Solving the Compliance Riddle with Compression Garments Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC
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1 Solving the Compliance Riddle with Compression Garments Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC Advisor, APMA Coding Committee Advisor, APMA MACRA Task Force Expert Panelist, Codingline Fellow, American Academy of Podiatric Practice Management Board of Directors, American Society of Podiatric Surgeons Board of Directors, American Professional Wound Care Association Editorial Advisory Board, WOUNDS
2 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
3 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 2010.
4 NORMAL ANATOMY DEEP VEINS SUPERFICIAL VEINS PERFORATORS VENOUS SYSTEM Semin Intervent Radiol. Sep 2005; 22(3):
5
6 ARTERY PROVIDES OXYGENATED BLOOD TO THE LIMB IS A FACTOR IN VENOUS DISEASE 20% OF THE TIME
7 Hypoxia in areas of venous congestion Growth factors get trapped
8 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: 2013
9 LYMPHEDEMA An abnormal collection of excessive tissue proteins, edema, chronic inflammation and fibrosis in the interstitial space. Blockage in the lymphatic system CHRONIC PROBLEM
10 EDEMA AND WOUND HEALING Inflammation Fibrosis Induration Elevated Proteases Ischemia
11 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?
12 COUNTERACT GRAVITY TREATMENTS EXERCISE THERAPY COMPRESSION SURGERY
13 COMPRESSION THERAPY Application of pressure to the lower extremities. Recognized treatment 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.
14 HOW DO WE DEFINE THIS IN PRACTICE?????? TYPES OF COMPRESSION ELASTIC INELASTIC STATIC DYNAMIC WRAPS HOSE
15 TYPES COMPRESSION WRAPS COMRESSION HOSIERY INTERMITTENT PNEUMATIC COMPRESSION (IPC) BUNGEE + ZIPPER
16 WHAT TO DO BEFORE COMPRESSION VASCULAR SCREENING
17 Duplex ultrasound Venous studies
18 Arterial Doppler
19 PURPOSE OF COMPRESSION 1. Counteract the force of gravity and promote the normal flow of venous blood up the leg 2. Acts on the venous and 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):
20 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.
21 TYPES OF BANDAGES Non-Stretch Short Stretch Long -Stretch
22 NON-STRETCH ZINC PASTE BANDAGES
23 SHORT STRETCH Bandages that stretch to less than 100% of their original length: minimal extensibility High Working Pressure/Low Resting Pressure
24
25 LONG STRETCH
26 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
27 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
28 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
29 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
30 Delivery of Compression Therapy for Venous Leg Ulcers A substantial variation in exerted pressures was found 11mm Hg 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
31 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 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
32 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
33 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
34
35
36 Compliant Compression! Instead of Velcro, Bungee system to adjust compression No neoprene = no stretching out Breathable
37 Compliant Compression! 10 DIFFERENT SIZES mmhg Garment, Liner, Bag Different Lengths
38 15mmHg just from zipping
39 Must have a venous stasis ulcer A6545
40 Recurrence 60% - 70%
41 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
42 Options
43 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 2010
44 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
45 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
46 CALF RAISES CALF STRETCHES MARCHES EXERCISE!! DAILY WALKING UP AND DOWN STAIRS SWIMMING
47 Compliance Can t get them on Uncomfortable Cannot tolerate level of compression required
48 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
49 58% 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):803-8
50 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.
51 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.
52
53
54
55 Compliant Compression! Instead of Velcro, Bungee system to adjust compression No neoprene = no stretching out Breathable
56 Compliant Compression! 10 DIFFERENT SIZES mmhg Garment, Liner, Bag Different Lengths
57
58 Liner
59 15mmHg just from zipping
60 Must have a venous stasis ulcer A6545
61 Conclusion
62 Solving the Compliance Riddle with Compression Garments Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC Advisor, APMA Coding Committee Advisor, APMA MACRA Task Force Expert Panelist, Codingline Fellow, American Academy of Podiatric Practice Management Board of Directors, American Society of Podiatric Surgeons Board of Directors, American Professional Wound Care Association Editorial Advisory Board, WOUNDS
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