Chronic Wound Care Ch13 22

Wound Care Processes-From Patient Assessment to Healthcare Delivery Systems
Wound Assessment and Documentation

Lia van Rijswijk, RN, MSN, CWCN;Jo Catanzaro, MSN, RN, CWOCN
Objectives
The reader will be challenged to: . Evaluate commonly assessed wound characteristics . Explain the rationale for assessing different wound characteristics . Analyze the purpose of wound assessment in your clinical practice
lntroduction 1f, ppreciation .rf the r'vound healing pr-ocess, factors that nral affect it. and rhe nurrrber oi dcvices !\ \available to manase rvounds has increased draI
rnatically during recent years. However, a significant portion of rvor.rnd-healing knowleclge is based on the results tivencss
tical application of available research as it pertains to the clinica'l assessment and docun'rentation of nonsuturcd, mostly chronic u,-ounds.The assessmellt of pressule ulcers is revierved in Chapter 58, and the assessment of rvound
pain is revierved in Chapter 11 of this textbook.
oflaboratory studies, rvhile data about the clinical effecof nrost u,ound care products rcmain limited. C)ne of the nranv reasons for this relativell, slow clinical
AssessmentWhat it is andWhat it is Not

Verbs commonly used to describe the process of
r-1p
follorv-
cal'c irrclucle
assess, eualuate,
fiortitor,
or
inspect.
It
is
progress is the challenge
of wound
assessment. Many
commonly used wound assessnrent ternrs remain poorly dcfined, and knorvledge about the validity and reliability is lirnited. In acldition, r,vound assessnrent validiW and reiiability str-rclies are ofteu conducted fron a rescarch, rathcr thcn a clinica[. perspectivc.
Slorvl,v but surelv, r.ve are starting to understand rvhich indiccs of u.ound hcaling Jr:c nort appropriate to evalu-
important not to Llsc them interchangeably, because their use aflects the levei of knowledge required to implenrent the process. To monitor or inspect nleans to watch, keep track of, check, or closely vierv a person or condition.'To evaluate, to determine the significance of an observation through appraisal and study, requires speci{ic skiils and
knorvledge. Similarly, (eg,
to
assess)
to collect, verify, and organize data is inrpossiblc lvithout specific skiils and an
ate." In addition, in clirrical practice, it is
generally
beiieved drat it is better to regular\ assess usins the samc possibly less-than-perGct tool than not to assess at a11.1 Every plan of care and intenentioll as wc1l as the clini-
understanding of the condition involved.' For example, the plan of care for a home-bound patient may include 2 visits per weck; once a week, the home health aide r'vrll change the dressing ancl monitor the patient and wound
ciani abi1iry to dcterr.rrine the effectiveness of cale is bascd on a complete patient historr., assessntent, ancl regular- follor.r,-up assessments.'This chapter rvi1l focus on the prac-
for signs of improvement, infection, or deterioration, and

once a n.eek, the registered nurse
nill
change the dressirrg
and complete a rvound assessment to quantifi/ progess.
van Rijsrvijk L. Crtanzero J. Wound assessnrent lnd clocunrcutation. [n: Krasner DL, l{odehe:rvcr GT, Sibba]d I{G. eds. Chronic Wound Core:A Clinicol Source Book for Healthcore ProFessionols. 4th ed. Malvcrrr, Pa; HMP (lorrrmunications. 2ltl)7:l1j 126.
CHRONIC
WOUND CARE 4th
Edtion
113
van Riiswijk and Catanzaro
unstable patterns may result
in
a desired outcome,
provid*
recent
ing one does not lose sight
ofit
(Figure 1).
Outcorne and treatrnent eflbctiveness. In

years, considerable efforts have been made
to discover and rnarkers ofnormal or or biological test physical, chenrical,
abnorrnal healing. 'While laboratory results have been encouraging, information about the clinical value and utiliry of measuring these markers is limited. For example, the ratio of tratrix metalioproteases (MMP, and tissue inhibitors of mltrix metalloproteases (TIMP, is known to change with the phase of the healing process, along rvith the amount, timing, and distribution of these chemicals. In a case series involving 4 patients with dilTerent qrpes of wounds, biopsies obtained every 2 weeks showed that MMP-2 expression paralleled climcal wound
improvement.' However, in clinical practice, regular clinical assessments and reassessntents are stil1 the only way to determine lvhether the rvound is rnoving in the direction of the goal of care or desired outcome.The effectiveness of interventions, that is, their abiiiry to produce the decided, decisive, or desired effect, cannot be ascertained unless baseline assessnlent data are compared to follorv-up data. In addttion to monitoring the ellectiveness of the plan of care, regular reassessments may help motivare patients and caregivers.
Systen'ratically gathered assessment and reassessment data
rvi11 also
Figure l. Clearly
defined and realistic
of care,
as
well as assessment tools that improve

among healthcare professionals, may help
desired outcome by stabilizing the seemingly tern of chronic wounds. the table pat-
help clinicians develop a treatnlent outcome data-
Clinical Wound Assessment

Goal of care. The patient history and
findirrgs are the foundation for developing the
assesslnent
base.
The gathered data can be reviet'ed, analyzed, and compared to outcomes reported in the literature to devel-
and patient care plan. It will help the cllnician rvound is inGcted, r'vhether rt can be surgically closed, and which treatnent should be used. If pressure redi ibutron is needed, a patient history and assessmerrt
of care nlne if a
op or rnodi$, wound care policies, procedures, and individua1 patient care p1ans. Because "real world" experiential outcome data is limited, this type of information is crucial when trying to develop care plans and pathu'ays.oe In summary, wound assessment and reassessment policies and procedures are a necessary and integral part patient's plan
will
nrine
iffre-
quent turning
is appropriate and Gasible
nt follow-
of the individual
up assessments designed to monitor outcome( rvi1l deterof the r.rlne whether the wound is moving in the
tool to accumulate lnuch needed outcome data on chronic wound care.''"'
of care as well
as a
I of care is particularly important lvhen managing pa ents with mber of chronic wounds because they often have a healing concomitant conditions that may affect t presents a process or the plan of care. A chronic
considerable burden to patients, caregivers, professionals.u healthcare
rea
ultimate outcorne, the goal of care.' Developing a realistic and clearly defined
Clinical Wound Assessment Frequency After gathering the baseline or admission assessment data, clinicians have to decide how often and rvhv the
r.vound should be reassessed. Overall patient condition, wound severiry patient care environment, goa1, and plan of care alTect the reassessment and monitoring frequency and rationale (Figure 2). For example, when a patient has a systernir: condition that has been shown to increase the risk of infection, the u'ound may require tnore frequent monitoring and assessments. Dressing/treatment selection may also
If the
goals
of care are not
lc or not
disclearly defined, patients and caregivers may m goals couraged. Defining short-term as u,ell as lon of care may help. For exanple, the overali goa of care for be coina full-thrckness wound with necrotic rissue plete healing, but the short-term goal of care ould be to reduce pain and obtain a granulating rvound
be affected by the reassessment frequency. For example,

ered
r.vor:nd that needs to be reassessed daily should not be cov-
In addihort-terrn
seerningly
with
a dressing that is designed days.
tion to developing realistic long-term

goals of care,
and
a number of
reasscssment
to remain in place for rationale fbr Stage I
it
helps to remember that eve
through Stage IV pressure ulcers has been reviewed elseCHRONIC
WOUND CARE 4th
Edition
van Rijswijk and Catanzaro
Figure 2. Wound reassessment and monitoring frequency/rationale are affected by the overall patient condition, wound severity, patient-care environment, goal of care, and plan of care.
where.t Since the reassessment frequency depends on the it is common for the frequency interval to change over time. During the first few weeks of home care, for instance, more frequent skilled nursing visits may be needed for teaching purposes and to ensure that caregiver monitoring procedures are understood and followed. Similarly, during the first Gw weeks of outparient care, more frequent assessments may be needed to assure that the wound is responding well to care and that there are no allergic reactions to the dressing(s) or bandage(s) used. 'W'hen a chronic rvound is progressing well, daily monitoring (even when the dressing is not changed) and regular assessment (at least weekly) are generally recommended."-"
reassessment rationale,
(Figure 3).A chronic wound has been defined as a wound that has failed to proceed through an orderly and timely process to produce anatomic and functional integriry or a wound that has proceeded through the repair process without establishing a sustained anatomic and functional result.'' Clinically, it is important to distinguish between these difGrent types of wounds, because generally, acute wounds heal more expediently than chronic wounds. Hence, the
goals of care are difFerent. Similarly, because superficial and
The use ofrisk-assessment tools and procedures for panens
with Stage I pressure ulcers is discussed in Chapter 60.
Assessing the Wound

General wound classification. The first step in the patient and wound assessment process is to classi$, the wound. For this purpose, 2 general categories commonly are used. The first category is related to the cause (surgical
or nonsurgical) and whether the wound is chronic or acute
partial-thickness wounds can be expected to take less time to heal and are less like1y to develop complications than full-thickness rvounds, the second general category is based on initial wound depth." "' Wound and skin variables that may affect healing also have been reconulended for inclusion when classifiing patients who are at risk for or who have venous ulcers or diabetic foot ulcers. For example, for venous ulcers, classification and grading includes clinical signs, etiologic classification, anatomic distribution, and pathophysiologic dysfunction.'' Using this classification, patients presenting with lower ieg skin changes (eg, pigmentation, venous eczema, lipodermatosclerosis) and active ulceration of any depth
115
CHRONIC WOUND CARE.4th Edition
Classifi cation
Algorithm
o1994 Diane Krasner, Lia van Rijswijk
Figure 3.Wounds are classified by cause
and
rvould receive a chnical classification of Clas Diabetic foot ulcers can be classified basecl on
(Co-6).
lvi1I ahvays require the talcnts
of a skilled
professional.
conrbina-
tion of anatomical wound
ncluding characteristics dcpth), the presence ofinfection, ischemia, and combination of ischemia and infection.'o'n Becausc t ultimate goal of any classrficatior systenr is to guide ca and plei.ate thet dict outcomes, the results of one stud-r,', r'vhich n systenl severity scores of a diabetic foot r-rlcer classific (the Universiry of txas'Wound Classilication stenr) can predict outcomes, are encoLlraging."' Regard s of the entioned classification svstem used, inclusion ofthe a the initial venous ulcer and drabetic foot ulcer variables
assessment is tecomrnended.'t''n
Before revierving the various r,vound assessment l.rethods that can be used, it is important to renlember that a reason for healthcare proGssionals'increased reliance on the use of equipment and tests is their abiliry to qtlantiE/ observarions.
Since conrmunication, including communicating r,vound assessrllent data, is such an integral part of achieving the goal of care, standardization of the terninolory and techniclues used is crucial (Figure 1).
Reliability and validity. Re1iabi1it1. and validity are -When 2 or n.rore people important clinical concerns.
it is important that the assessments are similar. For example, rvith respect to u,ound measuren)ents, specifying lvhich position the paticrlt shor-rld be in rvhen the nound is measured and rvl-rich
rnake the s:rme assessment, increase reliability. The vaLdity
Choosing a wound assessrlent
Clinical
primarily wound assessrnent is not an exact science. It rooted in clinical obsenation, a skill that ha lost value compared to the use of instruments and machi es.t When
tape 1ne:]sure or tracing should be r-rsed rvil1 greatly of an assessment, its abil-
it cotres to skillful
observation. available instr nrents and

t
ity to
equipment may enhance the process, but

replace the adcpt cxamination of the clinician
can110l
r 1ilte[Jrate
and evaluate the significance of all the patient d wound information obtained. in other rvords, the assesslnent
process, defined as collecting,
verifiing, and
zing data,
assess u,hat it is supposed to, can be increased by choosing the appropriate method. For erample, assessing rvound depth bl, looking at a photograph is not as valid a) n'rcd\uring actual deptJr. Qualitative and quantitative rr-rethods. A wound assessment method can be descriptive, quaiitative, or quan-
CHRONIC
WOUND CARE, 4th
Edtion
titarive.The use of descriptive and qualitative mcthods (eg, the u,ound has improved, it is red, snralier than last week, the surroundrng skin is healthy, and the patient does not complain of pain) is often insutEcient for evaluating the outcome of care. For the person who made the assessment, thrs chart entry nukes perfect sense and provides xn accurate description of the observations. Hor'vever, it does not provide a complete picture for sonleone who has not seen the rvound, and the resuitant documentation rvill not facil-
Stiaictiirea
involved
.,i:, ,..,.i. rr,.i..:ii..
'9.
Exarnples of wo_tlnds; ' onr monly qsed:,wo,Und
,r:r
,
,:,, ,..,:
:,9Qs.!,.!P{9n$.
..,. .,
:,::.r:
.,,
itate continuity of care.
If the
same wound assessrnent is

and
nrade using a conrbination
of standardized descriptive
. : : .:: ,:,' rrr ,ir r: . ..-:, ::iaaging System5r.. . Epidermis Superficial wound (strotum corneum, Stage I pressure ulcer* gronulosum,spinosum, Grade 0 (or 0) diabetic foot ulcer** ond germinotivum)
First-degree burn
quantitative methods (eg, it includes pain and rvound measurcments as well as strndardized descriptions of the surrounding skin condition), the finclings are easier to understand by someone r'vho has not seen the rvound, thus facilitating conrmunication and continuiry of carc. Assessing wound depth. Neither wound depth nor
the appearance
. Epidermis . Dermis
lymph vessels,
Partial-thickness wound
Shave biopsy Abrasion Skin graft donor site Stage ll pressure ulced
fion follicles, opocrine seboceous glonds,blood
ond and nerve endings)
Grade I (or l) diabetic foot ulcer**Venous

disease: clinical
classifi cation Class
ofthe rvound bed
can be accurately assessed
contains loose debris, particulate nratter, or dressing resrdue.Therefore, wor-rnd cleansing is the first step in the rvound-assessnlent process. For assessntent pllrposes, rinsing the rvound r'vith saline r,vill usually suffice. Howevel rvhen particulate matter is adherent to the rvouncl bed, higher prcssures (eg, pressures becween 4 and 15 pounds per square inch) may be needed."" If a u,ound is covered u.ith eschar, w-ound depth cannot be assc'ssec1. In these instances, document "unable to stage" wound depth" and explain',vhy."'IA1so, the exact depth of rvounds rvith sinus tracts or tunnels may be dillicult to assess because the bottom ofthe tunnel canasscss
if the wound
6#*
Second-degree burn
. Epidermis . Dermis . Subcutaneous tissue/ super{icial fascia (fot, fbrous ond elostic tissue, deeper blood vessels) . Epidermis . Dermis . Subcutaneous tissue . Deep fascia/underlying
structures (muscle,
tendon,
Full-thickness wound Punch biopsy Penetrating wound Stage lll pressure ulcer* Grade 2 (or l) diabetic foot
ulced*Venous disease:
clinical classi{ication Class
6w
Third-degree burn Full-thickness wound Dehisced surgical wound Stage lV pressure ulcerx Grade 3 (or ll/lll) diabetic
Venous disease: clinical classification Class 6***
or"unable to
bone) foot ulcer**
not be seen.These r.r,-ounds can be clas;ified as fu1l thickness (Table 1), and the amount ofrvound care product needed to filI the tract or tunnel can be used as a gauge for detcrrnimng the extcnt of tissues involved.
Third-degree (sometimes called fourth-degree) burn

*Notiono/pressure ulcerAdvisoryponelpressure ulcerprevolence,costond riskossessment.ConsensusDevelopmentConferenceStatementDecubitus.
Many woutrcls do not fit into sinLple depth categories and contain areas of partial-thickncss and full-thickness
dermal involvement.:3'when usinpr a :ressure ulcer
o'
, r,vound corrtaining areas of partial- rd fu1l-thickness dernar invorvement is crassified a full-thickness wound.
a as
ulcer staging system, the stage cor:esponding tvith the deepest area of rhe u.ound is docrmented. Similarly,
foot I::;::"^!if,::"::i#:;*.;;:;:"i;:l:::::Jr'i;l:;"';i:;t;:;;. *aWogner

Ylanaze. 1997;43(2):44-53. **aBeebe HG, Bergon
FW.The dysvosculot foot: o system for diognosis ond treatmenL
;".1T,irIîr'li!,'n!k','lt";!;"!l';::!;:l:;:'4,3.1r'ilij[,l:
ll,
Bergqvist D, et ol.
Staging.'Wound depth is an irnpcrtant sssessnlcnt

able, sincc
it
has a dir-ect effect
Varion hou long the rvound may
:J',','JfXfl::-':,iXi'i;:",{:[;ffi:ii:i'!iii"i'!fi!trf*i.?1';l:::i
':#":r!::r;l:,,*u^P
stosins del'nitions "suspected deep tissue iniurv" ond
Sur+. 1995;21:542-647. *The extent oftissue domoge connot be oscet'
take to heal. Hence, most clescriptive u,-ound-assessment nethods, including staging systems, are based on depth.The involved." " The Pressure Sore Status Tool includes, among rvork ofShea,t'rvith subsequent rrodifrcations, has resulted othels,5 pararneters rclated to depth, including tbe variable in the most coru:ionly used (and rccently revised) National "obscured by necrosis."t"
Pressure Ulcer Advisorv Panel (NPUAP) stagrng and the Burn u'ounds are classified based on depth and area. For European Pressure lJlcerAdvisory Panel (EPUAP) classifi- example, partial-thickness rvounds ar.e classified as superfi catiorl systen-N (Table 1).r*t' Other pressure ulcer staging cial or deep second-degr-ee burns, and wound area is systenm, such as the Yarkony-Kilk scalc and the Stirling defined as total body sur&ce area involved. Classification Grading S,vstem, are also based on the lcvel of tissue svstems for diabetic foot ulcers (eg, the'Wagner scale and
CHRONIC
WOUND CARE, 4th
Editon
117
van Riiswiik and Catanzaro
trr,ri.,i:11::::,i;riri:BgiilptioO,titrt::til
Lengch (longest area
of tissue breakdown)
and
width (longest measurement dicular to the length) are measure( using a

disposable
. Good interrater
and intrarater reliability
guide/ruler calibrated
in centimeters
Provides a clinically reliable
. Reliability
decreases with increasing
Record length, width, method of measurement, patient at time of as
record of
changes in
wound size over

ttme
wound size
Method may not

be suitable for research purposes
Tracing
Disposable acetate
sheeg measuring guide, or plastic bag
. Easy . Expense
.
is
to
held over the wound while tracing the

edges with a permanent, fine tip marker; add location markera (eg.head, toes), date,
determined by materials used
May be difficult see wound margins
. Tracings can be
a valuable
part
of patient
records and
changes in wound area can easily be compared
. lf transparency
does not contain grid, tracing has to be copied to grid paper to
calculate area
. Fast . Excellent interrater and intrarater reliability
patient number
Clean the sheet or remove

side of plastic bag/measuring guide
Manual counting
of squares on grid paper may

cause over- or
. Attach tracing to
chart and/or
area using 1.0-cm or 0.5-cm gr"id paper*
underestimation of actual area
Record area, method of obtaining and

latirng measurement Patient Position at
time of
*
Some
freosuring guides incotporote o l.O-cm or O.S-cm
See Figure 4.
University of Texas diabetic wound classrficat

also include a wound-depth assessment.rssr'T
system) classi6ca-
tion systenr all liave one major-advantage: they the ternrinologv used, thus facilitating Horvever, thev al1 rely on the clinician's a u,'ound depth, which nray not always be e
Assessing the extent of dermal involvement can
ardize nlcauon.
to
assess
chronic rvound classification systems have been tested for reliabiliry and validiry and in practicc, the most u.ide11, uscd pressure ulcer staging systelns are not ve1'y accurate.'''t'""tt' Research results of pressllre ulcer assessment instrurnents have been reviewed elsewhere,t'and recent research conlirnrs that both the intrarater and interrater reliabiliry ofthe EPUAP classification system, which is sinilar to the
y to
do.
partlcular\ ditlicult because dermal thickness varies age (thin at birth and after the {ifth decade of life), sex thicker in men than in women), and anatonical loca ranges from less than 1 nrm on the evelids to greater n J rnnr on rhe back. Another lirmretion i. that, to drtc, y a feu'
NPUAP grading systern, is 1ow among nonexpert nllrses.to Fina11y, staging systems were not designed to capture changes that occur during the healing process! and they
should be used to facihtate adrnission diagnostic procednres on1y.''" Just as u,e do not change the admission assessment
CHRONIC \l1/OUND CARE,
4th
Editlon
of a deep second-degree burn to a superficial seconddegree burn rvhen it is healing, presstlre ulcers should not
be downstaged or backstaged as they heal.While clinicians in some patient-care settings may be required to dorvnstage
for reirnbursement purposes, baseline and flollor'v-up depth assessments in the patient's chart should include a description of the tissues inr''olved andlor actual
pressure ulcers
depth or volunre measurenr.ent. The Pressure Ulcer Scale for Healing (PUSH), developed to address the concern of
downstaging, does not include rvound-depth inforn"ntron. Research indicates that the instrument may be valid, and
although the PUSH scale is widely used, usets have suggested additional improvements.'"'''; Describing the extent of tissue darnage.The previously described staging difliculties also apply to describing the extent of tissue damage. First, cliricians car-r tr.v to find markers of wound depth. For exanrple, islands of epithelium in the rvound bed n-Lay be indicative of a superdcial or partial-thickness rvound (Table 1). When underlying structures, such as fascia or tendon, are visible, the rvound
extends dou.'n through the dernris and can be classified
as
fu1l thickness. Second, it helps to remernber that dermal thickness ranges from approximlltely 1 Inm to '1 mm; thus, most rvounds that are deeper than 4 mm involve subcutaneous tissue and can be classified as fuil-thickness rl'ounds.t' Finally, document if the rvound bed is irregulaq eg, "latcral aspect of lvound extends through subcutaneous tissue, proximal aspect of the wound contains dern-fs."
Figure 4. Using a 1.O-cm grid to determine wound size, count the crosspoints that fall completely within the ulcer. This ulcer measures l3 cm'. When using a 0.5-cm grid, count the crosspoints and divide the number by 4.
rvhcre the measurement was obtained, drarv
a
Measuring wound depth, undermining, and tunneling. Wound depth is most commonly measured and
quantified
picture of the
bv gently inserting a sterile swab into
the
rvound. Find the deepest point and put a glovecl forefinger on the swab at skin level. Rentove the sr'vab and plece it next to a measuring guide, calibrated in cencimeters.r" This rvound assessment method is not very useful fol partialthickness or superficiai rvounds but can provide valuable information lor deeper rvounds.The presence or absence of undermining, a space between the surrounding skin and wound bed, and tunneling also can be determined in this manner. The depth of a tunnel or pocket of undermining can be measured using the same technique as described for inound dcpth. The validiry and reliabiliry ol this rnethod depends on clinician ski11s and documentation.
First, determine
rvound and mark the area or use a "c1ock" system. For example, for all assessment findings, the area of the rvound closest to the patient's head is l2 o'clock.There are no limitations on how' matr1, depth measurements can be made, and it rnay be helpful to take 2 or 3 different measuremcnts in different areas to get a clear picture ofthe rvound dirnensions. Taking multiple measurements close together and recording the average may improve accuracy. Insertion of any object into the wound mav cause tl:auma, and if cotton sw:rbs are used, particles can remain in the rvound bed. These concerns hal.e led some experts to recot-rrnend
assessing depth b,v
gently inserting a gloved {inger instead of
ifyou need
assistancc to help the parient
remain in the position reqr.rired to perform the assessment and n'rake sure that 1-ou have ali the equipment (eg, ruler, pen, paper) at hand. Second, the r,alue of the measurenient for evaluating change (reliabiliry) also depends on documenting how (patient position) and rvhere (eg, most lateral area) in thc r.vound it rvas obtained. If tunneling or undermining is present, record the percentage of the wound margin involved and the location. If it is dilficult to describe CHRONIC
a srvab." A variety of disposable w,ound probes with or without attached fbam tips and ruled ureasurenrent sticks are comnrerci:rlly available and, unlike cotton srvabs, rvill not deposit particulates in the rt-ound bed.
Regardless of horv depth is nreasured, once a method has been chosen for a particular r,vound, standardizing the procedure is crucial to evaluate whether the wound is moving
in the direction of the goal of care. High-frcquency ultrasound has been used to assess skin and skin thickness and
can also be used to assess rvound depth and estimate rvound volume -"vhen more objective assessments are needed.tut"
WOUND CARE, 4th
Edition
L19
van Rijswijl( and Catanzaro
Assessment Model
Surrounding Skin for: color, moisture suppleness.

Measure andlor trace wound area. Measure depth.
Wound Assessment
Wound bed
Assess for: necrotic and granulation tissue, fibrin slough
epithelium exu-
Assess for:
condition of
Figure 5. Wound assessment
'1994 Diane Krasner and
Lia van Rilswijk.
Assessing wound area/size. Measuling a the size of a w-ound upon admission are crucial ricrans dcvclop the goal ofcare and patient-carc initial rvound size rnay aflect tinre to healing. acute r'vounds have shou,.n that 1arge, deep r,r nrore time to heal than small, dcep rvounds, sturlies of dcep chronic r.vounds llar.e also shorvr u,-ound size atTects healing time."''' " Seco
u,-ound measurelrlents quanti$,- change
recording help c1iplan. First, Stuclics
infonnation about the progress of a u,-ound, the actual number obtaincd n'hen lnultipl_ving length and r.idth
fi]e:lsurernents is :rccurare only
if
the u,ound has a regular
of
geonretlic shape.t" Second, lvhile excellent correlations

have been found betr'veen planirnetric R-ound area, rvouncl
nds take
clinical that irritial , ongoing
area/ stze
in u.ou
ansu'er the question, "Is thc lvoun healing?" Clinical studies ]rave shor,vn that a reduction ir ulcer arca (epproxinratel,v 20%-lO')/o) after 2 l u,,eeks of t ntlsa predictor of healing for pressure ulcers, venous ulcers, and foot ulccrs in those rvith diabetes nr Lls.l!.lr.l;+) fherefore, if a r,vound is not getting srnallc-r after -4 ureeks oftreatnrent, x re-evaluation ofthe patient, u,ou , and plan of care is generally reconrrnended.'t''"'
to help
rvidth, lcngth, r,r,idth x length, perincter. :rnd area based on the fornrula fol an ellipse for snraller u,.ouncls (< 40 crn'), the accuracy of length x rvidth nleasurelnents and acetate tracings varies depending on thc srze of the $,ound."',t' Third, all rescarch related to the va1idit1,- and reliabiliry of ruler rneasurelrlents w:ls perlbrmed bv rncasuring the
longest rneasurement of the \\.ound
(-
length) follorved
b,v
the longest nreasurerncrlt perpendicular to rhe lengtlr (=

rvidth). Snrdy resr:1ts suggcst that this measlrrernent nlethod
is rnuch more reliable and valid than other methods.
includ-
irrg the "ckrck" method (head-to-toe = length and srde-to-
The most conulonly used techniques for

r,r,ound area/size ir.r the clinical setting include Llrelnents or tracings (Table 2, Figurc ,l). Both rnc'thods I'rave advantages and disadrrantages
r
asLlrlng
pe lneas
sLlrenlent
2), ancl
thcir accur:rcy depends to a large cxtcnt ou the clinician to precisely lintl thc rvound edge.
p1e,
abilin, of
r exaltl*
eliunr at nentlng a
= rvidth)." As rvith other assessnlents, paticnt position at thc time of nreasurenrent, rccording hon the measllrements were obtained (src measuring ttound depth). xtd rnethod consistency a1'e itnportant. At this tinie, llteasllrernent of r.vound surface is considered suiEcient for thc routine clinical docunrerrtatiorr of chronic lvound healing.t''t' A1so, it is encouraging to note th:rc assessirrg u,ound size
side does not involve a significant amount o[time.'When feasi
to scc neu.\ formed the wound margins. Befirrc developing and in

nr:ry take practice
it
u,ound-rlcasurcn rent protocol, the follotving r arch lind rngs anil hrnitations shoulil be consiilerecl. First, i is in-rpor-
brlity rvas evaluated, rcscarchers found that using papcr tapc or a grid tr:lnsparency takes approxim:rtel1, 1 minute.s' Whilc n-rost prxctical and valuable for assessing change or,'er time in clinical scttings, measLlrelnents obtained using instruments, such as dreiral irnaging and computerized planirnetry,
tant to renembcr that all 2-dirncnsional

tcchniques provide an index of r.".ound area. everl though lcngth x lvidth calculatiols p
sLlre1ne11t
cxample,
vair-rable
may be more :lccllrate. Research to develop ancl test ncrv CHRONIC
WOUND CARE, 4th
Editron
w,ound rneasutement svstens for use rn specific cJirrical setdngp or when conducting research is ongoing.t{5'to area/size, as
tn
into yel1ow, and dried debris (eschar) irrto b1ack, rvi11 only
capture Present
or absenl changcs.While relarively
easy to
Color photographs can also be used to rneasurc lvound long as the wound is not on a curved suface.t-
Pl-rotographs can be taken r'rsing a regular 35-nrm
or digital with a linear tneasurement scale next to thc w'ound and/or at a standard distance. Clinicians rvho possess the
camcra
teach and use, limitations must be kcpt in rnind (eg, bone and tendon are also ye1lou., topicai treatments may discolor a rvound, sutures may be black, and the presence offoreign bodies has to be documented separately).u'To date,
expertise and skill ro take qualiry photographs and calculate rvound area follou'ing projection r.vill 6nd that chrs method corrclates strongly rvith obaining tracinp." In addition, standard photographs or digital irnagcs can be a useful addition to the patient chart (see tlorumentatittn) and digital images can be used for telemedicine.'While the reliabiliry arrd vaLidity of spe-
one study of 6 observers has found good inter-observer agreenlent using the 3-color niethod of assessing chronic lvounds.tt Many rvounds contain a conrbination of granulation and necrotic tissue or fibrin slough.When tr,ving to
document the elfect of treatuents on wound debridement,
investigators have used rating scales (eg, no necrotic tissue, some necrotic tissue, some
fibrin slough, etc) or
have quan-
cialty camer:rs with grid film have not been established, stereophotogrammetl'y, using a video camera ancl special
compllter sofrware, has been found to be precise.o" Results of a study to evaluate the validity and reliabiliry of a tool to
measure and
assess
tified the amollnt of necrotic tissue by estinaring the percentage of tissue involved. Specifica1ly, they will facilitate the assessment and documentation of changes in the
r,vound bed related
to debriclenrent.
chronic r,vounds based on photographs are

assess
encouraging and may heip r'vound care experts
wounds
rvhen a be&ide assessment can llot be peformed.t"
Volurne. Wound volume can be calculated as follorvs: x depth x (.).327; horvever, this rnethod is not exact. Indeed, variations of up to 40% ofvolutne have been found rvhen this nlethod is used..r Other methods of measuritrg volume (eg, using dental impression materif,ls or {illing e lesion with saline) are nrore precise but also more expensive
ar-ea
and difijcult to peform irr routine clinical practice. Concerns about cast materials being used in wounds have
deep wounds, excellent correlations bet."veen r.vound volume and rvound circumference and bet-"veen ',vound area and circunference have been found.r'rd Some instrunrents, sttch as digital planimetrv systems, also calculate rvound volume from a depth llreasurealso been voiced.
Estinrating a lanlle (eg, less thtn 25(% necrotic tissue or 25"/,-50%o necrotic tissue) has been studied as part of the Pressure Sore Status Tool."' See Chaptcrs 513 arrd 59 of this sourcc book. A study involving 44 registercd nurse rvoutrd care experts suggested that percentage descrrptions of necrotic tissr-re/fibrin slough are valid concepts for dete'rmining which rype of dressing to use, and these descriptors are now- commonly requircd to be used r'vhen documenting the statlls of a wound.'" In another study, drarvingp of venous ulcers rvere used to compare the results of visually euantifyipg '"vound-bed appearance to using a digitalimage-analysis system for this purpose."'
In
In this small
study,
considerable inter-observer and iutra-observer valiations were found, but the averages bet',veen visual and equiprnc-nt obtained assesslrcnts dicl not differ significantl,v. Based on the limited research available, visr.ral estirnations may be
considered too unrcliable for research purposes. Horvever, fi'om a clinical pcrspcctive, the1, are rnore precise lvhen trying to ascertain outcomes than present or absent ratiugs. Assessing the wound edges and surrounding skin. In addition to assessing the extent and depth of urrdcmrin-
nrent obtained using a foam-tipped probe. ln sunrmar\r, obtaimng area measllrc'nrents has been found to provide clinically useful and valid inforrlation; u'hereas, the need to lnersure r'vound volume in clinical pracdce rernains the subject of debate. In addition, rcgardless of the nrethod or cquipment used to measure wound size or r-olume, clinical assessrnent and interpretation skills remain parantount. Results of one study sugsicst that the reliabiliry* of both
manual and computerized s,-ound measurements (tracings)
increases u,hen the av'erage
of3
repeated nleasures is used."
Assessing the wound bed.After measuring tl're size of the rvound, tl're appearance of the u'ound bed needs to be
ing, the conclition of the wound edges should be noted. Assessment of the rvound edges includes distinctness, degree of attachment to rhe rvound base, color, and thickness.rtttt'' For example, if it is difficult to see where the wound ends and the surrounding skrn starts, re-epithelization may be taking place. ancl this obscrvation shor-rld be charted. Chronic wounds may also prcsent r'vith thick
("ro11ed")
and docutrented (Figurc 5). Simply notirlg the or absence of granulation tissue, necrotic tissue, fibrin slough, etc is insufficient to monitor progrcss because this rnethod rvill not capture changes in the
assessed
wound margins. This condition has also been
prcsence
defined as epibole or "closed rvound edges."" Closed wound edges are usually an indication that the wound has been present for some time and that tlre newly formed
epithelial cells hav-e migrated dorvn and around the rvound edge because they did not find moist, healthy; granulation
tissue
wound bed until they are complcte (eg, completelv fi-ec of necrotic tissue). Similarly, the red-ye11or,v-black system, which translates granulation tissue into red, fibrin slough CHRONIC
to lesurface in the 'tvound bed.

121
WOUND CARE, 4th
Ed]tiON
van Riiswiik and Catanzaro
The conditlon ofthe surrounding skin tant information about the status of the wou effects of treatment. Surrounding skin assess
evaluating co1or, induration, edema, and su 5). Redness
imporand the
includes (Figure
the surrounding skin."'o In the clinic, rating the amount of wound exudate will be useful only if a description of each rating is provided. For example, when the wound is dry,
there is no exudate; whereas, a moist r.vound is indicative
of
of the surrounding skin can be icative of less-than-optimal patient and wound care, ie, unrelieved
or prolonged inflammation." Irritation the surrounding skin, which may aiso impair wound aling, can result from contact with feces or urine, from a 'eact1on to the dressing or tape used, or from a reaction to quent or inappropriate dressing,/tape removal. In patients th darkly pigmented skin, skin color changes (eg, a difference between the patienti usual skin color and the r of the
pressure
scant or small amounts of exudate. When the tissucs are w'et/saturated and there is exudate in the wound bed. the amount of exudate could be rated as moderate. and when the tissues are saturated (sometimes including maceration of the surrounding skin) and the wound is bathing in fluid, the amount ofexudate could be considered large.The content validiry ofthese descriptors, but not their prospective valid-
iry or reliabiliry has been established.' In addition to anlount, the type of exudate should be described. Most
commonly, exudate type is recorded as serous (clear fluid
skin surrounding the wound)

increase
should
noted.r'8
Furthermore, inflammation/vasodilation will cause an
in skin temperature. A
temperature using the
diflerence
without b1ood, pus, or debris); serosanguineous (thin, watery, pale red to pink fluid); sanguineous or bloody
(b1oody,
between the skin immediately surrounding and lance from the wound can be
assessed
short disk of the
bright red); and seropurulent or purulent (thick,
cloudy, yel1ow, or tan).2e,sd72\Irhile the validity and reliabili-
hand or finger."'Also, redness, tenderness,

swelling of the surrounding skin are the classlc
mth,
end
of inGction.''"' 'When the surrounding

exposed
slgns
skin has been

, slgns
to moisture for
a prolonged
period of
of maceration (pale, white, or grey tissue) may In patients with 1eg ulcers, the surrounding skin it signs of capillary leakage (hemosiderin p
lipodermatosclerosis)
observed
y exhibation,
or ischenria
(absence
of
growth,
leness
coo1, clammy skin)."' Assessing and
documenting
of the sr.rrrounding skin is important, because y molst as well as over\ dry skin (commonly seen in pa with impaired peripheral perfusion) is more prone to lnJury. Induration (an abnormal firmness of the tissues) edema are assessed by gently pressing the skin within a mately 4 cm of the wound. Document the locati and the extent (in centimeters) of induration and as well as pitting or nonpitting characterisric.. Assessing exudate and odor. The type and nount of
wound exudate should be assessed. because these haracteristics provide important information about wou and the most appropriate treatment. However, al t1me, no reliable and valid wound exudate assessment tool xists. One proposed definition includes a conbination of descriptions and quanti$ring the amount of ate when using gauze." In this definition, minima1 exudate 5 cc/24 hours) equates to no more than one (gauze) change per day, moderate exudate (5-10 ccl24 hour$ result in
ry ofthese descriptors have not been rested, their use in the clinical setting has not been disputed. Traditionally, the presence of wound odor (and pus) was used to diagnose inGction. Hence, when moisture-retentive dressings were first used, the odor that inevitably accompanied their removal was sometimes mistaken for infection. A11 wounds, particularly after they have been occlr-rded, will enrit an odor, and as with all wound-assessment variables, cleansing is important prior to assessing odor. Necrotic wounds tend to have an otlensive odor, and wounds inGcted
with anaerobic bacteria tend to produce
a distinct acrid
or putrid snee11.'5 Odor is a subjective assessment and cannot be quantified. However, a descriptive odor assessment can provide important information, because a change in the type or amount of odor may be indicative of a change in ing what to
wound status.As with all assessment parameters, standardizassess, how to assess, and how to document it
will
a
increase their usefulness. Odor assessments can include description ofthe odor (eg, sweet, iike fresh blood, putrid) as well as a description of the amount of odor (eg, fi11ed the
sme11
room, could only
it
imrnediately following dressing
'When caring for patients with fungating wounds, the goal of odor assessment may be to evaluate the ellectiveness of odor-control measures. To assess odor witl-r the dressing in p1ace, the following scale can be used: no odor at close range, faint odor at close range, moderate odor in room, or
strong odor in room."' Clinical assessment of infection. The classic clinical signs of infection, defined as the invasion and multipJication of microorganisms in body tissues that result in loca1 ce11u 1ar injury, include redness, tenderness, warmth, swelling of the surrounding skin, the presence ofpus, and skin anesthesia or sloughing."i" One or more of these signs of inGction
removal, disappeared when dressing was discarded).
2-3 dressing changes per
day, and
wounds with hi
amounts
g changes
of exudate (> 10 cc,zday) require 3 or more
per day. Unfortunarely. quanu6/ing exudate in thi not possible when using non-gauze dressings, a weighing dressings is time consuming and requires special ipment.73
Another commonly used method involves

amount of moisture in the wound bed and the
122
the
nof
CHRONIC WOUND CARE, 4th Edition
are usually readily recognizable in acute wounds. In chronic wounds, however, unrelieved pressure, chronic inflammation, and allergic reactions to dressings can also cause redness, tenderness, warmth, and swelling of the surrounding skin. As a result, inGctions in chronic wounds, particularly pressure ulcers, can easily be overdiagnosed or underdiagnosed, even when wound cultures are obtained.T' For example, when wound-care specialists were asked to diagnose infection by looking at the photographs of 120 nonhealing wounds, the percentage of correctly diagnosed
from all wounds, including the arypirecalcitrant, unresponsive wound.82 In addition to a patient history that may suggest an increased
ed. Indications range
cal wound,
to the
risk of
maiignancy, wound-assessment findings
that may
warrant a biopsy include increasing wound size, malodor, pain, irregular wound base or margins, exophytic wounds, excess granulation tissue, bleeding, or drainage.
Documentation and interpretation. In addition to documenting all findings in a standardized manner, interpretation and evaluation of changes in wound assessment
variables, including area, should be evaluated progress toward the goal
infections ranged from
37
o/r9 0%, indicating great variabil-
to
ascerrain
ity and low reliability-" It has been suggested that traditional definitions of
of care.While research to deter-
wound infection are too narrow for all granuiating

wounds.'5 Evidence suggesting that chronic wounds may present
mine which mathematical formula most accurately reflects wound-healing rates continues, clinicians may decide to
simply calculate the change in absolute area by subtracting the initial wound area from the most recent area (initial current). Methods that facilitate comparisons between different wounds include calculating percent change as a func-
with bacterial colonization levels that delay healing

con-
is increasing, and suggestions that wound infection is a
rinuum that includes critical colonization have been made." Future research to determine the clinical validity and reliabiliry of these terrns hopefully will help reduce current ambiguiry of diag'nosing infection and making appropriate Eeatment decisions.'When looking for signs of inGction, other assessment criteria that should be considered are delayed healing, discoloration, friable granulation tissue that bleeds easily, unexpected painltenderness, pocketing at the base of the wound, bridging (with epithelium) at the base of the wound, abnormal smell, and wound breakdown. For example, when assessing the wound, clinicians should routinely evaluate changes in the size and appearance of the wound and look for the green or blue hue of Pseudomonas,
the du1l appearance ofwounds infected
tion ofbaseline area (baseline

area
area
current area = baseline
x 100) or linear advancement of the wound edge.e'The
latter also involves measuring the wound perimeter.As long as changes in wound size are measured and calculated consistendy, their inherent imperfections will not affect the overall goal of clinica.l wound assessment. Color photographs and digital images can also serve as a perrunent record ofthe status ofthe wound at baseiine and at regular intervals thereafter. Photographs may also facilitate reimbursement and patient/caregiver teaching and can serve as motivarional tools.sa Most facilities have developed protocols for photographic documentation, including informed
consent procedures, that should be followed." Regardless of the rype of camera used, it is helpful to remember the definition of a medical photograph is a photograph that accurately maximizes clinical information while minimizing irrelevant data.o'' Focus on the wound and try to eliminate clutter around the area to be photographed. Always include a measuring tape next to the wound to increase perspective and facilitate comparisons. To maximize clinical information, taking a picture of the location of the wound (eg, the entire back or leg) may also be he1pful. Last, but not least, for all images, do not forget to develop an easy-to-use labeling and indexing system as
with
anaerobes, and
granulation tissue that bleeds easily and has a gelatinous texture. Also, it has been found that if a diabetic foot ulcer extends down to bone, osteomyelitis andlor joint infection may be present.80 If a wound infection or osteomyelitis is suspected based on the clinical assessment findings, a quantitative or semiquantitative culture, roentgenogram (x-ray), bone scan, magnetic resonance imaging, or indium 111 scan may be ordered to confirm the diagnosis.'r''du' Additional
assessments
of
s,rrstemic
sure) and results
toxicity (temperature, blood presofblood culture, complete blood cell count

creatine, phos-
with differential, and creatinine, bicarbonate,
phokinase, and C-reactive protein 1evels may have to be obtained to guide treatment.Tl Finally, when baseline patient and wound-assessment findings (Figure 2) indicate that the patient has an increased risk ofinfection, consider increasing the wound-assessment frequency and obtaining a swab culture or biopsy if the wound fails to improve 1-2 weeks
after appropriate therapy has been instiruted. In addition to infection, delayed wound healing may be the only indica-
well
as a secure storage system.
Conclusion
Wound assessments provide the foundation of the plan of of determining the effectiveness of interventions. Regular reassessments may also modvate patients and caregivers, and they will help clinicians
care and are the only means
develop
a much-needed treatment outcome

assessment
database.
tor of cutaneous
candidiasis
or carcinoma.t' There is
no
Knowledge about the appropriateness, validiry and reliabil-
standard or consensus on when a wound biopsy is indicat-
iry of commoniy used
terms and methods

123
CHRONIC
WOUND CARE,4th
Edition
van Rijswilk and Catanzaro

1999;26(5):238 2,{9. Cooper DM. Wound assessnrent irnd evaluarion. Irr: J3ryant R, ed. Aattc ard Chronic Wltutds: Nursirg Managenuir. St Louis, Mo: Mosby Year 13ook; 1992 : 69-90. MaklebustJ, Margolis l). L)ressure ulcers: deilnition ald assessment
u n d C ate. 1 9 L) 5 ;8 (1) : suppl (r-7. van Rijswijk L. Frequency ofreassessnrcnt ofpressure rrlcers. ldir Wouul Carc. 1995;8(4):suppi 19-2.t. l,'lerriant Webstet's Collegiate Di rtionary. 1 Oth ed. Springfi eld, Mass: Mcrriam Websrcr, Inc: 199.1.
remain
J)r
to
describe wounds, develop plans

oLrt(
care, and remains

1n
ertain
onrc) i. increl'ing. yet
nr
unknorvn.' However, application of existing the clinic rvill help chnicians provide evidenc
and
based care
pararrrcters.,4 dr I7b
optinize
or-rtcomes.
Take Home Messages for
A thorough wound
assessment lncludes
omplete
regular methods
van Rijsrvijk L. The languagc of l,ouods. In: Krasoer DL, Rodehcaver G'f, Sibbald RC, eds. Clrorir Wountl Care: A Clinical Source Book -fbr Heabbatc ProJess.iorLals. ,lth ecl. Malvern, Pa: HMP
Comrnunications: 2007:25 28. Karirn I\B, Brito BL, l)ntrieux RP L:rssance Fl HrgelJ MMl, 2 assesslnelt lls an indicator ofrvound lrealing: a feasibilit,v study,idl
Skin Wound Carc. 2006:1
9 (6)
. .
patient evaluation. Treatrrent is preoicaLec

assessments,
on rhe
res.Llis
:321 327.
In clinical practice, consistency of asses

r
rcar] ic - a',
,.
Ennis WJ, Me ncses P \Vound healing at the loc:rl level: the sturned rvoutrd. Osrony Wo u ru] 1,1 an.age. 2000 ;,16 ( 1A Suppl) : 3 c)S-.lt3S. Bolton L, McNccs P, 1:n11 [\i-i511:jjk L, et al; Vround Outcomes
10
Self-Assessment Questions
1.
Study Croup. Wound hcaling ourcomes using standardizecl assessInent arrd care in clirrical practtce.J ll1tnd OstLttty Oontincncc Nurt. 2004;3 1 (2):65-7 1. Polansky M, van llijsrvijk L. Utilizing survival analvsis techniques
in
chronic
l,ound
healing
studies.
I,I/OL,i\D,S.
Comrlonly
assessed r,vound char:rcterrstics
i
e
11
A. Wound depth, wound size, tissue type,

tissue perfuslon
, and
12
B. Wound depth, tissue perfusion, surroundin skin condition. and rvound odor C. Tissue tule, alnount of exudate, r,vound surroullding skin condition, r,vound eriologi and c D. Tissue q/pe, anount of exudate, r,vonnd and size, odor, surrounding skin condition, and rvou edges
t3
11
199:t;6(5):150 158. Bergstronr N, Bennett MA, Carlson CE, et a1. Clinical Prdtticc Guideline Ntnber I .5:1it:anrLenr of Pres,.rrt (/1ren. Rockillic. Md: US t)eparnnent of Hcalth and Hunran Serviccs. Agenc,v for Health Care Irolicv and Ilesearch; 1994.AHCPR Publication 95-0652. Ccnters lor Mcdicare aDd Medicaicl Services. Srare C)pcratirus llalral. Ilaltiruore, Md: Centcrs for Medicare and Medicaicl Services; 200,tr. Publication #100 07. Brem H, Sheehan 1l Rosenbers HJ, Schneider JS, Boulton AJ. Evidence-based protocol lbr draberic foot ulcers. PldJf R(.o/i-!tr Surg. 2OO6;1 17 (7 Suppl): I 93S 2095. Lazarus GS, Cooper L)M, Knighton DR. ct al. Delinitiors and guidelines 1br assessrncnr of rvounds aud evaluarion of healing.
Arch Dermatol. 1 99'1; 130(,1)::t89,193. Clark RA Cutaneous tjssue reprir: basic biological considerations. I. J An Aud Dernatol. 1985;13(5 Pt 1):70-5-725. Arurstrorrs DC, Laverv LA, Harkless LB. Valiclarion of a diabctic rvonncl classification systcn. Diabetu Care. 1998;21(5):855-859. Classification and grading of chronic venous disease in thc lorver lirtrbs. A consensus statenrcnt: Fcbrrrlrv 22 26, 199,1, Maui. Hawaii. l)ernatol Stry. 191)5;21(7):642 646. Lavery LA. Armstrong 1)G, Harkless Lll. Classification of diabetjc ioot wounds. O s t o rr y llit u nrl lla n agt. 19 L)7 ; 1 3 (2) : I 1-5 3. Frvkbctg R(i, Arrrrstrong DCi, Giurini J, et al; Arrrerican College of Foot and Arikle Surgcons. Diaberic foot disordcrs: a clinical practice guideliile.American College of Foot anclAnkle Surl;eons. J Foot Anklc Sarg. 2000;39(5 Suppl):S1 60.
2.Wound size is an inportant characteristic to

regular basis because:
16.
A. It helps clinicians select the right

B. Docurncntation of wound size
rates
dressing
7l rselnent
18 19
alTects rein
C. Change in rvound size is a predictor of hea D. A change in rvound size correlates rvith a hange in patient statLls
3.The process of r,vound assessment can best be elined as A. Collecting, verifying, and organizing i about the wound for the purpose of eva ting the effectiveness of the plan of care B. Watching end tracking changes in the rvou for the purpose of documenting its s131Ll. C. Keeping track of information about rd so as ro [:ci]it.rte contr nrrnicJtion D. Collecting wound status information lbr t purpose
of selecting the most appropriatc treatlnent
Answers: I-D, 2-C, 3-A
alitres
2-O
Association for the Advancenent of Wound Care (AAWC). Sutlrlary alsorithrl for venous ulcer care rvirh annotations of available evidencc. Malvern, Pa: AAWC; 2005. Worrnd, Ostomn:rnd Continence Nurses Sociery (WOCN). Guicleline for prevention ancl managenient of pressure ulcers. Glenvre*', ll1: Wound, Ostorrr,l', rnd Continencc Nurses Society
(wOCN);2003. 'Wound OstorDy and Continence Nurses Society WOC]N Guiciance Docunrert on Orsis Skin urd Wound Stetus (revised
07,u 06). Available at: hrtp://*,rvwu-ocn.org/educatior/pdt7\Xrt)C NOASIS guidancel\ev072-106.pd| Accessed October 30, 2006. llolton L, r,an Rr.1sw5k L. Wound dressings: ineeting cliiical arld biological needs. Dcmatol Nrr-.. 1991;3(3):1,tr6 1(r1. SheaJD. l)ressure sores: classification and nunagcrredt. CLin Orthop Relar Res. 1975;(1 12):89 100. l)tessure ulcers prev:rience, cost, and risk assessment: consensus rlevelopntent conlireuce statemcnt The National l)ressure (Jlcer Advisorv P atc1. D r ub tus. 19 8I) :2 (2:) :2 1 -28. L)et'loor T. Schoonhoven L, \,hndemec K, Westrate J, M,vn,v l). Rchabiiity of the European Pressure Ulcer Advisory Panel classi fication system. J.,1rlr Nirr. 2006;5.1(2): 1fl9-1913. Y:rrkorry GM, Kirk PM. Carlson C, et al. Classification of pressu-e
e i
21
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Tharvcr HA, Houghton PE. Woodbur,v MG, Kerst D. Caurpbell K. A conrparisorr of conrputer assisted ard rlarrual rr.ound size nlersllrcnrent. Ork)rr), I'l:ouild f,Idnaq( 2(X)2;-ltt(l 0):-16-53. Harcliue KG. Mcthocls 1br assessing charrge i:r ulcer status.,4rlr
Llo
u n
Buntinr
E.
Beckcrs
H,l)e
Kcvscr G, et
a1.
Intcr-observcr rariation
Care. 1 995:8(1) :rupp1 37--12,
in thc
3+
assessment
of skin
ulccration.
J \l\und
Care.
1t)96;5('1):166 17{).
Rrorqr-Etris M, Pribblc J. Lal-)rci:que J. Eralultion of tso tound rneasurerllent u)ethods in a rrulti-ccntcr. controlled stucl,v. O-rlorrrl
I
Woodburl, MG, Houghtorr PE. Carrpbell KE, Keast I)H. Pressure ulcer assessurent instruneuts: a i:ritical apprrisal. OstautJ, lVotnd
rUaruge. 1 999:.15(5) :-12-55.
li'rr/,/.\ldl/,t{r.
l.)r)+:-+r)(7):+-l-+8.
60
35.
Berlos.irz
l)R, l{etliff O. Crrddigarr J. Rodeheavcr G: Natiorral Presiure Lllcer Advisor,v Pancl. The PUSH tool: a surveJ, to cletcrnrirre ics perceivccl usefulness. AdL Sktn |Vpuutl
2ttt)5; I 8(9) :-l8t)--ltt3.
Odrc.
61
37
Krasncr l). Wound measu-erue1lts: sorl1e tools of thc trade. ,4lr -1r Ntr:t. 1 992:92(5):li9-90. Mrkkbut JA. Sieggrccn M. Pn:-rat Lilcer:: Orit,telinL's .li,r Prttrnrion ard Nllrlrlg llan.rytnuLt. 2nd ecl. Springhouse, Pa: Springhouse
Publications:
1
995:-13-66.
6+
38.
i9
llouranelli M. Maqliaro A. Objective asscssnlcnt in rvound hcaling. In: Kirsner RS, Falabella AF, eds. lllorild Hrollrp. Boca Ratou, I-la: Trvlor & Fmncis Crcup: 2005:671-679. L)vson M, Mootllcv S, Vericc L. Verling W, Weimuirn J, Wilson P Wound healirrg assess[lent using 2[t MHz u]trasouncl and photog -l raphl'. SAirr Rcs ednol. 20{ t.3;9(2): 1 I (r- I2 t. Mrrks J, Hughes t-E. Hardinc K(i, (-au1:bc11 H, Ribcirr CD. l)rcdiction of healing time as an ,ricl to the ruanagerncnt of open
ltranulatms rvourcls. II,brldJ Srrrg 19133:7(3):6.11-6-15. Skeue AI, Snrith JM. Dore CJ, Chrrlett A, Lcl.is Jl).Venous leg
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Langemo I)K, Mell:urcl H, Hansori L), Olson ts, Hurter S, Henlv S.f. Tivo-clinrensionirl wouncl nreasurernL'ut: corrparison of ,+ techniques. .-ldr [i irrrrrl C,rre. I 998; 1 I (7):3-]7-3+3. Houglrton PE, Kincricl CB, Cumpbcll KE, Wootlbury MC, Kcast L)H. I)hotographic assesr)e1lt of the appcarancc of clrronic pressure and leg ulcers. C)von),lliwild \linr.(r. 2(x)();l(r(l):20 3(t. Phssuran ll Mclhuish JM, Harcliug KCl. Methods of rneasurir[l uouucl size: l comparrti\re smdy tlOLII\iDS. 199.1:6(2):5.1 61. Melhuish JM. Plassrran P, Harcling KO. Circunrferencc, rrea and volurrre of thc healinu rvound. J lllt t md Ct re. 1 99.1:3(8) :.j80-396. Hasvard PG. Hilhnau CR. Quat MJ, Robsou MC. Sur{ace arca nreisurernent ofpressrrrc sores usinq rvc:und nrolcls and corrputcrized iutaging.J,4rr Ceriatr Sor. I 993;,11 (3):238-2.+0. Krasncr I). Wourd carc: hou to use thc red vc'llot black svsteur.
.4m
Nars. 199.5;95(5) :4-l-.17.
ulcers:
1
prognostic indcx
1 1
to
prcdict tiure
to
healmg.
Blf.
+2
,+3
9-1 121. vau Rijsrrijk L. Full-thickncss 1eg ulcers: patie:rt clertographics and prcclictors of lrealirtg. Multi-Center Lcg Ulccr Studv Ciroup. -/ Fiaar Prat t, 199 3 :36(6):625-632. tl-obson MC.]']hillips L(i. Larvrencc WT, ct rl.The safbtv ,rnd etlect of topical]y rppliecl rcconrbinrnt brsic fibrotrlast grorvth lactor on the hcaling of chronic prcssure sores. Antt Sa,!.
992:31)5 (6U62):1
1
Mekkes JR. Westchof W Inrase processing in the stud_v of woLuld hcalinq. Cli,r Dcmatol. 1995;13(1):401--107. Stotts NA. Itnpairecl wouncl he:rling. Irr: Carricri Kohhrran VK. LindsayAM,Wcst CM. c'ds. 1']allrtrplrltitlo.qiaL PlttnLtnenoti /',/ t\i/aili(. Philadelphia, Pr:V.B Srunders Oo; 1993:3.13 3(16. Bennctr MA. l\cport ofthc task forcc ou the irrlplicatjons ibr darklv pignrentcd intact skin in thc prediction arrd prcrcntiorr of prtssure trlcers. ,ldul.fbund C,in. 1995;8(6):3.1 35. Lorvthian P l)rcssure sores: a scf,rch ior deiiuition. Nili Srorrd. 1991;9(l 1):30-32. Altentcier W, Burkerts F. Pruitt L). Sanclrrsky ltrl lltnual ou Contrttl o-l' Inltctiou irr Sutgical Patiutrs.2nd cd. Philadelphir, Pa:JB Lippincotr;
19{J-l:19 -30.
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992r216(-l) :-l{t1--1{)6.
Stevens DL, Uisno AL, Charrrbers l[E er al; lnl-ectious l)iseirscs Societv ofAnrerica. Practice guidclines fbr the cliagnosis aud Drrn-
+l
.+5
Arnold TE. Stanley JC, Fcllorv EP et al. Prospccrive, rnufticenter stuc{y of rrranaeing lorver cxtreruit\ verlolrs ulcers. Aun Vasc Srug.
199-t;tt(+):356 362. -lalluran P, Muscare E, Crrson 1l Eaglstcin WH. I-elrngaV
.s.rDent of skin :rnd sofr-rissue irrfectiorrs. Clit lnltct

2l)i:)5;.{
1
Dis.
Lritill
373 1.10{r. Mulder GD. Quantihing rvowrd lluicls for the cliuician ard
(11)):
1
ratc 73
rrsearchcr. Ostrtny L|;owrd ,llarr,iqc.
9t)1;-l{ )(ti):(r6-69.
17
healirrq prerlicts coruplete hr'a1ing of venous ulcers. .4nlr Dcutatol. 1997 ;133(1 0): 123 I -1231. Kancor J, Mrrgolis DJ. Efficacv rnd prognosric value of sinrplc rvourrd nrersurrnrents. Ar& [)e r nntol, 1 998; 1 3.1(1 2) : I 57 1 1 57-1. Shcchan P,Joncs Il CiiuriniJM, Caselli A,Vevcs A. Percc'nt change in uouncl arca of diabccic foot ulcers ovcr r 4-rvc'ek pcriocl rs a robust pretlictor of completc healing in r I 2 rvcck prospective trial. ,P/a-rr
Rero,r.rtr -SrLg. 2t)t)6; I
17
of
Dcalc'y C, Cuneror J, Arro*'uuich M. A stuclv conrprring trvo objc-ccive rrrcthods of quantitr.ing thc production of sound esu
dates.rl
[/orrid Can.
Ia n a.qc.
1
2{}06; I 5(1): 1.19 153.

1
74
Baranoski S. lMoturcl assessnrent ancl dressing selectiou. OJrdrr),

ll'ot n d )
995;1 I (7 Suppl):7S 25.
(iutrinu KII Harcling I(C. Critcria 1br idcntif irg louuil intiction.
l.;Vowtd Care. 199-1:-1(1):198 2l)1.
(7 Suppl):239S-2+.1S.
1)rince S,1)odds SR. Usc'ofrrlccr size end iniriel responses ro trertrrrcnt to predict the healing time of 1eg Lrlccrs. J l1:ound Oare.
2t){)6; 1 5(7):299-3().3.
vau llijsrvijk L. Polarrksv M. Preclictors of time to healing

5(l 51. prcssure ulccrs. rl'Ot.'.\D-S. 1991:6(5):l 59-l(r5. Ma,vnrvitz HN. Shape and ilrcl rneastrrerlent consiclcrations assessDent of diabetic plantar ulcers. IT,'Ot,'\DS.
1
cleep
Faller NA. Llvrcnce KG. (Modi6cd Baker-Haig) oclor scrle. e;1992 Faller & Larvrcuce. Tirorrson Pt). Irnrnuttololl', uicrcbiologl,, ucl the recalcitrorc norrncl. Orara), Ilirund tr[magc. 2{){)0;1(r(1 A Suppl):77S-ll2S. Lorctttzen HE Cottrup E Clinical assesslrrcrlt ofinfcction in nou healing ulcers analvzetl bv latcrrc class anal-rsis. ll'ilrarl RcTuir Rcqrrr.
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tsr,rrnt JL. ltrooks TL, Schuridt li, Mostorv EN. Ilcliabi)ir,v of rvound rlelsuring techniques in rn outpatierrr rvouncl centcr. () t o ny lliw n cl -lIarargc. 200 1 ;"{7 ( 1) :{1-5 1. Roc'lcheaver GT, Srotts NA. Methods ior asscssing ch:rnge irr prcs
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1
ndium
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11 oxl'quinoJine. I
J-.{.\1.{. cause
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of
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clclayed srrrqicrl rvound healing. J An Atai

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-lessup

&
Francis
RL. What is the best method for
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the
o{ wound
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2006.
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Gilbert G. The Complete Photogruphl Careers Handboot. 2nd York, NY: The Photographic Arts Cente4 L992.
ed.
New
CHRONIC
WOUND CARE. 4th
Edition
Nutnitional Assessment and lntervention in the Adult with a Chronic Wound

Allen ).Zagoren, DO, MPA, FACOS, FACN; Deborah R.Johnson, MS, RN, CWOCN; Nancy Amick, MPA, RN, CWOCN
Objectives
Tê reader wl, be câ lenged
Lo:
Analyze
.Artcuaterl'e noactwrolebocyn-t"itonnasonrherne[aboliceavronn'enrofr.echroncwo-r.d ' lrrpie-nent a^d suooo't ruL'ition nLe've^Lior s oased o. scientiflc pri:c oles a.d, when ava abe, select evice^cebased rutrrrron nte've^Lrons Lo iac .rare c^ronrc wou^c êaling.
co'npone^Ls ol a n,rt"it on sc'een ro idenrrfy ad, rs w,t" malnrr.iL on nrplerrenr a nurnton aclon plan Lo address Lê nuri-ior celecr
(e/
o' at - sk fo-
.nalnurriL on
lntroduction rFhe Lrcets of the clrronic r.vound are rnanv and var,.0 Consenru' ('\isr: an)ong healrhcare protb.sionI I a-1s to explain rvhy some wounds do not heal: constant focal pressurer poor vascular inflow, inGction, con-
tive research data exist; data may be anecdotal and do not conforrn to higher evidence lel,els Level D: no evidence current\ found in the literarure.
coilitant
diseases,
healthcare professionals often neglect to
and poor venous return. How-ever, identift the con-
conitant and subtle nutritional defects that rnight prolong the healing process or contribute to nonhealing.
the reader to understand nutriassessment, and the irnpact of poor nutritron on the wound healing environment. Current evidence addressing the impact of nutrition on the healing rvound and potential nlltrition therapies to enhance wound healing will also be discr-rssed. Attention
The intracellular environrnent ultimately controls tissue if ceilular metabolisrn is inpaired, a cascade of events occurs, often leading to Foor trssue integriry ce1l desrruction, or ti'sue dcath. Whole body nutrition is reflected in this microenvironment. A well nourishe d person will not experience a delay
status;
This chapter rvil1
assist
in wound
tion screening, nutritionai
closure because of a s)rstenic nutrient deGct. ce11u1ar nretabolism is irnpaired or altered (sec ondary to poor or under nutrition), wound healing (ofanv and all tissues) will be significantly impacted. There is a delicate balance between the rnacro- and nricronutrient intake and resultant rvound heahng and tensile strength.
However, if
will be focused on the evidence current\
available regard-
ing the impact of nufirion upon the healing wound, utilizing the follou.ing generally accepted strength of evidence criteria:
Total body nutrition is a complex physiologic and biochernical illtegratiol] (a rhorough discussion and description are be,vond the scope and purpose of this chapter).
This compler integration is influenced by many patient

controlled" blinded data exist and factors. Examples include but are not
. Level A: randomized. .
support best practice Level B: controlled, randornized data or u,e1l designed nonrandornized data exist and support best practice
conscnsus! or descrip
[. Nutrition factors:
access
lirdted to: to food, food intake, and pro-
cessing of nutrients
2. Psychological factors: depression, dementia, or cognitive

changes
. Level C: expert opinion, editorial
Zagoren Af, [ohnson l)R, Amick N. Nutritional asscssment and intervention in the adu]t rvith a chronic rvound- In: Krasuer L)L. Rocleheaver GT SibbaldRG,eds.ChronicWoundCare:AClinicol SourceBookforHeolthcoreProfessionols.4thed.Malvern,Pa: HMPClonrnrunications,2(l(17:127 136
CHRONIC \II/OUND CARE, 4th Edition
127
Zagoren, Johnson, and Amick
Nutritional Assessment and lntervention
of the elderly is essential due to the prevalence of chron(% IBW)
= =
{BW (actual) x
IBW
100}
(% UBW)
{actual BW
100}
ic illness and socioeconomic factors that are 1ike1v to place them at additional risk. Nutrition screening tools identifi, patient characterlstics known to be associated with nutrition problelns. These patient characteristics can be objective, subjective, physical, psychological, socioeconomic, medical, cu1tura1, and/or functional. There are a number of screening tools avariable to guide the wound crre practitioner. The Nutritior-r Screer.ring Initiative Project' and the Mini Nr-rtritional Asscssment (MNA)] are 2 examples. Screening Initiative Project tool was in the outpatient, geriatric population and is nor'v being validated in other populations.r The MNA rvas also designed for the elderly popr-rhtron; it is easy to adrninister, patient friendly, inexpensive, highly
designed for and validated sensitive (96%) and specific (98%), and reproducible.':
, aDd
UBW
Men
106 lb/5
Women
l0%) ft + 6 lbladditional inch I00 lb/5 ft + 5 lb/additional inch (+ |
(t
Anthropometrics: ldeal body weight (lBW) is limited in the real world. Usual body weight a more realistic and useful assessmen[ tool.
The Nutrition
3. Socioeconomic factors: finarrces and support

,1.
111S
Environment:r1 factors: secure housing and ac and refrigerator
ss
to stove
5. Disease process factors: h,vperglycenria, nrenria.
The microcellular environment is directlv nfluenced

by these factors. The final metabolic endpoir
healed rvound) is the result ofa rvel1 coordir
ed, balanced event. Each step
,
(a stable,
integrat-
Once iclentified, the person with rnalnutrition or at risk nutrition intervention. The nutrition care plan is guided by a fbrnral rrutrition assessnlent; consultation with a registered dictitian is recommended. Traditionall,v, in clinical practice, the cornplex riutrition
can receive appropriate
und healironment, ing sequence requires a stable biochcmical ke and rvhich ultimately is the result of adequate food
in this complex
nutrient processing.
hurnan physiolog,v is resiliert, any the provision, availability, or processing of t
'Whi1e
a
atlon
1n
nutflents
mali and often r.vi11, alter the stabiliry of process. It is a tribute to the beauf,v of the int
physioiogic balance.
e healing Ihurnrn
milier.r that most rvounds heal, despite alteration ln lnacro-
only pedormed when a severe defect or nutritional alteration is identilied through nutrition screening. It is important to note, despite thc iogic, thcrc is no A or B :rtrength of evidence-based resealch to support that nutrition intelventron will rcduce the overall healing course. There is, however, 1eve1 C strength of evidence to support that nutrition intervenrion r,vi11 prevent or reduce the incrdence of negative healing outcornes.' Ultimately, r.vound healing is the result of protein proassessment is
cessing.This physiologic event (healing) recluires the assrrn-
Nutritional Screening and

The nricrocellular environment reflects the hysiologic is an environrncnt in rvhich it is found. Hence, if cellular alteration of balance. or an actual loss of availa Fect nrav metabolites and elements, a resultant tissue lead to occur. Impaired protein and calorie intake c protein rotal body protein depletion. Decreascd total timatel,v, 1eve1s reduce rvound protein content and, decrease wound tensile strength. Therefore nutrluon for poor screening is important to identify patients at r
or alteled nurrition.All individuais presenting chron-
ilation of protein (eg, anrino acids, peptides, polypeptide$ to fonn a healing matrix. Ener6X, is requircd for healing to
Nutritional assessment helps the observer identifi a deficiency in either of these rni.cro ol mrcrocnvironrncnts. Lean body mass is reflcctive of total body protein compartnlent (ie, in evaluation, the size and relative densiry of body protein to body fat).t Lean bodv rnass may be assessed
occur.
through direct or indirect lneasurenlents. Direct nteasurements (eg, isotope dilution tecl'rniques, nelrtron activation, bioelectric irlpedance analysis), rvhile extremely accurate and useful lor research purposes, are not practical, clinical, cost-effective tools. Indirect measurenlents (anthrcpomet-
ic rvounds should receive nutritiori

their initial evair-ration.
screening as
part of
Nutrition screening identifies individr-rals

nourished or rvho are at risk for malnutriti pose of the screening is to determine if a rn
are ma1-
rics) are rnore practical and less costly. Antlrropometric measurements are measurements of bodv ce11 mass, ancl examples include height, rveight, and body mass index
(BMI). Body
rnass
The purdetailed neters
(BUt = ll'eight
expressecl
index is a measure of r.veight for height in kilogranx divided by height
nutrition
assessment
is
necess:rr1.. Screening
should be simple, efiicient, and able to be admi by any member of the healthcare tean1. Nutriti screeilng
12fJ
squared in meters). The persor-r rvho screens as having weight loss (or massive rveight gain) should have anthropometric components assessed. A medical proGssional (eg, CHRONIC
WOUND CARE, 4th
Edition
A.
History
l.
Weight change
Overall loss in past 6 months: amount =

Change in past 2 weeks:
7.
kg; % loss =
increase;
no change;
decrease
Dietary intake change (relative to normal):(weeks) duration Change

type:
suboptimal solid diet;
No
change
full liquid dieq
_hypocaloric
liquids;
3. Gastrointestinal
- none;
symptoms (that persisted for > 2 weeks) diarrhea; nausea;- vomiting; -
anorexia-starvation
4.
Functional capacity No dysfunction (eg, full capacity)
type:
duration (weeks) Dysfunction ambulatory; working suboptimally;
bedridden
5.
Disease and its relation to nutritional requirements: Primary diagnosis (specifY) low stress; no stress; Metabolic demand
(stress):_
moderate stress;
high stress
B.
Physical (for eochtroitspecify:0 = normal, I =-mild,2 = moderate,3 - = severe): loss of subcutaneous fat (triceps, chest)
muscle wasting (quadriceps, deltoids) ankle edema sacral edema ascites
c.
SGA rating (select one): A = well-nourished B = moderately (or suspected of being) malnourished C = severely malnourished
dietitian,
nr-rrse,
physiologist, physician, pharmacist) can per-
form the assessnlent. lJsuai body lveigl.rt tilrmula is shou'n m Table 1. By calculating the ratio of the ditlerence
betrveen the lean bod1, cornparmrent and bodv fat, the person lnay be cornpared to a standard.Tl-ris can be donc rvith
li.i
l. ,rt .l.r
:.
.'r,
.rr,.
l,',
r:
.p;g6
,,,1
,'
.,1 ,
.p6k.r', ,.,.:l i '.: r ::,,r,,,rr ,,Riik
t:t.,.r,
.,
, ,.'
'
...:l.l
total bod1, u.eight and its rclat:iorrship to a stalldard:

9/n
Deficit
100
actual r.veight ideal rveight
100
Actnal u.eight and ideal rvetght are sr-rbjcct to various

inconsistencies ancl can be influenced b1' non-nutritional factors, eg, certain medications, bod.v rvater fluid changes,
2.5 < 3.0 to 2.5 < 3.5 to 3.0 Total Protein < 5.0 < 6.0 to 5.0 < 6.0 to 6.5 < 900 < 1500 to 900 < l800to 1500 TLC Albumin
<
r:henrical nleasLlrement. The decision to obtairl this biochen'rica1 data should be balanced with the common
to obtain
lirnb :rn'rputation, and/or chronic disease states.Total bodv

nrass nreasurement is an observation and
tnitst bc utillzed
zrs
scnse evaluation
ol the
person's st:ltLls. Most rvounds heal
or tool in further nutrlttonal evaluation. Thc wor.rnd care practitioner can better understand the person! ultimatc total body protern status bccause total body protein is also rcflcctecl in ]mtnoral proteirrs (eg. crrculating proteins that include albumrn, globulin, and hornrones). These humoral protcins sliould be evaluated as
a conlponent u,c11.The assessment of hurnoral or visccral proteins rcqtrires sonre invasion ofthe bodv collrpartlnent by clrarving blood
the decision to obtain brochemical data should be founded on the observer's key sense of need. This patient ma,v have a brochemical nutrition defect. Iftl'rere is sr:spicion or a question that there is I biochemical defect, the person's total protein, serum albumin, and total lymphocyte count (TLC) may give further
despite
nutrition
status; hcnce,
clues reg:rrding the overall
nutritional stallrs. More sophisti-
cated bioc}rernical markcrs may be asscssed (eg, transferrin,

129
CHRONIC
WOUND CARE, 4th
Edtion
% ideal body % weight loss
wt.
70-80
I
<70
>25
<
2.1
5*25
Albumin (gm/dl )
Transferrin (mgldL ) Total lymphocyte
2.1-2.7
t00-t50
800-t,t99
<
I00
< 800
count (mm3) prealbumin, retinoi binding protein) s,hen assessnlent has identified increased risk (Tab1e 3). Horvever, the healthcare prolessionai is certain non-nlltrition factors adr''ersely affect chemical data. Specific non-nutrition f these biochemical data can include, but are not trauma, sepsis, or concornitant medications. stress reaction rnay suddenly deplete these
greater risk
screenlnE and Table
for impaired u,ound healing
ancl
poor healing
outcomes unless the nutritional corrrponerlt is stabilized.
tioned,
as
these bioaffecting
The Subjective Global Assessment (SGA): is a tool used to assess nutritional status. The various conrponents of the SGA are fairlv self explanatory. Essentiall,r,', it provides a
reproducible template for ongoing n.rtrition rssessment and tirnely evaiuation of the patient'.s response to the nutririon plan of care (Tab1e 2A).
limited to,
acute mical
components.The acute phase proteins are depl 'ted, not as a result of patient protein energy rnalnutrition (PEN) but
rather as a result of other protein stresses. T must therefore be sensitive to these factors and alterations in perspective. It is important to
regardless
observer
ace these
lize that
visceral reason for aiterations rn healparalneters, if thev are significantly depressed, ing wili be alTected.The typical nutrition asses enl lncorporates both lean bod,v mass and humoral prot n leve1s to
of the
A nutrition-focr-rsed physical examination should be reserved for the patient dcemed at risk. The nutririotrfocused phvsical exanrination is an excellent tool to help evaluate nutritional status. The focus of this chapter does not allorv for a complete explanation and/or description of a nutrition-focused physical exarninarion; horvever, additional information can be found in the An'rerican Sociery for Parenteral and Enteral Nr.rtrition (A.S,PE.N.) Support Practice lvlanual.o
assess
rvound healing poterltial.
Other key components of a irutrition assessn nt include nutrition visual inspection or observation and a vet
health history.The u.ound care practitioner wi be able to identify subtle or not so subtle visual cues: r:heria or r:f a obesit,v. It appears that morbid obesiry has
Albumin
Albumin is the major circulatir.e hunroral protein. It is the major oncotic pressure stabilizer in both the cellular and intravascular compartment enrrironnrents. Therefore, lvhile albumin is the major rneasurable hurnor:r1 proterLr, its serum level can be altered by total bodv water status.
Serum albumin 1evels (expressed as g,zdl') are ret'lective of concentration per urit volume. If total bod1, r,vatcr is increased (eg, nephrotic syndrome, congestive heart failure), serum albr-rmin 1eve1s are decreased. Concornitantll', albumin is a rlajor amino acid storehousc for multiple biochenlcal svntheses. Massive injurl- or an acute phase reaction mav cause alburmn 1eve1s to drop precipitously; this is more common in the previouslv stressed or elderly patient. Decreased albumin levels mav or may not reflect total body albumin. Decreased serum albumin levels asso crated r'vrth massive injury atTect total bodv albumin and negatively impact rvound healing. If there is insufiicient circulatorv aibunrin to pror.ide amino acids/peptides for utilization in non-stress-related processes, healing nright
e strength regro\\'th impact on rvound heeling and (negatively atTects the rate and strength ofheal wounds) alert the than cachexra. Either of these observations sh rvound care specialist to further evaluate the dividLral\ nutrition
status.
comprehensive verbal health history is p
to
identi$'- those patients u,'ith poor nutritron or t
individ-
uals who have experienced signiiicant unintenti na1 weight k for poor 1os (10% or lareater in 6 rnonths) and are at nlonstrates rnound healing." Anecdotal obserr.ation also I resulr in that structured intentrona-l rveight loss also loss mav total bodv protcin loss, ,vet thc magnitllde of
be inconsequential to u,ound healing. However,
if a person
with a chronic nonheahng wound

(intentional
130
reports
ight
loss
or unintentional), this person \\
beata
CHRONlC WOUND CARE, 4th Edtion
be affected. Although healing will usually take place, ir may be prolonged, or rvound tensile strength may be
diminished.
Carbohydrate,
E!ergiy
Fat
Proteins
sudden decrease
in serum albumin
noted
within the clinical context of an acute stress reaction will

not alGt t roLal bodl alburnin. Regardless of the etiology, decreased serum albumn is associated wrth poor heaiing outcomes and, more importantly, poor clinical outcornes.' As totai body proteins (specifica111,, albumin) are acutely depleted, changes in intracelluiar fluid occur. This localized oncotic pressure deGct
may alter wound healing rates and outcome; pH, tissue orry-
DE:POT
(fat)
genation, volume concentrations of micromrtrrents, and capillary blood flow are altered, even in instances ofnormal -Wounds nutrition stability. will o en heal despite lor'ver albumin 1eve1s, but the time to healing or total wound tensile strength will be reduced. Nutrition assessment is therefore an important strategy
Figure l. Nutrient partitioning.

Albumin is synthesized in the hepatocytes. Flumans require 20 to 30 minutes to synthesize a molecule of albumin.The rate of supply to the tissue is strictly responsive to the synthesis rate.The most comnlon reason for reduction
to evaluate the patient with poor lvound 1-reaiing. However, improving the nr.rtrition status may not be
reflected in increased time to healing or improved wound tensile strength.
in
availabie protein is nutrient partitioning.
In
stress states,
there is significant alteration in the etEciency of energy
uti1).
lization. Increased energy demands alter the electron trans-
Gr
process,
with the byproduct being heat (Figure
Wound Healing-Physiology and Nutrition It is lmportant to recognize the relationship between

total body nutrition and wound nutrrtion. Each step in the heahng process (inflarnmation, proliGration, remodeling) is
Subsequently, there is a drain on the available nutrient lead-
ing to net catabolism.This diverts 20')/r30')/o of the available araino acids away from tissue replacement and results in delayed or poor wound hea1ing."'
ultinrately precursor dependent upon circulating anuno acids, lipids, and carbohydrates. Impaired nutrition not only can alter the modulation of collagen deposition, fibroblast
proiiferation, and hydrorryproline content but also inrpairs immune function and oxygen transport. Growth factor synthesis is also dependent upon adequate nutrient status.
Nutrition Repletion
The catabolic patient is at risk for poor or
delayed u,'ound healing. Logic r'vou1d therefore follow that correc-
tion of this catabolic state not only r'vould in:rprove overall health but also would provide available substrate to cor-
Protein deficiency can suppress angiogenesis, thereby altering capillary regeneration in the proliGration phase (reflected in a wound with rnininral granulation base). Malnutrition may alter fibroblast proliferation as well as
collagen synthesis, thereby altering the rate and fiual stabil-
ity of the wound. Even
altered lipid levels, important in
rect the wound healing process.There is some evidence to support this concept; however, much of these data are confusing. The strength of the evidence to support this concept is level C qualiry Many nutrition and wound healing models are based on animal data. These data may not truly reflect the human
membrane stabilization and inflammation. have been shown to adversely alTect rvound healing. Collagen sl.nthesis requires 1 K Ca1lgm ofcollagen synthesized.Any alteration in the avaiiabiliry ofprecursor amino acids or energy
condition. For example, rat metabolism is quite ditTerent

than human physiology. Rats continue to grow through the
will affect collagen deposition. Each 50{J mg of granulation tissue lequires 0.5 K Cal,umg for production.''
substrate
1iG cycle due to the availability of growth hormones. F{uman growth hormone levels plateau and diminish with age, but human tissue repletion occurs later in 1iG, despite minimal ievels of circulating growth hormone. C1ear1y,
human wounds heal, but in a different physiologic environment compared to the rat mode1. The provision of nutrient repletion can be provided in various forrns. Idea11y, an appropriate oral diet is the rnost efhcacious repletion available.The nutritlon assessment calculates a prediction of overall protein and calorie needs (Table 3) based upon either ideal or actua.l body mass needs. It is often drfficult to accurately predrct an individual's
131
In wounds r.vith excessive lactic acid production (eg,

crush injury, low availability oforygen), the lactate is recycled in the pyruvate cycIe, and the tissue becomes extreme-
ly energy inefEcient. Further, in
severe stress, protein becomes the preferred energy source rvith decreased abili-
ry to provide substrate. Decreased protein

tissue edema.
1eve1s
can cause
oncotic pressure alterations with a resultant increased local
CHRONIC
WOUND CARE, 4th
Editlon
rnineral requirements (beyond those for standard and stressed patients)
for indivrduals rvith acute or chronic wounds
are
Minor surgery Clean wound lnfected wound Malor trauma Major sepsis
Severe burn
E
t.2 t.2 I.3

t.5 t.5
nlllrients above that of the standard multivitanrin may not be warranted (except for acute burns in excess of 20ak total burn sudace area) unless clinical signs ofdeficiency are present.12
unknor.vn. Therefore, supplementing specific
Zinc
Zinc is an essential component of nut.nerous DNA RNA
polyrnerases and metalloproteases.
2.0 or >
It
is a required cofactor
multiply factor times the actual energy ex to obtain the actual energy expenditure
for more than 100 metabollc
steps. Ce11u1ar proliferation
exact caloric needs
in any girren circumst
needs are predicted using cither the actual or rveight. Obese individuals are a challengc; thei mass may be depleted or normal rvith the i stores creating an abnormal elevation of weig state will also alter the calorie requirement; he
:e. Calorie ideal body lean body

reased fat
and synthesis require adequate 1eve1s of zinc. Some data support increased healing of venous ulcers u.ith zinc supplementation in patients rvith 1ow zinc levels at pretreatment screening.'t However, other data are not lrs supportive.'*''t Setum zinc 1eve1s may not correlate with microcel1u1ar zinc availability. It seems logical to provide zinc sup-
The
a
stress stress
plementation to people r'vith chronic wounds.

lJnfortunately, data that indicate the required and specific dosage are limited.
or metabolic activitv factor must be utilized

calorie need prediction (Tab1e ,l). Consultation
istered dietitian (or equivalent nutrition proGssi
adjust the
a rega1) is
rec-
Copper and lron

Copper is essential for the cross-linking of hydrox,vproline and proline. lt is essential in hemoglobin synthesis and active in the action of superoxide disrnutase (an important antioxidant in various biochernical processes). There are knorvn de{iciency states as well as impaired physiology due to excessive intake. The recommended daily intake is 1 mg-l .5 mglday.There is no knorvn evidence frrr its use as an adjunct to irnpaired wor:nd healing, unless a documented deficiency state is present.'u
ommended to provide additional expertise in the nutrition care plan. The actual energy requirement can be obtai the use of indirect calorimetry, r'vhich measu energy requirement at a given nronlent in ti calorimetry is costly and cumbersome. For the is useful only in the research setting or critical
eveloping
through
the
actr-1al
Indirect
part,
1t
nrr atl ce-
Protein Requirement
Protein needs are assessed using totai body rass and a proteln stress or metabolic activirv factor. Thc nor per kilorequirement for a healthy adult is 0.8 g of lyam per 24-hour pcriod." This requiremcnt ries and is (eg, inGcdependent upon the degree of rnetabolic s tion, immobiliry tissue loss) to which the i ividual is from exposed. This protein requirement can be inc 1 .5 g/kg to 2.1 g,zkg or more in response to the ndrvrdualis achieved . linr, al conditjorr. Ongoing ptotein as:cs:tncttt
by nreasuring nitrogen balance. Nitrogen balance studies require normal ret When a person has irnpaired renal functio excretion of nitrogen is altered, and urine cannot be utilized (Tab1e 5). function.
Iron is another
essential nicronlltrient
for
optrmal
lvound healing. It is cssential for the production of stable co11agen. Alterations in iron intake, absorption, processing, and storage can lead to disruption ofnormal collagen dep
osition. Impaired metabolic states can lead to increased rron deposition r,vithin tissue (eg, hemachromatosis) that cau also alter wound healing.
Yitamin A
Tl're mechanisrl of vitarnin A and its relationship to wound healing is unknown. It appears that vitarnin A supplerrentation atTccts u-or-1nd healing." Vitanrin A supplementation increases n'ound collagen content and incrcases the breaking strength of anastomoses.There even may be a benelicial etlect of vitamin A supplementation in those
patients taking glucocorticoids.'''"'
the
renal
nitrogen
Micronutrients
Micronutrients function
as
cofactors and enz
1es
neces-
sary for physiologic reactions at the ce11ular
, enabling
protein and energy to be utilized elEcientll'. Sigrificant controversy in the requirements micronutrients on lvound healing exists. Precise
132
d efGct of
tarnin and
Vitanrin A may effectively enhance collagen deposirron systemically. Topical application of Vitarnin A may be clinically effective to help reverse the effects of steroids on chronic wounds though the extent of ffansrvound absorption is unknor.vn and the specific dose
either topicaily or
CHRONIC WOUND CARE, 4th Editlon
for use with rvound healing has not been established.,r:,r:, Some experts suggesr 25,000 U of vitamin A be given to at-risk patients.rl'Again, as in the case of zinc, no recomntendation can be made as to dosage or timing of supplenrentation.
Nitrogen ln = Protein lntake (gLx 24 hours
Vitamin
Nitrogen Out = g urinary urea nitrogenl24 hr plus g for other nonurea N2 losses Nitrogen intake is derived by dividing the person's protein intake by a factor of 6.25 Nitrogen ln = Prorein (g)16.25 Nitrogen Balance = (g protein intakel6.25)-UuN+3x
xThe correction factor of 3 accounts for no-urea losses, including stool expired and cutaneous nitrogen loss.
The presence of scurry is a clear-cut r,vor.rnd-related vitarnin deficiency-. Scurvy is perhaps the urost well docurnented r,vound-related vitamin deficiency state.rr Vitamin C is
required for proline cross-linking and, therefore, is an essen-
tial component of healing. Unfortunately, the amounts of intake above the daily minimal requiremenrs needed to enhance human healing are not evident 6-om animal
research models.
in vitaruin C-deficient patients have decreased angiogenesis, litt1e collagen deposition, and decreased and retarded tensile strength. A significant number of elderly people have low plasma and leukocyte ascorbate concentrations. It appears that preexisting vitamin C deficiency may predispose patients, especially the elder1y, to vitamrn C-deficienr urcund healing
Hence, vitamin C supplementation in patients wirh chronic nonhealing rvounds should be considered.
de1av.
'Wounds
Glutamine
Though glutarnine is not directlv linked to cnhanced rvound healing, this amino acid also deserves special mention. Glutamine is the rnost abundant arnino acid in the body and serves as an energy source for rnany rapidiy dividing ceils. Supplernentation has been shown to enhance and improve overall nitr-ogen balance in at-risk patients.16
Hor'vever, litt1e overt clinical data suggest that supplementa-
Vitamin
tion will alrer r,rorrnd healing orrrconre:.

E
Significant contloversy exists surrounding the sysrenric supplementation of vitamin E in the patient with the chronic nonhealing rvound. The clinical relevance rernains to be shown.There is no evidence that vitamin E has rnore
than a casual role in wound healing.There also is no known
Non-nutrient Agents
Much discussion and controversy within the healthcare conmuniry and literature regarding the use of anabolic
to enhance lean body rnass exist. The impact that enhancing lean body mass has Llpon the healing rvound (or
agents
deficiency state associated with trauma..]
Arginine
The amino acid, arginine, deserves special mention,
as
the chronic nonhealing wound) has been discussed.The use of agents, snch as human growth hormone (HGH), while
significant controversy surrounds its role as a supplement in wound management. Data suggest arginine supplementation prornotes r,vound healing. It appears that ornithine (the nretabolite of arginine) can be converted inro proline directly by wounds. This, in turn, lnay pronlote increased collagen synthesis. Some healt\ volunteers and elderly patiellts placed on arginine supplementation have shown increased hydrorryproline content and increased collagen deposition.:r'rj lt therefore appears arginine supplementation may bc beneficial. However, the healthcare pracririoner is cautioned to drarv conclusions about chronic wound healing etlicacy froln healthy volunteers and acute surgical
wounds. Currently, insulficient data from clinical tria.ls exist to recornmend at1 optimal level or duration of arginine supplenlentation to promote wound healing, and its therapeutic ellectiveness to facilitate wound healing is unknown.2r
ofits deleterious and potentially fatal ellecs.2i Anabohc steroids, such as oxandrolone, have been used successfully as adjunctive therapy in severely burned
pf,tients
dence;.
logical, is discouraged because
in enhancing lean body "','u "
ntass recovery
(C 1evel evi-
Nutrition Supplementation and Support

The vast majority of people u,,ith chronic rvounds can be treated in the ambr-rlatory setting. In fact, rnost of these individuals have no ditEculty oral1y ingesting nutrients.A nutri-
tion screen should be perforrned on all ofthese patients. If the nutrition screen identifies that the person is at risk for nutritional deficiencies, a cornpreheusive nutrition assessment should be pedormed. Consultation with a registered dietitian (or equivalent nutrition specialist) is recommended to complete the nutrition assessment and develop the nutrition care plan. This care plan rnay inciude, but is not
lin'ritec'l ro, dietary instruction, meal/rnenu planning, and
CHRONIC \MOUND CARE. 4th Edition
133
the use of oral supplements andlor calorie supplementation in order to enhance u.ound
. Overt
ing
has
ent in high concentrations, can danuge cellular membranes and impede tissue repair. Free radicals actually
enhance the healing environment by helping
not been sho\^,n to be beneficial. F{owever, ther is some C level and B level evidence that adjunctive or nutrition d/or presupplernentation in elderly patients may reduce vent the onset of pressure ulcers. However, the evidence
is
to
release
cytokines, promote leukocyte adherence, and kill certain rypes of bacteria. Hou,ever, excess free radicals can cause
further inflammation and the release of iron into the

ce11u1ar damage and Malnourished individuals rvill have higher cellular levels of oxrygen-free radicals; therefore, a good r,vound healing plan may include the oral or parenteral inge.rion of rntioxidarrr vitarr ins.
de1a1,sd healing.
is ired.t'rt' In intake, the situations where the person has impaired provision ofnutrition via the enteral or parent al route is necessary as an adjunct to good u,ound care.
not verv robust, and additronal research
rvound; this results
in prolonged
Entera! and Parenteral Nutrition

Enteral nutrition, the provision of total and sllb'rr.lre inro rhe gastroinrcsrin.r[ (Cl) trac
Proteln, is the pre-
ferred route for nutrition support. Prov nutrition directly into the GI tract is more eflicacious Delir.ering intains the enteral nutrition directly into the intestine health of the GI tract brush border; the brus border has
key protective immunological functions. Ente are less problematic to nlanipulate, and systemi bolic, infectious) complications occur less
enterally fed patient when compared to the pa products
(eg. rncra-
in the
nterally fed
patient. Enteral nutrition products are also costl.v than parenteral nutrition products. The manageme t of enteral Geding requires direct access into the GI tr via a nasoplacement enteric, gastric, or jejunal tube. Enteral requires direct intervention via a heaithca provider,
,. Horvever, potentially increasing overall patient the morbidiry is usually less problematic than t at associated with parenteral nutrition. Enteral nutrition rlcts pr1a a factory Therefore, nutrients can be added but not ren A small group of people cannot be fed ally due to Faiiure of the GI tract. In thesc instances, nutrltion should be provided. Parenteral nutrition be 6nely tuned for the person's needs; however, it does arry vu,ith it significant n-rorbidiry and mortaliry Parente I nutrition
Antioxidants exist in both the cytosol and lipid environment. Vitalrrins C, E, and A, beta-carotene, taurene, g1utathione, and pyruvate all act as antioxidants. The enzymes responsible for free radical destruction (ie, glutathione peroxidase, superoxide dismutase, and catalase) depend on adequate amounts of trace metal cofactors {iom the diet (eg, seleniuru, zinc, copper, magnesium).Vitamin E fr"rnctions in the lipid-laden cellular membrane as a major antioxidant. People with chronic wounds can generate excessive oxygen-free radicals that consume various parts of the antioxldant defense netu,'ork faster than repletion. This depletion leads to loss of glutathione, vitamins E and C, zinc, copper, and seleniun.The end rcsult is further cel1ular damage and impaired wound healing. The use of svs-
tenric and topical antioxidants carrres great scientific

the amounts and types of these trace uetals and vitarnins to adnrinister are unknor'vn. Logically, one can assume that antioxidant supplementation should aid in wound healing. This needs to be tempeled with the knorvledee that in some cases vitamin E, iron, and beta carotene, though helpr:rates, can quickly become toxic at the cellular level. There is minimal evir.veight.'' lJnfortunatell,,
marily are formulated and prepackaged
dence to sr-lpport the therapeutic use of these agents to enhance r'vound healing in nondeficiency states.r'
Summation and Outcome lmplications

A chronic wound develops for a myriad oli reasons. The individuali nutritional stabiliry plays a significant role in the
developrnent and ultimate healing of the injured tissue. It is obvious that the macro- and rnicronutlition envilonments affect wound healine. Essentially, all functions of rvound healing are related to this nutritional environment. Proteins (eg, amino acid, peptides, and dipeptide$ provide the matrix for collagen synthesis and h1,clr61yp1elene deposirion. The complexities of tl're rvound healing process are legulated by enzymcs and trace metals, all of which are pro-
requires fairly aggressive rnonitoring and Individuals on parenteral nutrition therapy
nagement.
at signifi-
cant rrsk for serious cornplications. People u1rlng parenteral nutrition are usually sicker than the aggregate of chronic rvound patients. Monitoring a nlalntalning individuals on parenteral nutrition is a c lplex task and should be managed by an experienced in fessiona1 nutrition support team.
Other Nutrients
Free radicals and antioxidants. Oxygen free ladicals are highly reactive molecules prodr-rced at the lular level as the result of ce11ular metabolism. Free I levels increase with inflammation and rn slrbseque phases of
the rvound heaiing process.These free radica
131
vided by nutrition-related processes.A failure anyrvhere in this system can ultimately affect the healing process. The healthcare practitioner is obligated to eva.luate and monitor the nutritional status of a11 peopie presenting with chronic rvounds. Often, manipulation of the nutrition envi-
rvhen pres-
ronment, along with appropriate wound management, produces successful heaJthy outcomes.
C. A11 patients D. Elderly

2. Positive chronic wound healing olltcomes occur with:
Most wounds will heal regardless of the person's nutritional status.While logic states that nutritional support can and will aid in the healing of a chronic wound, it appears that nutritional intervention alone will not affect the outcome.The logic that an adequately fed person is essentially in good health stands true; however, healthcare proGssionals must be cautious and understand that a nonhealing wound is an extremely complex phenomenon: the alteration of a single component may not affect the outcome. Whole body nutrition certainly impacts the healing process and is a tribute to the human physiology. The wound care professional needs a basic knowledge of human nutrition in order to recognize nutntion-related deGcts. These defects can often be corrected in order to optirnize the nutritional environment of a poor\ healing wound. Nutritional defects, even when corrected, are only a sma11 part of the complex physiology that leads to a nonhealing wound. manner.
A. Diet and exercise B. Manipuiation of the nutrition environment and appropriate wound management C. Daily dressing changes
D. Bed rest
3. Evidence-based data
to support chronic wound healing
at some accepted 1evel (A, B, or C) exisrs for the following
nutrition therapies EXCEPT: A. Zinc

B. Vitanin C
C. VitaminA D. Vitamin E
4. Ma-lnourished patients (protein calorie malnutrition) with chronic wounds will require which of the following
therapeutic measures to enhance wound-healing outcome? A. Anabolic steroids
Nutrition screening can be performed in a cost-effective When a patient screens with a possible nutrition
defect, nutrition professionals are required to intervene and
collaborate with wound care experts patient and wound healing outcomes.
to
achieve optimal
B. Antioidants C. Fluman growth hormone

D. Elemental copper
Answers: L-C, 2-8. 3-D, 4-B
References
1. 2. 3.
Lipschitz DA, Ham RJ, \Vhite JV An approach to nutrition screen ing for olderAmericans. Am Fam Plrysiciax. 1992;45(2):607-608. Guigoz! Lauque S,Vellas BJ. Identifiing the elder\ at risk for malnutrition. The Mini Nutritional Assessaent. Clin Ceiatr Med. 2002;18(1):737J57 . ShobellJM, Hopkins B, Shronts EP Nutrition screening and assessment. In: Gottschlich MM, ed. The Scjence and Pradice of Nutrition Support:A Case-Based Core Cuniculum. Dubuque, Ia: Kendall,/Hunt; 2001:107-110. Langer G, Schloemer G, Knerr A, Kus O, Behrens J. Nutritional interventions for preventing and treating pressure ulcers. Codrrare Databue Sysr Reu. 2003;(4):CD003216. Roubenoff R, Kehayiu lJ. The meaoing and measurement of lean
4. 5. 6. 7. 8. 9.
body mass. Nutr Reu. 1991;49 (6):1,63-17 5. Bergstrom N. Lack of nutrition in AHCPR prevention guideline.
Detubitus. 1993 ;6(3) :4,6.
Detsky AS, Mclaughlin JR, Baker JII et al.What is subjective global assessment of nutritional status? JPEN J Pilenter Enteral Nutr.
1987;1 1 (1):ti-13.
Merritt R,ed.
The American Sodety for Parenteral and Enteral Pradice
L4.S.PE.N) Nutrition Support
Manual.2nd
ed.
Nutrition Silver Spring,
Which of the following patienr populations require a nutrition screen upon initial evaluation of their chronic
1.
10. 11.
Md: A.S.PE.N. Publications; 2005. Doweiko JII Nompleggi DJ. The role of albumin in human physi ology and pathophysiology, Part III: albumin and disease states. JPEN J Parcfltet Enteral Nutr. 199 1 i19 (4) :47 6 483. Demling RH, Stasik L, ZAgoren AJ. Protein energy malnutrition
wound?
A. Obese B. Diabetic
CHRONIC
Medic jne. Dietary Refercflce lntake s Jat Energy, Carbohydute, Fibet, Fat, Faxy Adds, Cholestetol, Protein, and Amino Acids (Macronutienr,s). Washington, DC: National Academy press;
and wounds: nutritional intervention. Curative Health Services: Monograph #10;2000(6).
Institute
of
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12.

1
t3.
't4
15.
In: Matarese Mays T, Gottschlich MM. Burns aud wound heali Pructire: A LE, Gottschlich MM, e&. Contenporary Nutrition r Science; Clinicol Guide.2nd ed. St Louis, Mo: Saundcrs 2003:595-615. show diminRojas AI, Phillips TJ. Patients with chronic leg ulc ished levels ofvitamins A and I. carotenes. and zinc Dennatol Surg 1999;25(8):601-604. healing. Andrews M, Gallagher Allred C.The rcle of zinc in Adu Wound Carc. 1999;12(3):137-138.
97 2 :17 s (2) :23
24
SJ, Wasserkrug HL, tsarbul A. Metabolic effccs ofarginine in a health elderly population.,lPENJ Parffiter Extual Nu:r. 1995'19 (3):227 -23\\. Barbul A, Lazarcu S, Efron DT,Waserkrug HL, Efron G. Arginine enhances wound healing and )ymphocyte immune responses in
Hunon M, Regan MC, Kirk
-2 1{\.
26.
hunuus. Sar3cr1,. 1990;108(2):331-337. Heyland DK, Dhaliwal 1{, DroverJWl et al. Carodian clinical practice guidelines for nutrition support in mechanically venulated, crit-
Ackermau
Z,
Loewenthal
E,
Seidenbauru M
16.
Gorodctsky R. Skin zinc concentntions in ulcer. Irt J Dernatol. L990;29(5):36U-362. Denrling RH. Nutrition and wound healing. Kinner RS, eds. Wourul HealingBoca Raton, Fla:
Rubinorv A, with raricose

27.
ically il1 adnlt patients. JPEN J Parenltt Enterul Nutl

2003;27 (5):35s-373.
Falabella AE and Fmncis; ng. O\toml) and retinoids

28
MacGorman LR, l\izza RA, Cerich JE. Physiological concentrations ofgrowth horrnone exert iusuiin-like aud insulirr antagollistic effects on both hepatic and extrahepatic tissues in mm. J Clin
Endotrinol Metab. 1981 ;53(3):556-559.
2005:647-659.
17
1tt
Thomas DR. Nuritional factors affucting wound Wou nd Manage. 1 99 6 ;42(5) : 40-49. Wicke C, Halliday B,Allcn I), et al. Effects of on wounrl healiog. Arrh Surg 20OO;135(71):1265-1 Hunt TK, Hopf HWlWound healing and wound surgeons and ancsthesiologists can do. Srry 1L)97;77 (3\:s87-606. Ansread GM. Stercids, retinoids, and wound he
C are. 1998 ;l"l (6) :27 7 -285. Thonrpsou C. Fuhnrr.rn MP Nutritiorr rnd searching for the magic bullct. Nrarr Clin Pract.2005 Hirschmann JV l\augi GJ. Adult scurvy. J Anr 1999;41 (6):895-906.
What North Am Atlu Wouutl

healing: stiil :331-347 Ddtfldtol
Denrling RH, DeSanti L. Oxarldrolone, an anabolic steroid, significantly increascs the rate of wcight gain in the recover,v phase after major burns.J ?auna. 1 997 ;43(1):47 51. I{arim A, Ranney RE, Z:gerclla BA, Mnibach HI. Oxandrolone disposition and mecabolism in mtn. Clin Plurmacol T'lrcr
1973;1,4(5):862-866.
20
21
31
Ehrlich HI', Taruer H, Hunt TK. Inhibitory
e{l-ects
vitamin E on
collagen synthcsis and wound
repair
Ann
Srtg.
lor thc Prediction and Prevention of Pressure Ulccrs in Aduhs. Clixkal Prattice Cuideline Number 3: Presyua Ulcers irt Aduks: Predictioil and Preyentiotr, Rockville, Md: US Department of Health and Human Services. Agency for Health Care I)olicy and llcsearch; AHCPR Publication 92-0047 . 1992(5). tlergstrom N, Allman I\M, A.lvarez OM. Cliniul Practirc Cuidelire Number 15: 'fieatmefi oJ Prcssure Lilcers. Rockville, Md: US Department of Health and Hurnan Services. Agcrrcy for Health Care Policy and Research; 1994. AHCPR Publication 95-0652.
Pancl
CHRONIC WOUND CARE, 4th
EditiON
Wound Care Epidemiology

David J. Margolis, MD, MSCE, PhD
Objectives
The reader will be challenged to:
. .
Distlnguish between experimental and nonexperimenta studies

Recognize
. Compare incidence and prevalence

the possibilities for using literature-based evidence to support wound care practice
lntroduction
purpose of this chapter is to explore study designs r"xed by
N*":ji::T:i:*
jr*:ffi
':"":'j'.:$
epidenriologists to establish
franrervork for evaluatins the
treatnlents used to care for rvounds.
nrent, talking to G11or,v healthcare providers, reading the lay press, or reading academic journals. It is ofcen difficult
for busy wound care specialists to
fu11y evaluate a
"new"
treatmenr in order to determine horv helpful the nerv product will be before they start to use it. Unfortunately, few nerv u,'ound care treatnlents rvork lvell enough to become part ofthe standard therapeutic arsenal for chronic wouncl care. Most of these "new" therepies rapidly disappear
into our collectiv-e
consciousness, because they do
For the purpose of this chapter, studies that involve into 4 broad categories (Table 1). These categories are descriptive studies, case-control studies, cohort studies, and randomizcd, controlled trials.' r Thc study design that best tests the effectivcness of a treatment is the ranclomized, contr-olied trial.This tvpe of study is referred to as experirnental, bccausc a new treatment is compared to another u.ithin a study setring where the selection of treatnerlt is not determined by the healthcare provider but by the investigator (ie,
humans can be dividetl
not represent a clinically inrportant improveuent

accepted care or! frankly, because they
over
just do not work.
The failure of these therapies might have been suspected since the evidence supporting their uses often is not fiorn rigorous high-quality research.
Epidemiology is the study of the distribution ancl deternrinants ofdisease in populations. In the beginning, it was prirnarily the stud1, of epidemics-outbreaks of infectious
diseases
through random assignment).The other'3 study types are nonexperimental or observational. Hcre, the intervention is not actively determined by the investigator but is selected by rhe healthcare provic{er. As a result, the inferences
as
from these study designs are not considered to be

as
strong
those from a randomized, coDtrolled study. In
in large populations. Over the

diseases
past sevelal years,
eprdemiologists have becorne concerned rvith thc study
of
fact, the qualiry of inGrences derived from a study improves as the chosen study design rnoves in Table 1 from a descriptive study to a randomized, controlled trial.'-r It is important to realize not all hunran scudies
should be or ethically can be randomized, controlled tn-
chronic
and noninGctious acute
illnesses. The
Margolis l).Wound care epidcmiologr'. In: I{rasner DL. l\odehearcr GT, Sibbald llCi, eds.ChronicWound Core:A Clinicol Source Book for Heolthcore Professionols. 4th ed. Malvern, Pa; HMI) Comnuuications, 2007:1 37-l 42.
CHRONIC WOUND CARE 4th Editlon
137
Margolis
relationship between an exposure (eg, a ner,v treatment, clgarette srnoking) or risk factor (eg, size of a wound,
durltion
Declgn
,.:.:':r
i,:i
.ri::rl
Cornmgll!.s.
of a u'ound) and the outcome of interest (eg, a healed

to
efticacy based
Descriptive Study
.
. . . .
Hypothesis Should not be eraluate Subjects
rvound) is not sutEcient to conclude that there is a causal relationship betrveen the exposure and the outcome.r-r To demonstrate causation, it is necessary to demonstrate that
Case-Control Study
on their Need to
evaluate bias
Efficient design studying rare

Subjects
based
the risk factor played an essential role in establishing the outcome. Deternrining r'vhether a causal relationship exists involves evaluating scientific cvidence from multiple sources.There are no perfect rules for denoting causation.l In general, several criteria must be fulfilled.' First, the risk factor or exposllre must be shou,'n to precede the outcome by a biologically plausible period of time before the outcorne. Second, a dose-responsc relationship between the exposure and the outcome provides strong evidence for causation.Thircl, the relationship between the exposure and the outcome must rnake biologic sense. Fourth, the larger the magnitude of an association the less like1y it is to be explained by bias and the morc likely it is a causal one. Fina11y, the association betrveen the exposure and the or"rtcome should be observed consistently across different studin different settings.'' With respect to evaluating a treatme.t, 2 terms are used to describe the relationship between the treatment and outcome: efirucy and elfectiueness. Ellicacy is a measure of how well a treatnlent works in au ideal setting. Effectiveness is how well the treatment rvorks under usual conditions. The effectiveness of a treatment is often less than the efficacy ofa treatnlent. Two terms are used to further describe the fiequency of an event: preualence and incidence. The prevalence is the number of individuals who have an ailment (eg, rvound) at a particular time.These individuals nray have nervly acquired their wounds or may have had them for a considerable period of time. Prevalence is a rneasure of the burden of discase. This is not the same as rncidence. Incidence is often reported as a rate and is related to the nunrbcr of individuals who nelvly develop an ailment (eg, wound) as compared to all
ies
Cohort Study
. . .
on treatment Need to
evaluate bias Large cohorts important on safety and effectiveness Randomized,
. . .
ldeal design
Controlled Trial
treatment
Random alloca minimizes bias
Ethical
nced by The choice of stud.v design is often financial lrmitations, the amount of invest s tlme the ethics avlilable to obst'rve tht' prirrrary outcome. J of withholding or even randomly assigning a atrnent. A healthcare provider should not rely only on nformation fi-om properly conductcd randonrizcd, contro d trials
a1s.
Terms
When evaluating the results of a study, a consider random error and blas. Random error
difference betrveen the estimate of a trea study and the true effect of treatment, if know to chance. This form of error is expressed as a tistical power, or confidence intervals. In contr difference betrveen thc estimate of a trea observed in a study and the true effect ofthe knorvn, that is due to systematic (ie, nor There are several sources ofbias. In cpiderni bias i often described as being due to patient gathering and recording of information, or priate\ consider variablcs that may confoun aulmcl)t) rhe truc effect oIa rrcJrrr]ent. The purpose of most studies is to dernon assttciatiou..lz The denronstration of a statistica
138
should
ribes the
t
,
effect in a that is due

,
P value, stabias is the
who can develop the ailment.The cumulatiue incidence )s the total number of individuals who develop an outconle divided by the total number of individuals at risk to develop the outcome at the beginning of the study period. ,4r
rlsk refers to individuals rvho are free
effect
tment,
if
onset
uals
ofthe outcorne at the ofthe study period but have the potential to develop
error.
the outcome. Inciden.rc densitl, i5 the total nunrber of indrvid-
ic studies,
lection, the
re lo appro(re, mask
or
a musal
significant
who develop the outcome of interest during the study period divided by the total person-time contributed by all of the individuals at risk during the study period. For example, if an individual is follo',r,ed for 2 nronths and another is follou.ed for 3 months, they contribntc a total of 5 person-months of observation. In most settings, inv'estigators often measure first onset of the ailmcnt. This is espe
CHRONIC
WOUND CARE 4th
Edition
Margolis
cially important lvhen the risk factors for deveioping the ailment the 6rst time may not be the same as the second time (eg, the individuals with a history of venous 1eg ulcers are more 1ikely to deveiop second ulcers because the first ulcers may alter venous and lymphatic flow). In this situation, separate incidences for first onset and subsequent onset of the ariment can be reported.
compared
to that of
individuals r,r'ithout the disease (eg,
unhealed wound, controls). Case-control studies have also been called case-referent studies and retrospective studies.
This rype of study is an efficient and inexpensive way to

study rare diseases or outcomes.The case-control str:dy is an
important epidemiologic study design. In a case-control stud1,, selection bias can be an iurportant
threat to validiry. Differential surveillance, diagnosis, or referral betw'een the case and control Jroups can all contribute to a biased selection of cases or controls.' ' This is a critical issue.
Study Designs
Descriptive studies. Descriptive
studies describe pat-
terns of disease.l'' There are several different types of

descriptive studies: case reports, case series, ecological studies, and cross-sectional studies.
Ifthe r'vrong group ofpatients is used to create either the
case
case report
is simply
description of a single patient. Case reports may include
information about a new treatnlent and the

response
subject's
is a collection of patients w'ith similar illnesses who received similar treatments.A case series can be an incxpensive way to generate pilot data prior to evaiuation of a treatluent by a more rigtreatment.
case series
to the
orous study design. Case reports and case series are useful
group, the effect estimates will not accurately reflect the risks in the target population.This is best prevented by correctly identi$ring the study population.The control group nlust represent everyone free of the outcome frorn the same population as the cases. Thus, the controls should be seiected in an unbiased manner from among those individuals who rvould have been included as a case if thc.v had developed disease.*n In other words, the population must be defined so that everyone must have the same opportuniry to
be a case or
or control
for generating new ideas. Too often case reports and case series are used tojustify the use ofa new wound care treatment. Marketers may use case series to rapidly disseminate
product information, thereby circumventing more r..igorous study designs.While case reports and case series are helpful in generating new hypotheses and in educating healthcare
control.If the
case group is composed of all
indi-
viduals
with healed venous leg ulcers rn a
healthcare
in demonstrating that a treatment is efficacious. Ecological studres examine geographic and secular
providers, they are seldom helpful
changes
provider's practice, the control group rnllst be individuals who could have been treated by that healthcare provider. Since these studies are often done retrospectively, information bias is also a potential source of error. Information bias occurs because data are recorded incorrectly due to poor subject recall, poor or inconsistent recording practices, or inadequate measuring devices or tools. Information bias
can be nondifferential.
in a disease and how these changes relate to
a treat-
In this case, the bias is equally likely
ment or exposure.The unit of analysis is the group (eg, people in region A versus people in regron B). Often, no information is available on treatment and outcome in individuals, just the group.While the treatment under study may be the cause for the health change, the lack of information at the
patient leve1 rnakes it difiicult to interpret the results ofthese
studies.Also, this study design does not aI1ow control of con-
to occur in
patients
with and without the outcome of

in
interest. Nondifferential information bias usually results

an underesrimate of the true effect of treatment.
In contrast, information bias can also be differential.'When rt is differential, the error in measurement occurs lnore frequently in
1
of the 2 groups. For example, individuals vvith disease may
remernber treatrnents differently (re, more accuratel,v) than those

data
founding at the individual level.Therefore, ecological studies

cannot be used to establish causation.These studies, however, can be helpful in generating hypotheses. They usually are performed using existing databases, and they can often provide rapid preliminarv answers to important questions.
without
disease.
In addition,
exposure and outcome
A cross-sectional study, also called a prevalence study, examines treatment and disease status at a single point in time. These studies can be used to generate hypotheses and permit control of confounding. Howevcr, the usefulness of this study design is severely limited by an rnabrliry to establish the temporal relationship befi,veen the treatment and the outcome.
for case-control studies are often determined from the healthcare provider\ chart documentation. If the heaithcare provider presumed that a treatment was linked to an outcome, he or she might specitically report on that outcorne in the charts of treated patients and fail to report on it in the charts of the untreated population (eg, documenting weight in the chart of a patient who had a myocardial infarction versus not documenting r,veight in a patient evaluated only for athlete\ foot). Differential bias can result in
either an underestirnate or an overestimate of the trlre ffeat-
both the subjectt treatment and outcome status are knolvn before the start of the study.'rThe treatment history of individuals with the disease of interest (eg, healed vround, cases) is
a case-control study,
Case-control studies. In
ment effect. Therefore, ir is essential that the potential for information bias be minimized in a case-control study. If done correctly, case-control studies can be efficient
and powerful studies from rvhich to estirnate the associatron 139
CHRONIC WOUND CARE,4th
EditiON
Margolis
;iliir,
New. rl. ,,.:: Contrdl Treatment

Healed Unhealed
Odds Ratio:
Risk Ratio:
by bias is esscntial to a valicl interpret:rtion ofthe results. In a cohort study, the cxtent to u,hich the study subjects are replesentative of the population fiom which they arise rvill determine the cxtent to s-hich the stucll, is gencralizable. Another important limitation of cohort studies is that if the outconle is rare, the cohort may need to be large to detect difiblences betu''een treatnrent groups.The cost of pefon]ring the study increases as thc size olthe cohort incre:rses. In addition, in a prospectne cohort studv of a disease rvith a long interval betrvecn treatlrlent and cure, patient attrltlon mav reduce the studyi feasibiliry. For thcse reasons, casecontrol studies are often more cttrcient in tc'rms of cost and timc conrnitrncnt than cohort studies for studying r:are events or events that occLlr rnaDy 1.ears after a treatulent. The paramcter uscd to estirnate the association betlr.een the treatnler)t and the outcolnc in a cohort stud-v is called a risk ratiLt (Tab1c 2). Statistical tests, such as the MantclHaenszel test, logistic r-eeression, or the Clox proportional
+B
c
A+C
D B+D
+D +B+C+D
(A)(p)
(CXB)
(A/(A+c))
(B(B+D))
betu,ecr.r a treatment and an outcome. Furth possible to study several difTerent risk factors and controls, to evaluate tenrporal relat control for confounding.Therefore, case-co1 furnish information that is useful in establishi
cases
nlolc, rt
15
the sarne
ips, and to
studies can
causation.
Case-control studies, horver''er', are seldom reatments. This is bccause
to evaluate
to estimate this associ.rtion fronr a cohort study.' t * The cohort study design allow.s lor adjristlnelrt of couhazards rnodel, are comnronlv r:sed
it
is
dificult to
why indireason rvhy the
vrduals are or are not selected for treatllrent an individual was selected for treatrnent could
foundine, assuming that the appropriate confounding vari ables are identified and measr:red. Sevcral outcomcs can be
studied simultaneousll,, and
in certrin circurnstances, sever-
rclation betrveen the treatnlent and outcome. son is usually lrnknolvn, it cannot be adjusted Thc measure of association rn a case-control
the reais called

ar-rd
al different treatments can be assessed b-v constructing diffc'rent subcohorts. Contenrporary study designs called nest-
ed case-control stuclics and

these f,lcets
case
cohort studies cxploit
tn
odds ratio (Tab1e 2). Estimation of the odds
adjusttesrs,
nlcnt for confbunding can be performed usinq such as the Mantel-Haenszel test or logistic
ical
1()n
ofthe cohort study." '' Randornized, controlled trials. Randornized, con-
trolled trials
(RCT,
are experinrental studies in rvhich sub-
Cohort studies. In a cohort study, a group als is identificd without rcgard to the outc Sr-rbgroups ale identified on the basis of r,,, the1, reccived the treatnlcnt. Then they are time to determine the outcome.' t * "'The s ducted prospectively or historically (eg, c
Horvever, rvhether the study is prospective or
revieu,; indrvicluals are identified on the basis
individuof interest.
hcr or not
Llolved ovc'r
can be con-
jects are r-andoml.v allocated to r-eccive or not receive the therapy or intervention under study. ' In thc most basic RCI subjects are randonrl.v assigncd to 2 study groups or study ar1ns. One alrn receives tlle treatmeDt beine lnvesti
gated; thc other arn1, the control group, usuailv receir,-es the
rt
revier'v)
conventional treatluent or
a placebo.
l\andom assignment is
de
iom a chart
'their treatpr-esence Or
the nlost important aspect of this study
sign.
nlents rather than, like a case-connol study,

absence
Randomization reduces the potential for confounding bv ensuring that chance variation is the only thrcat to the comparability of the study eroups.'' The RCT is generally considered to be the statdarcl against r.vhich :r11 other trcatrrrent study designs are compar-ed because the process of
ofan outcome. Although selection ofa subjcct in a cohort
on his or her exposure and the outcorne is the exposure. iike a case-control study, a cohor prone to selection bias ancl information bias.'l ting ofa cohort stuciy, it is inlportant to u tain individr-rals r,vere selected to receive treau
y is based altcr
stucly is also
randonr allocation
a11ows
for comparability of the snrdy
- In the setnd rvhv cer-
groups and elirninates rnany types of selection bias. Several methods of randornization exist.rn Sinrple randomization means that each participant has an equal opportunitl, to be in either arm of thc stud,v. Blocked randornization is a form of simple rar.rdomization and is cornmon in
nt. IF selecen c:rrse the
tion lactors are not understood. selection
bias
inr''estigator to nisinterpret the rcsults of the
that the assignrnent of treatment is not r

usefulness of the cohort design lvhen evaluatin
The fact linrits thc

the effect
es,
of
a treatnlcnt. As for all nonexperimental understanding of how a particular cohort
a careful
is atTected
multicenter clinical trials.'' Study subjects are first arranged irrto blocks of a given size (eg, 2,4, or 6), and r,vithin each block, equal numbers of individuals are assigned to the lreatnlent arm and the control ann.'Another technique is CHRONIC \MOUND CARE. 4th Edition
Margolis
In this rype of trearmenr are initial1y grouped into strata defined by some clinical or demographic characteristic to achieve subject mix in the study arrns.'o ''V/ithin these strata, subjects are randonilv assigned to the arms ofthe study.
called stratified randornizatron.
assignment, individuals
str-rdy sample (eg, r,r.ound size,
This insures tl'rat patienrs rvith specific attributes enrich the rvound duration).
masked.
Randomized, controlled trials are often blinded or Blinding or masking is said to occur if thc rnves-
tigator or subject is unaware of the subjectt treatment

assignment. Double blinding is rvhen neither the investi-
gator nor the subject is aware of the treatment assilannrenr of the subject.-While randornization is useful to rninrnuze the potential 1br selection bias and confounding, blinding
is useiirl to eliminate corcerns aboul inforn.ration bias.'t If both the investigator and the participant arc blinded, reportinEJ by the subject or mersurements by the investigator cannot be biased by knorvledge of the subjeo'.s
treatnrent assignment. The ethics of conducting a RCT must be considered before starting the trial. If a treatment is already believed to bc in the patierrts'best interests, it rnav be inrpossible
to evaluate it in a RCT. For example, if one is trying to

deternirie the ellectiveness of antibiotic use for pneumo-
often encornpassing the heterogeneiry ofthe patients and healthcare providers in the population-at-1arge. These study designs are rrlore like1y ro yield results that are generalizable than RCTs. For example, rnany of the early RCTs evaluating cholesterol-lowering agents did not include women." As a result, conclusions frorn these studies r.vere thought not generalizable to an important segrnent of the general population. Final1y, the quality of all RCTs is not the same. Several methods exist for scor ing the quality of these trials with the expectation that those of high quality are more likely to provide bias-free generalizable results. A recent review of pressure ulcer treatrnent cvaluated the quality of these llCTs."' It should also be noted that nonrandomized clinical designs also exist. A complete discussion of a1l clinical study designs is beyond the scope of this chapter. These notttandorn designs are denoted by the US Foocl and Drug Administration as phase I, II, and IV studies.rr Treatment allocation in these studies r-rsua11y is nor random, since the str-ldy question r-rsuaIly is not one of treatment efEcacy or because the studv question does not ethica11y aliow for random treatlllent assignrnent.A phase III study is another narne for a RCT.
nia, for several reasons, randornizing individuals rvith pneurnonia to a "no antiblotic" control group would be problematic. First, for the treatment of pneumor-ria, the
use of antibiotics is standard care. Second, the use of antibiotics for the treatrnent of pneurnonia may be lifesaving.Third, not using antibiotics to trcat pneumonia is thought to be detrunental ro the rve1l being of the patient. Therefore, it r,r,ould be unethical to withhold antibiotic therapy for a control group. A potential weakrress of a RCT relates to sample
Conclusion
l'{ecent1y, there has been a lot of discussion concerning evidence-based nredicine. Practitioners of evidence-based
medicine evalr-rate a study or studics and then deternine hor,v r,ve11 the study relates to a clinical question they are
trying to ans\\,er. The evidence-based practitioner then u,eighs the results of the study based on the strength of the studyt design. A study u,ith a "stronger" design (Tab1e
1) has a greater impact on any decisions rcachecl by the practitionert rcview. It is important to note that expert opinion is evidence, albeit weak evidence (on par rvith
case serics
size."''' Randomized, controlled trials are

sma11
relatively
to the target population of thosc rvith the i1lness.r!' For exarnple, a uew
(eg,
as compared
N - 300)
or
case reports), and
fol many rnedical
prac-
tices, expert opinion and other descriptive studies are the
treatment was investigated in 300 peopie and shown to be safe and effective.Therefore, it was approved for general use. However, after it r,vas used in 10,000 people, 1t) dcveloped aplastic anemia. It lvould be unlikelv that this
clinically inlportant adverse event, rvhich occurs 1 in 1,000, would be identified in a RCT of 300 people.
Populations studied in a RCT tend to be selected by inclusion and exclusion criteria that are rigorously fo1ior,ved, but this is seldorn trLle once the treatnlent is r,vide1y used. Furthermore, the investigators are also selected and lvell trainecl to use the new treatment. The training and expertise of the trial invcstigators rnr) not rui.rror the usual irealthcare provider in the cornmunrty. In contrast, cohort studies and case-control studies may sufler from problerns ofbias but tend to be iarge, thereby
It is not always practic:rl or ethical to conduct a RCT. Evidence-based medicrne rs not a new concept. It is just another narne for a nethod oflearning that has been used by healthcare practitioilers since the beginning of the writen record. When a new treatttent is evaiuated. it is essential to understand the strengths and rveaknesses of the study design. Randomized, controlled trials are optimal for evaluating the ellicacy of a treatment. Hor,vever, observational studies can also provide useful information, especially concerning the safety and effectiveness of a treatnrent in the general population. This rcview is just a
strongest eviclence available. beginning. Interested readers are encouraged to read further and talk to colleagues r,vho are epiderniologists, biostatisticians. and health services researr;hers.'-r,'7
141
CHRON|C WOUND CARE 4th Editlon
Margolis
Take Home Messages
for Practice
experi-
Treatment designs can be observational

mental.
Experimental designs, like RCTs, are the gold standard when evaluating a therapy. Be carelul when consider.ing the use of a when the evidence that supports its use based on weaker study designs,
Elrvood MJ. Critical Apprukal oJ Epidemiologial Studies and Clinkal Tiiak. 2nd ed. Oxford, UK: Oxford Universiry Pres; 1998. Wacholder S, Silverman DT, Mclaughlin JK, Mandel JS. Selection of contmls in case-control studies. II. },pes of contrcls- ,,1m J EptJuuio[. I qq2:135(q)r ln2q-1r,41. '!0acholder S, Mclaughlin JK, Silvrrman DT, Mandel JS. Selection of controls in case-control studies. I. Principles. Am J Epideniol.
1 992; i35(9):101 9-1028. Wacholder S. Design issues in case-control studles. Stat Metlods Med Res. 1995;4(4):293-309. Wacholder S, Silverman Dl Mclaughlin JK, Mandel JS. Selection of controls in case control sttrdies. lll. Design options. ,4rr J
Epi
dtntol. I eq2: I 35(q): l0+2- I n50.
l.Which of the following
A. Ecological study B. Case-control study C. Cohort study D. A11 of the above
2. Randomized clinical trials are:
are observational
Prenrice RL, Design issues in cohort studies. Stat *Iethods Med Res. 1995;4(4):273-292. Ivliettinen O. Estimbility md estimation in case referent studies. Am J Epitlemiol, 1.97 6;103(2):226-235.
designs?
i0.
Hu X, Wright JG, Mcleod RS, Lossiug A,
Walters BC.
Observarional studies o alternativcs to randomized clinical trials in surgical clinical research. Sargery, I 99 6 ; 1 1 9 (1) : 47 3-47 5. Wacholdcr S. Practical considerations in choosiug betureen the case-
cohort and nested case-control designs- Epideruiology.

1991;2(2):1 55-1 58.
12. 13.
14 15.
Ernster VL. Nested case-control studics. Prev

1
Med.
A. Always ethical B. Useful when studying side effects like

C. Always generalizable D. Best form of evidence for evaluating the fficacy of treatment Ansrvers: 1,-D,2-D
a
994;23(5):587-590. Prentice RL. A cae-cohort design for epidemiologic cohort studies md diseae pre!-ention trials. Bionetika. 1986;73(1):l-11Wenger NK. Coronary heart disease in wornen: a'new'problenr.
Hosp Pract
Pa:
(Of Ed).
1992;27(1 1):59-62,64,67 passim.
Hennekcns CH, BuringJE. Epidemiology in Medirine. Philadelphia.

Sutvey Sanpling Belmont, Calit: Duxbury Pres; 1996. Piantadosi S. Clinial Ttiats: A Methodologk Pe$pectiue. 2nd ed. New York, NY:JohnWile.v & Sons, Inc;2005. Enas GG, Goldstein I{. Defining, monitoring and combining safe ty ioformation in clinical trials. Srdt Med. 1995 14(910):1099-1 111. Praus M, Schindel Il Fescharek R, Schwarz S-Alert s.vstems for postScheaffer
16.
17
LippinconWillians &Wilkins; 1987. RL, Mendenhall Wl O.t P..L. Eleflentdry
lil
References
1. Rothnran KJ, Greenland S.
Modern
19
2nd
ed
marketing surveillance
1 9 9
of
adverse drug reactions. Stat Meda
2.
Philadelphia, t'a: Lippincott Williams & Wilkins; 1 Kclsey JL, Whittemore AS, Evans AS, Thornpson
Obseruational Epidetniolrgy,
3 ;1 2 (2 1)
:23
83
-23
3.
20
Methods in
NervYork, NY: Oxford
versitl
Press;
Reddy M, Gill SS, Rochon PA. Preventing pressure ulccrs: atic reyies: IAMA. 2006;296(8):97 4-984.
system
1996.
CHRONIC
WOUND CARE,4th
Edition
Running an Outpatient Wound Clinic

Laurel A.Wiersema-Bryant,APRN, BC; Linda A. Stamm,APRN, BC, CON; Cassandra WaTd,APRN,ANP-C;John P. Kirby, MD, FCCWS, FACS
_he
Objectives
rade- w,l, oe chat,e^ged ro:
' Apprarse the need lor a dedicated outpatient fbcility for the increased number and variety of patrents wrth wounds ' Appreciate a wound clinic's abtlty to coordtnate care across medical specialties and to concentrate the use of avail.
able resources, both personnel and supplies,to optimally heal wounds Formulate the l<ey questlons in planning to begin a wound cltnrc
' '
Des.gr Lhe raci'.Ly at d sDace'eq-irerre-Ls oased on tne qpe o'paLrenrs w,Lh wou^Cs to De t.eated Orgaîze sLarrg and eq-ipn enL neeoed for rhe c.inic Hypotlês'ze rhe oene4rs and tne corl:nueo cna tenges to rhe co^cep, of a co.nprehersi,"e wo*ô clinc
Fulllll
the lncreased patrent demand for wound care excellence
as
the fleld develops as an interpro{bssional specialty
Our Experience: The Wound-Ostomy Center at Barnes-Jewish Hospital at Washington University Medical Center
rnanagement of patients with r.r.ounds so that an interpro fi:ssional approach could be reahzed for enhanced outcomes. Over time, the clinic has grown to become an integral part of a hospital based surgical servrcc. The clinic is
seen as .tn important resource for patients as they progress from inpatient to outpatient or extended care patient settings. It now a1lor,vs nr-rrsing to fuifill its niissions in wound care for patient ancl family education, direct pttient care,
consultation and u,ound care identified challenges in the management of patients rvith chronic wounds upon the patients'transition to the or-rtpatient setting. Largely out of
Ar#iRiH:+iiffi,:Hffit
and even continued staffdevelopnrent. Finally, the hospital

has realized a focal
fi,-
the parent hospital\ commirment to continued patient care excellence, patients with wounds rvere being seen in a valieq, of physicians' ofEces and inpatient areas. As appreciated by many institntions, the observation rvas n.rade tl'rat these outpatient settings rvere often i11equipped to handle the direct r,vound care needs, and the hospital nurses were challenged r,virh attempting to meet the needs of a specialized population over a considerable
geographic ar:ea. This resulted in dilEculry., tracking supplies, outcomes, and fo11ow-up and created stalEng issues.
pornt to concentrate its eflorts to satispatients and referring physicians with a clinic that otTcrs
corrprehensive rvound care ercellence.
lntroduction
This chaprer discusses the developnrent of an ourpatient rvound clinic for the care and rnanagement of nonhealing and chronic wounds. Providing for the coordinated managemenr of patients u.ith wounds is the focus of
an outpatient r,vound chnic.The concept of a interprofessional tean.r approach to the care of patients rvith r,r,.ounds
As the number and variety of patients u,'ith u,-ounds, as rvell as the potential inaltagelnent options for the treatment of those -,r,ounds, increased each year, it r,vas clecided that an outpatient rvound clinic u-as needcd. The u.ouud clinic offered the opportunify ro iluprove the care and
is not ner.v. Utilization of the team appr-oach rn thc care and management of rvounds has been encouraged in acute care and long-term care for some time. Data exist to support the intluence ofthe tearn approach in achiev
V/iersem:r l3rvant LA, Staran LA,Ward C, Kirb,vJP Running an outpatient rvouud chnic. lrr: Krasoer DL, Rodeheaver GT. Sibbatd RC. eds. Chronic Wound Core: A Clinicol Source Book for Heokhcore Professiono/s. 4th ed. Malvern. pa HMP Communications. 2r:)(17: i.+3- I 5 L
CHRONIC
WOUND CARE, 4th
Edition
+-,
Wiersema-Bryant et
al
Running an OutPatientWound Clinic
rncreasing cost-etTective outcomes. Patients with ingly are being cared for in the outpatient a na.r Indecd, is for much of the reimbursernent by third-party tionalll', a wound care given in the outpatient setting.T quick look at the practices in rvhich these patlents are being n'ranaged reveais home care, general practitioner olEces, general surgery ollices, dermatology, r hematology/oncology, internal medicine,
the clinic rvi1l serve, and hor'v they will reach the clinic. Next, the responsible provider needs to consider the reimbursement pattern for the erpected patient volume.The probabie mix of private pay, private insurance, Medicare, Medicaid, and healthcare colltrJcts is importa[t to assess. If yor-1r outpatient faciliry depends heaviiy on negotiated contracts, it is critical that those in the position of negotiating the contracts be ar.vare of the proposed service. Recently, rve have found it necessary to revisit coverage issues rvtth the providers. Recomrlended treatments may not be covered, resulting in potentially suboptimal clinical outcomes and frustrated clients r'vho are unable to obtain supplies and adjuvants {br care. Furtherrnore, these payer rnixes and reinrbursement contracts are not static and need to be revierved
rnatology,
surgery,
orthopedic surgery, cardiology, and vasct r surgery Management of these patients is as varied as the practice
settings, so coordination of cue can be ditfl t.
In
respouse
to the increasing number of atients with

clinics are
ed wound
nonhealing and chronic rvounds, more wou being developed. A well-p1anned, well
clinic provides comprehensive assessment surgical management, state-oathe-art treatm low-up care.The clinic should not be concei of last resort for treatment failLlres bllt as a c the rnanagement of wounds and patient/ca tion. This chapter will discuss the process of wound clinic and ongoing managernent of th
care
medical and
rcgular\ to align them.Assumptions need to be nrade from

the geographic and demographic information regardrng the anticipated volurne ofpatients to be seen during years 1 to 5.The projected volume ofservice should be described by visit rype, procedures, and diagnostic codes so that the capa-
nt, and fo1,d as a place

ra1
place for
ver educalishing a clinic.
bilities of the clinic can rneet (or exceed) the anttcipated patient population needs. Another aspect of volume projection is the opportuniqr for secorrdary inpatient admissions,
surgical procedures, and reterrals to other ancillary services as a result of the clinic volume. For example, there shor'rld be an anticipated increase
Identification of the Need

The initial step in the development of a the identification of the need for such a clinic
se
is
ice. Market
in the voiume ofoutpatient
vascular
n about the research must provide c1ear, concise infort if aveilneed for the clinic. Utilize a marketing depart p1'ocess Information ab1e, to assist in the needs assessmellt
regarding the demographics of the populat n served by
studies documenting a wound patient'"s blood flow.Wi11 the parent institution reduce inpatient days and contaln resource
utilization, adding a cost-saved justification for the clinic? Does the proposed patient population require expanded
services, such as lyrnphedenra care
pfoxlmlty your facility, referral patterns and netlvorks, t providers to of other of srmilar services, and willingness in included should that reGr patients is al1 information ry for the is data the market research. Demographic
ultimate volurre forecast: . 'W'hat is the specific geographic and
c1i
or hyperbaric
orrygen
therapy?The fie1d of rn'or-rnd care is an evolving interprofes* sional specialty and as such needs continued administr.rtrve support, physician leadership, and nursing expertise.
I population
. W'hat
to be served by the program? are the demographics of the pop lion to be served? Dernographic data should also ir ude populaphysical tion age, mobility, transportation qrpe and inforrnaneeds, and the wpes ofrvounds to be seen tion is critical in planmng for the type of pace needed
vices. lor the center and the rlecessary si-lpport Where is the care of these Patients current provided? It nal comis important to evaluate both internal and
Additional potential influences on the sltccess of the clinic require one to take a critical look at future trends in heaithcare that may irnpact the clinic. These trends may include but are not linrited to political,1egal, econonric, and social arenas. The economics of a cltnic are complex and require the clinician and financial analyst to be clear on financial targets. As clinicians, we advocate that a comprehensive wound clinic is cost effective in managing the patient with a chronic rvound. However, from a financial
perspective, concentrating this population
expensive. When the costs
in one
area looks are
of caring for this population
petitors to the proposed clinic. Competiti may be de trinental to the success o Therefore, the proxinrirv of other similar c
lor patients
dispersed throughor-rt the healthcare setting, the actual cost
the
:s
clinic.
or cen-
tcrs oftbring similar services rnust be asse Is there sutEcient physician comnxtment patient relerrals to lnaintain a stablc pati In essence, the rnarketing research refi needs of thc patients the clinic u,'ill serve, how
111
' approprlate
volume?
the clinical
rly patlents
care is otIset by those patienrs whose care is trot as both in tenns of dollars and tesource utilizatiol. Therefore, this concept, rvhich concentrates the care ofthe wound patient, now exposes these costs, and the clinlcian may be faced with developing a strategy to "lose less money" rather tharl to break even or potentially show a profit. Billing issues can be a concern for facility and practitron-
of
expensir.e
CHRONIC
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Running an OutpatientWound Clinic
Wiersema-Bryant et al
Patient Characteristics
Ambulatory
Speiial,,Needs,
Agcsi',RCquiied.,,.
:, ,.,::.,.':,,,,.:1 ,.
,1t. 1.
,,,
. .
None required
. .
Routine
Easy access
to parking
is helpful
Wheelchair-bound access for
Disability access
the disabled
May need
lift assist to examine
Located with ready parking Valet parkirrg is helpful Wheelchairs available near facility entrance Lift eguipment or lift orderlies/techs Movement of stretcher-bound patients may be restricted to area of access-evaluate routes when selecting clinic location Patient scales that range to 1,000 lb Assorted sizes of blood pressure cuffs Patient gowns in size 5X to 8X
Stretcher bound
Ready access for transport/ambulance to deliver patient for the visit
Weight challenged
. .
Exam rooms that accommodate weight-challenged stretcher/bed Waiting room and exam room furniture should be rated to I,000 lb Muy need
Malodorous wounds
to consider air purifica-
tion system for waiting and exam

rooms
cr. Horv the billing rvill be nranaged necds to be aclclressed at this stage of developnrent. Will there be one brll to the patient, r.vhich includes profession:r1 services as u,ell as facili6. procedure and dressing chalges, or rvill rherc be separ-ate proiessional aud laci1iq, charges? Standarcl otlice reinrbursenlents lnay not cover the cost of the dressings, r,vhich redi-
proGssional der.eloprnent of the clinic stall, resealch oppor--
tunities, monitors for success ofthe clinic, and cost savings
to the institution (if hosprtai based).Assumr]l the nrartet

for the r,vound clinic, there are a fer,v additional operational issues that r.reed to be assessecl. Thcse issues include the srze and type of space
research phase has supportecl the need
rects the need
lbr
careful discussion r,vith rhe insurance
necded bv the populatior-r expccted ro bc served, any spe-
providers before tl're clinic opens.
cial equipment that \\.ill be neecled, and satling neecls.
Planning for Success

The business plan shor-r1d incorporate the data obtained during the maLket research phase of the project. Key e1e, rnents of the busincss plan include thc introductiol, descriptiorr of the busrness, rrarket end cornpetition :Lna1y* sis, product development, rnarketing and distribution plan,
orsanizational plan, developnrent schedule, financial plan, and executive sunrnraryr Lt determining the direction and
focus
Location
The space necded requires a car-elul, thorough evaluatiol of the parient popnl:rtion erpecrecl (Table 1). The currcnt obesiry epidenric highlights the need for logistical forethought to accommodate patients rvith special
needs
or handicaps.This inibrnration should be available
as
a rcsult
of thc market research data.The fbllorvine Lluesrions
nnst be explored:
ofthe rvound clinic, it
is inrportant to
rvrite a nussion
statcrlerrr.The mission staterncnt shor-rld be global in scope and provide a shared scnse of purpose! dircctron, and achicvement both in temrs of focusing the chnic ancl also
. Is existing space available for the clinic? . Where is the space iocatecl? . If thc availablc space is a rnultiflnction .
for tcarn buildilg arrrong the clinic stail-' C)nce rvritten, rhe
mrssion statenlent r,vill help to define and focus the rcnrainder of the plan. The plan shor-rld inclr-rdc both short- rerrn (1 ycar) and long-term (3 to 5 vear) goals.The goals shoulcl
area, is the tirnc slot that is needed ro run the clinic etEcientlv open? If the clinic is open for patients on x part-time basis, horl'.
r,vi11
cmergency calls,/visits be hanclled?
include but not be linrited to patient visit volume projections, srolr.th in the t),pe of services pror.ided, conrlnued CHRONIC
. Hor'v and by rvhorn rs the staffro be trained? . Holv accessrble is the location to patiellts? . Do 1,ou anticipate patients arrivins b), arnbulance,
rr hcelchrir, .rnd
by
.rrrbuLturr
WOUND CARE. 4th
Ediiion
r45
Wiersema-Bryant et
al
diabetic foot ulcers desired flat physical therapy tables in the exam room, while another physician treatillg burns rry-anted
. . . .
Reception area
Storage spacq supplies, charts, study materials, etc. .
.
.. :Wound
sho*'ers. Others wanted traditional exam room furniture. The subsequent design allowed for traditional but easy-tocare
dressings
protoeols
clean exam tables with several rooms that accommodated stretchers and a storage area for a shower table, which could
facit-
.
' r
Diagnostic
ities;,vascular
4 to 6 exam rooms ologY vrith exam table,,good

lighting,
radi-
sretcher/bed
access,iphymomanometer with
,DiSital \Aleund devices

gen sys-
cuffs
in. a. variety.of sizes
. . . .
.Tr
tem
(
be used in any of the stretcher rooms. It sounds sirnple on paper but requires a great deal ofcareful planning and comrnunication rvith all involved parties. Clinic growth and developrnent may require additional services to be added. The presence of an orthotist durtug clinic hours and the presence of a durable medical equipment vendor representative may be beneficial.These additions ailorv patients an opportuniry to obtain wound care supplies and support equipment at the time of the visjt and nrinimize the need for them to go shopping after they leave the of{ice (Tlble 2).
Lin.en
Oxygen access
Vacuum access
Doppler(s)
Clear film
qaciqgq
wound
Personnel
Methocis of statEng the rvound clinic and developing the organizational structure may take on a variety of forms. Generally-, stafiing requires
ma11ager, nurses skilled
palette
If the patients
are wheelchair or
beil bound are stretchstretc
a medical director and clinic

care, and
a
er-beds available for then'r in the faciliry?
in perforrning u'ound
Is space available to accommodate
r- or bed-
secretarv and/or receptionist. Larger clinics may include
bound patients? . If a patient requires lift or transGr assistance is the clinic able to properll, provide this? access to Patients of high acuity will most iikely nr ex2n1 parenteral flr-rids, suction, and oxrygen. I[every eduling is room does not have these capabilities, patient not accomfurther complicated. If the space available seen lnav pati of modate patients on stretchers, the type OI are need to be restrrcted to those who lift equipwheelchair bound. Likewise, if the appropr be added ment is not available, this equipment w'il1 need
addrtional staff (eg, additional physicians specializing rn areas not represented by a medrcal director, physical therapists, dietitian, orthoprosthetist, social worker, home-health
or a combination of these).This patient population tends to require more nursing time itr care and teaching. It
nurses,
may be beneficial to stalf the clinic with technica-1 persons who are trained to perfbrm the basics, such as vital signs. dressing removal, and basrc wound care. Ancillary statT
includes laboratory technicians and financial, legal, supp11', and housekeeping personnel. The organizational structure
establishes the chain of corlmand, and the authoriq' ascribed to the members of the structure can be delineated
to the start-up
costs.
in the job Equipment

The rype of services the clinic provides w equipment needs.'When setting up one c1i ago, it r'r,as determined that existing space cou therefore. all the traditional examination rvas already available.The clinic referrerl pa cr-rlar iaboratory u,'hen vascular testing rvas referrals r'vere made for orthotics-pl-osthetics ed. Initial capital equipment included digital photodocumentation. More recently, the desi time wound clinic in a newlv coustructed bu for the planning of our ideal facility from sc cept brought new meaning to bringing all inte
together,
as
descriptions (Table 3). The
job
descriptions
deterrnine
should provide the mrnimum preparation steps for the position as well as detailed responsibilities for each member of
a few years be utilized; equipment to the vas-
the team. Expectations should be clear and accepted by

both the employer and employee. Intervals for perforrnance appraisal should also be identified.
ired, and
en indicat-
Scheduling
The actual daily operations of the wound clinic will depend on a number of factors. If the clinic is set up as a part-time service in a multifunction area, the time of actua1 patient visits will be confined to designated hours and
for
of a fu11allowed
This consted parties
of exam room configurations. A

146
the specialists involved had d physician
perceptlons
cializing in
of the week. The opportuniry afforded by initially opening as a part-time service takes advantage of exrsttng space and, to some degree, existing stafl This scenario provides lorv start-up cost relative to hiring staff and relrrng
day(s)
CHRONIC
WOUND CARE, 4th
Edition
Wiersema-Bryant et
al
Physicians/Specialty
Nurses and Allied Health
Office
Staff
Other
.
.
. internist .
vascular surgeon plastic surgeon general surgeon
. . .
. .
.
program director
. secretary
.WOCN/APN
. staff nurses
CNS, diabetes physical therapist occupational therapist social services home health coordinator
. orthopedic surgeon . dermatologist

infectious disease . pain management . behavioral medicine
. dietitian
. recePtionist . billing coordinator . marketing . data entry technician

.
scheduling person
. housekeeper
. lift orderlies
. CSS employee . orthotics
Vital signs
Wound:
. Gmperature, heart rate, respiratory rate, blood pressure, pain scale assessment
. Location . Measurement: Maximum
length, maximum width, maximum depth;Jeltrare mold
to
estimate volume (optional)
. Description of wound base: color, tissue type(s), and amount moisture level . Description of wound edge: attached, undermined, poorly defined .
. Description of periwound skin: color, warmth, induration, edema
Photography
. Wound tracing
Edema:
. Measurement of ankle and calf circumference

. Water displacement (volume)
Sensation:
. Monofilament
space lbr a full tirne service.A part-time service also allorvs for paticnt volume to build graduallli rvhich rs especially
ev-aluation bv the physician(s) and after physician hours in
irnportant if tl're volurne data gatherecl ciuring the assessment phase rvas largely theoretical. One ditEculq, lr.ith a part-tilne service is providing patients r,vith access to the staff in order to havc questions or problems rnanagecl after clinic hours. This problern can be easily har-rdled rvith appropriate telepl'rone triage br-rt needs to be pianned prior to the first patient visit (probierns or concerns rarely sccru to occlrr cluring oper:rting clinic hours). The number of patients scheduled cluring a grve.n tinre u,i11 depend on the rype of visit and the 1eve1 of actrrry.
patienr visits generally require a disproportionate allount of nursing to physician tinre. This dilEcultv can result rn lack of etliciency, especiallv for the phvsicians.The amount of time needed fbr drrect care, for teaching and support, and fol assessnent needs to be carefully taken into accounr. It rna1,' be helpful to have a schedule thet allorvs for patient support :rnd teachiDg afterSchedulrng is a challenge,
as
the clinic. Optiurally, r1-re recepnon statT can organize the schedule as it occurs rvith rnrtial paticnt evaluations and
patients rvith knor.vn tirnc consuming dressines or therapies accorded sultrcient time. Ir is helpful to be generous rvhen
as rve11 as allorving a grexrer :lmount of tiine for rnitial visits th:rn for follorv-up visi*. The patient visit r,vill be further expedrred if addirional inibrmation is available prior to the r,.isir. If testing is required,
initially scheduling patients,
it is beneficial to schetlule the test to a11or,r. time for the results to be obtained by the clinic staffprior to the prtienti next
appolnmrent. Ideall,v, nomnvasir.,e testing can be perforrned :it
the tirne of the inrtial visit. Patients reGrred to the r,vound clinic may arrive r.vith test results from rheir reGrral source,
rvhich tirrther facilitates the visit.When tcsring is required, the patient may require an appointrnent of scr.eral hours in duration; tl-ris nceds to be considered in the scheilule.
in
Another challenge for scheduling is patients particrpatinS; clrnical trials. ln general, the visits for partrcipation in t47
CHRONiC WOUND CARE. 4th
EditiON
Wiersema-Bryant et
al
Date of Birth:
Please check
your answer:
Have you had a change in weight over
OYes
tr Fair
ability to eat well-balanced mealsl
DNo
Poor
lf yes, how
much?
gain
2. How would you describe your aPPeti 3. Do you have difficulty chewing or 4. ls there anything that interferes with
lf yes, please explain:
0Yes BYes
ll Yes
DNo ONo
5. Do you experience: D nausea 6. Are you taking any vitamin or mineral 7. Are you taking a high calorie/high 8. Are you restricting anything in your
lf yes, what?
O No
DYes 0Yes DYes
DNo ONo DNo
9.
Have you seen a dietirian in the past
Figure l. Nutrition questionnaire.

clinical trials are longer and require separate and additional procedures from u'-hat may your clinic. This needs to be comnunicated
scheduling patient visits. Patients u.ith special needs must have t det;rils cour-
ntatlon
Assessment
Patient assessrnetrt and, specifical1y, r'vound assessment can take many forms. As previously described, the first portion of the assessment begins with the receptionist scheduling the patient. IJpon presentation
routlne
1n
the person
nrunicated to the scheduler. For exarlple, arrives on a stretcher, requiring a specific e
n a patlent
room, this
appropflaIe
to the clinic, the intake evaluation forrns should include an assessment of the history of the
wound, any associated pain, and the patient'.s expectations for the rvound.A careful medical history and physical exam should be peformed. Laboratory studies may be ordered and should include a complete blood count, a blood sugar, and, if needed, a hemoglobin Alc, nutritional indices, and rvound culture. A nr.rtritional history is also helpful (Figure
1), as is assessment for familial medical history. During the initial irlterview, it ls helpful to obtain social informrtion
s1-rou1d be comt'tunicated and room reserved. Perhaps a patient is bed bour and needs to riate bed be weighed.With appropriate planning, an ap perform the stall to rve1l as the scale can be available, as asslstxnce requiring Patients procedure. weighing efhciennray be coded on the schedule to allor'v for l roorn, teste lift specific assistance, cy in, for erarnple, patient may t needs of pr-ocedures. special Other ing, and
information
also be obtained prior to the visit including, ed to, an interpreter for non-English
not limitpatlents, an
interpreter for the deaf, and fanrily members if the patient is cognitively inrpaired. Optir also requires good communication between rnd the clinical staIl
be present
scheduling
e ofTice staff
rvith respect to smoking, alcohol consunrption, exercise re[limcn, and the availability of support persons. Final1y, it rs suggestcd to take an inventory of past and current wound care. V/hen eliciting this iirfomration, it is rnost helpful to identi$, actr-ra1 wound care being perfornred, as tlis nray di{: fer consrdcrabiy from the current order.The wound profi1e should be carefully documented. Quantitative and qualitaCHRONIC
WOUND CARE, 4th
Edition
Wiersema-Bryant et
al
tive information should be gathered.
Quantitative information inciudes wound size
and
depth, surface area, a photograph of the wound and surrounding skin, posibly wound volurne byJeltrate rnold, and wound perimeter tracitrg. If the r,vound is venous in nature, additional inforrnation regarding leg volume u,ith ankle and calf circumference nlcaslrremerlts is appropriare. The patient with a diabetic foot ulcer may need neurosensory
testillg, pressure rnapping of the foot, and assessment of the nonulcerated foot as rve11.
Define etiology Primary or secondary
Evaluate
for
cellulitis, dermatophytoses, and associated medical
problems
Qualitative information includes wound description, description of perirvound skin, odor, exudate, edema, anatomc location, pain (quanti$ r.vith self report using .r pain scaie if posible; we include this assessment as the "5th"
Maximally manage infections,

infestations, and associated
medical problems
vital sign lvhen
recordir-rg
vital sign$, type of
tissue
exposed, and color (Tab1e 4).
nstitute external
I
Depending on the differentiarion of r,vound by typ., other testing may be required.Wounds rvith a potential vascuiar origin may require vascular testing. Vascular testirlg generally involves noninvasive testing of pulses, Doppler r,vaveforn-r analysis, ankle brachial Doppler pressure, and
tlanscutaneous ot'1rgen analysis. Invasive vascular testing may involve arteriography. Other vascular testing nuy be indicated based on clinical assessment. Diagnostic radiogn-
comPression therapy, Pneumatic

PumPs,
comPressive leg wraPs
Figure 2. Management of lower-extremity edema.
phy may be indicated to rule out the presence of

This testing rnay require plain fi1ms, bone or rnagnetic resonance inraging (MRi). If inGctio1] is suspected, a wound bone biopsy nLay be indicated rvith operative debridement of the wound. Many documentation systems exist, including utilizetion of one of the comrnercially available cornputerized tools.A facilirv rnay opt to purchase an eristing coruputer-based documentatiorl systeln or develop a colrlputer database internally. Whichever system is chosen, it should facilitate data managentent for the tracking ofchnical outcontes, cost ofcare, and other flrcility needs.
osteornl,elitis.
scan,
Management of Referrals
The rnanagenrent of patient reGrrals to the rvound clinic depends on timely communication with the referrrng
source. The referral source may be a self reGrral, but more likely, it is frorn a physician or other hea-lthcare prcvider. One complaint about specialty-rype clinics is that of inadequ:rte comrnunication u.ith reGrral sources. A pian to provide such con.ulunication should be in place before thc 6rst
patient is seen.Another ntethod of rninimizing "referral anx-
iety" is to establish the u,ound clinrc as a "consult" service by stressing that it does not intend to take over prin.rary care of the patient but assists rvith the lnanagement of the patrent
Policy and Procedure

Applicable institutional policies and procedures nay be
utilized to the extent to which they fit the needs of the clinic. Applicable generai policies nray include patient scheduling, stafling5, medical authoriry documentation, and infection control. The lr,ound clinic tearn will want to develop policies specific to the service. These policies may include wound cleansing and debridement, use of sedation, wound culturing, topical wound care, and use of adjuvant managenlent, such as sequential compression therapy, orthotic devices, and pressure relief. Any protocols, which are developed subsequent to the policies and procedures, should be compatible with the same. An example of a flow chart for the management of lou.er-extremity edema is provided in Figure 2. CHRONIC
only r.vith respect to wound care. In fact, in a busy wound clinic, man1, chronically i1l patients can overload the cLnic with non-direct wound care activities. Having the prtrnary care physician nlanage these problenx improves wound clinic florv and patient outconre. Rapid communication of the u,ound care plan and progress ro the pr1mary physician leads to optimal care and future referrals. unless thc wound clinic plans to provide primary care, it is irnportant that all
patients scen have a primary care
p\sician. in place from
A w-ound clinic
evalr.ration plan should be
the inception and planning phases.The goal ofthe evahiation process is to measure progrcss, nroritor outcornes, and ev:rluate established goals and objectives. Program evaluatiorr rnay include such issues as infection rate, tinle to rvound closure, recidivisr-n rate, and others. Another aspect
119
WOUND CARE 4th
Edltion
Wiersema-Bryant et al
phics of the program to monitor is in the area of rnatch rhe Horv closely does the actual patient p concurrent projected statistic? Thrs information is useful mav have planning and for the marketing department t facilitated the research during the planning phase. With
u,ounds is an opportunity for ciinical excellence with cost

savrngs
lbr the institution, improved outcomes for

for
the the
patients, and continucd professional development
involved clinicians.
vlew a clinic as a r may be of new patients, and additional man needed. Conflicts are rninimized if the ori na1 nrission
t1me, some practltloners may
Our Experience in Summary

The initial planning for the wound clinic was cornpleted
source
with a marketing consultant, the physician champion of the

project, and nursing and hospital administrator. It was deter-
statement is adhered to and alternative

Fina11y,
rej ected
it
is helpful to have periodic team
ngs
to
dis-
the evaluation of findings. Staff meet opportunirv to hear the data, comment on formulete idees for firture researchcuss
provide the
results, and
mined that existing space and staff could be utilized on a part-time basis. Data rvould be gathered in order to obtain additional information regarding patient outcomes, costs related to care, facility costs, and the overall viability ofthe
program.The "ear\" years allowed for slow, gradual growth lvhile challenges were further identified. It was through this process that information regarding the population, includ-
Summary
Running an outpatient rvor:nd clinic can The concept is relatively new, and can be brought to such a setting will make a the staff, patients, and caregivers. A center
process.
an excltlng
vitality that nce for on the

wounds
care and managelnent
of nonhealing and ch
willing to brings together interested plofessionals who Iearn, to teach, and to share with the patient a coordinated approach to managenlent of an often difEcult blem. It is an area rvhere clinical research can be shed with a on the coordinated team etTort. This chapter has fo
process
ing the need for stretcher rooms, transfer assistance, special furniture in the exam and waiting room areas for weightchallenged individuals, and odor management was collected. Staffing mix and training r'vere evaluated and monitored, as understanding of the direct care needs relative to
the physician proGssional component evolved.
Take Home Messages for Practice
of formalizing an idea and bringing It is our will facilit
it to
realiqr
with
careful research and planning.
thrt the
the process contem-
in this chapter of opening a wound clinic for those indi

concepts presented
lrformation garhered f.orr the past ana evotved-prse^- allows ltê leam Lo erpand the scope ot se'v ce ard ask tne approoriare qLrefiions as a êw fLr -tirne
plating such a service. Certainly, there are a tional areas rt and use that could be covered, including the nd care. For ofprotocols lor both diagnosis and topical tlng a additional information on these aspects of this source wound clinic, we reconlmend other chapters
. .
'ac ty is planneo, Ihe costs to cale farthis populatron contrnue to

as re nrbu'sement continues
rise
ro
'ali.
f6n6snl-r31irg tne cosrs to one a'ea allows the Inancial experrs to icenr'y renrbu'senrert st'dtegies as well as deternn ne long-te'm survival and viabi,'Ly of
book and other articles on selecting

and uotrnd healing and repair.
treat
modalities
the project.
Conclusion It should be stressed that there are many

achieving organized treatment of nonhealing
lor
chronrc
1.Whar are the key elements in identification of the need for an outpatient rvound clinic? A. Physician commitment to support and reGrral is lacking B. Market analysis identifies an existing rvound center in a near\ facility C. The demographics of the population to be served
rnatch the proposed service plan D. A11 of the above
wounds. Establishing an outpatient wound cli ic is simply chmc, one of these ways. Even with respect to the
the structure may take many different for

model presented here or from any of a number including a "virtua1" clinic. The clinic, if it is ful, nrust meet the needs of the population Thereforc, careful analysis of that populati underestimated. Likewise, a careful, realistic potential referral sources and competitors pleted. The best designed, best planned cllnic vive withor:t patients. Hor'vever, a properly pos ic ofTering a comprehensive approach for pa
150
from
the
variati ons
be success-
be served. cannot be
ppraisal of to be com-
2.What are the necessarv componcnts of thc mission statement?
ill not
s
sur-
ed clinand their
A. It
is based on one person\ ideas B. The nrission statement is g1oba1 in scope with
a shared
CHRONIC
WOUND CARE. 4th
Edltion
Wiersema-Bryant et
al
sense ofpurpose, direction, and achievement C. The mission statement contains only short-terrn goals D. Team building of stalf is not essential in planning for the clinic
References
1. 2. 3. 4. 5. 6. 7.
Baxter CR. Wound care clinics
1993;3 (2):5.
need? Srcrs and Stipes
Johnson JE. Developing an etTective business plao. Nurs Eton.

1990;8(3):1 52-15,1. Shipes E. Continence clinics. In: Doughry DB, ed. Urinary dnd Fecal Ifltofttinence: Nursing Managemenf. St Louis, Mo: MosbyYear Book;
3.The business pJan should include rhe [olJowing: A. Concern regarding costs of operation is not rronsidered
1991:15 145.
Rees RS, HirshbergJ.Wound care centers: costs, care, and strategies.
.
in rhe !Lr5ir-rs5r plan

a
Arlu Wound Care. 1999;72(Sqpl 2):4-7
B. Billing issues are not titioner
concern for the faciliry or prac-
Valdes AM, Angderson C, Giner lJ. A multidiscipLinary, therapybased, team approach for efiicient and effective wound healing: a
retrospective stady. Ostomy l|/ounrl Manage. 1999;45(6):30 36. FLiescher 1, Bryant D. Prescription for excellence: an ostomy clinic.
Ostomy Wound Manage. 2005 ;51. (9) :32-38.
C. The marketing plan does not influence rhe busines plan D. The economics of a wound clinic are complbx and require the clinician and financial analyst to be clear
Establishment of wound ostomy continence clinics.JWounil Ostomy Continenrc Nar-r 1998;25(5):22A, 24A, 26A pasim.
on financial targers
Answers:
1-C,2-B,3-D
CHRONIC
WOUND CARE. 4th
Edltion
Wound Care in Home Care

Ben Peirce, RN, CWOCN; Rodney Hornbake, MD, FACP
Objectives -ê reader w.lt be c:allengeo

. Appraise how the Outcome
to:
and Assessment lnformation Set impacts wound care in the home Explain what healthcare professionals should expect from home healthcare agencies to {aciltate ef{lcient and
e'fuclive coordiratio' of ca.e
'o'
pat'ents wiLh wounds
ATime of Change
systern. Hospitals underrvent
the satne transition to (DRG$.
case-
Ai{: * *:":h :.' # ix:;[l n*; or

to the home
than care in
a
rate prvlnents
PPS,
in
1983 rvith the introduction ofpavnlents
based on Diagnosis Related Groups
emergency departlllents. This trend is being honres, fueled by new technolollies that reduce the length ofhos pital stay for rtan1, procedures and increase the cornplcxiry of care that can be managed in the home. Shilting cale
appeals
horne healthcare asencies are paid a predeUnder termined arlollnt for (r0 days of services, regardless of hor.v many visits the,v provrde or u.hat supplies they use. Caseratc payments are reGrred to as Home Health Related
Groups (HHRG$ and can range fiorn approxirnatel.v

$1,200 to $5,200.The HHRGs are basecl o11 3 faclors: 1) diagnosis and clinical status;2) patient 1eve1 offunction irr activitics of daily living (ADL): and 3) the need lbr rehabilitation services providcd bv physical, occr-1pationa1, and speech therapists.Thc HHRGs are thus designed to attract the greatest resources to the sickest, least independent, :rnd ncediest paticnts. The HHRGs are also adjusted for the patient'-s geographic area to reflect the variable cost ofproviding trre in el, h corttntuniq. The HHRGs are determrned r-tsing a standard national assessment tool knor'vn as the Outcome and Assessnrent Infi:rrnation Set (OASIS). Data for thc OASIS is collected at thc'start of honre healthcare, during resurnption of c:rre
to
pa),ers because
it
is less expensive
faciliry It appeals to consutlers because rnost wa11t to stay at home rathcr than go to the hospital for care. It appeals to legislators bccause go\rernment p:Lys for most nursing home care in the United States. Ironically, this trend represents a return to a care delivery model' sirnilar to rvhat u.as comrnon in this country prior to
WorldWar II. The home healthcare indllstq/ and the needs of socicw for hor.ne healthcare are changing simultaneousl-v. The pace of industrl,-u,ide change accelerated itt response to the nerv Medicare payment s-vstern, rvhich went into ctTect in 2000. At thal tirne, the Ceuters for Medicare and
Medicaid Services (CMS) cornpleted the transition from a fee-for-service system to a prospectrve paymellt system (PPS).Thrs transition has introduced a cxse-rate pa)rment
(in the event care is interruptcd by a rehospitalization), during recertification if care extends past 60 days, and at the end of I'rorne care. This serial assessmellt of patiellt
Wo
peirce B. Hornbake R. Wo11d carc i1 horne carc. In: Krrsner 1)L, Rodeheaver G! Sibbald 1{G. cds. Chronic Heolthcore Professioncls. 4th ed. Ma1r,ern, Pa: HMP Contnrunications.200T:153 15ll
und Core: A Clinicol Source Book for
153
Peirce and Hornbake
.:]
rFiii$ti iQ,urrtei:l_20.0,6,.
:Niinibeil'of:rPatie6ts
75 63%
Average age Women Average length of home healchcare stay

Reside in their own homes
56 days 76/"
80% 68%
2%
Had a recent inpatient stay lncidence of a wound or lesion on adm Sasis ulcer
Surgical wound Pressure ulcer
28%
7%
Ocher wound or lesion
3t%
condition gives the data a dr-ral purpose. It
the
1t
data
The Role of Home Healthcare

Home care is dilTerent from facility care because it is decentralized. Many clinicians are uncertain urhat home heaithcare rea11,v does. It can be generally defined as "the provisron of equipment and services to the patient in the horle for the purpose of restoring and maintaining his or
her maxrmal level of cornfort, function, and health."' What rs unique in home healthc:rre is the 1evel of collaboration across sites needed for care to be etTective. In the rypica1 scenario, the patient is in his or her home, the phl,sician is in his or her otlice, and the medical record is in the otlice ofthe honre healthcare agencv Because ofthe
challenges these distances create, home healthcare is a set-
to be r-rsed to deternine case-rate pa,vment, n'Ieasurement of the inrpact of home care

clinical status and functional independence.
Case-rate payrnents have resulted in a re-e
permlts
.l patient's
neering of t the rate
ependence
home care. For exarnple, agencies discovered
at r,vhich patients achieved functronal in
derermined the total cost and hence profitab v ofa case. Agencies learned to "front 1oad" physical and cupatlonWhile this al therapv services early in the process of c increased the initial cost of care. it reduced total cost of :rch:ieving the target outcolre of functiona independJust
is just one example of the change ir DRGs led hospitals to standardize and ly improve care, HHRGs have had the sam home care. In the hospital, standardization has
ence.This
as
home care. ontinuousimpact on
leant drug and device forrnularies, clinical pathrvays, and er lnnorrations. In home care, standardization lneans ical supp1y follnularies, similar plans of care for sirni patients, outcomes and continuous irnprovements in t1're cost of care. Even in not-for-profit agencies, achie ng overall
profitability is critical to the agenc,v's mission. For patients rvith rvounds, the impact has 1arl1, lmportant. Agencies have far more ince the patient regain independence quicklr,-. This bv motivating patients to become rnore care. The role of the nurse is to teach, reasse the plan of care to changing circumstances. Sa have also developed a heightened interest i u,ound care products. Whilc thcsc product expensive than ganze and saline, the,v acceler redur:e pain, ancl lorver infe'ction rates rvhi
reducing the frequencv ofdressing changes.
tr:anslate
ting rvhere efJbrts to improvc communication quickly improve both paticnt outcomes and patient satisfaction.r Case confurences are held regularly u,rth some disciplines linked via telephone to ensurc rneasurablc progress is berng made or that che plan of care is ad-jr-rsted qurck1,v. This is especially true for a patient nith complex and chronic u.ounds u.here rrultiple physicians may be involved and u,here the treatment mav change several times as the wound progresses through the phases ofhealing.
parEcuive to help is achieved
Who Receives Home Healthcare?

A benefit of PPS based on the OASIS dataset is th:rt CMS is able to use the data to create reports. Case mix and outcome reports compare each horne healthcarc
agency to national references (Tab1e 1).This information is available to each honre healthcare aElenclr and provides an interesting picture of rvho receives home healthcare
a Medicare-certified agenc)-. It should be noted that some honre healthcare agencies are licensed to provide care but do not particrpate in Medicare. These agencies
d in selfand adapt
agencles
advanced
are more
e healing,
generally features
liom
into avoidillg unplanned
hospitali
tions
and
do not collect OASIS data, so their information is not

included. CHRON]C
reducing resource utilization.

151
WOUND CARE, 4th
EditiON
Peirce and Hornbake
lnterventions
Select dressings that provide a moist wound environment, keeP surrounding skin dry, cc,ntrol exudate and bacteria, and eliminnte dead space; reassess for progress at each visit and modify the plan as nee:ded
,,Tiriieframei
Each visit
Emergent care
will be avoided
lndependence in dressing changes
Instruct in signs of complications and actions to take when needed Instruct in organizing suPPlies, removing
dressings, and aPPlying dressings safely and effectively; reassess for progress at each visit and modify the plan as needed
lnstruct within l-2 visits lnstruct within 3-4 visits
lndependence in
disease management
lnstruct in activicy, positioning. Pressure reduction rneasures, nutrition, hydration, and managing any urinary or fecal incontinence; reassess for progress at each visit and mrodify the plan as needed
lnstruct within 3-4 visits
Coming Soon: Performance-Based Payment

The CMS plans to begin modi$,'inq pavnlents to hotne
c:rre agencies based on measured outcomes as early as 200fl
Outcomes data captured in the serial OASIS assessrnents r.r.ill be used to provide additional inccntives to improve those outcomcs. Outconres targetecl for pa1'ment rvill likel-v be those that measure the impact of home healthcare on the patient's abi1iry to care for hirn or herself and on
r,vherher tl're patient rvas able to stav at home u'hen rlischargcd frotn horne he:rlthcare. This anticipated shift to outcornes-based reimbursemeilt provides additional incen
improving the consistenct' of care is by txing clinical pathurays to ensure goals and interventions are clearly definerl for the individual patient (Tab1e 2). Several OASIS qucstions that affect pa-vll1ent ar-e woundrelated and must be supported bv documentation for-rnd in the medical record. This has led to innovatir>ns in u'ound documentation to improve collsistencv and reducc subjec-
tivity in how clinicians dcscribe
rvounds. This focus on rvound assessnrertt docurlenlation not only supports
OASIS assessrrents but also allorvs clinical teatns to quickl-v identi$, rvounds th:rt are not progressirrg and to ensure con-
agencies focusecl on r-.e-eugineering care For patients u.ith .nvorurds, thrs change u't1l cause agencies to focus more on improving patients'abiliq- to care for them-
tives
to
therr discase states etTectivcl.v, and identifi'lng compiications earl,v enough to avoid unplanned hospiselves, managing
talization and emergencv department visits. Successfnl agencies lvi11 be those that have continuousl,v irnproved
their
ski11 at
sult:rtion with the phvsician and other tearn rnembers occurs to rnodify the plan of care. Atr enrerging technolog,v supporting coordination rs digital \vound photography While nor a replacement for w'ritten ll'oulld assessment. thcse photos help rnembers of the clinical team separrted b1, distance participate more ellectively in case conlerences.
identi6,'ing and elimirrating barriers to ellectrve
OASIS Assessment
The infornration used to determine payment comes fionr the assessrnent done b.v thc adnritting nurse or therapist using stat-rdardized questions knorvn as the OASIS dataset. This information must be transrnitted electronically to CMS on adnlssion and discharge in order to be paid for
senices. Because all reinrbursement is based on OASIS assessment data, many horne health clinicians and clinical managers understand that ellective assessnlent and ansrver-
their c:rregivers. Patient and caregiver roles are no\\i tllore importxnt to -[his ir rnanaging rnedical conditions than in lhe past. bccause clinicians only visit interrnittently but care is ongoing.The role of the home healthcare nurse as educator and
self rnanagement b)r patients and
coach has never been more criticai. Case-rate paYnlrlnt has
thc shift tor'vard fostering and promoting independence. Second tras the inprovement in eiliciency and elTectiveness of hotre cirrc. The rcsult has been a reduction in t1're grolr'th of holne healthcare costs. nlofe consistent carc. and enhanced oversight b,v Medicare. One r'vav home healthcare agencies are
resr.rlted
in 2 important
changes. First rvas
ing thc OASIS qucstions accurately are critical to ful home hcalthcare.
success-
der.eloping their ski1ls at compJctins OASIS assessrnents. clinicians must also sharpen their ski11s
In addition to
CHRONIC \MOUND CARE,
4th
Editron
155
Peirce and Hornbake
alini::it::ii::
]i*i{!:$
.i]
QU.gstlqEr:tit,]i]]]ll,:'':l']]],]],
M0230/ M0240
':
iDteg! t:iPtjq n...ri..1i iti.... Primary home care secondary diagnosis

1i i.
ly
is (or initial for selected
ICD-9-CM codes)
M02s0 lVlinfusion/
therapies
Orthopedic diagnostic group (DG), add I I to score; diabetes DG, add l7; neurological DG,
add 20 lV add l4;total parenteral nutrition (TPN), add 20; enteral,
add 24
M0390
M0420 M0440
Vision alterations
Pain, more
Add 6 Add
5
than daily
Wound/lesion
Add 2l if also have burn/trauma primary diagnosis
M04s0
M0460
Multiple pressure ulc Most problematic

Stasis ulcer status Surgical wound Dyspnea
:2 or more Stage lll or lV

re ulcer stage
Add t7
lf box (Stage) I or ll, add lf box 3 or 4,add 36 lf box 2, add 14 lf box 3, add 22 lf box 2, add 7 lf box 3, add l5 lf box 2, 3, or 4, add 5 lf box I or 2, add lf box 2-5, add 9 lf box I or 2, add l0 lf box l-6, add
3 15
t10476 M0488
M0490 M0530 M0540 M0550 M06 t0
Urinary incontinenc
Bowel incontinence Bowel ostomy Behavioral problems
Value
Dressing upper and
Bathing
body
lf M0650 = box l,2, or 3 (OR) M0560 = box l, 2, or 3, add 4

If box 2, 3,4, or 5, add 8
Toileting Transferring
lf box 2-4, add 3 lf box l. add 3 lf box 2-5, add 6 lf box I or 2,add lf box 3-5, add 9
6
M0700
Locomotion
:: ,,,:i:r.:.:.ii:rrir::ir:..,.,:,,:i::i:lll;li:::::il:i:xgieii!j!lr1!nli
'lla,iiiliiiiiiiaiiii:lii:iiii:i:iiiiiiai::llil:a:ill:::l:l:all:l:llllliai:aii:ii
:,:Qq!lCig!:t:':',tl:,.rtt.1.1.,:,:,:::rrt::1t1.:'t-D,:gl-c:f!it:iinrrr,r':r
M0175-line
No hospital di
past 14 days
lled nursing
lf box I is blank, add lf box 2 or

lf yes, add 4
3,
M0175-line 2 or
M0825-Receipt
Inpatient rehabilita facility discharge past
add 2
l0 or more therapy
ofTherapy
156
CHRONIC
WOUND CARE 4th
Editon
Peirce and Hornbake
at describing wounds on other assessment forms

data alone does
Thif
ad<li-
tional narrative information is necess:rry because the pASIS
to ensure accuracy. Potentiai problems or missed opportunities with these OASIS questions are related to well
sure ulcers
not adequately describe wounds. Mapy
c1i-
nicians struggle
with wound
3ssessmellt when the w$und is
irregularly shaped or hard to visualize due to locadion or

complications. They also strug+e because validated ']'vound
assessment tools have not been developed. Even witl]r these challenges and limitations, tentative strndards ... emfrgirrg.' Many clinicians now agree that a cornplete wound assessment includes u,ound location. size in 3 dit-nensions. fvound bed and perir.vound skin appear.rncc. and exudate ryle and anlount.They also agree that this information should l1e doc-
known limitations of the pressure ulcer staging system.6 Although the NPUAP has stated that downstaging is not appropriate, many clinicians are inclined to downstage pres-
sure ulcers to reflect improvement (ie, to err-oneously describe a healing Stage IV pressure ulcer as a Stage II
rvhen the wound bed is nearly fi11ed with healthy granulation tissue and is no longer deep).This impulse can result in decreased reimbursement r'vhen the err-or is tnade on a discharge or recertification OASIS assessment. An additional point should be n-rentioned-a pressr-rre r.rlcer that has been surgically revised by a flap procedure
umented weekly in home healthcare. Any sigrificant Lharge
in
conditions should also be describcd including inpreased
pain, the appearance after debridernent, or signs ofinfpction. Following is an overview of the OASIS quesdohs that
state surveyors
would be categorized as a surgical wound on an OASIS assessment. Surgical dcbridement, hon-ever, r'vou1d not change a pressure ulcer or stasis ulcer into a surgical lvound when cornpleting an OASIS assessment. The OASIS questions M0476 and M0'IBB relate to the status of stasis ulcers (M0476) and surgical wounds (M0188) that in-Lpact paylnent. The choices for these
OASIS questions are fu1l granulation, early partial granulation, not healing, and no observable wor-rnd.A stasis ltlcer or
surgical wound that is categorized as ear\/partial granulation or not healing would increase reimbursement, while
with a focus on those questiops that witl 1ike1y target.This focus will lead t9 a discu\sion of\trJrcgier fo Js\urr dc('urlte J\scs\n]ents. Twenty-two OASIS assessment questions affect paf'nlent, and 4 of these address wounds (Tab1e 3). It is thbrefore important to undersrlnd how to cnswcr these quesrions accurately and consistently. In addition to using O,{SIS as the basis for payment, the documentation of improdernent relates directly to emerging performance-based prj.met t. Moreover, Medicare is publicizing outconles deta in a sidc
atTect reimbursement
the other 2 options (fully granuiating, no
observable
by-side manner so consumers can use them in selecting an agency.'The CMS has also instructed state and fedeial surve)'ors to use outcomes data to help guide agency-dpecific
survevs
rvound; wuuld have no cffecr. 'When OASIS r'vas lirst implemented, many wound ostonry continence nurses r.vorking in horne healthcarc thouglrt
for license renewals
Wound-related OASIS questions

The OASIS questions M0230 and M02'10 refer to the primrry and secondary di:lgno.es. While .r conrpre\rerrsive discussion of International Classi{ication of Diseases] Ninth Rerision. Clirrical Modificetion (lCD-q-CM) co{ing in honre lrcrlth is beyond rhe scopc of rhi' chaprer. rhe issue oI rceutrte ,o.ling oi wourrd diagnoie, ts rvorth lroting. Diagnoses in the follor'ving 5 categories rllect rcinlbursement: neurologic, orthopcciic, diabetic, traumatic, and
burns. Ciinicians should use .are to ssslrte that thise are selected appropriately. If information is not accur:ite, the agcncy corr)d loo.e rhe rcvenuc alter I lert'ospcctire revicrv by Medicare. In addition, identifiing the underlyingi prol:lems lbr complex wounds is essential to help $atients understand how to manage their conditions to slupport healing and avoid rvound recurrcnce. The OASIS questions M0450 and M0460 acldress ,lr. *rg. of pressure ulcers. Stage IIi and Stage IV sigmft . ,ig]lificart
leve1
to answer because the tertns lacked universai definitions (fu11 granulation, early partial granulation, not healini, no observable wound). The 'WOCN Sociery subseqr-rently identified and validated definitions for these terms by creating a docurnent, Cuidance on
these questions were dil-ilcult the OASIS Skin ond Wound Status M0 llerr.s, which has be en accepted by CMS as appropriatc lbr defining these ternr 'nvhen ansrvering OASIS questions.T Errors
in
answering
these questions may reduce reitnbursement to the home
health agency. Many have integrated this guidance into

t1-reir
OASIS training profJra1]ls.
Physicians and Home Care

Physicians may be experiencing di{hculties
as
home care
:rgencies adapt to the new payment systt:m. Similar diIficulties were encoLrntered in hospitals during the transition to DRG-based paylnents. Length of stay became critical to hospitals'success, and p\sicians were asked to participate 1n the process of rnaking hospital care more efiicient and efTective. More than 20 years later, formularies, clinical pathways, and continuous improvement efTorts are an
of injury and also increase reimbursenrent. It is lmportant that clirricians ful1y understand the National dr.rrr.. Lllcer Advisory Panel (NPUAP) guidelines for staging presCHRONIC
accepted part
even partly responsible
ofthe hospital experience.These changes are for the eruergence of a ncrv physi-
cian specialty-hospitalists.
WOUND CARE, 4th
Edition
Peirce and Hornbake
In home
care, there are ferver
opportunit
cians to meet
cu1t.
with home
care proGssionals tha
for physiwith hosre diltrcollaborate
,Take'Home Messages for Practice
pital staff. This makes the transition potentially
. .
Parenrs wrtL woLl.cs a.e comTron in horre nealthcare.
Home healthcare agencies wi.l soo. nave

care p'ovided
Physicrars
r
{lnancial
The following observation on how to
ircentrves to focus on Uott- the qualiLv aô t1e costs
of
effectively with home care agencies ln the car of wounds comes from the vantage point of a physician ho is very invoived with home care. Physicians should keep open lines of nication with home health agencies by: 1. Promptly reviewing (and changing as the care plan provided by the agency; signing and re ning the document prompt\
2. Contacting
to patents with wounds.

agenc,es
who understand kome lêalthcare
needs. and.motivations.are in an.lexcellent position
to
,rnpactrhe efficiency ano e{ecliveness
ofwoJ.c care n
]'.'thel'homg'...'
1.The PPS based on the OASIS daraset impacts wound care
the agency
b1,
phone as nee
to
resolve
in the home by:

A. Encouraging home healthcare agencies to teach self care B. Encouraging home healthcare agencies to use lowcost medical supplies that require frequent dressing
changes
any questions or problens 3. Treating nurses, physical therapists, and othe
with
co1-
legial respect
in patient the agency 5. Calling home health nurses to report a c tion.

4. Communicating any change From the agency, the physician should expect
1.
C. Reducing
the paper-work required to
document
in condi[o11owing:
assessment
D. Al1 of the above
2. 3.
An
A
An accurate and complete rvound assessment assessment of factors that are barriers
healing
care plan
wound
2. Physicians should expect home healthcare agencies ro provide the follorving on each patient with a wound: A. An accurate and complete wound
assessment sent
reg-
for the wound 4. Periodic updates on the progress ofthe wou 5. Digital photographs of the rvound preferably
eiectronically 6. Prompt notification of any complications 7. A request for debridement as needed. So will prefer to do this themselves while assign this to others.
ularly B. Prornpt notification of any complications

ansmitted
C.AandB
D. None of the above
physicians
Answers:
1-A,2-C
preGr to
References
re and care 1s
a
Most of these are requirements for agencv for Medicare certifi cation. Fina11y, the ultimate collaboration in I
1. 2. 3. ,1. 5.
Sociery of Urologic Nutsing and Associatcs. Pdtient Access to Contifrefik Sewircs: ProtectitLg .it Under Mutagetl Care. I)itman, NJ:
AlterescuV: 7997:10 11. Home care in the 1990s. Counsel on Scienti6c Affairs. JAMA. 1990;263(9) :1241 L214. Naylor MD. Tiansitional care: a critical dimension of the home lrealthcare qualiry agenda.J Hedltfu Qtal. 201)6;28(1):zt8-54. Bates-Jensen BM,Vredevoe DL, Brecht ML.Validiry and reliabiliry of the Iiressure Sore Status Tool. Deurbitus. 1992:5(6):20-28. US Departmetrr of Heaith and Human Services. Home Health Compare. Available ar: http :,/ /wmr'.medicare. gov/HHCompare. Accessed September 15, 2006. Weir D. Pressure ulcers: assessnlent! classification, and management. ln: Krasner DL, Rodeheaver GT, Sibbald kG. eds. Chtonic l4/ound Care : A Clinial Soutce Book.for Heakhcate PtoJ'ess.ionals. 3td ed. Wa.vne, Pa: HMP Communications: 2001:619-627. Wound Ostomy Continence Nurses Society,. Wound Ostomy Contineuce Nurses Society Cuidance on L)ASIS Skin and Wound
with the home care nurse. in building tearnwork and improvi: and can make all the ditTerence in challenging
physician home visit rnvaluable
can be
outco11res
Conclusion
Wound management in the home mr-rst add
issues seen
the same
systerxc
,15
in other
6.
care settings: optimizing to ical treat7.
ment, managing underlying diseases, and providi
support.What is unique about home healthcare, the opportunity it affords providers to influ involvement in managing their own conditions
e patlent
Status
M0
Items.
Available
ar:
http://wwrvocn.org/education/pdtTWOCNOASISguidanceRe v072406.pdL Accessed October 27, 2006.
CHRONIC WOUND CARE. 4th Edition
Cost Effectiveness in Wound Care

Tania J. Phillips, MD, FRCPC
Objectives
The reader will be challenged to: . Differentiate between cost and cost effecttveness
. lntegrate cost effectiveness in the decision-making Process for chronic wound management . Critically assess outcomes of different treatments . Critically read published studies and take cost-per-unit outcome into account to determine if treatment
measures are indeed cost effective.
lntroduction rf hroughout the world, efforts to control healthI .r.. costs while maintaining high quality I po,i"rr, carc are increasinq. One result of these efforts has been decreased lengths of stay in acute care facrlities. Wound care is now often provided in the hon1e, olltpatient, or extended care setting. Without
any unifying definitions of formulas for calculating the costs of wounds and measuring costs and benefits of different rvound care methodologies, it is dillicult to corlpare cost effectiveness of different u,ound care treatments.
ments are not more cost effective if they cost more to achieve the same result. In thc hcalthcare literature, cost effectiveness has been defined as cost per unit of clinical effect of a treatment.r Clinical effects could
measure outcomes
in tcrrns of a large numbcr of
paranleters, such as healing or quality of 1ife.
Costs of Wound Care

The costs of wound care can be divided into direct indirect costs (Table 1). Direct costs (wound care perspective) include the costs of primary and secondary dressings used on the wound, ancillary sr-rpplies to cleanse and dress the wound, surgical and radiological interventions and
costs and
Cost Versus Cost Effectiveness Cost effectiveness refers to the cost of achieving
desired treatrnent outcorie. An extensive revie"v of the medical literature has revealed that there is nruch con-
fusion concerning the differences between cost and cost effectiveness. Many of the publications reviewed that purport to measure cost effectiveness in fact only measure treatment costs rvithout evaluating outcomes in terms of a large number of paranreters, such as heal-
investigations, treatment to manage rvound complications, n-redications to manage wound pairi, inpatient care directly related to the wound, caregiver time, travei by caregiver or patient, and disposal of wound care material or products. Indirect costs might aiso be called overhead costs.
1if-e, assistance
ing or quality of life. Studies of cost effectiveness

should measure cost-per-ul1it outcome. Cheaper treat-
Such coscs might include those related to quality of iri completing activities of daily living, days lost liom work, and litigation. Direct and indirect costs are referred to as societdl perspectiue.
Phillips TJ. Cost eft-ectiveness in rvound ctre. ln: KLasner DL, Rodeheaver G! Sibbald RG, eds. ChronicWound Care:A Clinicol Source Book for Heohhcore Professionols. 4th ed. Malvern, Pa HMP Conrmunications. 2t)07: 159-164.
CHRONIC
WOUND CARE, 4th
EditiON
159
Phillips
Statcs
lepolts that thc cost to heal 1
1eg
ulcer, ranges fronr
Diieatt,Cosi;rirrr.ir:.:
r'ri.i ::
,1r
1,:1',,,11 .,
$784 to $6,1149. In a rerrospectir.e studv ofn-redical costs of treatinl venous ulcers, Olin et aln quanti0ed all inprtient
. . . . . . . . . . . . . . . .
Primary wound dressing Secondary dressings/bandages covering primary dressings
aild outpatient costs rel:rted to \.cr1or1s ulcer treatment that rverc incurred during the vear follorving venous ulccr pres-
in
gloves)
Auxiliary materials (eg, saline, tape,

Caregiver time (eg, dressing changes, assessment! position
entation or until the ulcer healed, rvhichever occurred first. a coholt of 78 patients.The rnean + standard devi:rtion (SD) total cosr per paticrr $ias $9,685 t $1,+,136.
Consultations
Radiology, microbiology,
One cxanrplc of a cost-effectir,'eness stucl_v b,v Morell et alt evaluated the cost elTectiveness of conu.nunitv 1eg ulcer clinics in a randornized, controlled trial u,rth 1-year fol-
or other diagnostic suPPort
lon-up. Tivo hunclrcd and thirty-three patients with

venous 1eg ulcers
'nr.ere
Travel (caregiver
or parient)
allocatcd to u,cekly trcirtntellt with or
Auxiliary equipment (eg, specialty beds and

mattresses, compression pumps)
.{-lavet bandaging
in a 1eg ulcer clinic (clinrc group)
Operating room (eg, debridement, grafring)

Pharmacy (eg, antibiotics, pain medication specific for the wound)
usual care at home by the clistrict nursing service (control group).The ulcers of padents in the clinic gror_rp tended to heal sooner than those in the contr-ol group over the rvholc 12-n.ronth lbllorv-r-rp.At 12 weeks,34% of patients in the
lndirect,eosts
::
'
::..:::'
::
Extra inpatient days/visits necessitated by
or complications directly resulting from

Patient days lost from work Treating complications (eg, infectlon, hypertrophic scarring) Costs of waste disposal for used wound care materials Costs of litigation
wound wound
clinic group r,vcre healcd conrpared *{th 2l%u in the control. No significant cliflerences in health statlrs \\.ere lbund betr,veen the groups. Mean total costs were d878.06 per year Ibr the clinic group and d859.3,1 for the control group. Tl'rc authors concluded that colnrirunity-based 1eg r-rlcer clinics \&.ith trained nurses using 4-iaver band.rgrng werc more etli:ctive than traditional hon.re-based trear1nent. This benefit u,as achievcd at a snra11 aclditional cost ancl could be delivered at recluccd cost if certain servicc
configurations rvele used. For pressure ulcers, the cost in the Unitcd States to heal 1 rvouncl" has been reported ro range from $5,000 to $1ti,000. In a stud,v cor.rducted for the Agencv of Health Carc Policv and Researcl'r. the tota] n:rtional cost of pressure ulcer trertment rvas estimated to exceed $1.355 billion per vear." Pressrtre ulcer ntanagenlent costs ut The Nctherlands arc estilnatcd to be around 750 rrillion guilclers (appr-oxrmateiy [,lS 9,120 nrillion per yc:rr).,,
Problems u.ith nrau, publishcct cost-etTectiveness studics
Opportunity lost to direct resources to

of 46.
Adapted from lnternational Committee onWound Management (ICWM).An overview of economic cost-effective wound care.AdyWound Core. I From Bolton LL, van Rijswijk L, Shaffer FA. Nursing
M
o n
o gem
ent.
99 6:27 :3 0-37
Outcomes In lr,-ound care stuclies,

:rccorcling ies focus
outconles :r.e usurlJl- rneasured
to the Eoals of tref,tlnL-r1t. Mant- t-ound c.rre sturlon complete he:Lling. rcduction in sudlfr rrca and
as
voluine, reduction in pain, dcbridcl.lreltt. or redr-rcc.{ incidence
include the followins: 1. Cost is often conlirsed rvith r:ost effectiveness-studies of cost ctTectil,eness nc-ed to address the cost-perulrit outcorne
of cornplicatiorx, such
prevention
inGction. Orher per.une]t.,rs might
2. There is no standard rrethod of calculating lvouncl

care costs-cirlcul:rdons har.e included various contbi-
incir-rde restor:rtion of rnorbiJin-. improvcd
quali$ of life, and

cost-edlectiveness
of nound recllrrence. In all
nations of materials.labor, hosprtal ot.erhead, and corn-
'turlic.. tltt .I)ccit]r',rultorrrr h,t. ro hc,lcrcrntine,l.
plic:rtions'r
"
achicr-e
3.
C)n1v
Published Cost-Effectiveness StudieJ

L)ata exist regarding the anrual estimated cost of chr-orr-
a ibrv studies har-c rneasurcd costs to
ic rvouncl care in
several countrics. The .r.ru.il Jorr of th. Nationel Health service in the lJnited Kingdorn {o carc ib, les ulcers ranges fronr d100 nillion to {600 nrllion (US
treatnlent outcontes " r" 4. Olltcomes are often nreasurecl or reported difTc'rently fronr study to studr,. so it is ditEcult to perforrn rnetaanalyses on existing research ro c]arifi. cost effectrr..encss of treatnrcut, debrrclerncnt, or pain rolief.
$150 to 900 million).'r A srud1. r:onductecl in tl]re Unitcd
There are few cost-eflectiveness str.tdies that measnre the CHRONIC
WOUND CARE, 4th
Edltton
Phillips
cost to achieve nreasured treatment outconles. Only 2 publishcd trials of conrpression s,vstems have includcd cost conrparisons. The clata strongly sllggest that consistently applied compression systerns can improve effectiv'cness of care and may reduce overall costs. In a 12-u.eek sttrdv, venous ulcer patients received treatment with a modifiecl (Jnna'.s boot, 4-layer bandaee, or a foam clressing and Setopress bandage. Sixty percent healed in the Unnat boot
ferred treaturent for patients $,ith hard-to-heal r,enous ulcers as corupared to lJnna'.s boot but also rc'sults in lorver
overall ffe'atment costs. Hou'ever, it should be noted that thesc data rvere gener-ated by a decision-analytic rnodeline techniquc and not by observing actual patients receiving treatmcnt for r.'enous ulcers in clinical practice.r5
Ohlsson et al:'
assessed
the cost effcctiveness
of2 treatnrent
nrixecl
regimens
mrrses.
in an outpatier-rt population
treated b)' r.isitinq
liroup at an average cost/patient/12 r.veeks of d66.24;70%' healed in the 4-1aycr bandagc group at d82.54; and 2O%o healed in the fcram/Setopress gorlp (d58.33). Thus, the cost per percenterge of rvounds l.realed r,vas lorv'er fcrr both high conpression systems than for the foam/Setopress gror.rp, and the least costly systcnl rvas also the lerlst cost elTective.r'', ln a cornparative stud1, of comnrunity 1eg ulcer clinics in 2 health authorities in the United Kingdr:m, thc proportion of ulcerated 1ir-nbs compictely healed urithin 3
months and the total cost of leg ulcer carc wcre cornpared. lrr 1 comrnuniry the introduction of communiry 1eg ulcer clirrics inrproved 1eg ulcel healing b,v 1.6'/n (P < tJ 001) at reduced cost, compared to a conrmunitv with no leE ulcc'r clinic rvhere costs rose and healing rates lemained sitatic.rr In a nrulticenter, randornizc'd, clinical trial, Falangir ct al" shon'ed a I'rumau skin equivalent to be more ellicacior,rs in healinq venous leg ulcers than comprcssion therapy a1one, especially in ulcers present fi.>r grcatel thau I vc'ar in dulatiorr. The human skin equivalent \\ias ulore effcctiv'e than
courplession therapy
Thirty patients rvith leg uiccls of v'enous or
v-enous-arterial etiology u,cle randomized to tr-eatment
r.ith
saline-soaked Siauze or hydrocolloid dressingp. A1l patients rvere bandaged'"vith the sanre type ofconrpression bandage.
Outcome measures r'vere healing or reductiorr in sufacc arca

and pain. Costs included cost of materials and supplies, nurs-
ing time, tlav-eling tinre, and kilonreters drivcn. Costs for

drcssing materials rvere sinrilar
for the 2
groups.
When thc
total care, inch-rcling nr-rrsing time, traveling time, and kilome ters clrivcn, u.ere analyzecl, the r.nean cost of trcatn)ent was
$536 (412fi Srvedish kroner) u,ith salrze dressilrss
and
$203.35 (1565 Srvc'dish kroner) w'ith hydrocolloicl dressings. This cost ditlerence rvas because the gauze group rcquired
manv more dressirrs changes than thc hydrocolloid-treated group.Two patients in tlre g.rtrze treatlllet)t group .tnd 7 irr the hydrocolloid qroup hcaled cluring the stud-v.The reduc-
tion of
t1-rc
r:1ce-r area $'-as 19% in the sauze sroLrp and 51% in l.rvdrocolloid gror:p. Tirtal direct cost percentage ch:rnuc
in u'ound
area
pel rveek rvas $21t.42 for thc gauzc-treated
in median timc to u.'ound closure
(61
c'lays r,'crsus 181 da,v) and in the percentase of patients hcaled by 6 months (63% r,ersus 49'/o). A retlospective cost-eflfbctiveness analysis was condr-rcted using a Markov decisi<:n-an;rlvtic nrodel to conrparc the cost etGctivcness and annual rreclicai costs of treatini hard-to-heal l'enous ulcels. In this studyi patients receiv-ecl 1 of2 treatruent strategies, human skin equirnlent plus conrpression thcrapy or Unnai boot alone, and n:ere followed for i vear. Only direct medical costs \l'ere included. The healthcarc resource use evaluated included the plinraly thelapeutic intelvention, additional compression dressings, physician ofTicc visits,
group and $3.97 for the h1,droco1loid-treated group.ri' Thoniast exanrined cost-effectivencss data for treatmet)t of 1eg ulcers u,ith paraflin gallzc conipared rvith alqin.rte
dressir-rgs. The effe'ctiveness parameters nreasured u,cre healing rate (cr.lr' per da.v) and tinre to heal in davs. Includecl in the dircct costs wele cost of materials iurd nursing costs. Although there u,as a r.narkcd difference in the price of dre
2 primary dressinss ($.29

sus $3.20 ld1
t40
1Ul for the paraffin sauzc'\:er-
.95] for the alginate dressings). the :rlginate-
treated gror.rp healed more quickll'.Thus, thc cost plete healing of the
lou,.er than
ftr
conr-
rvould in the alginate group \,as nruch
horne health r.isits, labclratory tests and procedures, lrlanaEie-
ment of side elIects, and l-rospitalizations.Thc results of the model indicate that the annual cost oi nranaginp; patients r'r.rtl-r lrard-to-heal venous ulccrs r.r,as fi20,257 for those initiallv mar-raged r'vith hr:man skin equiv:rlent plr.rs ,:omprcssion and $29,656 fol those treated rvith Unna! boot. Increased costs in the Urrnat boot group were par-tl,v rclated to inct'eased l-rospital aclmrssions in this group. In aclcliti,rr,
in the paratlin q:urze-treated [Jloup. The author concluded that ifs-astc is to be avoided and products are to be used cost effectivel1., nursing staffmust carefully monitor' cost effecti',.eness of all nerv and expensivc- trcatnrents b.v measurirrg and recording thc' area and lolunre of the treatcd u,ounds on a rcgtrlar basis. Bolton et al:" applied a cost-efectiveness modcl of cost
ofutilizing hvdro-
per percent reduction in rvound area to 3 ptrblished alticles and reported improved cost effectivcness
treatment with hunran skin equivalent led to approxinrately 3 uronths of additional I'realine per persorl per )rear tnd 23%'
colloid tlrcssings cornparcd to gitrrze
dressings, principall.v
morc healed ulcers overrrll conrpared to lJrura's boot. The

authors concludcd that the results suggcst that hunran skin
.lrrc to co.t slvinr:: irt rur.irrEl tirrrc. Meta-an:rl1.sis of data fronr pressure ulcer and venous ulccr studics also indicates thrt the principal lvound carc costs are
rc'latcd tt-r labor and that labor-saving dressings, snc]r as r.noi:161
equivrlcnt plus corupression is not only clinic:rl'ly the preCHRONIC
WOUND CARE. 4th
Editon
Phillips
Cost Effectiveness in \Mound Care
Bed type
Cost per 100

Patients
ulcers Per 00 patient 80
Cost saved
100
per patiena
Pressure prevented I 00 patients
ulcers per
Cost effectiveness
ratio*
Standard ICU Air-suspension
bed
bed
125,177.12
51,019.52
prevented
t6
74.157.60
64
<0
* Cost per pressure ulcer

1993;269:|139-1 143.
Adapted from lnman KJ et al. Clinical utility and
effectiveness of an suspension bed in the prevention of pressure ulcers.fAMA.
turc-reterrtive dressings, while initi:1l1y more the long run more cost effective than saline-soa$ed gauze.tl
assessed the clinical utility and cost effecofan air-suspension bed in the preven$on ofpressure ulcers. In this study,100 consecutive Nritically ill
presumed soft tissue inGction; 2) culture-guided empiric treatlnent for presumed osteorrr.velitis; 3) 71 combinations
lnman et a1''
of diagnostic tests preceding antibiotic therapy for

osteomyelitis; 4) 71 combinations of tests preceding ampu-
tiveness
patients at risk for the development of pressurclulcers were

suspensior.r bed
randomly assigned to receive treatment on ei{her an arror a standard intensive care unflt bed u,ith lrequent nurse-assisted turning. The air-stspens]on bed r'vas
, multiple
tationl and 5) imnrediate anrputatiorr. Thc main outcolrle nreasures were qua1iry-adjusted life expectancy and average costs. The authors found that culture-guided empiric treatment for osteomyelitis r.l,ith 10 weeks of oral antibiotrc therapy was as ellective as prolonged antibiotic therapy in any patient with a posirive test result. It was conclLrded that noninvasive testing adds significant expense to the treatment of patients with rype 2 dia* betes in rvhom foot osteomyelitis is suspected, and such testing results in httle improvement in health outcornes. Tests that clecrease diagnostic uncertainry are preferred by physicians but may expose patients to additional risk and engender unnecessary costs.t" Several other analyses have shorvn that empiric therapy within limited clinical settirrgs produces health outcomes equivalent to more aggressive and expensive approaches. These outcomes include the empiric treatment of dyspepsia (reserving esophagogastroduodenoscopy only fur patients who have an inadequate response to fieatment);t' empiric treatments of patients infected rvith the HIV virus rvho present with syrnptoms suggestive of pneumocystic carinii pneumonia (reserving bronchoscopl, for those who do not respond rvithin 5 days of treatment);3r and ernpiric treatment of patients with idiopathic nephrotic svndrome (avoiding renal biopsy).r'
associated r.vith fewer patients developing
or severe pressure ulcers (Table 2). In patients at risk, the use ofan air-suspensror| bed in the prevention of pressure ulcers was a cost-effective therapy. Detskl. and Naglie" proposed that neur be
introduced when any ofthese 3 conditions are 1. The new technology is less costly and
et:
at least as
effcctive as the current standard The new technology is more costly and effective than the current standard; horvever, the benefits costs of the new technology are worth the 3. The new technology is less eflective and rss costly; however, the added benefits of the curre: standards are worth the added costs. The authors concluded that the air-suspe n becl fuldcally il) fillcd the first condition when applied in a patient population at risk.The air-suspension increased effectiveness in the form of feu,cr
provided
ure ulcers
standard
for
less money than
the current program of
intcnsive care unit bed and frequent patient
In 2001, Kantor and Margolist' estimated the cost effec-
Eckman et al:o exarnined the cost effect

to diagnosis and treatmcnt of 2 diabetes meilitus rvho had foot infections
approaches
a
es of
with rype
suspected
tiveness
of common treatment models for diabetic foot
The prevalence of osteornl,elitis, he nujor complications and efhcacy of long-term antib therapy and surgery, and the performance characteristics 4 diagnoitic tesrs (x-rayr. g,j6 Ir ngliurrr.Tt 99n r bonc ing, indium in 111 labeled white blood cell scanning, an magnetic resonance imaging) were examined. The rventions
osteornyelitrs.
of over 26,000 patients with neuropathic diaberic foot ulcers seen in lvound care crenters.They estimated the cost effectiveness ofstandard care, good wor.rnd care in wound care centers, becaplermin gel,
ulcers. They used a database and platelet releasate to be 30.9%, 35.6%, 13%, and 36.8%, respectivel)'. Platelet releasate, becaplermin, and good rvound care in a r'vound center all provided improved healing rates over standard care.The incremental cost ofincreasing thc odds of healing by 1"/o over standard therapy was $414 for platelet releasate and $36.59 for becaplermin.t'''o
following hospitalization for surgical debride. and intravenous antibiotic therapy included 1) trea nlent for
1,62
CHRONIC
WOUND CARE,4th
Edition
Phillips
Using a Markov simulation model, Ghatnekar et a1'"' determined that the ulcer-free interval rvas increased bt1 24% and the amputation risk reduced by 9% with becaplermrn plus good rvould care compared to good nound care a1one.
B. False
5. There is a standardized methodologv wound care costsA.True

B. False
6.
for
calculating
studies comparing rhe cost effectiveness of wound care modalities. the lack of standardized methods of calculating costs of wound care, and the differences in outcomes that are measured, it is impossible to clarify the cost effectiveness of healing, debridement, or pain reliefrvith regard to existing resealch studies. Measurement scales should be developed to produ,ce a umversally acceptable method that includes only objective, measurable data." Such
scales
Conclusion In view of the paucity of
Direct costs include the following except: A. Costs of dressings B. Caregiver tir:re
C. Days lost from work
Answers: 1-A, 2-B, 3-A, 4-8, 5-8, 6-C
should be patient centered and show
Consensus StatementsT
wound type plus numbel of scores before and after treatment. Until universal objective scales to measure cost effectiveness are available, the clinician nrust read published studies critically and take cost-per-unit outcome into accoullt to deterDrine
1. 2,
Diagnosis and prevention (of primary disease and recurrence) should be the first aim ofall those organizing and providing wound care.
Patients, carers, health professionals, and those rvho pay
if treatment measures are indeed cost effective.
for care all need scientifically valid data on the econonric value ofwound care therapies.
Take Home Messages
for Practice
3.
i
Economic modeis should take direcr and indirect cost

and outcomes
. .
into account.
Costs are not the same as cost effectiveness.Tl\e costper-unit outcome must be assessed to determine cost erecl iveness.
4. The
direct costs ofrvound care can be identified and substantial and
calculated.
5. Direct costs of care constitute a 6. 7.
Until universal objeAive scales to measure cofl effectiveness are available, the clinician must read published studies critically and take cost-per-unit outcorne into account to determine whether treatment mteasures are indeed cosr effecrive.
increasing proportion of total healthcare costs.
Indirect costs should always be taken into account and their influence on total treatment costs evaluated.This influcnce cJn var)/ From serring to sctring. Indirect costs irrclude costs of opportunities lost fcrr patients, carers, and health proGssionals to perform other valuable activities.
by
8. In wound care, cost effectiveness can be expressed

Direct cost, indirect cost, and outcome are important in assessing cos! effectiveness of treatment.
1.
the equation: Cost efectiueness :'direct +'?indirect

achieuing 'parametcrs o;f period of time.
success
costs
(f
prcdetennined
in a
specifc
A.Tiue
B. False
1. Direct
2.The cheapest treatment is ahvays the most cost effecrive.

A. True
B. False
3. Studies
include costs of primary and secondary on the wound, ancillary supplies to cleanse and dress the wound, surgical and radiological interventions, treatment to manale wound compiications, rnedications to manage wound pain, inpatient care directll, related to the wound, caregiver tirne, travel by caregivcr or patients, and disposal of
cosrs
dressings used
ofcost effectiveness should mcasure cosr per-unit
r,vound care n.raterial or products.
outcome.
2. Indireu
rosrs
A.True
B. False
4.
assistance
include costs relared ro quality of life, in complering activities of daily iiving, cost
of days lost from work, and cosrs of litigation.

3. Pdrdmeters of suress
The words "cost" and "cost effectiveness" of trcatment

A.True
Examples could include any
rlay vary rvith patient and setting. of the following: com-
may be used interchangeably.
pletc healing, reduction in rvound care, and reduction
in wound surface
area.
CHRONIC WOUND CARE,4th Edition
163
Phillips
Cost Effectiveness in \ffound Care

Ohlsson P, Larsson K, Lirrdholm C, Moller M. A cost-eilectircness study ofles ulcer treatment in primary care. Comparison ofsaiinesauze and hydrocolloid treatDterlt in a prospective, randonrized strdv. ScanilJ Prim Heabh Carc.1994112(4\:295 29(). Colgan M!Teevan M, McBride C, et a1. Cost comparisons in the nxnasernent of venous ulceratiol. PrLtcccdings 5th Europeat Con-lerore on Aduanrcs in Wound lldnalcneftt. London, UI(: MacMillan Magazines; 1996. Taylor AD, Taylor I!, Marrusson R-W Prospective comparison of healing rates and therapl, costs fbr conventionai and,+-laver tlratnlent of venous trlcers. Ph lebology. 199[l; 1 3:20 24. Simon DA, Freak L, KinsellaA, et al. Cornntuniry leg uJcer clinics:
References
l.
2. 3.
S, Migdail I!, Strickland D, Youngs M! lledkal Outc<tnts and Gtideline: Sourcelool. Ner.York-
Vibbert
. Tlrc
1995
Y: Faulkner
(ira1,, 1n6, 1995:675.
Thomas S. Cost-effective managemeDt of 1eg ulcers Comnttnity

Ortlook. 1990:March:21 2.
Wilsoo E. Prevenrion and treatnrent ofvenous les

Tetrds. 1989:21:97
.
rs.
Health
T.
6. 7. 8. 9.
10
Bosanquet N. Costs ofvelous ulcers: {ion r)ainten investulent progranis. Phlebology. 1992;7(Suppl):;14 46 Wood CR, Margolis DJ. The cosr of treatinE vcrrous courplete healing using an occlusive dressing and a bandage. L/OLTNDS. 1992;:l(,1):138 141. Olin JW, Beusterien KM, Childs MB, et al. Medical ing lcoous stasis ulcers: evideuce from a retrospecti\rc Var LIed. 1999;1(1):1 7.
therapy to ulcers to
oDrpresslve 23
a comparative study iD trvo health authorities.
Br'14/.
of treatstudy
1996;312(7 r)47) : 16,+8-1 651. FalangaVA nerv cost-etTective therapy for the treatntent ofhard to heal venous leg trlcers. Wuntl Reltair Rcpca. 1998;6A:2,tr.1. Schonfelcl WH,Villa KE Fastenau JM, Mazonson PD, Falanga V An
Morrell CJ,Walters
1
SJ,
Dixon
S,
et al. Cost
nity lee ulcer clinics: randomised

998;3 16(7 1,13):1,187-1 491.
controllecl
comnluBt[J Dunatol.
iVars Clin
Ticdilnenl Studies; 26
economic assessnrent ofApl:igraf (Graftskin) lor the treatment of hard-to lrca1 verrons leg ulcers. Wound Repdir Regert.
2Otli);8(,1) :25
1-257.
Kanj Lf;Wilking S\{ Phillips TJ. Pressure ulccrs. /,4n 1998;38(:t):517 536. Maklebust J. Pressure ulcers: etiology and
North
An.
1987 ;22(2\
:359 377.
27
tsolton LL, van l{ijswijk L, ShatTer FA. eualiW rvound care ecluals cost-effective u,ound care: a clinical rlodel. ,\iaru Malage. 1 99 6;27 (7 :30j2-33,37 . ) Harrington, 13th Anoual Synrposiun on Advanced Wound Care.
Dallas, Tex. Desky AS, Naglie G.A clinicial's guide to cost elllctiveness analv, sis. Ana lntcrn Mcd. 1990;1 13(2):147-154.
Miller H, Delozicr J. Cost Impliations of the Prcs*re Cuir{elines. Colunbia. Md: Center for Health Po
1
994: 17. Contract No. 282-91-001J0.
11.
Haalboorn JR. Enkele aspecren van decubitus u'or andling kunst en rvetenschap. Symp Proc. Errerpta Mct{ica. I99( 39-42 Gorse GJ, Messner RL. Llproved pressure sore healirrg hvdro-
MH, Grc-enfield S, Mackev WC, et al. Foot infcctions in diabetic patients. l)ecision and cost-elfectiveness analysis. J,4,,U,.1.
Eckman
1
91) 5;27
3(9 ) :7 12-7 20.
colloid dressings.,4
rch D e nr at o l. 1987
; 1
23
(.6) :7
66-7 7 1.
14. 15.
16.
Coirvell JC, Foreman MD, Trottcr J11 A conrparison ol: etlicacy and cost-et-lbctiveness of two nethods of nana!!ing ulcers. Dcatbirus. 1993 ;6(4) :28-3(). Alterescu V The financial costs of inpatient pressure i ters to an acute care faciliry. Dcarbitus. 198!l;2(3):1:t 23. Meredith K, Gary E. Dressed ro hea1. J Dl 1 988;7(3):8-1 0. Roberts L\Il McManus WE M:son AD. Pruitt BA m in the managettent of skin graft donor sites. Iu Hall CW, Surgital Reseanh : Reccnt Derefop[]errJ.Perqiinlon; 1 985:55 58. lDrnan KJ, Sibb:ild WJ, llutledge FS, Clark BJ. Clinic :nd
cost-etTectiveness of an air suspensioD bed in the pressure ulcers.J,4,i\,1,4. 1 993;269(9) : 1 139 1 1'13.
v1
32
Moskowitz AJ, Kuipers BJ, Kasirer JP Dealing u,ith uncertaintl,, risks, and tmdeotii in clinical decisious. A comitive science approach.,4rn LLtern Me d. 1 988; 1 08(3):435 449. I{ahn KL, Greenfield S.The eilicacy ofendoscopy in the evaluatioo ofdyspepsia.A review ofthe literature and developuent ofa soun<j strategy.J CLin Gastrocnterol. l986;8(3 Pt 2):346 358. TU J\4 Bien HJ, Detskv AS. Bronchoscopv versus enpirical thera py in HtV infected pxtients with prcsumptive pneunrorystis aritii
pneumonia. A
1t)9 3 ;1 18 (2) :37
decision analysis. ,4rr Rcz Rcsplr

7
.
Dls.
0-37
33
Levey AS, Lau J, Pauker SC, Kassirer JP ldiopathic nephrotic syn-
drorrre. Puncturing the biopsl. myth. Ann lilterLt Mill.

31
1 987 ;1t)7 (5) :697 -7 1 3. Kantor J, Mrrgolis ljJ. Trearlnent options for diabetic neuropathic
l\obinson tsJ. Randomized comp:lrative trial oF Viscopaste PB7 and bandage in the mauaselrent of uiccration and cost to the conrmunitr'. In: Rlan TJ, OttLusiLut: Wouwt Carc Proccedings. Lilemdtiofidl Congtcs! Scrlcs #136. London, UK: Ro1a1 Societ_v of
1
1111
VS
foot ulcers: a cost efi'ectiveness analysis. Defitntol

2t)01;27 (4):347-351. 35.
Sw!.
nous leg
Beyond
Setvices;
-gaLrze
Warriner RA, l)riverVI\.The true cost ofgrou,th facror therapy in diabetic foot ulcer care. I4lOLI\DS. 2006;1tl(Suppl):3-10. Ghatnekar O, Persson U,Willis M, Odegaard K. Cost efectiveness
9811:1
01-10,1.
19.
Xakellis GC, Chrischilles EA. Hydrocoiioid versus dressiugs irr treating pressure ulcers: a cost-etTectiler Arc I L Ph1,s NI d Reh abi l. 1992;7 3 (5) : 463- 469.
e
rnrly.r.
37
of becaplerrrin irr the treatlnent of diabetic loot ulcers in four European courrtries. Ph arnacoeconomits. 2001 19(7):7 67 -778. Special report: International Coturlittee on Wound Managemc-nt world council on cost-effective wound care. riloLTNDS.
1995;7 (3):119-120.
Regulatory lssues and Reimbursement C hallenges

Glenda J. Motta, RN, MPH, ET
Objectives
-he reade'wi
I be cha lenged to:
. .
.
Distinguish lederal reimbursement as it rel:[tes to wound care provded n a specific clinical setting Utilize the documentation elements that ccf nstitute medical necessity to suPPort rermbursement for wound care services, producrs, and Lechnotog es Analyze Medicare coverage requ rements
ii:r I adjunctive wound
care theraPy.
lntroduction R. ecul.rron irsucr and rcintbttrsetrretrt tncchanisttt ;. .r..r.rou impact otr the quaLiry o[ care, the P I \,,,.oJr.tion of neu ccclrnolog.icr. the uriUzrriorr of
products and services, patiellt access to care, payment for
service is leimbursed. To ansr'ver this question, several pieces of information are required, including: . Clinical setting ofnse (eg, acute care hospital, rehabilitation center, subacute care or skilled nursing laciliry home health agency, p\siclrn oltrce, outpatient clinic,
ploviders, and the actual outcomes

Program budgets, such
as those
of carc delivered. '
for Medicare and Medicaid,
arc fixed in advance, and the rcimbr-rrsement or payment rnechanisnr often deternrine how funds are distributed and rvhich services, products, and technologies are corzeted. Healthcare pr-ofessionals are often uncomforr;ab1e with the busiiress aspects ofpatient carc. Horvever, like it or not, hea-lthcare is big business, resources are tight, atld patients
are being identified by hor.v much revenue 1[sr1 generate
ambulatory surgerlr center, a paiient'.s home) Payer qPe (eg, Medicare, Medicaid, managed care organization, health maintenance orqanization IHMO],
supplemental insurer, private insurer, Veterans'
. . .
Administration, rvorkers' cornpensation) Coverage policy for the individual payer Medical necessiry lecluirements for coverage of the service, dressing, supply, devrce, biologic, drug, or technology
Patient diagnosis rhat supports the medical necessity for
or lose for healthcare providers. Smart wound ,care clinicians are expanding their advocacl, role b,v considering
these factors r'vhen caring for their patients.To ensure ade-
the service, dressing, supply, device, biologic, drug, or
. .
quate coverage and pal,ment for services, dressings, suppIies, devices, biologics, drugs, and other techno.logies, c1i-
nicians must learn how

as
to
document assessments, inter-
ventions, patient adherence to treatment plans, and clinical
technology Codes assigned/verified by various insurers for billing :rnd reporting costs Fee schednle, assignecl paynrent amount, payrnent lnethodology, or procedure for determining the anlotlnt to be rcimbursed for covercd ffeatment.
rvell as financial outcomes of care. Clinicians often ask manufacturers, sale representatives, ol distributors rvhether thc nerv dressing, technology, or
Motta
Key Elements of Reimbursement

Reimbursernent conrprises thesc key elements:
1)
CiJ.
Book for Heolthcore Professionols.
Regulatory issues ancl reimbursement challenges. In: Krasner DL, ll.odehear.er GT, Sibbald 11G, eds. ChronicWound Core:A Clinicol Source 4th ed. Mah'ern, Pa: HMP Communicrtions,200T:165 175.
CHRONIC WOUND CARE 4th Edtion
165
Regulatory lssues and Reimbursement Challenges
r.vhether or not the service, dressing, supply, dev
biolog-
Medicare & Medicaid Services (CMS).The federal statutes

set forth broad parameters for coverage, eligibiliry and payment; the DHHS promulgates rules and regulations that
ic, drug, or technology is a covered bene{it of t specific insurer in the particular clinical setting where and 2) whether or not the amount paid is adequate appropriate or "a11 inclusive." Each insurer determir coverage policy and payment (ie, covered benefit) for new hnology based on a review ofclinical evidence.These tews afe conducted by a number of entities. For example the Blue Cross and Blue Shieid Association Technology va-luation Center (TEC) assesses available evidence on the agnosls,
treatment, management, and prevention of disease
is an Evidence-brsed Practice Center (EPC;
govern these programs. The traditional Medicare fee-for-service program consists of 2 benefit categories. Part A covers services that require hospitalization on an inpatient basis or that are pro-
vided by a skilled nursing facility (SNF), home health agency, or hospice. Part B covers services provided on an
outpatient or ambulatory basis, such
as
physician otlice vis-
eTEC
Agency
prepare
its, outpatient hospital visits, physical therapy, or care
in sur-
o[
for Healthcare Research and Quality.' The E

evidence reports and technologv assessments on do not make clinical or reimbursement and reconrmendations. The nedical directors and
each individual insurer assume that responsibiliry
gical centers. Part B also covers medically necessary DME, prosthetics, orthotics, drugs that are not self adnrinistered,
and nedical supplies subject
but
to certain conditions.
and
policy
staff
The Medicare Prescription Drug, Improvement,
of
For Medicare coverage policy decisions, the
rnment
utilizes a National Coverage Determinatio

process.A formal request for a
(NCD)
either
NCD
can be
initia
Modernization Act of 2003 (MMA; Public Law 108-173) established and regulates the Medicare Prescription Drug Benefit, knorvn as Part D.'As ofJanuary 1,2006, Medicare coverage for prescription drugs is now provided under pnvate prescription drug plans and insurers.
by an outside party or internally by Medicare ff. A key part of the NCD pr-ocess is an evaluation of w ther an item or service rs reasonable and necessary. Med re poli(ylnakers . aU ltor the be.t .r'icntifit ancl t lirrjcal idence available on the ellectiveness ofthe procedure or to evaluate it for coverage.' Payment mechanisms vary by insurer as w-el1 edicare, the largest payer for healthcare in the United , sets
prices administratively and pays for services usi generaliy organized by delivery setting. Services the acute care hospital, skilled nursing faciliry
agency, inpatient rehabilitation hospital, hospice
systems
1n
Medicare*Choice, authorized
by the 1997
liom
a
Balanced
Budget Act, allows a beneficiary to select plans provide standard Medicare Part
number of
private insurance plans to receive Medicare benefits.These
A and Part B benefits
and may also offer additional benelits not generally covered
under traditional Medicare. Examples of Medicare-lChoice plans are private fee-for-service plans, Medicare savings
accounts, and managed care p1ans, such as HMOs and preGrred provider organizations (PPO$. For traditional Medicare, actual day*to-day implementation of the ru1es, determination of eligibiliry and payment are handled by various insurance companies under contract with CMS. Fiscal intermediaries (FIs) process claims for Part A bene{its and hospital olltpatient services. Local carriers process Part
health hospital
relmoutpatient center, or an ambulatory surgery center bursed under a prospective payment system (PPS). nls auinclusive" payment mechanism does not pe separate billing for equipnent, devices, or supplies used in settings because they are "bundled" into the PPS.
Part B pays for physician ser-vices, outpatient thera-
B claims for professional
services,
including
physician, nurse practitioner, physical therapy, and podiatry

services. Durable medical equipment Medicare administra-
other proGssional services (eg, podiatry nurse er, clinical nurse specialist), durable medical (DME), prosthetics, orthotics, and supplies in c according to an allowable amount or Ge schedule programs are administered individually by the involve a number of dillerent payment mechanis
p)',
tlonlpment
settings
tive contractors (DME MAC$ process Part B claims for DME, prosthetics, orthotics, eligible drugs, and supplies. Although traditional Medicare benefits are the same
netionwide, coverage and payment may vary by contractor. For Medicare*Choice, the claims fi1ing process and payment amount are determined by each individual p1an. Medicaid is a medical assistance program that provides healthcare services for individuals who are elderly, b1ind, disabled, or members of families with dependent children who rneet specific eligibility requirements.The program is adnrinistered by an agency, such as the Department of Social Services or the Department of Health. Some states contract r'vith a fisca1 agent to process and pay clairns and interact with providers. Benefits nray be offered through contracts with HMOs or other rypes of prepaid, capitated,
icaid
and
.
Private
insurers pay using negotiated rates, discounts calc
from
actual charges, capitated amounts, or other mecha
Overview of Medicare and Medicaid

Regulatory overview and administration of 2 government programs, Medicare and Medicaid, are the biliq, of the Department of Health and Fluman rvlces
(DHHS), acting principally through the

166
Ce
rs for
CHRONIC WOUND CARE 4th Edition
Motta
or managed care plans.The Medicaid statute mandatps mlnimum services. However, each state may elect to provide additional benefits, such py, or support surfaces.
as
r.vound dressings, physical thera-
l.
Case: managers..or utilization. r.eYiew
coofdinator!
are key players in determining coverage.

2. Payment is made only for those products and services tha!,are deerned rea,sqnab,le and medically necessary for the diagnosis and treacment of an illness or injury.
Regulatory lssues and Wound Care in Various Clinical Setti

To facilitate reimbursement by any third-pa
some basic tenets apply (Tlble 1). Coverage for serv products is determined by the individual plan personnel, such
as
as
for
payer,
and
.rs
key ut1-
professionals is the basis on which medical
medical directors, case managers,
for lization review coordinators. Payment is made necesand medinlly deemed reasonable and services products irrt.rtsary for a patient's specific diagnosis. For exampl.,
a The singlq;1mo!t critiaal key torfavqr:able . . cove6gg.decisions is complete, accurate, ald

,
descriptive documentation.
b. When in doubt, include as much information, I history, and ratiqnale as possibie'in'a,clear, concise fashion.
if the primarl,
er would deny a claim for treatment of a diabetic fobt u1.er diagnosis code subnritted was diabete[ meli-
"{
,.
tus.The service and products are medically necessary] for the ulcer, which should be the prirnary diagnosis. Failing to code the diagnosis to support medical necessiry for tl]ie service is a rnistake commonly made on innumerable cl1ims. Other documentation supplied by healthcare proftssionals is used by insurers to determine medical necessitr For a new dlagnostic device or treatment modaliry it is cr[tica1 to provide the payer rvith an information packeie that includes published clinical data. protocols, case studies, and prorluct-specific literature to educate the clairns revip-e. or
case rnanager. Many manufacturers offer reimbulisement support services, billing guides. and telephone hotlifes th:t assist customers and provide payer information matbrials to
q. For a new ploducl.oq sirvice,alwavi provide an inforlmaqion pagkage with pr.ofetsional artiqles, testimonial letters, clinical studies, protocols, and produ ct-spec ifi c l iterature.to educate' ihe claims reviewer.
4. One company could provide hundreds of different types of insurance plans. Moreover, each payer has speqific rules for claiimi processing and t documenlation. Learn them. . '.. r
l
.
5. lf a claim is denied, always file an appeal with additional documentacion.
.ubnut to insurerr.
Submirting rccurJte. complete in[ormarion ior senices provided to patients in the acute care hospital, subacl.rte care unit, SNII hospital outpatient department, hospice, dr home health agency setting is critical to support medical pecessi-
ty requirements established by third-party payers. Documentation of pertinent observations. profgssionel actions, and other treatment interventions i: cru{ia1 and must include findings from patient assessment, {roblem identification, goals of care, implementation/trdatment
p1an, and an eva.luation
manufacturer has verified coding u,ith the appropriate agency, such as the American Medical Association (Current Procedural Terrninology [CPT]), the fiscal intermediary (revenue codes), local carrier, and the Statistical Analysis Durable Medical Equipment Regional Contractor (SAD MERC; Healthcare Common Procedure Coding System [HCPCS]). This is true not onlv for acute care hospital service. but .rlso for all care settings. Subacute care. Subacute care is provided to patients who no longer satisfii Medicare, Medicaid, or other payer medical necessity criteria for acute care ser-vices but sti1I require inpatient skllled care for rehabiiitation or wound treatment.This leve1 of care is designed to meet the needs of a growing group of patients who are sufliciently stabilized and no
of the outcomes.
by Medicare and Medicaid using a PPS. Private insureps often negotiate discounted rates or predeternrined lees ftr services rather than reimbursing lor actual costs or (harges. Wound dressings, technologies. and othcr devices. such as support surfaces, are not bi11ed separately to Medicare or
Acute care. Hospitals are paid a 6xed amount
longer require costly hospitalizarion. Nearly all healthcare

payers recognize and reimburse
for subacute care
ser-vices.
Flowever, there is no standard payment mechanism
or
rate.
Medicaid, since payment is rncluded

PPS.These may be itemized separately
in the
all-ijrclusrve
for cost accpunting
purposes and payment by private insurers when "unbun-
dled" services, devices, or supplies are reimbursed s+parately from the daily rate. Before assigning codes {or cost accounting and billing, it is important to deterrnir]e if the CHRONIC
Subacute care facfities are reimbursed on a program-specific and site-specilic basis. Payment varies by payer source, based on a faciliqr-specific contract, or may be determined on a case-by-case basis. Examples of possible reimbursement arrangements are fee for service, discount-off charges, per diem, fixed per case rate, and a capitated rate. IJnder
167
WOUND CARE,4th
Edition
Medicare, subacute services are covered
as
SNF
ca
and pay-
ment is based on the docurnented level of ca Medicare pays SNF car-e using a PPS, described in the nex section.
regimen);2) expected outcomes;3) progres or decline actuaUy obsencd: and ,lr applopriate intervennon'.
Skilled nursing facilities. Medicare Part to 100 days of care in a SNF per spe11 of illness
covers
L1p
all of the [ollolving critcria are met: . The required skilled nursing services and/or rehabilitation services can only be provided on an in nt basis
. . . .
Most state Medicaid progralns pay a fixed per diem alnount for SNF care, and rvound supplies are often included in this allorved rlnount. If the resident's nursing home care is paid for by Medicaid and the resident also has Medicare, lvound dressings may be reimbursed under the Part B Surgicai Dressing benefit (see "Medicare Part B" for
eligibiliry requirements). Horvever, DME, such
as a
Services are needed on a dailv basis The beneficiary has a qualifiing hospital stay consecutlve days
support
fat
least 3
sudacc, is not covered and paid under Part B
ifthe benefi-
The beneficiary is transGrred to the SNF of hospital discharge Skiiled services are necessarv for the sanre problem related to the reason for hospitaliza For services provided under Part A, Medicare
c
n 3ft days
lnora
SNFs supplies, PPS rate.
under a PPS.The costs of all treatments. wound

therapies, and support surfaces are rncluded
in
Medical sr-lpplies and services may not be billed during the SNF stay.This is knorvn as "consol The SNF Medicare prospective payment is
r Part B
bil1ing."
d on the
ssment
level of care documented on the Resident

Instrllment, which contains a rninimurn data
screening and assessment elements. Clinicians
(MDS) of
resl-
dent needs and staff tirne required to provide rnedicalll necessary care. Anticipated tre:rtrlents for each are categorized into service blocks known as Resource Utilization Groups (RUG$.The RUG cl r system is organized into 7 major categories: 1) rcha tation; 2) extensive services; 3) special care; ,l) clinically c rplex; 5) impaired cognition; 6) behavior problems; and redrrced physical function. Each RUG category is furt r divided
ciary resides in a SNF. Private insurers may supplement Medicare and pay the deductible and copayrnent for dressings or other items covered r-rnder Medicare Part B. In general, eligibility requireinents will follorv Medicare policies. Federal regulation, specifically Federal Thg 314, Pressure (-Ilcers, reqr-rires that all residents in nursing homes (regardless ofpayrnent source) receive the care and supplies necessary to prevent the development or r.vorsening of pressure ulcers.The intent ofthe legularion is to ensure that residents in long-terrn care facilities do not develop pressure ulcers unless their climcal condition renders the ulcer unavoidable. A surveyor u.i11 cite a facility for auoi.dabh pressure ulcers ifthe resident develops a pressure ulcer because facility stafflailed to do 1 or more of the lb1lowing: evaluate the resident's clinical condition and risk factors; define/implenrent interventions consistent with resident goals/standards of practicc; monitor/evaluate the impact of interventions; and/or revrse
irrterventions.r The CMS considers pressure rlcers unduoidable
if
the residcnt develops a pressure ulcer cven rhough the
faciliry evaluated the residenti clinical condition and risk

factors; defined/implernented interventions consistent
with
resident goals/standards
of
practice; rnonitored/evaluated
interventions.
into specific patient groups used to detennine t
a1110Unt
the irnpact of interventions; and revised
of payrnent. Special care ancl clinically

RUGs specific to wounds. Healthcale providers in a SNF must conrple according to a mandated schedule. Failure to do in either a "defau1t" payment, tl.re lowest
under the RUG system, or no payment at all. It is the appropriate
are the the MDS
will resuit
Palrment
itical that residcnt. payFor
RUG category be
t1're
assigned
to
e
:111
If the
category documented does not reflect
mcnt will be too low. On

Medicare Part
ues
other hancl. ove

conflnunrelrt-
nursing and therapy needs can be considered fra
coverage, proof that the benefic
to require skillcd nursing care rnust be clearly
ed
in the MDS, clinicians'notes,
care plans,
p\sician
rovided is
orders. Docunrentation n1l1st prove that the care
Facilities are also required to provide the necessary treatnrent and services to prolnote healing, prevent inGction, and prevent nerv ulcers frorn developing when a resident has cxisting pressur-e ulcers. The content and quality of docunrentation is criticai. Clinicians caring for residents in a SNF should docurnent risk assessment; develop a comprehensive care plan that reflects measures taken to prevent ulcers; treat eristitrg ulcers according to the standard of care; and record subsequent outcomes of all interventions.The CMS criteria for nrinimal pressure ulcer documentation include location and stage; size; exudate; pain; color and type ofwound bed tissue; and description of the r,vound edges and surrounding tissue. Facilities may irnplement docuntel]tation regarding
avoidable versus unavoidable status that addresses risk factors, cornorbidities, and other situations that predispose or lead to a pressllre ulcer for an individual.
skilled or rehabilitative and can only be perfor under the supervision of liccnsed nurses or the
medical record should also indicate: 1) the reason
by or
The benefici.
ary is certified for Medicare (eg, rnonitoring of vit signs and other conditions, provision of a cornplex wound atnlent
158
Horne health agency. Skilled nursing and rel'rabilitative

services pr-ovided
in the home are covered by Medicare and
CHRONIC
WOUND CARE, 4th
Edition
Motta
many other payers.'Wound care services generally fall into the follorvrng categories: 1) observation and assessrnent;2) teaching or training; and 3) direct hands-on care. Medicare considers observation and assessnrent to be reasonable and necessary rvhen a beneficiary's condition requires skilled nulsrng personnel to identi{, and evaluate for either modification of treatment or initiation of additional
medical procedures.Teaching and training activitics are covcaregn-er how to the wound, reinforce teaching previously provided in an irxtitution or at honre, imtrete instmctions, or tcach
Open wounds draining purulent or colored exudate or that have a foul odor and/or for which the beneficiar.y is receiving antibiotic therapy Wounds with drains or t-tubes requiring shortening or movement
ered
to teach a beneficiary', the fanrily, ol
lnanaJe
. Wounds requiring irrigatlon or installation of sterile

or medication solutions into several layers of tissue and/or packing wich sterile gauze
cleansing
ploper application ol a specialized dressing. The Medicare Regional Home Health Internrediary Manual (HIM 11)
fu11y explains
Recently debrided ulcers
the types of r.vounds that usual11, qr,re1ifi under

w-ound specialist
the Medicare home healthcare benefit (Tab1e 2).
Medicare pays home hea1tl'r agencies under a PPS based on a 60-day episode.Thc alnount rs all inclusive except for DME and certain diabetes supplies that are paid under a fee schedule. Honre health agencies are reqr-rired to provide (r'vithout billing separately) the basic supplies used in c'rnng for patients. The CMS has bundled approxirnately 194 rnedical supplies into the relrnburserlent rate. If a medical supplicr provides these supplies, the home health agencies
pay the supplier rather than the supplier brlling Medieare. Examples include catheters, irrigation supplies and solutions, skin barriers and ostorny supplies, wound dressings, conlpression bandages, and tracheoslorny supplies.
to consult on
cases
lvithout
a home visit
and provides valuable feedback to physicians rvhen request-
ing a change in the treatment plan.
Hospital outpatient. Medicare and rnany other pavers cover r'vound care provided in hospital outpatient clinics and u,ound centers.The number of l,isirs covered and payn'rent are deternrined by each individual insurer. For eramp1e, managed care organizations often limit the number of visits, and providers must obtain prior authorization to
ensure reirlbursenrent.
The Medrcare honre health agency PPS establishcs
an
adjustment to measure the intensiry of each beneficiary's service requirements based on a standardized evaluatron
Medicare Part B pays for hospital outpatient serviccs under a PPS.The PPS consists of arnbulatory patient ciassific:rtion (APC) groups, each lvith a payment rate thrt is adjr-rsted by geographic region. Services rvithirr an APC are
clinrcally related and require sinrilar resoLlrce use. Payment is calculated based on the r.nedran cost (operating and capital) of the services included in tl're group. Thc total APC paynrent is cornposed of the Medicare payrnent arnounl and the beneficrary copaylnent anlount. A hospital m:ry require a number of APC payments for the services furnished to a patient on a single day. In this setting, Medicare pays for diagr.rostic laboratory services, orlhotics, prosthetics, and take-horne surgicel dressings based ot-t a Ge sched-
instrurnent knorvn as the Outcornc and Assessment Inforrnation Set (OASIS). The OASIS is a group of data elements used to conrplete a comprehensive assesslttellt. These same elements forrn the basis for measuring out-
or evaluating horne health agencl, performance. Items specific to wounds, including pressure ulcers, stasis ulcers, and surgrcal u.ouncls, are inclr-rded in the OASIS dataset. Each beneficiarl, is scored in ,l clinical,5 functiona1, and 4 service utilization OASIS items.The calculation of these scores results in categorization in t home l'realth resor-1rce group (HHRG). Each HHRG is assigned a pa1,conles nlent r:rte that corresponds to a spccllic leve1 ofservices. Documellration and data collection are par:ticular\ inrportant in hone I'realthcare to nuximizc payruent and
ensnre finlncial profitabiliry Ideal inforrnation syslems should include individual data point collection lbr wound
rneasllrements and descriptions agencies analyze patients
a11ow
Exceptions from APCs are services provided at critical (formerlv called rural care hospitals) and hospitals in Maryland that qualiS, for payrnents under the
u1e.
access hospitals
payment system established b1, the state.
Medicare Part B Wound Care Coverage and Payment

Medlcare Part
pays for covered DME, prosthetics,
in discrete fields. Successful wound care data to obtain aggregated
trends on healing rates and other clinical outcortres. For with multiple wounds, staff should have tools that
thorough docurlentation lor each rvound, especially

a
if the etiolog-v varies. Digital rmagc input can allow

CHRONIC
orthotics, supplies, physician/profcssional services, and hospital outpatient senices. Although the CMS has primary responsibiliry for Medicare, it contracts rvith insurance conpanies to process and pay claitns. Medrc.rre administrative contractors (DME MACs) process and pay covered DME, prostl-retics/orthotics, and supplies (DMEt69
WOUND CARE, 4th
Edition
POS) and certain drugs The DME MACs are 4 insurance companies conMACs tract to the CMS. As of July 1, 2006, the replaced the 4 DMERCs that previously proc DME_ POS clairns.The DME MACs process claims ing to a :h DME beneficiary's permanent residence. In addition, MAC establishes coverage policy that defrnes me cal ner:essiry documentalion requirements, and utilization Some medical policies are identical
Payment for iterns submitted to the
(eg,
blood sample) other than the site of an indwelling It

also
catheter or needle.The coverage policy sets forth utilization parameters and definitions of many wound dressings. stipulates that the dressing size must be based on and appro-
priate to the size of the u,ound.' If a physician or other healthcare proGssional applies
idelines.
for
al1 4
MACs.
based on
DMI
MACs
(
a fee schedule
as
or allorvable amount. Rei
nt for
covered item is B0% of the Ge schedule amount rvhiche-ver
known
the Medicare allowable) or the actual charge/ tail price, is lower. The beneficiary pays a c ndar year deductible and the remaining 20% (knorvn as a c Supplemental private insurance plans and Me (for the medically indigent) cover the deductible and payment
amounts for covered items.
surgical dressing as part of a professional service bi1led to Medicare, the surgrcal dressing is considered incident to the service and not separately payable. Claims for these dressings must not be submitted to the DME MAC. Claims for the professional service may be submitted to the local carrier or fisca1 intermediary However, if dressing changes are sent horle with the patient, claims for these dressings may be subrnitted to the DME MAC. 'Wound care supplies that are not covered by Medicare inclr-rde skin sealants or barriers, rvound cleansers or irri-
gating solutions; solutions used
to moisten gauze (eg,
Surgical dressings. Reimbursernent for nd dressB is provided under Surgical Dressing Benefit. The DME MAC policy stip that
ings under Medicare Part surgical dressings are covered when either of the [o11owing is medically necessary:
[) treatrnent of a wound
used by,
or treated by, a surgical procedure or 2) debr

wound. Surgical dressings covered by Medicare i
t of a
pr1ings
saline); silicone ge1 sheets; topical antibiotics; enzyrnatic debriding agents; and gauze or other dressings used to cieanse or debride a wound but not left on the wound. In addition, any item listed in the latest edition of the FDA's Approued Drug Products with Therapeutic Equiualence Eualuations (eg, an antibiotic-impregnated dressing that requires a prescription) is considered a drug and is not covered under the Surgical Dressing Benefit.
mar; drctsings (ie. therapeutic or
prorecrive
Cornpression bandages. The DME MAC surgical

dressing policy also addresses compression bandages. Light
applied direct\ to rvounds or lesions either on t skin or caused by an opening to the skin) or seconda dressings (ie, materials that serve a therapeutic or protecti function and are needed to secure a primary dresing). M icare also
requires that the surgical procedure or debriden be per-
compression bandages, self-adherent bandages, and con-
forming bandages are covered when used to hold wound cover dressings in place o\rer any wound type. Moderate or
formed by a physician or other healthcare profl a1 to the extent perrnissible under state law. Debrid nt ofa wound may be an1, rype, including but not [nri to surgical (eg, sharp instrument or laser), mechanical irrigation or wet-to-dry dresing$, chemical (eg, topic I application of enzymes), or autolytic (eg, application o: occlusive dressings to an open wound). Dressings used for chanica1 debridement, over chemical debriding agen , or over wounds to al1ow for autolytic debridement are c red, but the agents themselves are not covered.
Surgical dressings are covered by Medicare
as
high compression bandages, self-adherent bandages, and padding bandages are covered when they are part ofa mu1tilayer compression bandage system used in the treatment of
a venous stasis u1cer. Al1 of these bandages are not covered when used for strains, sprains, edema, or situations other
as
long
they are medically necessary. Dressrngs over percutaneous catheter or tube (eg, intravascular, epidural nephrostomy) are covered as long as the catheter or tube place and after removal until the wound heals. D
a cutaneous fistula that has
rtalns ln
ngs are
not covered for the following conditions: 1) drai age from

not been caused by or
ted by a surgical procedure;2) a stage
pressure ulcer;
a 6rst-
degree burn; 4) wounds caused by traurna th require surgical ciosure or debridement (eg, ski
abrasion); and
170
do not
teaf or re slte
5) a venipuncture or arterial
than as a dressrng for a wound. Gradient compression stockings are covered when used in the treatment of an open venous slasis ulcer.They are not covered for venous insuficiency without stasis ulcers, prevention ofstasis ulcers, prevention of the recurrence of stasis ulcers that have healed, or treatment of lymphedema in the absence of ulcers. Compression burn garments are covered under the Surgical Dressing Benelit when used to reduce hypertrophic scarring and joint contractues following a burn injury. Durable medical equipment. Medicare Part B also covers certain DME used lor wound care if a beneficiary does not reside in a SNF. Examples include pneumatic compression devices, negative pressure wound therapy (NPW.T) pumps, support sur{aces, therapeutic shoes for patients with diabetes, and transcutaneous electricai nerve stimulation (TENS). Coverage and payment requirements are detailed in the corresponding DME MAC policy.
Regulatory lssues and Reimbursement Ch
Clinicians should revierv these prior to recommen Lng any DME for a Medicare beneficiarrr Pneumatic compression devices are covered in th[ home
setting for treatment of chronic venous insuficienc|, of the lower extrenritres only if the patient has 1 or more venous stasis ulcers that have failed to heal after a 6-month trial of conservative therapy. This trial must include a com$ressron bandaging system or compression garment, appfopriate The dressings for the wound, exercise, and limb physician must document the patientt diagnosis an[ prognosis; symptoms and objective findings; reason the {evrce
rs
bed system; or the electrical system is inadequate to meet the anticipated increase
in energv consumption.8
Therapeutic shoes, inserts, and,/or modifications to therapeutic shoes are covered under Part B Medicare if a patient has diabetes mellitus and 1 or more of the following: previous amputation
ofthe other foot or part ofeither foot; his*

pre-ulcerative
tory of previous foot ulceration; history of

calluses; peripheral neuropathy
required; treatments tried and failed; and the clinical response to initial treatment u,'ith the device, in$uding
changes in pretreatment wound measurements, aliliry to tolerate the treatment session, and abi1iry of the pafient or caregiver to apply the device for continued use at Negative pressure wound therapy pumps and supplies may be covered in the home setting for a patient with a chronic (present for at least 30 day$ Stage III {r Stage
u,ith evidence ofcallus formation; foot deforrniry; or poor circulation. In addition, the certifiing physician must document the diagnosis and quali{,ing condition and the comprehensive plan of care.' Medicare covers TENS when prescribed for relief of acute pain experienced after surgery or chromc, intractable
pain that has lasted at least 3 months. Medical necessiry may be of limited duration and subject to a trial basis.''l
'Wound care services provided by professionals

and clinics. Healthcare professionais (eg, physicians, physical therapists, occupational therapists, podiatrists, chiropractors, nr.rrse practitioners, clinical nurse specialists, nurse
IV
pressure u1cer, neuropathic ulcer, venous or arteri+l insuf-
ficiency u1cer, or ulcer of mlred etiology. The policy requires extensive documentation on general
MA(]
that should be addresed, applied, or considered and r led out
prior to NPWT application. Coverage will
be
ifa
nent ls wound has 1) necrotic tissue with eschar and debr not attempted; 2) untreated osteomyelitis; 3) or4) a fistula to an organ or body caviry within the Pressure ulcer support surfaces are grouped into 3 cate-
midwives) and hospital outpatient clinics bill for services under Medicare Part B. The CPT codes identify medical services and procedures furnished and are used for billing these services. The inclusion of a code in the CPT codebook does not imply any health insurance coverage or a reimbursement policy. For example, electrical stimuiation (unattended) may be reported with code 97014 for all payers except Medicare. A National Coverage Policy details Medicare coverage for this modaliry which is limited to
gories by DME MAC policy. Group 1 includes {nattress overlays; pressure pads with pr.rmps; ge1 pads; air. waterf, or dry pressure nlattresses; and sheepskin. A beneficiary witlrout an
such as a nutritional deficit
uicer rvho has limited mobility and a complicatin$ factor, or incontinence, qualifips for a group 1 product. Group 2 products include powere$ flotation beds, powered pressure-reducing mattresses and (ver1ays, and nonpowered advanced pressure reducing overi[ys and mattresses.These items are covered if a beneficiary hfrs mu1-
certain fypes of ulcers that meet specific requirements. Medicare requires the use of G0281 for electrical stimulation iattended) ro code this service. Medicare claims for professional and hospital outparient services are processed and paid by the 1oca1 carrier or fisca1 internrediary. Payment for professional servi.ces (other than hospital outpatient, which is under PPS) is according to a fee scheduie that lists services by CPT codes and associated
payment rates.The fee schedule assigns each service a set
of
tiple Stage II ulcers on the trunk or pelvis, has be$n on a have group 1 surface for at least 1 month, and the
worsened or remained the same. In addition, they are for patients with large or multiple Stage
d
3 relative weights intended to reflect the resources needed to provide the service.These weights are adjusted for geographic differences in practice costs and multiplied by a
dollar amount-the conversion factor-to determine payment. In general, Medicare updates payments by increasing or decreasing the conversion factor." Various adjunctive therapies used in wound care may be covered by Medicare and other insurers and bi11ed as a professional service. Examples of these include electrical stimulation, hyperbaric oxygen therapy, transdermal and topical oxygen, selective debridement ofdevitalized tissue (eg, high
pressure waterjet), monochromatic infrared photoenergy,
IiI
or Stage
on the trunk or pelvis or with a recent
If ulcers (within (0 day$
myocutaneous flap or skln graft for a pressure ulcer if]using a group 2 or group 3 support suface immediately prfor to a recent hospital or nursing faciliry discharge (wlthin the last 30 day$.Air-fluidized beds comprise group 3. Eight
criteria must be met for coverage. An air-fluidized $ed will

be denied if the patient has coexisting pulmonary dis(ase; the
patient requires treatment with wet soaks or moist wound dressing unprotected with an imper-vious covering; tl|e careC CAIC; giver is unwilling or unable to provide app is the of the structural support inadequate to support CHRONIC
ultrasound, and contact casting. Providers should always veri$, coverage poiicy with the individuai payer. For certain adjunctive therapies, Medicare publishes National Coverage
WOUND CARE 4th
Edition
Guidelines that include rnedical necessify cr mentation requirements, and coding lowing are examples of National Coverage Gu t1're Medicare Coverage Manual System:
ia, docuThe folines from
platelet-poor plasma is reasonable and necessary
it
remarns
noncovered for treatment of chronic, nonhealing cutaneous wounds.Additionally, the clinical evidence does not support
a
. Electrical stirnulation. The use of electrical
imulation
plasmal
benefit in the application ofautologous PRP [platelet-rich lor the ffeatnlent ofchronic, nonhealing cutaneous
(ES) and electromagnetic therapy for the atment of wounds is only covered by Medicare for Stage I or Stage IV pressure ulcers, arterial ulcers, diabetic , and venous stasis ulcers when per{ormed by a ,by" physical therapist,
wounds. In light of the absence of data on the health outcomes of this ffeatment. CMS deterrnines
it
is not reasorr-
able and necessary and is therefore nationally noncovered.

Coverage for treatments utiiizing becaplermin, a nonautol-
or incident to a
physic
ogous growth factor for chror-ric nonhealing wounds, rapy for

stipulates
will
lJnsupervised use of ES and electromagnetic
remain nationally noncovered under Part
B..."tl
wound treatment is not covered. Medicare that coverage is only provided after appropri
rvound therapy has been tried for at least 30
'standard
and there Standard
Wound Care Documentation Guidelines

Appropriate docr-rmentation is critical to guide treatment decisions, evaluate wound healing progress, protect against litigation, and support reimbursernent clairns. Documentation that is inconsistent, ambiguous, and
inconrplete will result in reimbursement denials.The key to reimbursenent by Medicare, Medicaid, and private
payers is docunentatiorr that clearly outlines the required
are no rneasurable siErs of improved heali wound care is defined in the policy as nutritional status; debridement by any nleans devitalized tissue; rnaintenance of a clean, n granulation tissue with appropriate nroist d necessary treatnlent to resolve any infection preserlt. For the specific rype of wound, standa inclr-rdes frequent reposrtioning of patrents w: ulcers; ofloading ofpressure and good glucose
patients
rization of
to
renlove
ist bed of
and
rnay be
care also
pressure
ontrol for
with diabetic ulcers; establishrrent of quate cirof comculation for patients with arterial ulcers; and pression for patients with venous stasis ulcers.'' Hyperbaric oxygen. Hyperbaric oxygcn apy 1s covered for diabetic wounds of the lower e ties in beneficiaries rvho meet 3 criteria.The Jry r.nust have type I or type II diabetes and a I wound due to diabetes: have a rvound c (:ourse Wagner grade III or higher; and fail an adeq of standard wound therapy. Medicare defi standard care in this policy as assessment of vascular status and correction ofany vascular problerns in the a ted limb if possible; optinization of nutritional status . glucose control; debridement by any means to ren devitalized tissue; nr.rintenance of a clean, moisr of granuprlate lation tissue with appropriate nloist dressings; y infecofiloading; and necess:iry treatnrent to resolve tion that nright be present. Failure to occurs
wherr there are no measurable signs of at least 30 consecutive days.Wound care rnust be ted and tlocurnented at least every 30 days during nlstratlon of hyperbaric oxJgen therapy, and contin trertment will not be covered if no measurable signs of aling are
demonstrated
skills of the individual professional, the medical necessity and reasonabieness ofthe service, the treatment goa1s, and outcomes. For physical therapy and other therapy services, Medicare specifically requires tl-rat docunrentation establish through objective nleasures that the patient is making prolress toward goals.ts Standardized flow sheets, digital photography, and software progralns are necessary to ensure greater accuracy of
r'voun d assessment and documentation. "' Software databases al1or'v comprehensive data collecrion and analysis of
patient progress. They also provide patient demographics, wound characteristics, and prodr-rct utilization statistics and can track adverse events for cost reporting and quali-
ty assllrance monitoring.
Such data will be critical as Medicare advances into a pay-for-perforrnance system. In 2005, the Medicare Payment Advisory Comrnittee (MedPAC) recommended to Congress that thc Medicare paynlent system change to
encourage quality care and that Medicare introduce
a
pay-
for-performance progranl. I-Jndesirable outcomes of crre often result in additional payment to providers. For example, a wound infection develops that requires patient trans-
Gr fiom a SNF to an acute care hospital. The
adverse
event of emergent care due to wound inGction or deterioration will 1ikely be part of the pay-for-perfonnance initiative and have significant impact on home health agencies, SNFs, hospitals, and other providers." Medicare reimbursement for SNF and home healthc.rre is dependent upon documentation
assess
within
a 30-day treatment pe
states
. Blood-derived products. The Medicare that "the clinical etTectiveness of autol

[platelet-derived growth fa,ctor] products c be adecluately proven in scientific literature.As
PDGF
on the appropriate instru

A11
to not
evidence P
ment, the MDS and OASIS, r-espectively.

patients
personnel wl.ro
and
with wounds must receive training in both visuassessrnent.
is insuficier.rt to conclude that autologous
ln2
al and interpretive
To ma-rinrize payment
CHRONIC
WOUND CARE, 4th
Edition
Regulatory lssues and Reimbursement Ch
enges
ensure consistent, accurate docurnentation, ongoing
eduon
Patient's levei ofindependence

Progress toward rvound healing
in
care
cation th:rt provides interactive learning with an
uniforrn in
assessn.lent,
dcscription, and docurnentarion
of
each
P.rticnt or wolrrrd dererior-atiorr.
wound type is essential. Follou,-up evaluation for cor

assessrnent and docurnentation should also be a
ncy nelrt
Part B. For
surgical dressings, the
DME MAC requires
of the educational process.
that suppliers maintain cLrrrent clinical information, rvhich includes, at a rninimum, the number of u,ounds, the size (including depth) of the rvounds, the fi'equency of dressing
changes, and the nurnber ofdressings per rvound to support reasonableness
Medical Necessity Requirements

Medicare policy and paycr coverage gpidelines requlre justify that healthcare professionals provide infornration ngs, tl're medical necessity for r'vound care services, d
and necessity of the type and cluantity of
supplies, devices, biologics, drugs, and techr logies. 'Without such docurnerrtation, paylrrel]t rvill be den The tatlon follorving are cxanrples of Medicare docu
required to support medical necessity
lny :rcute problems, in the amount ofdrainage or percent of necrosis, inGction, and the developmerrt of additional
surgical dressings provided. In addition, such
as an increase
wounds" sliould be docurncntcd. To Justi$, the use of support sutfaccs, a comprehensive pressllre ulccr treatment prograln must be recorded that includcs education ofthe patient and caregiver on the prevention and/or rnanagement of pressure ulcers, regular assessrnent b1, a healthcare proGssional (usua11y at least weekly for a patient rvith a Stage III or Stage IV ulcer), appropriate turning and positioning, appropriate rvourrd carc, lnanagement of moisture/incontinence, and nr,rtrition11 :lsle5\ltrclrt and intervcntion. For NPWT pumps, a 'nvound evaluation is required at least monthly that includes length, rvidth, and depth over a
in
acute
, suba-
r'utc cJre. rnd SNI \ctting5: . Assessment of ulcers (including rvidth, length,
depth
in centimeters) on admission and daily or rvee . 'Wound parameters that dcmonstrate improve progress in healing
. Assessmcnt of rvotind healing progress . Turning anJ po.itionirrg .('he(lules . Asscs.nrcnr rnd docrrrrrent.rtion of gencrrl .kin cotdirion. . Evaluation and documentation of nutritiorr"l irrt{ke . Use of protective or pressttrc-rcdut ing devices . Topic.rl treJnnenr oF wound' . Dcbridenrerrt q pc ur.d rrtd outcotttc' . Skilled c.rre provideJ . MDS pcr itt :ubacure at:d SNF .crrings, 'chedrrlc Horre health agencies. Skilled nursing cfre ttor
rvound treatment provided in the hone must be reafonable and ner'e.:rry. lo .upptrrt McJicare payment. .'1[ni,'ianr
specified time and
the amount of drainage that
has
occurred. A1so, dressings used
to maintain a moist wound
must document the lollorving wound characteri]stics

asscsslnent
at
and reassessment visits: size, depth, nalture of
drainage (ie, color, odor, consistency, and quantity),
[nd the condition and appearance of the surrounding skin. The

OASIS nrust be completed as required. In additiorf, clinicians should photograph wound(s) at least every 4 weeks, record wound nreasurements at ieast once per weik, and sLrmmarize treatrnent oLltcomes rveekly. for The plan of care must contair specific instruct
cnvironment shor-rld be recorded as well as removal of devitalized tisstre and a nutritional asscssment. There are also specific documentation requirements by rvound type. For pressure ulcers, positioning, support suface use, and moisture management nust be included. For neuropathic ulcers, there rlust be evidence of a cornprehensive diabetes management program and prcssure reduction on the ulcer. Lastly, for venous insutEciency, the use of compression bandages and leg elevation nlust be dctailed. Other National Coverage Policy determiuatiot.ts, such as those lor electrical stinlulation, hyper-baric oxJgen therapy, and therapeutic shoes, include specific documentltion requirements to justify medical necessiry Clinicians arc advised to revierv these to ascertain the likelihood of coverage for individual patients and thcir conditions.
the treatment of the wound. The follor'r,ing

cacy
are
tcomes etEdicare
and accornplishnlents that may be used to dcmonstr
Conclusion
To support reinrbursement in anlr clinical setting, wound
care ciinicians should r-evierv coverage policies, understand
of
care anrl medical necessity
to
support
reimbrirsement:
. Education of fanrily,/caregiver . Understanding demonstrated by family,/caregi . Progress torvard goal . Any changes in patient status or treatment plan
Wound documcntation Outcornes of care Outcomes of teaching CHRONIC
paynlent mechanisms, study coding instructions, and learn documentation essentials to support paymcnt.The availabilprodr-rcts and services to treat or lnanage wounds often depends on reimbursement by third-party payers. Regulatory issues and reinrbursement mechanisrns har''e
iry of
enorrnous impact on the quality of care, the introduction of new technology, utilizatioll ofproducts and services, patieut Edition
173
WOUND CARE, 4th
access
to
care, and
the actual outcomes of
delivered
mance
1. How are wound care supplies reimbursed under the Medicare prospective payment system? A. Based on actual charges B. According to a fee schedule
C. Al1 inclusive
Soon, payment may be predicated
on
actual
and achievement of documented qualiry measu
Every claim subrnitted for reimbursement

premise that the care rendered or the supplies
is
on the
were This
a
medically necessary and appropriate to treat the

means that facifities, practitioners, and suppliers claims filed for wound care services, products,
apies, and
in the payment rate
liable for tive therMedicaid

and
D. 80% with a 20%o copayment by the beneliciary
DME.
Payers, particularly Medicare ar
aontinue
to conduct fraud
investigarrons rg.rinst
providers, alleging that the development or
ofpres-
How does an insurer determine if a service, technology, or product is medically necessary for a particular patient? A. By contatr.ing rhe phyrician
2.
sure ulcen and other wounds indicates the

receive the care that was reimbursed.
did not
care out-
B. By interviewing rhe patient

C. By determining
ments
if it
meets coverage policy require-
Clinicians should avoid documenting wou comes with vague terms, such as i worsening. Quantifiable and measurable wou: sions and treatnlent outcomes should be rec include factors, such as a patient's overall con nutritional status. that aflect the course of wound healing. In general, any information validate the treatment plan or the outcomes o rtlve or negatlve) 1s important to support pay Coverage and reimbursement policies for and other payers do not often reflect tec advances in wound management nor do they tain interventions for early wound preventio rence. Payers too often focus on unit cost r long-term costs ofcare or cost ofa treatment payers continue to seek ways to reduce healthc ditures and additional clinical and cost data are coverage decisions w111 hopefully change to be clinical practice. To support reimbursement payers to cover new technologies, clinicians n strate cost etlicacy of new products and docu tive outcomes, such as decreased healing tim utilization of more expensive services, and
complications.
stable, or
D. Based on the documentation that supports the claim

3. For what conditions does Medicare cover unsupervised
dimen-
ed and
ition
and
OI
electrical stimulation?
helps (pos-
A. Stage III or Stage IV pressure ulcer B. Venous stasis ulcer C. Diabetic foot ulcer D. Medicare does not cover unattended electrrcal stimulation
Ansrvers:
Medicare nological r cer-
1-C,2-D,3-D
or recufthan the men.As re expenshed.
References
1.
Agency for Healthcare Research and Qua1iry Evidence-based prac tice centers. Synthesizing scientific evidcnce to improve qualiq, and effectiveness in health care. Available at: http:.//u-uv.ahrq.gov/clin-
r reflect
convlnce demonnt posi-
2. 3. ,1.
iclepc/. Accessed March L, 201J7. Medicare Corcrage Guidance Documents. Overview. Available
http://urvr-.cms.hhs.gor,/coverage/guidance.asp.
at:
Accessed March
1.2007.
Federal Register.Vol. 71), No. I {J. 42 CFR Parts ,10t1, .103, 411, ,117, and,l23. Medicare Program; Medicare Prescription Drug J3enefit; Final Rule.January 28, 2005. Department of Health & Human Services. Centers ibr Medicare &
reduced
patlent
Medicaid Services. CMS Manual System. Pub. 100-07.
State ati
Operatioos. Provider Certification. Transmittal 19. June 1, 2006.
F314 5483.25 (.) 5.
Pressure Sores. Available
Take HomerMessages for Practiee ., Pr:oviders Should veiift codrhg cover.age, and
,umen-
6.
tation lor woun.d tadatments with the
.in
paye!
,Previder.s rirust beginr.develop,ing and ulilizing
tation and data'collectlon systems that will itabiiity of wou,nd cere. under a pay:for.
umenprof-
http : //www.cms.hhs. gov/transnittals,rdownloads,/R1 95MA.pdl Accessed March 1.2007. Surgical Dressings. In Home llledical Equipment Answer Book.Volume 1.4-2. Rockville, Md: DecisionHealth/UCG; July 2006. Department of Health & Human Services. Centers ibr Medicare & Medicaid Services. CMS Manual System. Pub. 100-03, Medicare National Coverage Determinations Maoual. Chapter 1, Part 4. Sec. 280.6 Pneumatic Compression Devices (Reu 1, 10 03 03) CIM
60- 1 6. Available at: http://wrvw.cms.hhs. gov/manuals/downloads/ncd1 03c1_Part4.pdf. Accessed March 1, 2007.
7.
tech.
reim'bursement system.
Beqause payers
Negative Pressure Wound Therap;r Ia Home Medical Equipmcnr Answer Book. Volume NI-2. Rockville. Md: I)ecisionHealth,zUCG: July 20{)6.
do not keep abreast of
8.
'nelogical advances rn wound rcare, alinicians responsibility to educate third-party payers

beneflts, efficacyi and, poailive outcornes
take cost
tr!at-
of
Deprtment of Health & Hurun Services. Centers for Medicare & Medicaid Senices. CMS Mamral System. Pub. 100-03. Medicare National Coverage Determinations Manual. Chapter 1, Part ,1. Sec. 280.8 Air fluidized Bed (Rev 1, 10 03 03) CIM 60-19. Available at: http://wwwcms.hhs. gov/manuals/downloads./ncd 1 03cl_Part4.pdf.
Accessed March 1.2007,
ment and management approaches for

.
care
9.
Department of Health & Hunuo Seryrccs. Center for Medicare & Medicaid Services. CMS Manual System. I,ub. 100-02. Medicare

Benefit Policy Manua.l Chapter 15, Sec. 140 Therapeutic Shoes for Individuals with Diabetes (Rev 1,1G01-03) B3-2134.Available at: http: //wwrv.cnrs.hhs. gov./manuals/Dowloads./bp 1 02c 1 5.p df . Accesed March 1,2(X)7. Department of Health & Human Sewices. Centen for Medicare & Medicaid Senices. CMS Manual System. Pub. 100-03. Medicare National Covemge Determinations Manual Chapter 1, Part 4. Sec280.13 Tnrocutaneous Eiectrical Nerue Stimulators (TENS) (Rev l,
10-03-03) CIM 60-20. Amilable at: htp://wcms.hls. gov/manuAccesed March l, 2007. Department of Health & Human Senices. Centers for Medicare &
als./dorvnloads/ncd103cJ-Part4.pdl
Motta
Effective,/Implementation Dates: 0G19-06) CIM 35-10. Amilable at: http : //wmv cms.hhs. gov/manuals/downloads,/ncd1 03cl_Part1 .pdt-. Accessed Mrch 1,2007. Department of Health & Fluman Services. Centers for Medicare & Medicaid Services. CMS Manual System; Pub. 100-03. Medicre National Coverage l)eterminations Manual Chapter 1. Part 4. Sec. 270.3 Blood-Derived Prcducts for Chrcnic Non-healing Wounds (Effectivc April 27, 2006) (Rev 59, Issued: 06-09 06, Effective 04-2706, Implementation: 07-10-06). Available ati http : /./ww. curs. hhs. gov/mmuals/dowrJoads/ncd 1 03cl_Part4.pdf. Accesed March 1, 2007. Department of Health & Human Services. Center for Medicare & Medicaid. CMS Manual Svstem: Pub. 100-02. Medicare Benefrt Pol1cy Manual Ch:pter 15, Sec.220 Documcmation ReqLrirements for Therapy Scrr.ices (Rev. 63, Issued: 12-19-06, Effective: 01-01-
1+.
Medicaid. Ph1'sicran Fee Schedule Overview. Available
at:
15.
t2.
Available at:
13.
http://www.cms.hhs. gov,/PhysicianFeeSched/o 1-overview.asp. Accessed March 1,2007 Depament of Health & Hurun Scruices. Centen for Medicare & Medicaid. CMS Manual System; Pub. 100-03. Medicare National Covenge Determinations Manual Chapter 1 , Part 4. Scc. 270.'l Electrical Srimulation (ES) & Electromagnetic Therapy lbr tire TiearDeirt of$/ounds (E$ective July 1, 20O4) (Rev 7,03-19-04).
07, lmplementation: on or belore 01-29-07) Available

16.
1,7
at:
http:.//wurvcms-hhs.gov,/manuals/downloads,/ ncd103cl-Pan4.pdf Accssed March 1, 2007. Department of Health & Hurmn Seniccs. Centers for Medicare & Medicaid. CMS Manual System; Pub. 100-03. Medicare National Coverage L)etenninations Mmual Chapter 1, Part 1. Sec. 20.29 Hyperbaric Oxygen Therapy (Rev 48, Issued: 03-17-06;
http: //u,ww.cms. hhs. gov/manuals,/Dowloads/bp 1 02c 1 5.pdf. Accessed March 1, 2007. Motta GJ,Whitaker KW. Defensive Woilnd Managenefl t. Mitchellville, Md; Pathways to Empos'crment, 2006. MedPAC. Rcport to the Congress. Medicare Payment Policy. March 2007 Available at hnp: /,/ww.medpac. gor,/publications/congressional_repors,/MarO 7-TOC.pdf. Accessed March 1 , 2007.
CHRONIC
WOUND CARE. 4th
Edition
t75
Best Practice Guidelines, AlgorithffiS, and Standards: Tools to Make Evidnc-Based Practice Available and User Friendly
Heather Orsted, RN, BN, ET, MSc; David Keast, BSc(Hon), MSc, Dip Ed, MD, CCFP, FCFP; Karen Campbell, RN, MScN, PhD(c),ACNP
Objectives
The reader will be challenged to: . Differentiate the terms best proctice guideltne, algorithm, and standard . Distingursh the relationship between best practice gurdelrnes, agorithms, and standards . ldentify the stages in the development of best practice guidelines
Summarize a process to evaluate the quality of existing best practice guidelines . Analyze barriers to the implementation of best practice guidelines and describe methods to overcome them
Propose effective interventions aimed at adoption and translatlon of best practice guidel nes into practice.
lntroduction A j evidr'llcc aceuurul.rtes rtgnrdirrt hcrlthctre pralticcs. oo,r* t]riLrg, "thc *.ay uc havc' al*'a],s done them" is I f \',,. 1nnge, aceeptable. In the past, part of the art and
ofdre pr:actice in healthcare r"as making decisions orr thc basis oftradition and, in nr"env cases, inadequate evidence. This oftcn 1ed to 'nariauces in practice. inrppropri.rte c.rre. ancl
necessiry-
be scientificaii,v robust, the enr.ironrnent or contc'rt h:rs t<; reacly fbl change, and the change process has to bc appropriatelv facilitated. Bcst practice neccls to be r.nore than a thcory
In clinical
practice settings, multiple ruodaLities arc required to provitlc-
and trans{brnr the evidencc into usable frarnervorks that enablc appropriate facilitation ar-rd ldoption ofbest pracricc
bv hc'althcare agencies.
Btst pructicc .qidelirie,s (BPCis), also sometinrcs called cLinical
Llncontrolled costs.': Rapid atlvances alnrost inrpossible
in
healthcale make
is
it
to keep up to date on u,hat
"knonn."
Inadcqr,rate care is norv x rL'sponsc to inadequate prccluction, cvaluation, disse[rinatron, :rnd tisc of informanon. The provi-
practice euiclelines (CPGr, arc s)'stenuricaiiy der.eloped

statelnents
to
assist
pr:rctitioner clecisions about appropriatc

car:e
sion of care based on eviclence is rcquircd to support a best practice approach that requires standards of cpraliry pctfornr,lncc nl('ilsures, lnd
healthcare for specifc c-linical circnrnstances.t The,v conrbine
evide[ce, cxperie[ce, and oprruori to inrplove paticrlt
rcrie\ critcril.
Best Practice Approach to Care

Evrdence alonc is not enouqh
through rcducing inappropriarc r';uiatior.ts iu practice and pronroting the delivery of high quahry evidc'nce-based healthcare.'' Guidelines forru the fiarnelrork for practice in
Algorithrns
to
c'lrsurc best pracrice. In
2000, Sackett et al-' defincd evidcnce-based nrcdicine (EBM) as follorvs: "Evidence-based mcdicine is best rescarch evidence
sripporting policy and proccdure tccomntendations. bv contr-ast :rre graphic maps that visualize the
the integration of with cljnical expertise and patient val-
major cognitir.'e conlponents rcqnirc'd to resolve a problcrn. Tl'rey car.r act as clinical decision r-naking frameu,orks, rvhich
ucs." Kitson, Har-r.-e1i and McCormackr sllggcsr x slrnerg,v
of
crn act as crial/er:s tosard the inrpiemcntation of BPGs.

Startdanls
"
:rctions is requicd to enablc successful implerrcntanorr of the
differ in that tl'rey are ruies or rnodcls of carc estab-
evidence to support best practice: the evidcnce is rcquired to
lishcd by proGssional organizations
or
repgletory boclies.
nser fiicrrdly. Iu: Krasrrer L)L. llor{eheaver CT, Sibbald RG, ccls. ChronicWound Core:A Clinicol Source Book for Heolthcore Professiono/s, 4th ed. Meh-ern. Pa: HMP Comruunications. 2i)()7:177-183.
CHRONIC
WOUND CARE, 4th
Edition
177
Orsted, Keast, and Campbell
Best Practice Guidelines,Algorithms, and Standards
which often set the minimurn acceptable 1eve1 of

Standar& may be speciflc to each discipiine and
rformance.
1n some
able and prescribed behaviors yet not be so narrow or rigid
that they create a detrimental effect on innovative and individualized patient

care.13
jurisdictions be enshrined in legisiation. Other

be flexible and responsive. For example, a dard
may
legal stan-
of care is to compare the care provided to
of a reaeft-ective
ton.rble clirucian in :imilar circumstances.
The first hurdle is promoting a culture or environment that supports the development or adoption and applicacion of evidence-based pmctice. Gurdelines involve change, and any
change must be based on a need.Therefore, any systems change
In practice, BPGs help healthcare c[niciarx

and appropriate practices based on current and
sclentools
:
should be based on
ti6c research and available evidence; algorithms re or enablers that aid in the implementation of dards set minimum levels ofperformance.The 3,
ent, are intimately related.lo
The needs
assessment should involve
nee& assessment that identifies care gaps. not only the developers
and standiffer-
but also users, recipients, educators, and appropriate administrators who may be involved in ultimate implementation.Toward
The Registered Nursing Association of Ontar

Best Practice Guideline 2005,Assessment and
(RNAO)
ment
of
Foot lllcers for People with Diabetes, illustrates

ship in many sectiorx. For example, the Best Prac
relacion-
Guideline
RNAO guidelines not only idenri$. clirrlcal practice recommendations but also contain a recommendahon section specific for operation and policy development as well as a secrion dedicated to the educational requirements related to implementation of the guideline.''
this end (system change), the
rationale
is
presented under
the heading "
ground
to
Quality guideline development requires that relevant literature and practice patterns are reviewed and the data appraised for weight of evidence.The results are then distilled and co11ated into a succinct, user-friend1y format. In the fina1 stege, these
griideLines are reviewed
Context" and then accompanied by an algorithm Diabetic Foot lJlcers) to enable further underst
concepts discussed. er
of the
discussion
The same document contains

asks
relating to sharp debridement that
the
to consid-
widely and modified based on Gedback
if the task is within his or her standard of prac
by experts in the fie1d before being endorsed by a credible sponsoring body or associarion. At this point, the guideline is
ready for dissemination to appropriate bodies leading to
How are Best Practice Guidelines Developed? In the years that have passed
knowl-
edge rransGr or implementacion into pracrice. ,S Wefe rmeated
since BPGs or introduced into the healthcare system, they have
An often overlooked stage is
sustainabliiity.
The RNAO
to
less
guidelines were evaluated independendy

5%
of the RNAO
into every area of clinlcal practice. Originally, he chief executive oficers regarded BPGs as "the answer to reduce
inappropriate or unnecessary variation in clinic Between 1990 and 1996, the Agenry for Health
practice.o
review their irnpact. It is esrimated that this occurs in
than
of
a1l
guidelines irnplemented.l5
Practice
and Research (AHCPR), presendy called the Healthcare Research and QuaLty (AI{RQ,
practice guidelines
methocls to
for
19 e-based
in an efort to
support
The fina1 important stage in the cycle ofBPGs is a feedback loop ofongoing re-evaluatron and refinement through gathering ofnew evidence as the cycle continues. Regular\ scheduled revieu.s should include changing practice patterns, new evidence, and barriers and enablers to implementation. For
example, the
assess medical treatments and to set standar& for the development of guidelines. In Canada, the RNAO is being funded by the Ministry of Health and rm Care in Ontario to develop, pilot, implement, and nurslnEl
RNAO
guidelines are revised every 3 years.l'
According to Roberts, attributes of a good pracrice guideline are validiry reliabiliry reproducibiliry cLinical applicabrliry
cliruca.l flexibiliry clariry interdiscipLinary process, scheduled review and documentation, and sirrrplicity.o
tsPGs." The association's goals are to:
. . . . . . . .
Improve patient care Reduce variation in care

Transfer research evidence inro prucrice
Evaluation,Adoption, or Modification of Existing Best Practice Guidelines

Developing BPGs is an expensive and time-consuming If one wishes to adopt or modif,,' an eristing guideline, how does one select the most rigorous yet practical one? The AGREE Instrument is a tool designed primarily to help guideline developers and users assess the methodolopqical qualiry of CPGs.ru This tool asks the reviewer to look at 23 key items listed under the following categories:
process.
Promote nursing knowledge

Assist
base
with c[nical decision lnaking Identi$, gaps in research

cause
Stop interwentions that have litde effect or Reduce cost.
Guidelines are designed ro be used as reco rather than rules for care to enable the practi vide the best possible care by adopting new infor changing practice.lz Guidelines must provide healt fessionals with adequate notice ofthe boundaries
178
r to proand
.re
. .
pro-
Scope and purpose: overall aim question, and target population
ofthe guideline, clinical
accept-
Stakeholder involvement: extent to which the guideline
CHRONIC
WOUND CARE, 4th
Edition
represents the views
ofthe intended
process used
users
. Rigor of development: . Clarity
to gather and syn-
t\ , \\(Jrganrzauonat Changei Sustainability )^ -\_b/ '& \ram.ertng

Appraisal
thesize the evidence and methods
to formulate the rec-
Evidence
ommendations and to update them and presentation: the language and format of the
guideline organizational, behavioral, and cost
. Applicability: . Editorial
impliKnowledge
Translaticin
cations of application
independence: independence of the recommendations and acknowledgement of posible conflict of

interest from the development group.
& I ransler
Recommendatlon &
Consensus
Once the revierv is complete, the revierver calculates the domain scores and provides an overall assessrlent and recomnrendation relating to the qualit), of the guideline development process. Care Canadian Association of relating (CAWC) authored best practice recommendations to wor:nd bed preparation and the prevention and manage-
K.,"-;*",K1
Figure l. Broad overview of stages from research to sustained change. Reprinted with permission from Tazim
Virani, RN, MScN, PhD (candidate).
In 2000, the
'Wound
ment ofpressure ulcers, diabetic foot ulcers, and venous 1eg ulcers. These were not intended to be BPGs but rather a distillation of existing guidelines into a succinct practice article and bedside enabler (the Quick ReGrence Guide or QRG) backed by the exist:ing articles, research, and guidelines
Health Quality Council (HQC) and the
Saskatchewan
Association of Health Organizations (SAHO) convened a provincial Skin and Wor-rnd Care Action Committee to
develop a strategy to ensure patients receive consistent, qualcare. The results of their initiative involved a partnership between HQC and RNAO to adapt the RNAO guidelines to pr-oduce a regionally specific pres-
iry skin and wound
lor rnorc in-depth inlorrn.rtion.

the CAWC recornmendations were being published,
"While
obtained stabie long-term funding from the Ministry of Health and Long-Term Care in Ontario to undertake a rigorous nursing guideline development and mainte-
the RNAO
sure ulcer guideline.t'
nance process.Though the
RNAO
is a nursing body, its guide-
Implementing Best Practice Guidelines and Algorithms

Many BPGs have been developed and dissenrinated; however, their implementation across all disciplines and delivery sites remains a major challenge. In a Minnesota study, approximately two-thirds of farnily physicians were unaware of the existence of the 2
lines were developed \ "ith interprofessional support as well as pauent guidance and advice. Since 1999, the RNAO has
der''eloped and maintained (through revisiorx every 3 year$ 30
English publicauons-S are available the
in
French. Additionally,
a best
RNAO utilizes
the
AGREE Instrument to support
practice approach to guideline developrnent.'u When it came time to update and revise the CAWC recommendafions, the CAWC board recognized the quality
AHCPR guidelines for pressure ulcers (#3 and #15).

Ninery percent of the physicians who had browsed the prevention guidelines had found them he1pfu1, and all who read them in entirery said they were helpful.'o A survey of Ontario farnily physicians showed that 78% indicated that they complied n'ith lipid-lowering guidelines, but further questioning revealed that only 5% actually followed them."' Davis and Taylor-Vaisey'' revierved the literature on adoption of CPGs by healthcare professionals. They found that the vatiables atTecting adoption include the qualities of the
guidelines, the characteristics of the healthcare professional, the characteristics ofthe practice setting, incentives, regula-
of
the RNAO guidelines and decided to create regional teams to revise the recommendarions ucilizing the RNAO woundrelated guideLines. The updated articles and QRGs serve as practice enablers that help to interpret these guidelines for the multiple healthcare proGssionals involved in the management of chronic wounds. Each article takes the practice enabLing statements and discusses their relationship to the corresponding RNAO guideline as well as additional resoutces from
the literature to enhance and support an interprofessional

approach.To further enable practice, each
QRG is related to
a Pathrvay to Assessment and Tieatment, which provides an algorithm to guide clinical decision making. A Health Canada initiative to encoura[Je adaptation of the RNAO guidelines stimulated the development of regional wound care guidelines in Saskatchewan. InJanuary 2004, the
tion, and patient factors. Davis and Taylor-Vaisey'' also reviewed intervenrions aimed at the adoption of guidelines and classified them as weak (didactic, traditional continuing medical education, and mailings), moderately effective (audit and feedback, especially concurrent, targeted to specific providers
179
and delivery by peers or opinion leader$, strong (rerninder systenm, acadenic detailing,
ir.rterventions). Challenges to implementing BPGs occur
relativeiy
a
rnr-rltiple
ac
all servr
and
10n trans-
ice delivery sites (hospital, outpatient clinics,

long-ternr care).These challenges include inforn Gr, rntegration of payment sources to realize
ings
iai savlnanage-
in overall prograln
costs, consistency
ofrvotu
in rvhich they attempted to cstablish conrent validation data for a set of r'vound care algor:ithrns. They tried to identi{, strengths and u,eaknesses ofthe algorithnrs and gain further insight into the u,ound care dccision-making process.With this set of r,vor-rnd care algorithms, they identified 11 thernes ofditliculq, in 5 areas.These 5 areas i,cluded the length of the algorithrn, wound c:rre ternaillology. wound assessment, wound context (patieut issues), and clinical decision nraking. The algorithms provided 3 positive aspccts to care: a focus on goals, an ability to improve consistency, and a high
rnent appr-oaches alnong all service deliv-ery development and maintenance of interdisciplinarv c teanls. Successful implementation strategies have i . Providing educational otTerings that teach sof the BPG . Providing an educational offering for each ne BPG . Inclr-rding a pathophysiolog- rcvierv during e educa-
content validiry index of the wound assesslnent and care concepts. They concluded that the wound care algorithm
studies wete valid; however, the algorithnrs lacked valid and reliable wound assessment and care definitions.
Best practice guidelines. In a study of5 clicnt care settingp, includirrg a horne care agency, the prevalence rates
tional ofGring
. Providing routine, ongoing educational o rlngs
of
o1'l
pressure ulcers showed
BPG inforrnation.6 The literature is replete u,-ith barriers ro guide ne implenlentation, which can be condensed into 4 rain categories.'"-" No listing of barriers rvould be corn te with-
a decrease {ron L9',/o to 7.4% 4 months after the introdr:ction of guidelines. The decrease
continued to
6.7%o
after 8 months and 6.L%u after 1 year.,,
The responsc to BPGs is not completely positive. Many

practitioners, especialiy physicians, worry that CPGs r,vi11 lead to "cookbook medicine" rvith little room for clinical decision making, consideration ofpatient and loca1 condition variations, or innovation. Many practitioners Gar that even the slightest variation frorn the guidelines will make
recomrlended solutions (br ). Thble 1 reviews "bridges for barriers," discussing solutior from the
discussingJ
out
literature and frorl clinical experience.:5 Bcst practice guideiine implementation reqr leadership fi"om clinicians rvho understand planned change, program planning and evalu research utilization. This knorvledge rvill support opnlent of a program plan that enables thc tr
res strong
ncepts of
tion,
and
them more liable to be successfully sued. Legal concerns relating to guidelines have been addressed by Goebel and Goebel't r,vho reviewed legal databases for rnalpractice for prcssure ulcers.The authors {bund tl'rat substantial savings in malpractice costs would have occurred and onlv 4 of 14 frndings in favor of tl're deGndant u,-ou1d have
arvards
he devellnalloll
of organizations to$,ard best practice. In 2002, t RNAO developed a toolkit to assist organizations in de ing the leadership required for successful irnple Graham et aIr indicated that in order for gui ines to be inrplemented successfuliy, a critical initial step r t be the fornral adoption of the guideline recorlnrel.) into the policy and procedure sffucture. Thrs key provides direction regarding tl're expectations of the 11zat1o11 and facilitates integration of the guideline in systenls,
the qualiry manauernent process." If healthcare professionals are to provide best practlces, they nrust seek valid, reproducible, useful, and nt studies that enable tl're grou,-th of their practice to a practice standard.rs They also need to participate ir1 ognized, accredited continuinl educational opportunities t allolv thenr to participate with ski1l and confidence a rnernbers of interprofessional wouud care te:ints. Agencie need to provide a fu1l scope of support for nurses seeki g professuch
as
been reversed had guidelines been followed.
An even greater fear is that guidelines r,vill be developed r.vith the sole purpose of controlling costs. The volurne of neu, CPGs remains a major problem for general practitror-rers.Thc number of guidelines deGats the purpose of making
evidence-based practice easily available to all practitioners.
It is irnportant to remernber tl'rat in the complex rvoundhealing environment, interventions, even those based on guidelines, need to be regularly assessed by skilled proGssionals to ensure that olltconles of care are achieved. Even then the reconrmendations for care must be based on iiGstyle and client choice as r,r,'e11 as best practice.
Conclusion A Health Policy Forum
convened an interprofessional
sunrnit in Toronto, Canada, including patierlt representatives, practicing physicians (both generalists and specialists), nurses, researchers, and healthcare adnrinistrators.I The fo1
sional education.re,r'l
Are Algorithms and Best Practice Guidelines Effective?

Algorithms. Beitz
and van
Rijswijkl
pu
a study
lowing 3 qllestlons u,,ere asked: . What goals should uuderlie CPG development? . Hou. can we improve CPGs? CHRONIC WOUND CARE. 4th Edition
Categ6ryrl':r:.r Finaniial
. ,:a.
,r
Earfir
. Support for programs
interdisciplinary teams
and
Biidge
. Clear identification of outcomes will support a cost-effective delivery of best
Practices
ls3ues'r,
:a
..
..: .,::
.a..
.:,.aa ,
.a
. Technology
. lnfrastructure to support guidelines

Educational lssues
. . . . . .
Locate existing guidelines Dissemination of guideline-specific education and knowledge

Changing the attitudes and
. Websites specific
to
needs
. Program leader to integrate guidelines into policies, procedures, and protocols
expectations of healthcare providers Understanding the tools for documentation

Lack of leadership
. Newsletter to provide ongoing information . Regularly scheduled staff and team meetings
at levels to educate, learn, provide a forum
for discussion, and support
change
. Easy to read, healthcare provider-specific,

and client-specifi c evidence-based educational materia[ (current, simple, holistic, and easy to adapt based on client need and clinical judgment)
Educational resources and time
. Patients refusing evidence-based

Practice
Practice Isiues
. Clinical integration of . .
Staff skill level
evidence-based
. Clinical integration of evidence-based

practice among healthcare providers
practice among healthcare providers
Staff stress level and staff shortages
. Clinical parhway . User-friendly format for protocols and

procedures
. lnterdisciplinary team (opinion leaders) to provide ongoing support to staff regarding

clinical issues and change
. Agency support and effective resource manaSement . Alternative, cost-effective methods of service delivery (clinics)
W'ho shor.rld palticipate

ev:rluation?
in CPG
development, use, and

gl'or1ps were
involvecl in care
4. Patient input: patient representatives nnst have rrrearring-
The
re'sr,rlts
I}om the various workirrg
ful input at all
stagcs
of CPG clevelopment, includine
rcmarkably consistent.They agr-eed that CIPGs should serr,-e 1 central goal: providitg better care for paticnts. The fomm made a nurnbcr of recomurendations legarding the procluction and role of CP(ls that inclurle the following: 1. Eciucation: CPGs are an educational tool and nlust not
be used to regulate mcclical practice
oLrtconle rreasules used 5. Qualiry assurance: a stanclarclizctl process for devcloping ar-rd evaluating (lPGs should be employed rvith periodic
or continuous revierv plocesses

CPGs up to dlte 6. Accountabiiity: tl-re
incorporatecl
to
keep
accountable
CP(i proccss must be visible and to hcalthcare professional and patient

of cvidencc nsed to ibmrr.rl:rte a CPG
2. Flcxibility: CIPGs must be flexible enough !o meet the
groups; the levc1
of individual patients while incorporating all aspects ol cale 3. Multidisciplinc: the CPG process must be trul). interprofessronai rvith a focus on front line caregivels rathet than acadernics the process must include all partics
needs CHRONIC WOUND CARE 4th Edtion
must be explicitly stated, as must potcrltial bias 7. Outconres orientation: CPGs shoulcl flrcilitate treatrnent
choices by providing clear information about rvhat rvor*s and whlt does not $rork-thc outcomes examirrc.l 'hrrrrld reflc( r F.lri('rrt prit,ritie.
1U1
Best Practice Guidelines,Algorithms, and Standard
Evidence Based in the Literature
Clinical Experience
Expert Opinion
B st Practice Guideline
Qu :k Reference Guide
and
Corre ponding Interprerive Articles
Pathwz / to Assessment/Treatment Algorith r for Clinical Decision Support
Patient Risk Factors and

Preferences
Available Resources
Target Barries
. Education . Communication . Clinical Practice

Financial
. Education . Communication .
. Clinical
Financial
Enhance Facilitators
Practice
Bes Practice
At the Bedside
Used w ith permission Keast D. Orsted H.'"
Figure 2. The pathway to best practi c(

8. Accessible: succe.sful )rraregies
Io
et] C( )urage a
oprion of
rsultatron
CPGs must be shared and rnaterials an
technolr ;ies devel-
une
oped to rnake then'r immediately avail al r1e for ct 9. National clerringhouse: nrlny parti. ,ants ide need for a centr:rl body to oversee IPG der funding, and r-rse.This central body r i( ruld ens updating and revieu,- of exisring CP s and sh mentation strate6lies. Marketing experts have suggested that rther tha
tified the rlopment,

re regular
. . Documentation tl rat is consistent, colnplete, .

Care that
specific.
Gurdelines and all lorithm. inregrared inro rhe .onrinu of care can provi de: Cost-ellective carr r delivery
standardized, comparable, r )r,rtcome generated, and shared
will
be evidence based, holistic, and patient
re implefocus on
anization,
To support the im1 lementation of best practice at the bed-
side, clinicians and
lcfities rnust integrate Best
Practice
the change about to be
encountered
yanol
}The
ad ption and implementarion of new tools can provi Ir 'the im Iementers and the users sonrething of va-lue. Guide 1i :res defir ,, through cxperf opiruon lnd t'urrent extcnsive r, 'ntific re :arch and
encourage the focus to be on the exchang
Guidelines that endor ;e recomrlendations related to not only praclice but a-lso educ; tional, organization, and poliry changes.
available evidence, best practices that in tul :r, support he attainment of competency and skil1 1eve1. Basin a woun( care pro-
Regional difierences r elated to population and resources need to be considered wher program development is considered.To accomplish this, the bi rdside clinician must be supported in an environment that bre rkr do\n btrrier: oi (onununi(ation,
L
education, practice, anr 1 resource related issues. Barriers to best
gram on tools that enable evidence-based
l1 actice w:
r
promote
rd
excellence in skin care, foster collegial rela ri, :rnships, replication with other clinical populations
permit
practice must be id entified and modified, and bridges to best practice must be identilied and enhanced.This is an active process that rr quires a receptive environment sllp,NlC
WOUND CARE 4th
Editlon

10.

Tellez RI).Wound clre 2000; challenges to integntiorl across the continuurrr. -Flrac Care houkl. t997:2(,1):192 196.
ported by administrators, the allocation of appropriate resources, and the cooperation of interprofessional team
members. Figure 2 summarizes the entire process.
11.
llegistered Nurses'Association of Ontario. Assessrucnt and management of fbot ulcc'rs for peoplc u.ith diabetes. Available at: http;/ /srvrv.rnao.org/Pagc.asp?PageID=924&Contentll):7 1 9.
Accessed Scptember 2006. Davis DA, Tivlor-Vaisev A. Translating gudelines into practice.
Most impoltantly, whcn it comes to best practice, may know best practice, but are you providing it?
you p.
s-
13.
Take Home Messages
for Practice . Not all guidelines are created equal. . Knowing the best evidence does not ensure a change
,n practice.
E.
15.
The stren$h of the evidence must be combined with a willingness to change practice and appropriate facilitation of the new information.
t6
tematic review oftheoretic concepts, practical experience and research evideuce in the adoption of clinical practice guidelincs. CtlL4J 1997;157(.1):.l08Jl 6. Goebel RH, Goebel MII-. Clinical practrce oidelincs for pressure ulcer prer'cntion can prevent nralpractice Iatsuits in older patients.J ll'orrrd Ostony Cortiwnte Nrr. 1999;26(-l):175-18't. Registered Nurses'Associatiorr of Ontario. Nursing bcst practice guiclelines. Ar.ailable at: http://u rrrrnao.org/Page.asp?PagelD =861&SiteNodelD=133.Accessed Septeruber 2006. Edrvards N, Dar.ies B, Ploegj, et al.The el.aluation ofnursing best practice guidelincs: proccss. chirlenges, and lessons leatned. Tht Canadian \tar-v,. 2(X)5;1 0l (23):19 23. The AGREI Collabontion. Appraisal of guidclines for rescarch and
evaluation. Arailal:le
pdf/aitnining.pdf
t7.
rt:
http://mvu,.agreecollaboration.org/
Accessed September 2006.
Gander L, Delaney C. Saskatcheran l{ealth Qualiw Council test drives ne\{: presslrre ulcer guidelines. Ll/outd Care Canada.2006;1(2):26 27 .
Self-Assessment
Questions
18.
Kinura
S, Pacala
JT
Pressure ulcers
1.A guideline is a document that outlines the best available evidence for a health-related problern. A. Tiue B. False 2.The AGREE instrument a1lows the cliuician to evaluate if the recommendations outlined in the guideline will work
at the
edge, attitudes, practice prefcrcnces, and awareness
19.
lrnes.J Farr Praa. 1997 Rosser WWI Palmcr WH. Dissenunation of euidelines on cholestercl. Elilct on patterns ofpracticc ofgencrd practitioners and f:nri1y phvsici:rns in Ontario. OntarioTask Forcc on LJse and Prcvision of Medical
Services. Can Farn Physiciat. 1993;39:280-2iJ,1.
in adults: familv phvsicians' knorvlofAHCPR guide:41(4\:361 368.
20. 21.
22.
bedside. A. True
if sup-
23.
ts. False
21.
3. Guideline recon-rmendations are more effective ported by agency policy and procedr"rre. A. True
R- False
23.
McA.llister M. A nursing inregrarion fiarnervork baed on standads of practice. .\arr,l.farage, 1 990;2 1 (,1) :28-3 1. Owcns DK. Use of niedical inlorruatics to irrplement and develop clinical pmctice guiclelines. ltrte t J )Ie d. 1 998; 1 6tt(3) ; I 66-175. van Rijswlk L. Clinical pmcticc guidelines: ruor-ing irlto the 21st cenilty. Ostoilry Wbun.l l,Iaugc. L999;15(1A Suppl):.17S-53S. Kmsner DAH(--PR Clinical l)ractice Guidcline Nurrber l5,Treamrent of Pressure Ulcers: a pra;prratisr\ critique for rvound care prol'idcrs. Osrony l4/otrd l,Iana.ge. 1995;-11(7A Suppl):97S-102S. Trelease C. Developing standards for rvound care. Ostony Wound ! 1 an age. 1 9 88 ;20 : 46- 5 6 Orstcd H,Attrell E. Makins c[nical practice gpideJines u'ork: the experiertce of one hortte healthcare aeency. Ostorly Wound Nlamgc.
1999;'+5(9):18 56.
26
Registered Nurses' Associrtion of C)nnrio.Toolkit: iniplementation of clinical practice euidelines. Availrrble at: http:/,/uu'w.rnao-org/
Page.asp?PageID=92.1&ContentlD=U23.
Accessed September 2006.
Ansu.ers:1-A,2-I.,3-A
References
1. 2. 3. .1. 5. 6. 7, 8. 9.
Leape LL. Practice guiclelines ancl staldar&: an overvier: Rer Brril. I 9utt;16i1,; -1-1-19-
27
Harrison MB, Rrcurcrs M, Davies BL, Dunn S. Facilitating the use of evidence in practice: evaluating and adapting ciiuical practice gridelines for locai use by health c:rre organizatious.J Graharr Rlan
Obsto Cyrccol Neoaata/ Nrr: 2002;31(5):599-{1 1. S. Perrier L, Sibbald llG. Searching ftrr evidence based nedicine
II)
QRn
Qacl
28
in rvound
).9
care:
an introduction. Osrorry
job
Woun.rl
Mauage.
Atkins Q Karrercrv D, EisenbergJM. Evidence-based nredicine rt the Agencl, lor Health Care Policy and Resc'arch. ACP J Club. 1998;128(2):A12-A14. Sackett DL, Stmus SE, Richardson WS, Rosr:nberg \!i Ha-voes 1lB. Euidewe -Baed l'fediciw: Hou ro Pmte anl'feail EBM. 2nd ed. Nerv York, NY: Chrirchill Livingstorrc: 2000:1. Kitson A, Hancl G, McCormack B. Enabling the trnplenentation of cvidenced based pmcticc: a concepmal frame'rvork. Qtal Heabh Carc.
1
2OO3:49(11):67-13. Best MllThurston NE. Measuring ntLrse 2004;3.1(6):283_290.
sadsfaction. _/ Nran.4dur.
30.
Goctrup E Optimizing
lound
treannent thrcugh health care structurRt.qan.
i,rg and
2t){)1;12(2)
:1
professional education. Wound Ilepair

29-1 33.
l1
32.
Beitz JM, van llijsrvijk L. Using u'ound care algorithms: a content validacion itudyJ li,irr ud Osntry Cottinence Nurc. 1999:26(5):238-2,19. Hanson l)S, Lmgerno D, Olson B, Hunter S, Burd C. l)ecreasing the prcvalence of pressure ulcers using agencl, standards. Honrc Hulthc \imc 1996;1 4(7):525-531. Usher S, ed. Healtir Policy Fomm. Montreal, Canada:June. 1999. Lrndrum BJ. Marketing innorations to nurses. Part 2: malketirg's role in the adoption of innolarions. J ll'btnd ()stony Continence ir-urs. rqqR
e98;7(3):149-1 58.
Field MJ, Lohr KN, Clinial Ptaaice Guidelines: Direthns Jor

Prograrn, Washington,
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Roberts KA. Best practices il the development of clinical prrcnce guidelines.J Healr/r Qrnl. D9a:2O(6):16-32. Gaines C. Concept mrpping in sy,nthesizers: instnrctional strategies for
encoding and recallhg.J NursesAsoc. 1996;27(1):14-18Hadorn DC, McCormick K, Diokno A. An annorated alSlorithnr approach to clinical guidelinc developnrent.
State
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NY
)i/{\.).7 )tl
35.
Suntken G, Starr B. Ernrer-Seltun J, Hopkins L, Prcftakes D Implenentation ofa comprehensive skin care prograrl acrcs! care settin19r using thc AJ-1CI'R pressure ulcer prerrntion and treatment guidelines. Ostonry ll,bturrl llanagt. 1996;12(2):2(l-32. Keast D, C)rsred H.The prthrvav to best practice. Wouxd Care Canada.
.lAnIA.1992:267 (24):331 I -331J.
Tallon 1\. Critical paths

1995:8(1 ):26-3,1.
lbr
q'ound care. Adu Wound
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36.
20{)6;-1(1):
{).
CHRONIC WOUND CARE,4th
EditiON
183
Mentoring: The Ultimate Professional Relationship

Anne E. Belcher, PhD, RN, FAAN; R. Gary Sibbald, BSc, MD, FRCPC (Med, Derm), MACB DABD
Objectives
I he .eader
wrlr be chal e^ged to:
. Conceptualize the continuum of learnrng, including role modeling, networking, . Synthesize the attributes/subroles of a good mentor and mentee . Extend the concept of mentoring to peer and lateral mentoring.
preceptoring, and mentoring
Introduction
uch has been rvritten rn both the 1ay and professional litelature about the role ofthe rllcntor in business, industry, governltlcnt, education, Historicali.v, lnentors pror'lded their healthcare. ancl assistance. In business, mentors or 1lnailcia1 with nlentees senior managers groomed illentces for rapid promotion.l
Passive
Figure l.The
Active
Belcher-Sibbald Continuum of Learning.
In more recent tinles, rnentecs have been nrore likelv to

receive cateer advice, education, artd social support fi'om
nentors. This type of assistance enables the young/new professional to gain new- skiils and confidence to tlke risks.Thesc ectivities can greatly accelerate career growth
ancl development.'
opment. The tnentee'.s developrueut irrvolves klorvledge, skrlls, and appropriate attitude :rcqnisition (espccially the conccpt of profcssionalisrn), licilitated by interaction with other rnore experienccd and proficient professionals. The Belcher-Sibbald Continuurn of Learning describes the relationship among the concepts of role nrodeling, netnorking, preccptoring, and mentorrng (Figure 1). Each collcept rvil1 bc delined and described as a unique relationship that promotes professional gror.vth ancl dcvelopnlent.
This topic has becu r-rnderdcvelopec'l in rvound care. A search of PubMed rer.eals 1,t151 citations for urcntoring
and 539 thrt relate to healthcare proGssionals.There are
only 3 that re1:lte to wound care: 1, rvritter.r by the current :rllthors, appcared
in
OstomyWound Mandgt'fient and

and
2 others (1 on borvel and bladcler clysfunction

matic brain inlury).
Role Modeling
Role nrodeling is vier.ved as the most passivc relation ship on the contiuuurn, inr"oiving one persont ernulation of, identification rvith, arid/or irnitatlon of another person. A personal relationship is l)ot a requirement irl role nrodeling in that the role tnodel and the person
lnother on tele-rehab to pronlote rccovery fi'onr tr:ntThe purpose of this chapter is to place the role of mentor in the cotltext of v:rrior:s relationships th:rt are believecl lo promote the individualt proGssion:r1 grorvth and devel-
Wound Core Llelchcr AE, Sibbalcl RG. Mcltoring: the ultirn;rte prolessional rclationship. Irt: i{rasner [)L, Rodcherver GT, Sibbrld ]l(1. ecls. Chronic
AClinicolsourceBookforHeolthcoreProfessionols.4thed.Malr'err,Pa:IIMPComuuuic;rtions,2007:185
190.
CHRONIC
WOUND CARE, 4th
Edition
185
Belcher and Sibbald
viewing that person may never have met or interact briefly at meetings, often in a group during a question-and-answer period. On hand, one might identify a role mode1, i se1f, and ask to interact rvith, observe, and/or that person for some period of time. A role
those characteristics that the person attain and provides a goal for that person to terms of education, experience, professiona ment, andlor scholarly productivity.
sesses
may only setting or he other e oneudv with odel posishes to e1n
Preceptoring
Preceptoring involves a more dynamic interaction than either role modeling or nerworking. This relationship is often established for the purpose of orienting the new professional/member/employee
to the
proGssion/organiza-
tion/workplace andlor the role. The preceptor is usually someone rvho is an expert clinician, teacher, manager, or researcher.The preceptor is viewed as a role model who has
values, skills, and knowledge that should be instilled
involve-
in the
Networking
Networking is a useful strategy, especially r persons new to a profession, an institution, or a g The goal of networking is to meet people ho know about the profession, systeln, or organization and rvho
have achieved sonle measure ofcareer success
novice who is assr-rnring the same or a similar role. The preceptor/preceptee interaction is usr-ra1ly time lirnited and is
prescribed in rerms of information and
ski11s to be transmrtted from the preceptor to the preceptee. This relationship may be so effective and mutually beneficia.l that the precep-
tor becomes the mentor and the preceptee becomes the rnentee. Preceptorships are quite useful when a professiona1 identifies a gap in knowledge or skill and seeks a preceptor who can help him or her in closing that gap.s
come should be the establishment of valua a roster of people who can serve as resou may provide opportunities for consultation professionally rewarding experiences over the one's lifetime.' Networking can help identify who n ill validare onc'5 opinions. confirnr r of data, and increase awareness of what collea profession are doing and saying. Netrvorking doors to useful professional contacts. It e learn the system, to find out who's who and contacts for help, to brainstorm, and to services and products. Netrvorking can with resources when quick intcrvention is ne as when treating a patient with a complex u,hour existing techniques are inetTective. Networking groups often provide social su may stimulate the pairing of experienced p novices. Onek network may consist of ntetr same profession, dilTerent professions, and/ or
business, industry, government, and education
ontacts,
and who
For example, one rnight ask a skilled wound care special-
nd other
ourse
ist for the opportuniry to visit the clinical setting

observe thq spscizlisrs prrcricc.
and
of
lleagues accuracy
s
Mentoring
The concept of mentoring has its origins in Greek mythology. Athena, goddess of rvisdorn, disguised herself as
Mentor, a wise old nobieman,
in the
ns the
s one to
iir order to act as a self:
the best
ide
one
d, such
rd for
appointed guardian to Telemachus, the son of Ulysses during Ulysses' 2}-year absence from home during the Trojan 'War. Mentor acted as the protector, advisor, and guide to Telemachus. It is rather ironic that the {irst mentor was a woman whose role was to guide and facilitate the career development of a young man.u
t
s
and
e with
of the
ns
1n
A mentor is someone who may choose a mentee or who is chosen by a prospective mentee to work together to help the mentee develop professionally at a particular
point in the mentee's life. Many people had mentors when they were students; others benefited from this relationship when they entered their professional careers. Likew-ise, some gain or change mentors when they decide to make
a career move. Egan' described 3 stages in the nrentor and mentee relationship:1ook at the present situation, imagine
Networking strategies usually include atte nce at professional meetings. Close coileagues shon attend different sessiorrs in order to gain as much i matl on and to meet as many people as possible. It is o helpful to visit the exhibits and to talk with peop at each booth about their products and services. H Ithcare
professionals should ahvays carry business c rds that contain their name, titie, alfiliation, address, lephone number, fax number, and e-mai1 address.
the preGrred position, and then reflect on how to get from one to the other. Freeman. emphasized the role of
reflection in this process. A mentor is a person who is willing ro commit time and
elTort to share experiences and expertise and to guide the professional growth and development of the mentee. This gfowth and development can guide the mentee to become
Other suggestions include preparing
-second
"elevator" speech that enables you to sav who u are, what you do, and what you are looking for. D onstrate interest in others and follow through with romised materials/expressions of appreciation.a
the best proGssional possible, to be a survivor in an organization, or to have a positive impact on the profession andlor organization. The mentee will also learn how to relate elTectively to other disciplines andlor how to be an
CHRONIC WOUND CARE. 4th Editlon
Mentoring:The Ultimate Professional Relationship
Belcher and Sibbald
outstanding scholar/researcher/educator/clinician. A mentor is usually an older, nlore mature person who takes on a ,vounger, less experienced mentee. The mentor
and mentee may come
999.r:gle:,,
Teacher
,,:tt
,sitrr
, ,1;;,, , 1i :.:.1 i:,,,'r
:.y:'r,:;1,
;.1
to
share, over time, a unique com-
munication sryle, a unique way to view problems, resolve

issues, and de6ne professional goals.
To develop the menteet intellect and career-related

skills
Sponsor
The mentor has been described as having the roles of

protector, advisor, and guide.The mentor serves several sub-
To arrange and share a network of personal contacts

To facilitate an informal
which are listed in Table 1. Identification of a potential mentor often requires finding the right person at the right time in the right situation. A mentee often selects a mentor because that person has
roles
as we1I,
HosdGuide
social network
Counselor
already been identified ed that there be at least

ence, that is, 8
as a
role model. It has been suggestone-halfofa generation age difter-
To provide advice, guidance (personal, professional), moral supporq and nurturing (stress management) To demonstrate a standard of excellence (model), which the mentee will aspire to surpass
Exemplar
to
15 years, between the mentor and mentee.
How-ever, knowledge and skills are changing at such a rapid
pace that a younger person may mentor an older person in such areas as computer skil1 development.
In addition, the
mentee may become the mentor rvith regard to particular
knowledge or skill. lt is also often appropriate to have more than 1 mentor.There might be 1 person who is a skilled clinician, another who is a successfui researcher, and a third
rn'ho is an accomplished teacher.
ig!.to19,,,,t,,
Learner
oq! ,,,. ,,, ,,,
,.,, ,,,,,',,., .,,.
To recognize knowledge deficiencies and fill in the gaps from the classroom to the career/work place needs To appraise skills and attributes of others for integration into practice (eg, psychomotor activities, empathy) To ask questions from peers or other members of the health-care team To cooperate with coworkers/ teams
The issue of gender in mentoring deserves brief attention. In the literature ofthe 1980s, particularly in business settings, men were reported to be mentoring women into opportunities that previously had not been available to
r.vomen.'This was probably an early recognition o[the glass ceiling effect. A proGssional mentoring relationship betrveen members of the opposite sex may have set clear personal boundarres to prevent any damage to the personal life of the mentor or mentee. Social boundaries may be a problem in selected cases but certainly should not preclude male,/female mentoring relationships. It would seem that the rationale for selecting a mentor or mentee should be
the knowledge and skills to be shared, the compatibiliry and
Observer
Inquisitor
Collaborator lmplementor Contributors
to increase
effectiveness
To apply new skills through repetitive trial and improvement To associate with others through workplace committees or professional organizations To appraise opportunities for
updates, independent study, advanced degrees
Continuous
Professional
or
the mutual respect of the 2 individuals. One dovu'nside to avoid is the potential sexist or racist component to a mentoring relationship as reported in the iiterature."'Another potential pitfall is that the mentor nray become possessive, promote dependency, encourage a nar-
Development
(cPD)
rowed scope of opinion, and negatively influence the mentee\ individual identiry. Some mentors like to be in charge and use the mentee to promote their own careers or agendas. The mentor's thinking might be, "I have this prot6g6 who relies on me for whatevel inforruation or opportunities come alone; this is great, because I can throw a few crumbs their way and use them to make me look good." The mentor might preGr the nrentee have the same opinions in order to avoid disagreements or challenges to his or her own thinking. In turn, the mentee may become dependent on the mentor, having always been that r.l,ay in
to be parented in his or her particular situation. In addition, the mentee may perceive that it is better to buy into the mentort perspective and not "rock the boat." A mentor must ask him or herself if a dependent mentee
professional relationships or wanting
to be raised; it would then be important to provide the mcntee with opportunities for
has lo'r,v self esteern that needs
success.
A mentee must decide whether
encouraged
dependenc-v
or compliance is hindering personal and prois
fessional development.
The ultin-rate goal of a mentor./mentee relationship

that, over time,
as
the mentee is guided by the mentor, they becolte comfortable sharing with one another and reach a
1.87
Belcher and Sibbald
Altribqtt
Responsibility
,,,1
Traditional
Mostly mentor
Finite boundaries Hierarchical Vulnerable to move and
Shared and flattened levels
Shared Experience
Broad base of shared experience
of
responsibility Political Obstacles Potential Behaviors

Resources
the wrong
supervrsor
gender,
Fewer political dangers Collaborative community with checks and balances from others Practical guidance, collegiality, shared resources
Jealousy,
racial splinter
Often territorial
Communication Technology
With each
Used individually
With the group

Used collectively in a constructivist model
point r.vherc they can address issues fronr differen as well as sirnilar pcrspectir.es. Coll:rborative resolution oi problenrs :rnd progress in the profession or organizatio becornes
mutually supportive.
5. Can givc pool' or inapproprirte
ac-lvice.
I(rarni: also defined diilelcnt kincls of nrentorins relationships, including inforrnation peers u,ho share infbrmaLion: colJegial peels
rvho irrcorporltc (rrcer strtrcgiTitlra.
The Mentee
The rnentee also has sevcral subroles in
c
develop-
nielt
ar:d
in personal
ancl prolessional interacti<;

r'vi11
rvith the
often make a ignilicant time commiunent to the n'rentce, and in return, ntelttce rmtst be activel), engaged iu his or her career Lopnrent. Five gcneral principles for a mcntee to bling to successful nrentorship include: . Know yourself . Dcvelop realistic expectations
lnel]tor (Table 2).The rnentor
job-relatcd leedback, and friendsl'rip; anrl spccial pcers rvho provides cnrotional support, personal fcedback, and friendship. Many r.vound c:lre specialists havc rnultiple mer.rtors,/nrentees for ditferent functions, overlapping or secluenti:1lly tiilrcd durirrg thcir carccrs.
Peer Mentoring
Glass and Walter't
The concept ofpeer co-mcntorins *,as expanded u,hen '' describecl student enhancenrent rnd
professional grorvth through shared learning, sharcd carirrr,
reciprociry conulliturent to each other''.s personal ancl prolbs-
. Reach out arld get to know othcrs . Negotiate for rvhat is needed
Learn tiom evcry experience. Kranr' has cle{inccl .{ stages in the mentor rela.t irritiatiorr, 2) cultivation, 3) separation, rnd 4)
rship: ilon
1)
The initiation st:rge facilitates bonding and

Clultivation is ch:rracterized by thc mentce'.s icleally resulting in a sense of fultilhlent Iirr both
ng oll
elncnt
:s.This
f icnclship.Thery encouraeed nurses to be open and rcflexive :rnd to dynarnicall1, lviclen the current concr-pt of mentoring.Through a series of sroup discussions :rnd personal diaries, the arlthors eluclclated several comnlon themcs supporring and strengthening the nrernbers of thc groLlp: a sensc of belouging, bcing ackuor.vledgecl, feeling
sional grorvth, and
cormron projects (6- to 12-month average tirne period).
validated, r,erbalizing vulnerabilit,v, and nnderstandins

dualisms.
The biggest cr>nflict was betu.cen thc need Ii:r
acccptancc ofothers and issues ofhigh acadcrnic perfonlr:rrice ancl career aspiratiorrs.There was a high vilue placecl on the need for: healing and caring for each other.Li Elfective peer mentoring can be ar exccllent substitr.rte ol cnhancemcnt to the rviser and older trac'litional lnentor moclel. I)eer nlel)toring was shor'vn tO pronrote reflective' teaching for nursing faculry in an article by Heirilich and Scherr."'
strge oltcn i:Lsts years belbre the enlotional and ructural separ:rtion. A redcfinition ofien results il a lasting fi'fenclship. Some authors havc aclvocateil rnultipic role rno[els'' ancl possible subsequent rnentorships to cover diflblen]t aspects of carccr developnrent. Al o..,.rp.tiorr.1 tlicr.rpy,,rr[].rnr".iuate nlodel by Nolinski" sllqgests sever;rl sttrdcnts sJrould be attached to several lields,ork clinic.rl cdr.rcatols aslpossiblc lrrentors. Sevcral potential dansers ofa sirigle nrentior exist.
Lateral MentoringrT
Lateral nlentoring descrrbes a situation rvhere a diverse group ofpeople is engaeed in a task over tinle.The nrenlbers of the group utilizc each other as a sounc'ling boarcl, cc-rteachers. and group learners.
Thc nrerlrtrr:
'1
Cannot be all things to the
mcrtee
che rttctrtec
2.
3.
.1.
Mr1 hlrc Iler\()tt.tlitv cotrilicr. rvjtlt
May dcvelop varving deErees of favoritism May cxperience pressure to enstlre ntentec
The franre.,,,'ork is within

as:
sLl(
cornrnuniry oflearners defined
CHRONIC WOUND CARE 4th Editlon
Mentoring:The Ultimate Professional Relationship
Belcher and Sibbald
A grcup
oJ indiuiduals r.vithin a circlc
tf
shared rcmmittncnt to
knotuletlge. This cit'de is euer changing as indiuidudls are -freely encout'aged to rnoue both within and withttut the circle ttf cxpt rrisc
continuum.The ruthors would also rvelcome your Gedback and suggcstions for helping others identifi a fratlleu<rrk for rnore effective continlting education ar-rd lifelong learning.
ond thuryes.'fhey enrrge ttut of neccssity: grcu1ts of people-find thL:ntselves drdwtt to ttne arLttthct b' o.forc that mn bc
tlnt
artolut:s
social, proJessiotral, ttr hoth.Togethcr the

solues
cttmtuority builds things'
Take Home Messages

serve as resources
prohluts, learns -fitw
edth rtther, invents neut things and
for Practice . Netrvorking is the rneeting of valuable contacts

. . .
to
shares the ,qrottps expcrtise, krntuledgt dntl hout to tllr-rtgtt it.'This inforrnal slrtlcture was molcled iu :rn onlinc course
u.ith
1B participating students enrolled
in the Pepperriirre
lJnivcrsity Master of Arts in Educational Technoiog-v. The instructor, Linda Polin, nicknarned herself the Shcrpa, to serve as a gr.ricle arrd stay oLIt of the s'avThis process facilitated serreral infornral co-tlentor tilnctions betlveetr the students, avoiding nrany of the polentlal problems of a traclitional nlentoring relationsh:ip (Tab1e 3).
for consultation and social support. Preceptoring is a time-lirnited pcriod where a novi.e accluires new knorvledge or ski11s fiorn an expert. Melltoring is a comruitment of a senior colleague to act as a prorector, advisor, and guide to promote the car-eer of a junior colleague. The concept ofmentoring can be excended to peers (peer rnentoring) and to the classroom (latcral mentoring) to cnhance lcarning tlrrough coilaboratiotl.
Advanced Education and Mentor Evaluation

Mentoring has been seen as a positive influence rn doctoral edr-rcation ancl a compottent of striking a balauce bctrveen tcaching, rese:rrch, and scn'ice.L" Mentoring is tirle
:r speaker'.You decide
to obtain obj.:.-tir-e of this activiry value :rppropriate the to shorv evaluation rn medical cdlrcators clinician ntorc of 01' Sixty percent mentoring their havc et a1"' by Beasley sr:rveyed schools ski11s evaluated by 3 methods: 1) peer input; 2) extertral
consunring, and there nrust be tnethods
asscssnlents
1.You attend a conference and:rre particularly inrpressed by to itnitate her preselltation style-You
:rs a:
ale vierving her
A. Role lnoclel R. Netu'orking partrler

C. Prcceptor
D. Mentor
of facultv ncrnbers
.1) tr,rirtqc
trainees (outside itlstittt-
rionrl irtpttt)::trtd
irtltrt. to facilitate veluable rletr'vorkrng at a professional mcctrng. Thcy include a1l of the
2. There are nulnerolls strategies
Conclusion
Mnch rese:rrch is neeclccl on all aspects of the continuurn
of leai'ring. Questions of particular interest to healthcare

professionals shoulcl include the ctTects ofthesc diverse rela-
tionships on he:rlthcare outcolnes, on p:rtietlt satisfactiolr, and on proGssional gr-owth ancl developtrent.'Wc r'r'ill cnd rvrth rvise rvords for evely l-rcalthcare proGssional: Those who seek mentoilng, will rule the great expdnse uniler heauen,
Those who boast they arc gredtev than others Those who are
follolving erccpt: A. Distributing vour personal busincss cards B. Visiting and talking lvith cxhibitors C. Attcnding sessions rvith your colleagues from r'r'ork
I). Using vour "elevator"
speech
3. Inrportant skills for etTective preceptorine include: A. Authoritarian leadership stylc

13.
willfdll
short
willing to learnfrom othets, become greater Those who are ego-inuolued, will be ctutnbled anil made small As quoted in reJercnce 77: Shu Ching translateil in "Tao Mentoring' by Chungliang al lluang anil Jewy Lynch.
Expertiscr rn the role of rvouttcl cale specialist C. Focus on nelJative feedback D. Belief in the value of realitv shock
.1.
O[.]
A.
potential rrrentors, select the best choice: physician rvith several vears of experience in
The Reader's Challenge

collvert frollr r -vou, The Reacler, to passive to an active ro1c. I{eflect o11 vollr former and present ilcilitators and identifl,- the role rnodels, netr'r'orking cotltacts, pr:eccptors, lnd ntentors that have playecl a part in your
XVe
lr.ound care
norv challenge
B. A rvound care providcr rvhosc goals are sirlilar lo your

o\ rn
career.Where do vou lr,ant to be
in
5 veals? By
lvriting
a 1-
C. Someone who knows the resourccs of valuc :in develuping rr otrrtd c.rre exl( rlise D. A supervisor fiom rvhorn you want positive evalu-rticrn
Ansrvers: 1
page sllmntary of your prolessional gor1s, you can identily any g:lps and thc need for further lacilitators along rvith the
A,2-C,3 B,4-C
189
CHRONIC
WOUND CARE 4th
Edition
Belcher and Sibbald

minoriry faculty at the University of Pennsylvania School of Medicine.,4rad Med. 1999;7 4:376 379. NolinskeT. Multiple mentoring relationships facilitate learning during fi eldu'ork.,lm J Ouup Ther. 199 5 49 (1) :39 43. Kranr KE. Mentotin! at Work: Deuelopmental Relatioxships in OtganizationaL Life, Glenview, Ill: Scott, Foresman; 1985. Glass N, Waltet R. An experience of peer mentoring with student nutses: enhancement of personal and prolessional growth. J trriars Edac. 2000;39(4):155-160. Glass N,Walter R. Exploring women's experiences: the critical relationship betueen nursing education, pee. nentoring and fenule friendship. Contemp Nurse. 1998;7 (1):5 77. Hall J. Cirallenges to caring: nurses as wounded healers. Australian J
;
References
1.
Lundin
E
Clenrents G, Perkins D. Mentoring re
ps: everyone
who
makes
it has a mentot.
Haruard
s
A
Reuieu
11
1978;7(8):89-101.
Belcher AE. Beyond preceptorships: internships, a mentorships. In: Flynn J, ed.The Role of the Nurse Educators and Clinidans. NewYork, NY: Spri
Company,2005. Capell Il Finding tine: blending netrvorking into at: http: / /rvwv carej ourrral. com/marketplace
Chicago.asp. Accessed
12.
nticeships, Cuide-for
Publihing
Avaiiable
13.
19-
t4
April 6, 2007. Bradford SL. Expetts oiler their tips for fruitfirl networkirg Available at: http://uvwcareerjournal.com/ networl<5. 6.
15
ing,r2005021-5-bradford.html. Accessed 1 9, 2006. HCPro, Inc. The Efectiue Nurse Precepor Harulbook.2
at: http:/,/mvw.hcpro.com. Accessed
ed.
Available
16
17
April
6, 2007.
7.
8. 9.
10.
Partnership: making the most o{ ng. lv4rulrg Spectrum. May 3,2004:26 29. Egan G. Tlre Skilled HeLper 5th ed. London, UK able;1990. Freerrran R. rVerroring in Gened Prartlre. Oxford, UK tteNorth Heinemann; 199i3. Haseltine Fl Rorve M! Shapiro EC. Moving up: roie tors and rhe "Patron System." SLoan Mdfrdge Reu Johnson JC, Williams B, Jaladevappa R. Mentoring
Restifo
Holutir N-ars. 1 99 6 ;3 (2) :12-1 8. Heinrich Kl Scherr MWI Peer mentoring for reflective teaching: a model for nurses rvho teach. JVarse Educ. 1994;19(l):36-41. Atwood-Blaine D, Bates K, Brattan Il et a7. lateral Mentoring Culver, Calil Pepperdine urriversityVircual Camp; 2001. Norbeck JS. Teaching, research, and serr.ice: striking the balance in
doctoral education J Pt o.f N ur. 1998 ; 1 4 (4) : L97 205. BWlWright SM, Cofrancesco J Jr, Babbott SII Thomas pA, llass EB. Pronrotion criteria for clinician-educato$ in rhe United States and Canada: a survel' ofpromotion comnittee chairpersons. JA MA. 1 997 ;27 8 (9) :7 23-7 28.
.
Beasley
CHRONIC WOUND CARE, 4th
Edit]ON
Opportunities for Wound Care Specialists

Janice M. Stanfield, MBA, RN, CWOCN
Objectives
Tê reader w,l be
chal
. Envision opportunities within various care settings for the wound care specialrst i Appraise the iniportance of identifying the ineeds of potential .or existing clients . Fxamire Lhe advantages ol nre'â n'ari.eting and its effect on,ob securry.
my of an independent practice. One must decide how
srged to:
lntroduction needs posed by patients with chronic r'vounds -Fh" I contrnue to overwhelm the healthcare system I Nuu;gu,irrg rhe ever changing face of reinbursement while addressing the needs and desires of our
aging population remains a challenge. Hou'ever, over the past several years, wound care specialists have been quite successful in proving their value in all l'realthcare environments.'With increased focus on quality of care and cost-etlective managementl the demand for wound specialists is increasing. It is important that u,ound care spe-
to deliver services (ie, as an employee or
as a contrac-
tor). Either way, the key to a securel successful practice is communicating the value of the service, also known
as
marketing.
cialists continne to focus marketing efforts on the impact that they can make to traximize quality care u'hile containing costs across the healthcare continuum. It is also essential to remain sensitive to the needs of a
more informed and involved patient population.

lJnderstanding and addressing these needs in a bold and creative way rvi11 continue to lead us toward strategies that maximize patient outcomes and wound care specialist opportunities.
Marketing Specialty Services

While some rvound care specialists enjoy the routine of institutional employment, others prefer the alltono-
There are 2 basic types of service promotion: internal marketing and external marketing. Marketing to an existing client or employer is merely reinforcing the value of your service.This is also referred to as internal marketing. A successful internal marketing plan will result in strong job securitl'. Marketing to a new client requires identification of potential opportunity and then convincing the client your services best meet the challenge. Marketing is a continuous process in which commr-rnication will always be the most important component. Becoming successful at marketini the skrl1s of a wound care speciallst depends on many factors. Early identification of opportunities, understanding client needs, and a progressive philosophy toward planning are essentiai elements of success. Once the wound care specialist understands this, he or she must position his or her practice to effectively meet the changing needs of clients.This discussion is most focused rvhen opportunities are viewed within specific care settings.
StanfieldJM. Opportunities for u'ound care specialists. In: Krasner DL, Rodeheaver GT, Sibbald RG, eds. ChronicWound Core:A Clinicol Source Book for Heolthcore Professioncis. 4th ed. Malvern, Pa: HMP Coormunications, 2l)07:197-195.
CHRONIC
WOUND CARE, 4th
Edition
191
Stanfield
Opportunities forWound Care Specialists
Acute Care
Acute care facilities oller the most tradition wound care specialists. Challenges begin rvith ment for Medlcare and nranv indenrnitr
grarns,
Tele-health
roles for imburse-
nce pro)r_1p1n,js
An opportunity that estabLishes inrproved:tccess to oLltlying and rernote sites is the developrnent a "tele-hea1th" or "teleassess" center.'W'ourid nranagement rernains one of the fastest growing areas for telernedicine. 'Wor-rnd care specialists, via
phone and colnputcr
ed
(te1e-assess), are available
which are dictatecl by diagnosrs-related
(DRG$.These challenges along r,vith the incre
rn capl-
to people locattravel to a facil-
tated insurance contracts within the rnanaged re ill'ena have placed rnany lacilities in crisis. Facilities are being forccd to heavily weigh thc costs of providing rypes of care. To assure their solvencv. facilities are ex their services. Many acute care facilities have set up iostic and outpatient clinics, sat.ne-day surgery cente subacute or transitional c:rre units, telemedicite ccnters, affiliated honre-health agencies. For r,vound care providers, this is goocl nervs. cutc care facilities are bringing broader rnarketing oppor unltles to
these specialists.
in remote
areas and
to patients r,vho
callot
This courmunity outreach progranl provides a marketing opportudty for wound care specialists and facilitics by creating previously untapped revenue centers \1.hi1e addressing the needs of the conlnunity. A tele-assess center
case.
ity n'ith
pernilts
a facility to serve 1])ore p:rtients in the same arnount of tirne and expands geography. It enhances the ability to lrionitor paticnts and facilitates a stlong potential to improve out-
conres
by enhancing
access
to high cluaLiq, rvound expcrti:c

I)ocumentation pro-
while helping to
duced
1olr,-er readrnission rates.
For cxarnple, wound care
speclialists can
in
a tele-assess center is high qualit1,, inrage enhanced, Tele-asscss increases contact
becorne involved in staffeducation by preparing classes on
and inm'rediately retrievable.
prevention of skin problems, wound assessnie[rt, documentation, and education on the use and selection of
betrveen the expert and the patient, r,vhich can impr-ove prtrent satisfaction while cutting thc cosr of ser-vice delivery
wound care products. They can rssisr with the in.rnagerrent of rvound care supplies, frcilrtation of rfirnburse, rn('nt. and the corrsolidariorr o[.upplics i,, ,'cnr]rl ..rui.es.Aclditiolally, they can serve as the 1i:risol to irssociated
vendors and can clevelop and implerncnt policie( .urd pro-
Subacute, Transitional, Rehabilitation, and
Long-Term Care
Subacnte, transitional, rehabilitation, ancl long5-term care
ccdurcs. MonitoIing pdticnt outcon)c\. crrrpha:izing

inlprovement in cluality paticnt c:lre. d".re"rirJ nosocornial brcakdown, ancl providing patient educ{tion can enhance a faciliryt irnage end dccreesc 1i.rbilit[,. 'Wound care specialists can follorv patients after ilischargf, thereby providing continuity of care fi'onr hospital to subacute care and fronr rehabiiitation to horne care. Many wound care specialists function as gate(eepers of specialry-bed leasing, saving thousands (sornetime! million$ of dollars relatcd to inappropriate bed rentals. At the sarne tirnc, they are in a position to assure that the beds {re placed for at-risk patients in order to prevent in-house {omplications, thereby inrproving qurliry of crre and p:rtiedr s:rrisfac tion and recir.rcing faciliw liability. They are alfo taking responsibiliry for managenrelt of sorne higher eJd r.vound proclucts, such as negative pressllre wound therapl..
facilities otTer sirnilar challenges. Although these facilities have long bcen faced with r,r,-ound care problems related to longer acute care stays, the facilities are usually snaller; therefore, the population, which directly and clearly benefits fi-orn the ernployment of a r.vound care specialist, is 1imited. Some of thesc facilities are monitored and controlled
by state and/or Gderal prograrls ancl face challenges not

founcl in the acute care setting.'Wound care specialists are usr.rally able to best lturket their ski1ls in these settin[Js on a contractual basis.This cnables the facility to be less investecl
while still being in a position to benefit fiorn the services of the specialist as well as show accrediting bodies its corunit, ment to quality care. In skilled nursing facilities (SNFr, consolidated billins ancl tracking ofper*beneficiarv costs for resiclcnts denrand a close monitoring of costs related to patient care. At the same tinte, quality of care remains an issue.The wound care
specialist should be focusingJ on cost ofresolution, using the rnosl efTective products, not necessarily the least erpeDsir..e prodllcts. Utilizing this focus in rn:rrketing to skilled facilities, specialists may wish to elnphasize their value by prornoting multidisciplinary nlanagement of patient skin or rvoLrnd care and rnanaging costs and r-rse of products,
Outpatient Centers
care specialists are in a unrque position to establish :r rcvenue-generating center afEliated with an acute care faciliry.This is acconrplished through the devfloprnent
'Wourrd
of a rvound clinic r,vhere one cannot on1_v establi{h outpatient revenue but also create an attr:rctive site ftr clinical
research, olltp:rtient retail supplies, or both.Wound care spe-
cialists can also take this opportunity to set up cohlnunity cducation and outreach progr:rilrs, creating increlsed consunrer visibility for their facility.
1L)2.
including those costs related to specialry bed rcntals. Creating case studies, utilizing costs prior to implernentation of specialty services, and cornparing thern to the cost
a technique
of healinp5 following implementation of specialist services found quite effective by many specialists.
is
Stanfield
Home Health
As our aging popuiation incrcrses, the home is becom-
Industry also hires clinical advisors who meet rvith key persornel to discuss and revierv the r'vound care rnarket rvith
respect
ing the setting of choice for providing and rpceiving healthcare. According to the Centers for Mediriare and
Medicaid Services,' spending for freestanding home healtlr realized double-digit grou,th-an average 9f 12.5%
pcr yc.rr-sittcc 2ll0o.
to product
needs and positioning. Advisors, like
investigators, are usually experienced wound care specialists r'vith diverse practices. Since it is ituportant for industry to consult:L variery of specialists, the opportuniry is usr-rally lirn-
Tlis enviror-rment presents tretnendous opportuniry lor u.ound care specialists r'vho m.rrket their .rbiliry to rapidly improve outcolnes rvhile idcntif ing cost-etTectivc' woltnd llranagelnent techriclues. Many horne ca.e ,gen,iics have found there is significant value in ordering :r worf;nd carc specialist consr-rlt ear\ in the patient care reginre. The r'vound care specialist is often able to saGly decrease visit
frequency, order more cost-effective treatlnent, ancl provide the patient better outcottres. The wound special]st otTers
ited lvith each company and often t:rkes the form ofan advisory board. Many companies hir-e wound care specialists to provide other ty-pes of internal education. Classes are taught to sales associates to cover all aspects ofrvound n)ana[Jenlent, marketing to specialists, competitor challenges, and marketing strategies related to competitive products. Requests are oftcn rnade of both independent specialists and cornpany-enrployed lvoutrd care specialists to develop nranuscripts that relate to the slrpport of their pr-oducts. These manuscripts are then subniltted to journals for publication or usecl as seiling pieces by their sales stall In some cases, cornpanies hire rvound care specialists ro become sales msociatcs. Other comp:rnics hire or contract
other benefits, such as statT ancl patient edtlcation on the prevel)tion of recurriug skin-related problerns throngh rvound assessment, wound care documentation, aild selection of appropriate u,'ound care prodncts.The specialist tnay also assist in tl-rc developtnent of patient c:rre pfians and nanagement of ellcctive outconles. Incorporatipg tele.r\sc\\ progrJlil\. . duc.ttiott. rrld crr)1 initill visit. lor plricnrs rvith wounds, wound care specialists in thrs .rrcna ele able to lnanage an agency's wouncled population much rrlore productively than if they r,vere rnking
:11
thc visits thenrselves.
wound carc specialists for clinical sales support.These specialists ale utilized to provide education rvhilc assisting the cornpany to position proclucts for use in a particular factlity.The opportunities in industrv secnr endless.'Whether one chooses to become employed or to contrtct his or her services, becotring an active participant in industry is very important to the wound rnan:lEJertlent illdllstry. Clirlical
involvenrent assures proper development and irnplellrentation of products and services in the wound care market. Another opportuniry rests in consulrler eclucation aucl
developmcnt olconsnrner educatiott too1s, sucl.r as pamphlcts and videos. Many cornpanies seek prxcticing professionals to
assist
lndustry
Industry ofTers diversity to employment a1ld colltract fol wound care specialists.With the sophiisticetiou ofproducts and the hugc itrflux ofdressings and tleatlnent
rnarkets
nrodalities to the marketplace, irrdr-rstry is utilizint r.vound care speci:rlists in a variety of new ways, such as ihvestig-r tive product trial monitors, research associ:rtes, and clinicel investigators.These options irl,-olve investigating potential products and/or troublesh ooting current p.o.lr.{r rrrarrrf:Lctured or distributed by r cornprny. Compar-ries usually en:rp1oy trial motritors and research associates; hor,vever, sorle u'ound carc specialists are indcpendent collltr:lctors. A clinical background rvith additional experience relatcd
in the development of educ:rtion:rl tools for consunlers.

r-isua11y
Again, this opportunity is holvever,
lirnited to the task at ha1ld;
in nratry other areas. Media forrnats, such as CD-IIOM and the Intcrnet, 1encl thenrselves to opportllnitics for the developnrcnt of continuing educ-Ltiotr prollrams lor profesionals rnd disexse or management proopens doors
it
granx for consurners.A small amount of financial invcstm.ellt can prove to be prolbssiotrally rewarditrg and lucrative.
to statistics is beneficial. Clinical investigators are
usr'ra11y
Legal or lnsurance Consulting

Insur:rnce conlpany litigators and attornevs ritilize expe rienced wound care specialists as expert witnesses.This type ofutilization is rlore oftcu contractcd on a fee per-servlcc basis, basecl on hours spcnt revier.ving charts, flagging pcrti-
practicing wound care specialists rvho have diveise practices and tl're ability to work with institutional review
boards
(IRts$ lvithout creatirl5l cielays for stucly $ponsors. Sponsors usua1l,v prefer an investigator rvith a minirnut.tl of
years
of cxperience in patient care. Investigators
are
nent data, writing suttunaries, investigating stand:Irds of

care, and locating suppol-ting docutnentation.
often
ca11ed
uporl to publish the findings of a particular
In
adclition,
study and,/or present the findings at a n:rtional coltference in oral or poster forll. In addition, investigators ;ire often used to present findings and to ansr.ver qr-restiorls of the sponsor'.s sales force prior to the introduction of tfue prod-
specialists are cotrtracted to servc as expert r'vitnesses during
depositions, sit on court review boards, aud even take the stand in jr-rry trials. Expert r.vitnesscs are usually clinicians
rvith at least 7 years oferperience.These opportunities can

be rnarketed through insurance litigators and attorncys.
uct into the marketPlace.

CHRONIC
WOUND CARE, 4th
Edltion
193
Stanfield
lmplementation and Management in All Environments

In all environments,
a
wound care specialist has the abili-
ty to implement and manage evidence-based programs that support the use of the most effective treatments. Some of these treatments may appear to be more costly; however, they may speed time to rvound resolution, thereby improving the qualiry ofcare, decreasing related complications (eg, infection), and increasing patient satisfaction.
wound care, hoping to attract nurses or patients r,vho can purchase products or services from the program sponsor. Some u'ound care specialists teach programs independent of any institution or vendor and do so by utilizing their independent provider numbers for continuing education. A wound care specialist rnight also work fu1l or part time as faculty at an established wound/ostomy/continence nurse or wound care specialist progranl or serve as contract
adjunct faculty, teaching cornmuniry college- or universirylevel nursing education programs.
Prograrn review. Some facilities prefer that an expert

prepare a "report card" of sorts.'Wound care speciahsts collect pertinent data regarding facility practices, including a review of supply contracts, durable medical equipment (DME), and disposable equipment; interview stall; and
Conclusion
A ttemendous number of opportunities exist for wound opportunities are only some of the open doors one might explore to create a practice that is not only diverse but also secure. Good market research, a clear plan that will assist clients in achieving thelr goa1s, excellent client communication, and development of strategies for promoting onet self and services are truly the key to securing a roie in the fie1d of wound managenent.
care specialists.The previously described
determine the assets and liabilities of each facility.They then create a document that contains a detailed picture of the faciliry status and recommendations for cost-effective, qual-
ity enhanccd managcnlent. Prograrn developrnent and rnanagernent.
Somedrnes
a recommendation that wound care specialists participate
in
the development ofa program geared toward patient and staff education is appropriate. Wound care specialists also may select and train a skin and wound nunagement team that
when the wound care specialist leaves. Addirionally, wound care specialists who are more knowlassumes responsibilities
Take Home Messages for, Practice
edgeable
with
respect
to wound carc
products, diagnosric
Wou^d ca.e soec.alisrs sôulc focus on .narl.eting tne r-rpact Lhat they can mdre to maxirr:ze q-dr,ty care
wl^r.e containi^g costs rnrougnout rne lealtnca.e conT
tooIs, and specialry bed sales or rentals should become an inre-
gral part of,
ifnot
solely responsible for, negotiating contracts

specialists
NULM, sensiTlve
with related vendors. In addition, the
might asist
. .
Wound care specialtsls shou,d rerain

needs
larro^.
to the
popu-
with developing standardized protocols, setting up "outcome

profi1es," downsizing central supply inventory and evaluating
ola .nore infor^red and involved patient
and making recommendations to the faciliW wtth respect to
documentation and liabiliry
r.-.1^derstar^d ^g a^d adoress,ng these êeds n a bo.d and creative way will cont,nue ro 'ead wo*nd ca-e
Wound managenent progranx that rely on specially trained experts to irnplement detailed clinical protocols, including drug and treatment algorithms, have shown eficacy in managing chronic wounds. By fostering integration ofcare across specialty and medical-social boundaries, such systems enabie wound healing by embracing rreatment of
the rvhole patient, not simply treatment of the wound itself.
speciaiisLs Loward srraLegies L"ar maxirr,ze DaL.err oJt-
comes and oppoftu^rtrs.
1.'Which of the lbllowing environments otTer opportunities for the rvound care specialist? A. Acute care, long-term care, and home health
Working closely with primary care physicians, often by telephone-mediated interaction with patients, rvound care specialists may take an expanded role in meeting the challenges of patients u,ith chronic wounds by embracing the
role of program manager.
B. Subacute, outpatient clinics, tele-health

C. Medical legal, industry research, education D. All of the above
Educators
The role of educator is extremely diverse.'Wound care specialists are often hired to participate in traveling speaker bureaus where a number of lectures are scheduled each year. Vendors or manufacturers, home care agencies, and hospitals all have been known to hire a specialist to teach
194
2.To be successful at marketing the skills of a wound

specialist, the specialist must:
care
A. Cleariy understand the
needs
of the client faciliry and

needs and be certain
develop a proposal meeting those needs
B. Clearly understand their personal
that the proposal addresses those needs
Opportunities for Wound Care Specialists

Block P F/arle-ss Consubing:
Stanfield
C. Be certain not to present ideas that seem
"o
box"
D.BandC
Answers:1-D,2-A
Reference
l. & Medicaid Services. growth rate coutinues to decline in
Centers for Medicare
1750.Accessed March 7. 2007.
A Cuide to CettingYour Expertise Used. 2nd ed. San Francisco, CaliiJossey-Bass; 1999. l3ogart J13. ltgal Nurse Consulting: Principles axd Practice. Portland, Ore: American Association of Legal Nurse Consuitants; 1997. Milazzo V How to Develop an Action-Oriented Marketing Stategy Jor Your Nursirg Barlness. Houston, Tex: Medical Legal Consulting Institute, Inc; 200 1 . Nomood S. N'nrsrs as Consultants: Esential Conccpts and Processes. Menlo Park, Calif Addison-W'esley Pub Co; 1997. Richmond TS, Thompson HJ, Suliivan Max EM. Reimbursement
for actrte care nurse pnctitioner services.,4n J Cit

spending
Cate.
2004 http : //www. cms.hhs. gov/apps,zmedia/press/re1ease.
ilable
asp
at:
7.
2000;9(1):52-61. Taheri PA, Butz D, Griffes L, Morlock DR, Greenfield LJ. Physician impact on the total cost of care. Ann 'Weiss A. Gerdrg Started in Consubing. 'wg.2000231(3).132-435. 2nd ed. Hoboken, NJ:Johu
Wiley & Sons, Inc;2004.
Suggested Reading
1.
Bemis P Making Money in Nursing faudio CD]. Roc National Nurses in Business Association: 2006.
Profesional Practire Manual. Chicago, Continence Nurses Society; 2006.
Wound, Ostomy aod Conrinence Nurses Sociery I4IOCN Ill: Wound, Ostomy and
CHRONIC WOUND CARE.4th Edition
1,95

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Wound Care Processes-From Patient Assessment to Healthcare Delivery Systems

Wound Assessment and Documentation

AssessmentWhat it is andWhat it is Not

progress is the challenge

ate." In addition, in clirrical practice, it is

for signs of improvement, infection, or deterioration, and

change the dressirrg

and complete a rvound assessment to quantifi/ progess.

WOUND CARE 4th

van Riiswijk and Catanzaro

Wound Assessment and Documentation

unstable patterns may result

ing one does not lose sight

Outcorne and treatrnent eflbctiveness. In

to discover and rnarkers ofnormal or or biological test physical, chenrical,

defined and realistic

well as assessment tools that improve

help clinicians develop a treatnlent outcome data-

Clinical Wound Assessment

is appropriate and Gasible

tool to accumulate lnuch needed outcome data on chronic wound care.''"'

of care are not

be affected by the reassessment frequency. For example,

r.vor:nd that needs to be reassessed daily should not be cov-

a dressing that is designed days.

tion to developing realistic long-term

to remain in place for rationale fbr Stage I

helps to remember that eve

through Stage IV pressure ulcers has been reviewed elseCHRONIC

WOUND CARE 4th

Wound Assessment and Documentation

van Rijswijk and Catanzaro

The use ofrisk-assessment tools and procedures for panens

with Stage I pressure ulcers is discussed in Chapter 60.

Assessing the Wound

CHRONIC WOUND CARE.4th Edition

van Riiswijk and Catanzaro

Wound Assessment and Documentation

o1994 Diane Krasner, Lia van Rijswijk

Figure 3.Wounds are classified by cause

lvi1I ahvays require the talcnts

tion of anatomical wound

Choosing a wound assessrlent

observation. available instr nrents and

equipment may enhance the process, but

WOUND CARE, 4th

Wound Assessment and Documentation

van Rijswijk and Catanzaro

Exarnples of wo_tlnds; ' onr monly qsed:,wo,Und

itate continuity of care.

same wound assessrnent is

nrade using a conrbination

fion follicles, opocrine seboceous glonds,blood

ond and nerve endings)

Grade I (or l) diabetic foot ulcer**Venous

ofthe rvound bed

can be accurately assessed

bone) foot ulcer**

Third-degree (sometimes called fourth-degree) burn

foot I::;::"^!if,::"::i#:;*.;;:;:"i;:l:::::Jr'i;l:;"';i:;t;:;;. *aWogner

FW.The dysvosculot foot: o system for diognosis ond treatmenL

Staging.'Wound depth is an irnpcrtant sssessnlcnt

has a dir-ect effect

Varion hou long the rvound may

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