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
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$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
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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
28
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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 ●
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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?