Providing Advanced Wound Care in the Outpa5ent Se7ng

Providing  Advanced  Wound   Care  in  the  Outpa5ent  Se7ng     Presented  by     Lori  Richwine,  D.O.,  FAPWHc   Medical  Director   Atlan=Care  Wo...
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Providing  Advanced  Wound   Care  in  the  Outpa5ent  Se7ng     Presented  by     Lori  Richwine,  D.O.,  FAPWHc   Medical  Director   Atlan=Care  Wound  Healing  Center   Healogics  Specialty  Physician  

Disclosure     • 

Lori  Richwine,  DO,  FAPWHc  reported  that  she  has  no  relevant  financial  rela5onships  to   disclose.  

Objec5ves   1. 

Overview  of  the  significant  impact  of  untreated   wounds  in  the  US  

2. 

Overview  of  advanced  wound  care  

3. 

Referral  guidelines  for  Advanced  Wound  Care  

Impact  of  Wounds  on  the     US  Popula5on  

Many  suffer  for  months  and  years  with   wounds  such  as  these:  

Venous  Stasis  

Osteoradionecrosis  

Pressure  Ulcer  

Diabe5c  Foot  Ulcer  

Providers/Hospitals/Payers  are   Challenged  by  Trea5ng  Wounds   • 

By  having  an  outpa=ent  Wound  Healing  Center,  the  problems  of   trea=ng  difficult  and  expensive  wounds  can  be  helped    

• 

The  Advisory  Board  es=mated  that  inpa=ent  wounds  were   cos=ng  hospitals  on  average:   • 

Four  addi5onal  days  per  discharge  

• 

7.2%  increase  in  mortality  discharges  

• 

$5,423  addi5onal  costs  per  discharge    

• 

OKen,  a  transfer  to  an  outpa=ent  wound  healing  center  may   lead  to  reduced  lengths  of  stay  and  costs      

• 

Care  will  be  regular  on  a  weekly  basis  for  visits  to  reduce   complica=ons  and  readmissions      

• 

Care  is  coordinated  with  all  providers  on  an  outpa=ent  basis   including  Home  Health  Nurses  ,  dressing  companies,  PCP’s  

Cost  

Chronic  wounds   affect  6.5   million   Americans  per   year  at  a   treatment  cost   of  $25  billion   per  year  

Cost  

Cost  

By  the  Numbers…  

Addi5onal  $39   billion  in  lost   wages  per  year  

$15.3  billion   es5mated   expense  on   wound  care   products  in   2010  

Diabetes  Growth  =  165%  from  2000-­‐2050   Diabetes-­‐related  complica5ons,  including  amputa5ons,     lower-­‐extremity  neuropathies  and  premature  cardiovascular   disease  are  a  major  cause  of  chronic  wounds.   Prevalence  of  diagnosed  diabetes  in  America

40 30 People (Millions)

20 10

1960 1965 1968 1972 1977 1982 1987 1992 1997 2002 2020 2040 2050

0

The  Poten5al  Impact  Of  A  Diabe5c  Foot  Ulcer  

Amputa5ons’  Mortality  Rates     Compare  to  Cancer   Pa=ents  with  amputa=ons  and  diseases  related  to   diabetes  die  at  a  rate  as  high  as  many  cancers.   Five-­‐Year  Mortality  Rates     Pancrea=c  Cancer  

97  

Lung  Cancer  

86  

PAD  

64  

Ishemic  Ulcer   Ischemic   Colon  Cancer  

55   48  

Amputa=on  

47  

Neuropa=c  Ulcer  

45  

Hodgkins  Disease  

 

23  

Breast  Cancer  

18  

Protstate  Cancer  

18  

Sadly,  30%  of  chronic  wounds  le6   untreated  result  in  amputa:on;   over  47%  of  amputees  die  within   five  years.  

Cancer  

Diabe5c  related  amputa5ons  

Overview  of     Advanced  Wound  Care    

What  is  a  Chronic  Wound?     “An  insult  or  injury   that  has  failed  to   proceed  through   an  orderly  and   5mely  repair   process  to  produce   anatomic  and   func5onal   integrity”    

Masoro  and  Austad,  2006    

Normal  Wound  Healing  

Cellular  Ac=vity  

Chemotactic Migration

Inflammation

Mitosis Proliferation

Angiogenesis Synthesis of ECM

Remodeling

Proteolytic Turnover of ECM

Chronic  Wound  Delayed  Healing     Repeated  Trauma   Local  Tissue  Ischemia   Necro=c  Tissue   Heavy  Bacterial  Burden   Tissue  Breakdown    

 

Degrades  ECM  

             Prolonged  Inflamma=on      S=mula=on  of  macrophage  and   neutrophils  to  wound  bed   Ac=va=on  of  macrophages  with   release  of  cytokines  

•   impaired  cell  migra=on   •   impaired  connec=ve  =ssue  deposi=on  

Degrades  Growth  Factors    

TNF!    and  IL-­‐1!  

!  Produc=on  MMPs  and    !    TIMPs   3Mast  BA  &  Schultz  GS  (1996  )  

What  is  Advanced  Wound  Care?   Types of Wounds Treated:

Specialized  wound  care  is  a  focused,   evidence-­‐based  specialized  approach   to  the  treatment  of  chronic    wounds   through  clinical  prac5ce  guidelines  to   achieve  the  best  outcome.       Specialized  wound  care  addresses  the   many  condi5ons  and  co-­‐morbidi5es   that  impact  wound  healing  requires   the  interven5on  by  mul5ple   healthcare  disciplines  applying  the   appropriate  therapy  at    the  proper   5me.          

Venous  Ulcer   Loca5on:  midcalf  to  heel  (Gaitor  area)   Appearance:  shallow,  irregular,   exudate  is  common,  painful   Origin:  Venous  valve  incompetence     • 

Venous  hypertension  

• 

 Extravascular  blood  loss/edema   •  RBCs  !  hemosiderin  staining   •  WBCs  !  enzyme-­‐mediated  5ssue   destruc5on      

Venous  Ulcer  

Arterial  Ulcer   Loca5on:  distal  lower  extremity   Appearance:  dis5nct  margin  (cookie  cuner),  with  central   necrosis  in  se7ng  of  PAD:   •  Cool  extremity   •  Diminished  /absent  pulses   •  Shiny  skin  /hair  loss      

Arterial  Ulcer  

Diabe5c  Ulcer   Loca5on:  typically,   plantar  aspect  of  the   foot  beneath  a  bony   prominence   Appearance:  ill-­‐defined   borders,  prominent   callus,  and  palpable   pulses  

Diabe5c  Ulcer  

Pressure  Ulcer   Loca5on:  beneath  a  bony  prominence  (heel,  sacrum)     Appearance:  irregular  in  size  and  depth   Origin:  prolonged  contact  with  inappropriately   padded  surface  !  focal  ischemic  necrosis     Worsened  by   •  fric5on  /  moisture   •  malnutri5on     •  co-­‐morbidi5es  

Pressure  Ulcer  

  Staged  according  to  DEPTH  of  injury…  

Atypical  Wounds   Depend  upon  Causa5ve  factors   Examples:       •  Brown  Recluse  Spider  Bite   •  Post  radia5on  treatment   •  Malignancy   •  Autoimmune  process          

Atypical  Wounds:  Autoimmune  

RA, Sojourns

Pyoderma

Vasculitis

Factors  Affec5ng  Wound  Healing   SoK  Tissue  Infec=on   Pressure  

Systemic  Illness  

Chronic   Wound  

Oxygen  

Osteomyeli=s   Nutri=on  

Perfusion   Systemic  Healing    Ability   Compliance  

Wound  Environment   Edema  

Advanced  Therapies  

Using  HBO  Therapy  As  Part  of  the   Approach   Hyperbaric  Oxygen  Therapy  (HBOT)  is  a   powerful  adjunc5ve  therapy,  reimbursed  by   Medicare  and  most  payers,  that  is  indicated   for  10-­‐15%  of  pa5ents  with  chronic  wounds.     Medicare-­‐Approved  Non-­‐Emergent  Indica5ons:  

Acute  peripheral     arterial    insufficiency  

Acute  trauma:c   peripheral        ischemia  

Osteroradionecrosis  

Chronic  refractory   osteomyeli:s     Compromised   skin  gra6s  

Crush  injures  and     suturing  of        severed  limbs  

Progressive   necro:zing  infec:on  

Diabe:c  wounds  of   the  lower    extremi:es   So6-­‐:ssue   radionecrosis  

94%  of  diabe5c  foot  ulcer  pa5ents  treated  with  HBOT  maintained  an   intact  limb  at  55  months  post-­‐treatment1   1

.  Cianci  P.  Advances  in  the  treatment  of  the  diabe6c  foot:  Is  there  a  role  for  adjunc6ve  hyperbaric  oxygen  therapy?  Wound  Repair  Regen  2004;12(1):2-­‐10

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Causes  of  Hypoxia  in  Wound  Healing   Arterial  Insufficiency   •  Diabetes  –  impaired   microcircula5on   •  ABI/TCOM/Vascular  Studies   • 

Smoking  

Infec=on   •  Bacteria  promote  an  oxygen   dump  

Edema   •  Compression  required   Radia=on  =ssue  damage   •  Decrease  in  the  quan5ty  of   blood  vessels  

Hyperbaric  Oxygen  Therapy  (HBOT)  Defini5on   • 

The  administra5on  of  100%   oxygen  at  greater  than  1   atmosphere  pressure   absolute  (ATA)  

• 

Achieved  in  a  chamber  in   which  the  whole  body  is   ins5lled  

• 

Only  method  of  HBOT  that  is   approved  by  CMS  (Center  of   Medicare  Service)  

Hypoxic  Tissue  Benefits   •  Restora5on  of  

microcircula5on   •  Decreased  local  edema   •  Improved  cellular   energy  metabolism   •  Improved  local  5ssue   oxygena5on   •  Improved  leukocyte-­‐ killing  ability   •  Improved  effec5veness   of  an5bio5cs  

Indica5ons  -­‐  Wound  Care   } 

Diabe5c  wounds  of  the  lower  extremity  

} 

Acute  peripheral  arterial  insufficiency  

} 

Treatment    of  compromised  skin  graqs   or  flaps  

} 

Chronic  refractory  Osteomyeli5s  

} 

Osteoradionecrosis  

} 

Soq  5ssue  radionecrosis  

} 

Acute  trauma5c  peripheral  ischemia  

} 

Crush  injuries  and  suturing  of  severed   limbs  

} 

Progressive  necro5zing  infec5ons  

} 

Gas  gangrene  

   Debridement   Why?     •  Enhance  wound   assessment   •  Decrease  poten5al  for   infec5ons   •  Necro5c  5ssue  delays   formula5on  of   granula5on  and   epithelial  5ssue  

How?     • 

Mechanical  

• 

Autoly5c  

• 

Enzyma5c  

• 

Surgical  

       

Addi5onal  Advanced  Therapies   • 

Topical  Growth  Factors  

• 

Compression  

• 

Bioengineered  Skin  Subs5tutes  

• 

Topical  An5microbials  

Advanced  Dressing  Decision  tree  

Referral  Guidelines  for     Advanced  Wound  Care  

Benefits  to  Pa5ents  as  part  of  the   Wound  Care  Con5nuum     • 

Faster  healing  and  a  shorter  recovery  period  

• 

Limb  salvage  

• 

Restora5on  of  health  and  mobility  

• 

Improved  quality  of  life  

• 

Wound  Care  educa5on  to  help  pa5ents  understand  their   condi5on  and  prevent  complica5ons  

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What  Can  You  Do?   •  Recognize  who  is  at  RISK  for  chronic  wounds   •  Perform  an  accurate  assessment  of  the  WOUND  and  the  

PATIENT  

•  Implement  PREVENTATIVE  measures  

Nutri5onal  support   •  Surface  offloading/  Skin  protec5on   • 

•  Choose  appropriate  DRESSINGS   •  Make  prompt  REFERRALS  for  wound  care  and  HBOT  

Guidelines  For  Referral   ● 

● 

● 

● 

● 

● 

● 

Full  thickness  wounds  that  fail  to  show  significant     improvement  in  2  weeks  or  complete  healing  in  4  weeks   All  full  thickness  ulcers  that  involve  tendon,  ligament,  bone  and/or   joint  and/or  are  significantly  infected   Neuropathic  ulcers  in  diabe5c  pa5ents,  especially  those  with   accompanying  foot  deformity   Any  wound  in  a  diabe5c  pa5ent  due  to  the  compromised  healing   ability   Ulcers  in  compromised  pa5ents   Venous  ulcers,  especially  those  with  arterial  component  or  chronic   lower  extremity  swelling   Ulcers  with  significant  ischemia  

Ques5ons?    

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