapy Foam pushes blood out of the way Foam fills the vein Scleroses internal lining leads to clotting Moisturizing legs Diet modifications Nutritional supplements Smoking cessation Weight reduction Healthy cardiac status tt Strong psychosocial supports Factors associated with recurrence of venous leg ulcers: a survey and retrospective chart review Finlayson K, Edwards H, Courtney M Int J Nurs Stud Aug; 46(8): Venous leg ulcer patients: a review of the literature on lifestyle and pain related interventions Heinen MM, van Achterberg T, op Reimer WS, van de Kerkhof PC, de Laat J Clin Nurs Mar; 13(3):

8 A large body mass index (>33 kg/m2) and short walking distance during the day (<200 m) associated slow healing, Milic DJ, Zivic SS, Bogdanovic DC, Karanovic ND, Golubovic ZV J Vasc Surg May; 49(5): COMPRESSION THERAPY Application of pressure to the lower extremities. Recognizedtreatment of choice for venous leg ulcers. Systems include hose, tubular bandages, bungee systems, and bandage systems of two or more components. These systems aim to provide graduated compression to the lower limb in order to improve venous return and to reduce edema. Compression Amount of pressure need to collapse superficial veins in the ambulatory patient. Initial pressure to narrow a vessel: mmhg sitting or standing Hegarty M,: Am Overview of Compression Therapy. Today s Wound Clinic vol 4 issue 10-Oct

9 Full Occlusion Resting: mmhg Standing: mmhg Ambulation: - 70 mmhg Hegarty M,: Am Overview of Compression Therapy. Today s Wound Clinic vol 4 issue 10-Oct 2010 Partsch H, Annuals Vascular Disease 2012 HOW DO WE DEFINE THIS IN PRACTICE?????? TYPES OF COMPRESSION ELASTIC INELASTIC STATIC DYNAMIC WRAPS HOSE TYPES COMPRESSION WRAPS COMRESSION HOSIERY INTERMITTENT PNEUMATIC COMPRESSION (IPC) BUNGEE + ZIPPER 9

10 WHAT TO DO BEFORE COMPRESSION VASCULAR SCREENING Duplex ultrasound Venous studies Arterial Doppler 10

11 Evaluate Arterial Doppler Waveforms ABI TBI Segmental Pressures Waveforms Triphasic Biphasic M h i Monophasic Flat 11

12 ABI Under 0.5: Severe arterial disease : Moderate arterial disease : Mild arterial disease or 1.3: Normal vessels > : Noncompressible, severely calcified vessel TBI Greater than 0.6 low risk Between moderate risk Less than 0.2 high risk 12

13 Segmental Pressures 20mmHg drop from level to level 20mmHg difference same segment contralateral PURPOSE OF COMPRESSION 1. Counteract the force of gravity and promote the normal flow of venous blood up the leg 2. At Actson the venousand lymphatic systems to improve venous and lymph return and reduce edema 3. Causes narrowing of the superficial veins Meissner,M, Lower Extremity Venous Anatomy, Interventional Radiology, Sept. 2005, ; 22(3): WHAT IS ADAQUATE COMPRESSION Overcomes intravenous pressure Exerts a sub-bandage resting pressure that is well tolerated in a resting position Provides a pressure increase when the patient rises to a standing position: (50-70mmHG) Provides external compression improving venous reflux during walking Fletcher, Moffatt, Partsch, Vowden, Vowden: Principles of Compression in venous disease, a practitioner's guide to treatment and prevention of venous leg ulcers; Wounds International: 2013 Partsch, H; compression therapy of venous ulcers;, Hemodynamic effects depend on interface pressure and stiffness; EWMA Journal 2006, vol 6 NO2. 13

14 STIFFNESS OR EXTENSIBILITY The relationship between the resting and working pressures of a compression device Achieved through use of inelastic bandages in multiple layers Measured in SSI (Static Stiffness Index) -LOW SSI: <10: Knitted Stocking, Elastic Bandages -MED SSI: Flat Knitted Stocking -HIGH SSI: >10 Short Stretch, Multicomponent Bandages, Zinc Paste Wraps, Velcro Wraps Partsch, H; compression therapy of venous ulcers;, Hemodynamic effects depend on interface pressure and stiffness; EWMA Journal 2006, vol 6 NO2. LA PLACES LAW A formula that defines the pressures exerted on curved surfaces Pressure = T x N CxW N= number of layers applied T= bandage tension C= limb circumference W= Bandage Width World Union of Wound Healing societies (WUWHS). Principles of best practice: Compression in venous leg ulcers. A consensus document. London: MEP Ltd,2008 TYPES OF BANDAGES Non-Stretch Short Stretch Long -Stretch 14

15 NON-STRETCH ZINC PASTE BANDAGES SHORT STRETCH Bandages that stretch to less than 100% of their original length: minimal extensibility High h Working Pressure/Low Resting Pressure 15

16 LONG STRETCH LONG STRETCH Expands over 100% of its original length Low Working Pressure/High Resting Pressure Contains Elastomeric Fibers: fibers that are able to stretch and return to almost their original size. World Union of Wound Healing societies (WUWHS). Principles of best practice: Compression in venous leg ulcers. A consensus document. London: MEP Ltd,2008 Delivery of Compression Therapy for Venous Leg Ulcers Assess whether home care nurses achieve adequate subbandage pressure when treating patients with venous leg ulcers 13 months 68 nurses Delivery of compression therapy for venous leg ulcers AMA Dermatol doi: amadermatol Zarchi Kl, Jemec GBI 16

17 Delivery of Compression Therapy for Venous Leg Ulcers Participant masked measurements of subbandage pressure Three bandage types: 1. an elastic, long stretch, single component bandage 2. an inelastic, short stretch, singlecomponent bandage 3. a multilayer, 2 component bandage Delivery of compression therapy for venous leg ulcers AMA Dermatol doi: amadermatol Zarchi Kl, Jemec GBI Delivery of Compression Therapy for Venous Leg Ulcers Association between achievement of optimal pressure and Years in the profession Attendance at wound care educational programs Previous work experience Confidence in bandaging ability Delivery of compression therapy for venous leg ulcers AMA Dermatol doi: amadermatol Zarchi Kl, Jemec GBI Delivery of Compression Therapy for Venous Leg Ulcers A substantial variation in exerted pressures was found 11mmHg exerted by an inelastic bandage 80mm Hg exerted by a 2 component bandage Delivery of compression therapy for venous leg ulcers AMA Dermatol doi: amadermatol Zarchi Kl, Jemec GBI 17

18 Delivery of Compression Therapy for Venous Leg Ulcers The optimal subbandage pressure range, defined as 30 to 50 mm 39 of 62 nurses (63%) applying the 2 component bandage 28 of 68 nurses (41%) applying li the elastic bandage 27 of 68 nurses (40%) applying the inelastic bandage Delivery of compression therapy for venous leg ulcers AMA Dermatol doi: amadermatol Zarchi Kl, Jemec GBI Delivery of Compression Therapy for Venous Leg Ulcers Pressures less than 30 mmhg Inelastic 56% Elastic 53% 2 component 27% Delivery of compression therapy for venous leg ulcers AMA Dermatol doi: amadermatol Zarchi Kl, Jemec GBI Delivery of Compression Therapy for Venous Leg Ulcers None of the investigated factors was associated with the ability to apply a bandage with optimal pressure. Delivery of compression therapy for venous leg ulcers AMA Dermatol doi: amadermatol Zarchi Kl, Jemec GBI 18

19 WHY IS IT SO HARD TO DO THE RIGHT THING IN WOUND CARE 17% VLU patients received adequate compression Inadequate reimbursement Lack of familiarity with clinical practice guidelines 19

20 Compliant Compression! Instead of Velcro, Bungee system to adjust compression No neoprene = no stretching out Breathable hbl Compliant Compression! 10 DIFFERENT SIZES mmhg Garment, Liner, Bag Different Lengths 20

21 15mmHg just from zipping Must have a venous stasis ulcer A6545 Recurrence 60% 70% 21

22 Below knee graduated compression stockings or hosiery likely to prevent recurrence of venous leg ulcers Application of external pressure with compression to calf muscle raises interstitial pressure resulting in improved venous return and reduction in the venous hypertension Compression for preventing recurrence of venous ulcers. Nelson EA, Bell Syer SE, Cullum NA Cochrane Database Syst Rev. 2000; (4):CD Options THINGS TO CONSIDER WHEN CHOOSING COMPRESSION ETIOLOGY OF WOUND PATIENT S MOBILITY PATIENT S ACCESS TO CARE ULCER SITE PATIENT S TOLERANCE CLINICIANS LEVEL OF EXPERIENCE COST Sullivan V: Compression Pitfalls: improving patient Adherence with Compression Therapy. Today s Wound Clinic. Vol 4 Issue 12-Dec

23 HOSE/SUPPORT STOCKINGS Made of elasticated textile Styles: knee, thigh, pantyhose lengths Custom or off-the-shelf Can be used as first line treatment in patients with small ulcers 2-component systems LEVELS OF COMPRESSION Class I: mmhg: Anti-Embolism hose Not a therapeutic level of compression Class II: mmhg: dependent edema, non-ambulatory, CHF Class III: 25-35mmHg: Venous Insufficiency Class IV: Lymphedema, need to have active muscle movement OTHER COMPRESSION DEVICES 23

24 INTERMITTENT PNEUMATIC COMPRESSION INTERMITTENT PNEUMATIC COMPRESSION EVIDENCE SUGGESTS A boot composed of air-filled chambers attached to an electric pump, used in combination with compression bandaging, may be more effective that bandaging alone. Schuler JJ, Maibenco T, Megerman J, Ware M, Montalvo J; Treatment of chronic venous ulcers using sequential gradient intermittent pneumatic compression; Phlebology / Venous Forum of the Royal Society of Medicine; 1996, vol 11,issue 3. CALF RAISES CALF STRETCHES MARCHES EXERCISE!! DAILY WALKING UP AND DOWN STAIRS SWIMMING 24

25 Compliance Can t get them on Uncomfortable Cannot tolerate level of compression required Not using compression = High degree of recurrence Compression for preventing recurrence of venous ulcers. Nelson EA, Bell Syer SE, Cullum NA Cochrane Database Syst Rev. 2000; (4):CD % noncompliance failure in Class 3 stockings Prevention of recurrence of venous ulceration: randomized controlled trial of class 2 and class 3 elastic compression. Nelson EA, Harper DR, Prescott RJ, Gibson B, Brown D, Ruckley CV J Vasc Surg Oct; 44(4):

26 Recurrence is common Recurrence is more common in patients who are noncompliant with compression therapy Healing of venous ulcers in an ambulatory care program: the roles of chronic venous insufficiency and patient compliance JOURNAL OF VASCULAR SURGERY November[1995 Curtis A. Erickson, MD, Debbie J. Lanza, BSN, RVT, Donna L. Karp, BSN, RVT, Janice W. Edwards, RN, RVT, Gary R. Seabrook, MD, Robert A. Cambria, MD, Julie A. Freischlag, MD, and Jonathan B. Towne, MD, Milwaukee, Wis. Compliance is dependent on compression garment Healing of venous ulcers in an ambulatory care program: the roles of chronic venous insufficiency and patient compliance JOURNAL OF VASCULAR SURGERY November[1995 Curtis A. Erickson, MD, Debbie J. Lanza, BSN, RVT, Donna L. Karp, BSN, RVT, Janice W. Edwards, RN, RVT, Gary R. Seabrook, MD, Robert A. Cambria, MD, Julie A. Freischlag, MD, and Jonathan B. Towne, MD, Milwaukee, Wis. 26

27 Compliant Compression! Instead of Velcro, Bungee system to adjust compression No neoprene = no stretching out Breathable hbl 27

28 Compliant Compression! 10 DIFFERENT SIZES mmhg Garment, Liner, Bag Different Lengths Liner 28

29 15mmHg just from zipping Must have a venous stasis ulcer A6545 QUALITY INDICATORS Physician Quality Reporting System Data Driven Care Quality Reporting Fife C; The changing face of wound care: Measuring Quality. Today s Wound Clinic. Oct 2012 : pages

30 QUALITY INDICATORS Conclusion Solving the Compliance Riddle with Compression Garments Jeffrey D. Lehrman, DPM, FASPS, MAPWCA Editorial Advisory Board, WOUNDS Consulting Editor, Podiatry Management APMA Coding Committee Expert Panelist, Codingline APMA MACRA Task Force Fellow, American Academy of Podiatric Practice Management Board of Directors, ASPS Board of Directors, APWCA 30