LeadingAge Nebraska Presents. NEBRASKA REGIONAL WOUND SEMINAR For Long-Term Care

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1 LeadingAge Nebraska Presents NEBRASKA REGIONAL WOUND SEMINAR For Long-Term Care FACULTY: PAMELA SCARBOROUGH PT, DPT, MS, CWS, CEEAA DIRECTOR OF PUBLIC POLICY & EDUCATION AMERICAN MEDICAL TECHNOLOGIES Copyright 2018 Gordian Medical, Inc. dba American Medical Technologies. AMT Education Division Disclaimer 2 This information is provided for informational purposes only. Patient management decisions should be based on a number of factors, including (but not limited to) professional society guidelines and published clinical literature relevant to a patient s condition. Providers are encouraged to rely on their training and expertise, as well as any and all available information, prior to making management or treatment decisions for any individual patient. American Medical Technologies. 1

2 Objectives 3 Recognize the components of the pressure ulcer/injury prevention program; Stage pressure ulcer/injuries according to the State Operations Manual; Define the Kennedy Terminal Ulcer, Unavoidable Pressure Ulcer/Injury; Design the wound management plan of care using the Wound Bed Preparation model; List components of F687 for care of the feet of people with diabetes; Participate in a wound type/tissues recognition skills lab; THE MOST COMMON TYPES OF CHRONIC WOUNDS AMT Education Division American Medical Technologies. 2

3 F684-Quality of Care-Previously F309 Review of a Resident with Non Pressure-Related Skin Ulcer/Wound Residents may develop various types of skin ulceration. At the time of the assessment and diagnosis of a skin ulcer/wound, the clinician is expected to document the clinical basis (e.g., underlying condition contributing to the ulceration, ulcer edges and wound bed, location, shape, condition of surrounding tissues) which permit differentiating the ulcer type, especially if the ulcer has characteristics consistent with a pressure ulcer, but is determined not to be one. This section differentiates some of the different types of skin ulcers/wounds that are not considered to be pressure ulcers. Other types of wounds specifically mentioned are arterial, diabetic neuropathic, & venous ulcers, but includes ALL etiologies NOTE: ALL wound etiologies must have a wound assessment including measurements. Arterial Venous Diabetic Neuropathic Most Common Chronic Wound Etiologies American Medical Technologies. 3

4 Other Frequently Encountered Wounds 7 Moisture Associated Skin Damage Deep Tissue Pressure Injury Kennedy Terminal Ulcer (KTU) AKA Skin Failure Medical Adhesive Related Skin Injury (MARSI) American Medical Technologies. Medical Device Related Pressure Injury Must be staged and reported on the MDS Other Frequently Encountered Wounds 8 Surgical Dehiscence Infection Poor closing technique Too much strain on incision by patient Skin Tears Can be partial or full-thickness injuries Considered traumatic wound Atypical Wounds Host of different etiologies often associated with autoimmune diseases American Medical Technologies. Cancer Wounds Aka Fungating wounds American Medical Technologies. 4

5 Mixed Etiologies 9 xx xx xx XX Xx xx xx Arterial and Venous Venous Insufficiency and Lymphedema AKA Phlebolymphedema Pressure and Arterial American Medical Technologies. Moisture Associate Skin Damage (MASD) and Pressure Autoimmune & Atypical Wounds 10 Attribution: Dermatology Information Center Pyoderma Gangrenosum Beware of Pathergy Effect Vasculitis Inflammation and destruction of blood vessels Pemphigus Vulgaris Autoantibodies against some part of epidermis Oral lesions seen 1st Bullous Pemphigoid Most common autoimmune dermatosis (Allergy to one s own skin) American Medical Technologies. Bullous Diabeticorum Spontaneous noninflammatory blistering unique to patients with diabetes American Medical Technologies. 5

6 11 Moisture Associated Skin Damage Urinary + Fecal Incontinence 22 times higher risk for PU/PIs with fecal incontinence!!! 37.5 times higher riskfor PU/PIs in residents with both impaired mobility and fecal incontinence!!! Ammonia found in urine reactivates digestive enzymes found in stool, further erodes skin surface opening skin to infections. American Medical Technologies. What Stage? Stage 1 Stage 2 Stage 3 Stage 4 Unstageable DTPI American Medical Technologies. 6

7 PRESSURE ULCER/INJURY PREVENTION ACCORDING TO REGULATORY AND BEST PRACTICES This section of the SOM continues to evolve as better understanding of skin issues come to light within the health care community and is shared with CMS. Copyright 2018 Gordian Medical, Inc. dba American Medical Technologies. American Medical Technologies Education Division F658 Comprehensive Care Plans INTENT (b)(3)(i) The intent of this regulation is to assure that services being provided meet professional standards of quality. GUIDANCE (b)(3)(i) Professional standards of quality means that care and services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting. Standards regarding quality care practices may be published by a professional organization, licensing board, accreditation body or other regulatory agency. Recommended practices to achieve desired resident outcomes may also be found in clinical literature. IMPORTANT when you are negotiating with a surveyor regarding an F tag. Ensure you or your consultants are delivering the current standards of care for assessments and treatments American Medical Technologies. 7

8 F658 Ties to All Care Including F686 If a negative or potentially negative resident outcome is determined to be related to the facility s failure to meet professional standards and the team determines a deficiency has occurred, it should also be cited under the appropriate quality of care or other relevant requirement. For example, if a resident develops a pressure injury because the facility s nursing staff failed to provide care in accordance with professional standards of quality, the team should cite the deficiency at both F658 and F686 (Skin Integrity). KEY ELEMENTS OF NONCOMPLIANCE: Instructions to Surveyors To cite deficient practice at F658, the surveyor's investigation will generally show that the facility did one or more of the following: Provided or arranged for services or care that did not adhere to accepted standards of quality; Provided a service or care when the accepted standards of quality dictate that the service or care should not have been provided; (e.g. debridement of heel PU/PI with arterial insufficiency without objective blood flow studies (ABI). Failed to provide or arrange for services or care that accepted standards of quality dictate should have been provided. American Medical Technologies. 8

9 Questions the Surveyor Will Ask Do the services provided or arranged by the facility, as outlined in the comprehensive care plan, reflect accepted standards of practice? Are the references for standards of practice, used by the facility, up to date, and accurate for the service being delivered? NOTE: Standards of practice change as we learn more. Who is keeping up with your wound prevention and care standards of care? How do you know the services provided by outside contractors are up-to-date and appropriate? New State Operations Manual Released November 22, 2017 American Medical Technologies. 9

10 Why Prevention? National priority Decrease PU/PI incidence Survey (F-Tags, monetary penalties) Reimbursement may be affected in future (P4P) Framework for identifying unavoidable pressure Injury Facility reputation (5 STAR Process) Litigation IMPROVED QUALITY OF LIFE Why Use a Risk Assessment Tool Although the requirements do not mandate the use of any specific assessment tool (other than the RAI), many validated instruments are available to aid in assessing the risk for developing PU/PIs. Research has shown that in a skilled nursing facility, 80 percent of PU/PIs develop within two weeks of admission and 96 percent develop within three weeks of admission. American Medical Technologies. 10

11 Frequency of Risk Assessment When the Score Doesn t Match the Risk Regardless of any resident s total risk score on an assessment tool, clinicians are responsible for evaluating each existing and potential risk factor for developing a pressure injury and determining the resident s overall risk. It is acceptable if the clinician s assessment places the resident at a higher risk level than the overall score of the assessment tool based on assessment factors that are not captured by the tool. Documentation of the clinician s decision should be placed in the medical record. American Medical Technologies. 11

12 Essential Components PRESSURE ULCER/INJURY PREVENTION PROGRAM Skin Inspection Risk Assessment Pressure redistribution and offloading Maintaining skin health Nutrition & hydration Patient & family education What Stage? Stage 1 Stage 2 Stage 3 Stage 4 Unstageable DTPI American Medical Technologies. 12

13 Blanch Test (Capillary Refill) of EVERY Heel Consider capillary refill exam of most common areas for pressure injuries in those patients/residents with significantly impaired mobility, Sacrum Trochanter Malleolus Heels Other risk areas associated with bed positioning Specific Considerations for PrU Risk Impaired Mobility Comorbidities Drugs (e.g. steroids) Impaired Diffuse or Localized Blood Flow Previously Healed PU/PI Cognitive Impairment Refusal of Care Nutrition Hydration Impairments Sensory Perception American Medical Technologies. 13

14 Braden Parameters Sensory Perception 1. Completely Limited 2. Very Limited 3. Slightly Limited 4. No Impairment Mobility 1. Completely Immobile 2. Very Limited 3. Slightly Limited 4. No Limitations Moisture 1. Constantly Moist 2. Very Moist 3. Occasionally Moist 4. Rarely Moist Nutrition 1. Very Poor 2. Probably Inadequate 3. Adequate 4. Excellent Activity 1. Bedfast 2. Chairfast 3. Walks Occasionally 4. Walks Freq. Friction & Shear 1. Problem 2. Potential Problem 3. No Apparent Problem Predispose to intense pressure Affect tissue tolerance Predispose to intense pressure Predispose to intense pressure Affect tissue tolerance Affect tissue tolerance American Medical Technologies. 14

15 Number 1 Reason for Acquiring Pressure Ulcer/Injuries Immobility Create a Culture of Mobilityin your Everything else is a contributing factor building Mobility Assessing accurately for mobility impairmentsand implementing a mobility plan of care is probably the most important componentof a pressure Injury prevention program Bed mobility Roll side to side Hold side lying position Scooting up in bed Lying to sitting Sit to stand American Medical Technologies. 15

16 Assessment for Mobility- F688-Lots of NEW Language The resident s comprehensive assessment should include and measure: Resident s current mobility status Identification of limitations, if any and opportunities for improvement. The MDS tool provides an assessment of the resident s ability for movement including: To and from the lying position, Turning and side to side movement in bed, Positioning of the body, Transfers between surfaces such as to and from bed or chair, standing, and walking The resident s comprehensive assessment should also address whether the resident had previously received treatment and services for mobility and whether he/she maintained his/her mobility, whether there was a decline, and why the treatment/services were stopped. For resident with limited mobility assessment should address, if he/she is not receiving services, the reason for the services to not be provided. See Range of Motion section Rehab Can Help-Make Sure Rehab Read F688 Ensure your rehab team involved with residents who have mobility & activity issues OT & PT can assist in evaluating & treating residents with mobility issues by improving: Strength Body movement strategies in bed & chair Sitting & standing balance Teaching residents, staff, & family members how to use adaptive equipment (i.e., transfer/gait belts, walkers, canes) Restorative program Therapists also provide assessments & make suggestions or create proper seating interventions when sitting mobility issues American Medical Technologies. 16

17 Braden Scale Scores At Risk = Moderate Risk = High Risk = Very High Risk= 9 or below Advance Level of Risk-Original Braden Documents Ifother major risk factors are present Advance age Fever Poor dietary intake of protein Diastolic pressure <60 Hemodynamic instability ADVANCE TO THE NEXT LEVEL OF RISK!!! American Medical Technologies. 17

18 Pressure Points and Tissue Tolerance Assessment of a resident s skin condition helps define prevention strategies. The skin assessment should include an evaluation of the skin integrity. and tissue tolerance (ability of the skin and its supporting structures to endure the effects of pressure without adverse effects) after pressure to that area has been reduced or redistributed. The measurement of tissue tolerance can be done in a variety of ways and the method chosen for use in the facility should be identified. NOTE: Strike through language removed from 11/22/17 SOM version latest version to date. American Medical Technologies. 18

19 Case Study Previously active independent 68 y/o female with L- partial hip replacement 5 days ago due to femoral neck fracture after fall in home Admitted to skilled services for nursing and rehab with goal of returning to daughter s home for continued recovery rehab with home health. Vitals: T=99.6, R=17, BP=92/58, P=100bpm Goal: return to highest level of functionality as an independent community ambulatorand return to her personal home to live alone Let s do the Braden together New femoral head Braden Parameters Sensory Perception 1. Completely Limited 2. Very Limited 3. Slightly Limited 4. No Impairment Mobility 1. Completely Immobile 2. Very Limited 3. Slightly Limited 4. No Limitations Moisture 1. Constantly Moist 2. Very Moist 3. Occasionally Moist 4. Rarely Moist Nutrition 1. Very Poor 2. Probably Inadequate 3. Adequate 4. Excellent Activity 1. Bedfast 2. Chairfast 3. Walks Occasionally 4. Walks Freq. Friction & Shear 1. Problem 2. Potential Problem 3. No Apparent Problem American Medical Technologies. 19

20 Braden Score Other Risk Factors Risk Level? Training in the Braden Clinicians performing the Braden should review methods for scoring correctly Surveyors may check medical records and MDS for use & accuracy of the risk assessment with corresponding subscales In-services on how to perform and use the risk assessment scale are important components of the pressure Injury prevention programand should be required for all nurse managers and other individuals delegated the task of completing the risk assessment In addition, a quality assurance (QA) review is recommended to ensure accurate determination of the subscales of the risk assessment tool being used American Medical Technologies. 20

21 What Stage? 41 Stage 1 Stage 2 Stage 3 Stage 4 Unstageable DTPI Describing Tissue Destruction in Your Documentation Partial vs Full Thickness Pressure Ulcer Staging American Medical Technologies. 21

22 43 All wounds, regardless of etiology, can be assessed as either partial or full-thickness wounds. Classification of Wound by Tissue Destruction Partial thickness Full thickness Extends through the epidermis (first layer of skin), but not through dermis (second layer) STAGE 2 PU/PI Extends through epidermis and dermis; may involve subcutaneous tissue, muscles, joint capsule, bone STAGE 3 and 4 PU/PI CMS Survey & Cert Appendix PP-Advance Copy-7/2017 CMS is aware of the array of terms used to describe alterations in skin integrity due 44 to pressure. Some of these terms include: pressure ulcer, pressure injury, pressure sore, decubitus ulcer and bed sore. Clinicians may use and the medical record may reflect any of these terms, as long as the primary cause of the skin alteration is related to pressure. For example, the medical record could reflect the presence of a Stage 2 pressure injury, while the same area would be coded as a Stage 2 pressure ulcer on the MDS. CMS often refers to the National Pressure Ulcer Advisory Panel s (NPUAP) terms and definitions, which it has adapted, within its patient and resident assessment instruments and corresponding assessment manuals, which includes the Minimum Data Set (MDS). We intend to continue our adaptation of NPUAP terminology for coding the resident assessment instrument while retaining current holistic assessment instructions definitions and terminology. The adapted terminology was used in the development of this guidance. American Medical Technologies. 22

23 Comparisons of Definitions 45 F-686/Formerly F314 Pressure Ulcer/Injury (PU/PI) Refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skinand may be painful. A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities and condition of the soft tissue. NPUAP Pressure Injury: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcerand may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, comorbidities and condition of the soft tissue. 1. Centers for Medicare and Medicaid Services (CMS) - State Operations Manual: Guidance to Surveyors 2. CMS -MDS 3.0, Section -M 3. National Pressure Ulcer Advisory Panel: Prevention and Treatment Clinical Practice Guidelines American Medical Technologies. 23

24 47 What is the Purpose of Staging? To indicate the depthof tissue damage RAI language: Pressure ulcer staging is an assessment system that provides a description and classification based on anatomic depth of soft tissue damage. This tissue damage can be visible or palpablein the ulcer bed. Pressure ulcer staging also informs expectations for healing times. NOTE: More mistakes on Staging than any other section of the MDS! Staging per the SOM Stage 1 Stage 2 Stage 3 Stage 4 Unstageable Deep Tissue Pressure Injury (DTPI) Medical Devices Related Pressure Injury 48 American Medical Technologies. 24

25 Stage 1 Pressure Injury Stage 1 Pressure Injury: Slide 1 Intact skin with a localized area of non-blanchable erythema (redness). In darker skin tones, the PI may appear with persistent red, blue, or purple hues. Stage 1 Pressure Injury with Edema American Medical Technologies. 25

26 Stage 1 PressureInjury Slide 2 The presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes of intact skin may also indicate a deep tissue PI. Blanchable vs. Non Blanchable Erythema Blanchable Erythema Non-Blanchable Using clear plastic sheet to blanch American Medical Technologies. 26

27 Stage 2 Pressure Ulcer Stage 2 Pressure Ulcer Slide 1 Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. American Medical Technologies. 27

28 Stage 2 Pressure Ulcer Slide 2 This stage should not be used to describe moisture associated skin damage including incontinence associated dermatitis, intertriginous dermatitis (inflammation of skin folds), medical adhesive related skin injury, or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Ulcer American Medical Technologies. 28

29 Stage 3 Pressure Ulcer Slide 1 Stage 3 Pressure Ulcer with light slough Full-thickness loss of skin, in which subcutaneous fat may bevisible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. Stage 3 Sacral Pressure Ulcer Stage 3 Pressure Ulcer Slide 2 The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may Shallow Stage 3 occur. Fascia, muscle, tendon, ligament, cartilage and/or bone Deep Stage 3 are not exposed. If slough or eschar obscures the wound bed, it is an Unstageable PU/PI. American Medical Technologies. 29

30 Epibole Rolled Edges Shallow appearance at ear Stage 3 Examples Deep appearance at hip Stage 4 Pressure Ulcer American Medical Technologies. 30

31 Stage 4 Pressure Ulcer: Full-thickness Skin & Tissue Loss Stage 4 pressure injury with light slough in wound base. Full-thickness skin and tissue loss with exposed or directly palpablefascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscuresthe extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 with tendon exposed Attribution: Dot Weir, RN, CWON, CWS Deep Stage 4 Stage 4 Examples Stage 4 into ear cartilage American Medical Technologies. 31

32 Unstageable Pressure Ulcer Unstageable Pressure Ulcer Slide 1 Unstageable Pressure Ulcer due to Eschar & Slough Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Unstageable Pressure Ulcer due to Eschar American Medical Technologies. 32

33 Unstageable Pressure Ulcer Slide 2 Stable Eschar On Great Toe Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) should only be removed after careful clinical consideration and consultation with the resident s physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. Unstable Eschar In Pressure Ulcer Unstageable Pressure Ulcer Slide 3 Attribution: Dot Weir, RN, CWON, CWS Pre-debridement Post-debridement If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur. American Medical Technologies. 33

34 67 M0300E: Unstageable Pressure Ulcers Related to Non-removable Dressing/Device Only on RAI/MDS -Not part of NPUAP staging definitions DEFINITION NON-REMOVABLE DRESSING/ DEVICE Includes, for example, a primary surgical dressing that cannot be removed, an orthopedic device, or cast. Courtesy: Dot Weir Unstageable due to Slough Attribution: Dot Weir, RN, CWON, CWS Unstageable due to Eschar Unstageable Examples Unstageable due to Slough and Eschar American Medical Technologies. 34

35 Deep Tissue Pressure Injury Deep Tissue Pressure Injury (DTPI) Intact skin with localized area of persistent nonblanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. American Medical Technologies. 35

36 Deep Tissue Pressure Injury Slide 2 DTPI on Admission xxxxxxxxxxxx DTPI 30 days later This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure ulcer. Deep Tissue Pressure Injury Slide 3 Once a deep tissue injury opens to an ulcer, reclassify the ulcer into the appropriate stage. Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. Initial Presentation 19 Days Unstageable 1 Month Stage 3 3 Months Attribution: Dot Weir, RN, CWON, CWS American Medical Technologies. 36

37 NPUAP Position Statement on Staging January 2017 When classifying injuries caused by pressure and/or shear, the clinician has the following options: 1) If the type of tissue in the wound base can be evaluated, numerically classify as Stage 1 or 2 or 3 or 4, based on the deepest tissue type exposed. 2) If the wound base cannot be evaluated, classify as: a) Deep Tissue Pressure Injury (DTPI) when the skin is intact with deep red, purple or maroon discoloration or blood blister(s). b) b) Unstageable when the base is obscured by slough or eschar. 3) If on a mucosal membrane, document, but do not stage. What Does the MDS Say About Blood-Filled Blisters Examine the area adjacent to or surrounding an intact blister for evidence of tissue damage. If other conditions are ruled out and the tissue adjacent to, or surrounding the blister demonstrates signs of tissue damage, (e.g., color change, tenderness, bogginess or firmness, warmth or coolness) these characteristics suggest a suspected deep tissue injury (sdti) rather than a Stage 2 Pressure Ulcer. XX Stage 2 Serum filled blister DTPI Blood-filled blister with evidence of surrounding tissue damage American Medical Technologies. 37

38 New Ulcer/Injury Definitions in the SOM New Definition Medical Devices Related Pressure Injury Medical device related PU/PIs result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system. Courtesy: Dot Weir Bed pan medical device related pressure injury Stage 2 MUST be staged. TED hose not removed for several days Caused full-thickness Stage 4 Medical Device Related PU/PI American Medical Technologies. 38

39 News Definition Mucosal Membrane Pressure Ulcer/Injury Mucosal membrane PU/PIs are found on mucous membranes with a history of a medical device in use at the location of the injury. Due to the anatomy of the tissue, these ulcers cannot be staged. RAI Coding Tip: Oral Mucosal ulcers caused by pressure should not be coded in Section M. These ulcers are captured in item L0200C, Abnormal mouth tissue. Mucosal ulcers are not staged using the skin pressure ulcer staging system because anatomical tissue comparisons cannot be made. What We Do NOT Stage American Medical Technologies. 39

40 What We DO NOTStage 79 Top-down injuries Moisture associated skin damage (MASD) Intertriginous dermatitis -Inflammation in skin folds Periwound MASD Maceration Peristomal MASD Incontinence Associated Dermatitis (IAD) What We DO NOT Stage 80 Medical adhesive related skin injury (MARSI)- term brought forward in 2012 Defined as an occurrence in which erythema and/or other manifestation of cutaneous abnormality including, but not limited to, vesicle, bulla, erosion or tear Common skin damage due to use of adhesive products particularly (but not exclusively) in institutional healthcare Denuding (adhesive removal over MASD) American Medical Technologies. 40

41 What We DoNotStage 81 Skin Tears -International Skin Tear Advisory Panel Type 1: No skin loss Linear or flap tear that can be repositioned to cover the wound Type 2: Partial flap loss Partial flap loss that can t be repositioned to cover wound bed Type 3: Total flap loss Total flap loss exposing the entire wound bed What We DO NOTStage Peripheral Arterial Venous Insufficiency Diabetic Neuropathic Lymphedema Disease (PAD) Foot Ulcer Chronic wound etiologies other than pressure must have good wound differentiation skillsto determine wound etiologies; 82 All etiologies should be validated by the practitioner in the medical record American Medical Technologies. 41

42 What Stage? 83 Stage 1 Stage 2 Stage 3 Stage 4 Unstageable DTPI 84 Other Tags Reviewed when F686 Deficiency Given Surveyors Instructed to Review EACH of These Tags F710 Physician Services F641 Accuracy of Assessment F880 Infection Control Comprehensive Care Plan F656 What must be included F655 F636 Comprehensive Person- Centered Care Planning Resident Assessment F657 Other Tags to be considered Comprehensive Care Plan Effectiveness of CP and who must be included F552 Right to be Informed F580 Notification of Change F635 Admission Orders F637 Significant Change Copyright 2017 Gordian Medical, Inc. dba American Medical Technologies. American Medical Technologies. 42

43 Unavoidable Pressure Ulcer/Injury, Kennedy Terminal Ulcer, Skin Failure: The Clinical and Regulatory Perspectives as We Know It Today FACULTY: PAMELA SCARBOROUGH PT, DPT, MS, CWS, CEEAA DIRECTOR OF PUBLIC POLICY & EDUCATION Copyright 2018 Gordian Medical, Inc. dba American Medical Technologies. AMT Education Division Skin is largest organ of the body Introduction Fails same as other organs: heart, kidneys, liver, etc. With acute and chronic illnesses body systems can fail, sometimes suddenly Skin failure is an unavoidable condition Older adults have higher risk for skin failure due to more fragile overall organ physiology, including the skin When patients/residents deteriorating physically, skin failure may not be preventable American Medical Technologies. 43

44 Difficult to Tell the Difference Between PU/PI and Skin Failure Necrosis Ulceration Blistering Pressure Ulcer/Injury Usually over bony prominences Necrosis Ulceration Blistering Skin Failure Mottling-shunting blood from skin Gangrene Anywhere on the body Skin Mottling. Pt. in respiratory failure and hypotension Avoidability/Unavoidability of Skin Breakdown Terminal (end of life) ulceration is NOT new concept 100 years old and documented in historical medical literature Lack of complete understanding of skin failure Some people think, erroneously, that ALL PU/PIs are avoidable CMS agrees not all PU/PIs are avoidable Research needed on topic of terminal skin failure/ulcerations Shared terminology needed that defines process of skin failure/ktu/unavoidable PU/PI American Medical Technologies. 44

45 Decubitus Ominousus Courtesy of Jeffrey M Levine MD Skin breakdown heralding impending death of the patient decubitus ominosus. This nomenclature (name) was forgotten until the late 20 th century when Karen Kennedy recognized and published information on the what became known as the Kennedy Terminal Ulcer in 1980s. Terms to Describe Unavoidable Skin Changes Several classifications/terms for similar/overlapping clinical syndromes Kennedy Terminal Ulcer (CMS recently recognized-f686) Trombley-Brennan Terminal Tissue Injury Skin Changes at Life s End Skin Failure Unavoidable pressure ulcer/injuries (CMS SOM F686) All of these terms may be a component of multi-organ failure where the skin is failing in concert with other body systems. Similar meaning of these different terms creates confusion for clinicians trying to communicate and design plans of care that are appropriate for end of life skin deterioration American Medical Technologies. 45

46 The Kennedy Terminal Ulcer (KTU) Kennedy Terminal Ulcer Unavoidable skin breakdown or skin failure that occurs as part of dying process Not a causeof a patient's death Occurs in spite of good quality care Appears quickly and progresses rapidly sometimes within hours May start out superficially as a blister or what appears to be a Stage 2 May have early characteristics of a DTPI American Medical Technologies. 46

47 The Kennedy Terminal Ulcer (KTU) per SOM The facility is responsible for accurately assessing and classifying an ulcer as a KTU or other type of PU/PI and demonstrate that appropriate preventative measures were in place to prevent non-ktu pressure ulcers. F684: Quality of Life Kennedy s Terminal Ulcer: Pressure Ulcer Kennedy Terminal Ulcers are considered PRESSURE ULCER/INJURY per CMS Pressure ulcers that generally occur at the end of life For concerns related to Kennedy Terminal Ulcers, refer to F686, (b) Pressure Ulcers. NOTE: From Presenter not CMS statement, but reality. These skin changes are not pressure ulcers they are the result of skin failure due to the dying process or during multi-organ failure. The resident is in the dying process and the skin largest organ of the body begins to also fail. If you recognize this situation and your MDs/NPs documents accordingly, then you can at least document them as unavoidable pressure ulcer/injuries. American Medical Technologies. 47

48 Characteristic of Kennedy Terminal Ulcers - F686 Know When to Use This Designation!!! KTUs have certain characteristics which differentiate them from pressure ulcers such as the following: KTUs appear suddenly and within hours; Usually appear on the sacrum and coccyx but can appear on the heels, posterior calf muscles, arms and elbows; Edges are usually irregular and are red, yellow, and black as the ulcer progresses, often described as pear, butterfly or horseshoe shaped; and Often appear as an abrasion, blister, or darkened area and may develop rapidly to a Stage 2, Stage 3, or Stage 4 injury. CMS and Avoidable/Unavoidable PU/PI American Medical Technologies. 48

49 Currently Pressure Ulcers Considered a Quality Measure Centers for Medicare and Medicaid Services (CMS) Joint Commission for Accreditation of Healthcare Organizations (JCAHO) Agency for Healthcare Research Quality (AHRQ) National Quality Forum (NQF) Institute for Healthcare Improvement (IHI) INTENT of F686 Related to PU/PIs The intent of this requirement is that the resident does not develop pressure ulcers/injuries (PU/PIs) unless clinically unavoidable and that the facility provides care and services consistent with professional standards of practice to: Promote the prevention of pressure ulcer/injury development; Promote the healing of existing pressure ulcers/injuries (including prevention of infection to the extent possible); and Prevent development of additional pressure ulcer/injury. American Medical Technologies. 49

50 Pressure Ulcer/Injury Development More than 100 risk factors cited in literature related to PU/PI development Affirms multifactorial etiology of PU/PI development Braden captures SOMEof these factors; not all Comorbidities listed as contributory include: Diabetes, infection, PAD, cardiovascular disease, anemia, hypotension, advancing age, vasopressor medications, and many more The research, literature, and experience of clinician over the decades agree that ALL pressure ulcer/injuries are NOT preventable Delmore, Cox, Rolnitzky, Chu, Stolfi, 2015 F686 Unavoidable Pressure Ulcer in State Operations Manual Guidance to Surveyors (b) Skin Integrity (b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that (i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual s clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. American Medical Technologies. 50

51 Avoidable Pressure Ulcer/Injury per CMS pg /22/17 SOM Avoidable means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident s clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. Unavoidable Pressure Ulcer/Injury per CMS pg /22/17 SOM Unavoidable means that the resident developed a pressure ulcer/injury even though the facility had: evaluated the resident s clinical condition and risk factors; defined and implemented interventions that are consistent with resident needs, goals, and professional standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate. CHF example for unavoidable American Medical Technologies. 51

52 KEY ELEMENTS OF NONCOMPLIANCE To Cite Deficient Practice at F686 Surveyor's investigation will generally show that the facility failed to do one or more of the following: Provide preventive care, consistent with professional standards of practice, to residents who may be at risk for development of pressure injuries; or Provide treatment, consistent with professional standards of practice, to an existing pressure injury; or Ensure that a resident did not develop an avoidable PU/PI. What Stage? Serum-filled blister Stage 1 Stage 2 Stage 3 Stage 4 Unstageable DTPI Dermal layer exposed American Medical Technologies. 52

53 Trombley-Brennan Terminal Tissue Injury (TB-TTI) Trombley-Brennan Terminal Tissue Injury (TB-TTI) Purple maroon discoloration that may appear suddenly at end of life Further description: Patient will exhibit these skin changes on bony and nonbony prominences These injuries do not evolve into full thickness wounds with non viable tissue Frequently characterized by an increase in surface area No drainage present Linear and mirror images may appear on lower extremities No complaints of discomfort Do not follow the same course as the KTU American Medical Technologies. 53

54 Trombley-Brennan Terminal Tissue Injury (TB-TTI) Spontaneously appearing skin alterations (rapid evolution, speed of enlargement and progression, appearance in areas of little to no pressure such as shins, thighs, and mirror imaging found in patients at the end of life. Trombley Brennan (TB-TTI) (2010) Skin Failure and Skin Changes at Life s End American Medical Technologies. 54

55 Pressure Ulcer/Injuries at End of Life F686 Page 269 SOM 11/22/17 Guidance to Surveyors It is important for surveyors to understand that when a facility has implemented individualized approaches for end-of-life care in accordance with the resident s wishes, the development, continuation, or worsening of a PU/PI may be considered unavoidable. If the facility has implemented appropriate efforts to stabilize the resident s condition (or indicated why the condition cannot or should not be stabilized) and has provided care to prevent or treat existing PU/PIs (including pertinent, routine, lesser aggressive approaches, such as, cleaning, turning, repositioning), the PU/PI may be considered unavoidable and consistent with regulatory requirements. Skin Failure Definition An event in which the skin and underlying tissue die due to hypoperfusion that occurs concurrent with severe dysfunction or failure of other organ systems (Langemo, 2005, Langemo & Brown, 2006) Skin Failure and pressure ulcers are 2 distinct, yet related clinical phenomena (Delmore, Cox, Rolnitzky et al, 2015) American Medical Technologies. 55

56 Physical Manifestations of Skin Failure Hemodynamic changes Hypoperfusionof skin shunting of blood to vital organs to preserve life Impaired thermoregulatory control Metabolic abnormalities of toxic metabolites from catabolism American Medical Technologies. 56

57 Skin Changes at Life s End Physiologic changes that occur as a result of the dying process (days to weeks) may affect the skin and soft tissues and may manifest as observable (objective) changes in skin color, turgor, or integrity, or as subjective symptoms such as localized pain. These changes can be unavoidable and may occur with the application of appropriate interventions that meet or exceed the standard of care. Skin Changes at Life s End Skin changes at life s end are a reflection of compromised skin (reduced soft tissue perfusion, decreased tolerance to external insults, and impaired removal of metabolic wastes). American Medical Technologies. 57

58 Skin Failure Based on the SCALE document (2008) and NPUAP position statements (2011, 2014), two conditions necessary for establishing the diagnosis of skin failure are skin hypoperfusion and severe organ dysfunction or failure (White-Chu & Lagemo, 2012) ICD-10 diagnosis of skin failure: L98.9 Disorders of the skin When it appears skin failure/ktu involved in failing skin integrity have practitioner collaboration a.s.a.p. Organ Failure Stratification Acute Skin Barrier Failure End-Stage Chronic American Medical Technologies. 58

59 Types of Skin Failure (Langemo& Brown, 2006) Acute Skin Failure: an event in which skin and underlying tissue die due to hypoperfusionconcurrent with a critical illness (e.g., MI, sepsis, etc.) Chronic Skin Failure: an event in which skin and underlying tissue die due to hypoperfusionwith a chronic disease state (e.g., PAD, MS, neuropathy, kidney disease) End-Stage Skin Failure: an event in which skin and underlying tissue dies due to hypoperfusionconcurrent with the end of life (e.g., cancer, MS) End of Life Considerations May involve short periods of overwhelming illness (acute) Or slow deterioration lasting months to years (chronic) In both cases, the skin becomes particularly vulnerable to breakdown Witkowski and Parish concluded that skin breakdown is often unavoidable at this point American Medical Technologies. 59

60 INTERVENTIONS to Mitigate Chronic Skin Failure Well documented multidisciplinary interventions -Nutritional support -Hydration -Medical management -Hygiene -Functional rehabilitation -Pressure redistributing surface selection End-Stage Skin Failure Skin and underlying tissue die due to hypoperfusion concurrent with end of life Challenges to maintaining skin integrity Transition from acuteto chronicto end-stage -not easily observable continuum American Medical Technologies. 60

61 End-Stage Organ Decompensation and Failure Large and unusual presentations of skin failure Body shunts blood to vital organs Widespread and deep tissue destruction over stressed areas can appear in a matter of hours or less Sacrum Heels Posterior calf muscles Arms Elbows Conclusions from SCALE Expert Panel Current Understanding Limited Additional Research Needed Observable Changes SCALE (2009) Education: Clinicians, Laypeople, Policy Makers American Medical Technologies. 61

62 Healable Wounds Clinicians should strive to distinguish the difference between: Have adequate blood supply Can heal if underlying causes addressed Sibbald: 2011, 2015 Maintenance Wounds Nonhealable Wounds Healing potential Patient/resident or health system barriers compromising healing Patient/residents may be nonadherentto treatment Patients/residents may have resource limitations Includes palliative wounds Cannot heal due to irreversible causes/illnesses Critical ischemia Non treatable malignancy What Stage? 124 Stage 1 Stage 2 Stage 3 Stage 4 Unstageable DTPI American Medical Technologies. 62

63 125 F687 FOOT CARE F687 Expanded Content - Replaces F To ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must: Provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident s medical condition(s) and If necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments. American Medical Technologies. 63

64 F687 Guidance 127 Facilities are responsible for providing the necessary treatment and foot care to residents. Treatment also includes preventive care to avoid podiatric complications in residents with diabetes and circulatory disorders who are prone to developing foot problems. Foot care that is provided in the facility, such as toe nail clipping for residents without complicating disease processes, must be provided by staff who have received education and training to provide this service within professional standards of practice. Residents requiring foot care who have complicating disease processes must be referred to qualified professionals. 128 Specific Foot Disorders Mentioned in F687 Foot disorders which may require treatment include, but are not limited to: Corns Calluses Neuromas Hallux valgus (bunions) Digiti flexus (hammertoe) Heel spurs Nail disorders American Medical Technologies. 64

65 Surveyor Probe Questions Slide For residents selected for review determine the following: According to the medical record, does the resident have a diagnosis or condition that poses a risk to foot health (e.g., diabetes, peripheral vascular disease, ingrown toenails)? Does the comprehensive care plan adequately address the resident s risk with appropriate interventions? Observe resident s feet for lack of nail care, presence of calluses, and/or other foot problems. 130 Surveyor Probe Questions Slide 2 Are residents with foot concerns seen either within the facility or community by a qualified foot care specialist? Do residents with mobility concerns have foot care concerns, and did the facility address these concerns? Are qualified healthcare providers available to see residents either in the facility or in the community? What preventive foot care do staff provide and to what resident population? Are staff performing foot care to the resident when needed and ordered American Medical Technologies. 65

66 131 The Wound Assessment and Documentation With each dressing change or at least weekly (and more often when indicated by wound complications or changes in wound characteristics), an evaluation of the PU/PI should be documented. Purpose of the Wound Assessment 132 Create a functional plan of care Follow CMS pressure ulcer documentation guidelines/mandates Track pressure ulcer healing/deterioration Communication between disciplines Communication with family Legal protection American Medical Technologies. 66

67 F686-MandatedWeekly or Dressing Change Monitoring 133 Location and staging Size (perpendicular L x W, depth Location & extent of: Undermining/tunneling/sinus tract Exudate: type, color, odor, amount Pain: nature and frequency Wound bed/base: color & type of tissue evidence of healing or necrosis Evidence of healing Description of wound edges & surrounding tissue 134 Location Left trochanter and left iliac crest versus left hip. Left scapula versus left shoulder Courtesy: Dot Weir American Medical Technologies. 67

68 MDS-Section M 135 Size = L x W x D 136 Head Feet American Medical Technologies. 68

69 137 Wound Measurement: Depth: Distance from visible surface to deepest point in wound base not covered with necrotic tissue Insert moistened sterile cotton swab NOTE:Do not record depth if not able to see bottom of the wound bed/base. Use unstageable designation if PU/PI. 138 Wound Measurement Tunneling/Sinus Tract A pathway that may extend in any direction Tunnels Photos courtesy of Dot Weir American Medical Technologies. 69

70 Tissue Types Wound Base 139 Epithelial Tissue Epithelium is white. Formation, growth and migration of new skin cells to cover the wound surface. Granulation Tissue Granulation tissue is red/pink, soft and granular. Slough Yellow stringy or thick devitalized tissue, that can be adherent on the tissue bed American Medical Technologies. Eschar Dead or devitalized tissue; hard or soft in texture; usually black, brown, or tan in color; usually firmly adherent to the base of the wound Wound Base Issues XXX Exposed Achilles Tendon Foreign object/exposed metal implant visible at base of wound Hypergranulation Tissue (exuberant granulation tissue or proud flesh) extends abovewound edges Courtesy: Dot Weir, RN, CWON, CWS 14 0 American Medical Technologies. 70

71 Describe Wound Edges 141 Attached, Well-defined Irregular wound edges Edge not attached Epibole Callus 142 Color Consistency Amount Odor Wound Drainage (Exudate) American Medical Technologies. 71

72 Exudate - Amount 143 None Scant/small Moderate Large Copious Poorly managed exudate Courtesy: Dot Weir When was last dressing changed? 144 Exudate - Character Serous clear, may be slightly yellowish, thin, watery Serosanguinous pink, thin, watery Sanguineous red/bloody, thin, watery Seropurulent yellow or tan, cloudy, thick Purulent (aka pus) thick, opaque, green with odor American Medical Technologies. 72