Tag Archives: wound care

Caring for Wounds eBook Series: Pressure Injuries

This e-book is sponsored by Angelini Pharma, Inc.

angelini pharma ebookPatient care teams rely on the wound care nurse alone to implement a pressure injury prevention program; however, a successful program requires involvement from the entire care team and is a 24/7 endeavor.

Learn how your healthcare team can provide better patient care, topics include:

  • Prevention Programs: Where to Begin
  • It Takes a Team
  • Establish a System
  • Empowering Your Patients
  • Prevention Education
  • Pressure Injuries

Case study: Maggots help heal a difficult wound

Using maggots to treat wounds dates back to 1931 in this country. Until the advent of antibiotics in the 1940s, maggots were used routinely. In the 1980s, interest in them revived due to the increasing emergence of antibiotic-resistant bacteria.

At Select Specialty Hospital Houston in Texas, we recently decided to try maggot therapy for a patient with a particularly difficult wound. In this case study, we share our experience.

About the patient

Mr. Green, age 52, had a history of diabetes, which led to bilateral below-the knee amputations. His medical history also included coronary artery disease, peripheral arterial disease, and anemia.

Alert and oriented, he was able to give a detailed account of his recent wound. On August 12, 2015, Mr. Green cut the distal tip of his right third finger while preparing food. Having already lost his legs, he was concerned about the possible need for another amputation, so he made an appointment to see his primary care physician. The physician instructed him to keep his finger clean and dry and to observe it. Nonetheless, it became infected and his finger had to be amputated at the base on September 11. A week later, he was admitted to an acute-care hospital for pain, swelling, and erythema. He received I.V. antibiotics along with pulsed lavage, treatment with Arobella Medical’s Qoustic Wound Therapy System™, ultrasound, and finally, negative-pressure wound therapy (NPWT).

When Mr. Green was admitted to our long-term acute care hospital, the wound bed was pale pink with the hazy, gelatinous look associated with high bioburden tissue, although no bacteriologic testing was done. (See About biofilm.) The wound measured 5 cm x 3.2 cm x 0.9 cm, and lacked the cobblestone appearance usually seen with recently discontinued NPWT.

Maggot therapy

Based on the difficulty of healing this wound, we decided Mr. Green was a good candidate for maggot therapy, which we’d been wanting to introduce into our facility. Mr. Green and his family were concerned about his lack of healing and eager to try maggot therapy. We selected maggots contained within mesh bags because nurses were reluctant to handle free-range ones. (See Maggot application options.)

Applying the maggots

With Mr. Green’s consent, 10 clinical staff members attended the first day of maggot therapy, when the maggot-therapy containment dressing was applied to the wound. Most were surprised to learn that larvae don’t have teeth in their mouths and don’t bite. Instead, they score the wound surface with their mandibles and secrete an enzyme that liquefies the microbes, which they then ingest. The excess fluid is absorbed by the upper dressing.

Applying the containment dressing took 5 minutes. Then zinc oxide cream was rubbed into the periwound skin to protect it from moisture damage and the bag containing the maggots was placed where it contacted the wound bed. Wound location made this a bit difficult, but we managed it by placing multiple pieces of fluffed saline moist gauze on top of the bag and wrapping it firmly with a sterile gauze bandage.

Changes in the wound bed

After 24 hours, the wound bed was predominately a beefy red color and the dressing was saturated. What we’d assumed was slough in the bed actually was a tendon; striae were clearly visible and the surface had a shiny cream color. After 3 days of maggot therapy, the wound bed consisted entirely of moist red granulation tissue. Mr. Green experienced some pain, as would be expected with a wound proximal to nerves in the hand. We also suspected the biofilm had been coating and protecting the nerves until this time, so we chose to remove the maggots with the understanding that the biofilm should have been eradicated.

Additional therapy Mr. Green then underwent NPWT for 1 week, after which antibiotic ointment, petrolatum gauze, and sterile gauze were applied daily until discharge. He was discharged November 25, 2015 with an appointment to see a plastic surgeon to evaluate him for a planned skin graft; at discharge, the wound measured 1.6 cm x 2.5 cm x < 0.1 cm. The plastic surgeon told Mr. Green he’d need no further treatment.

Broadening the treatment options

Engaging other staff members and encouraging them to attend dressing changes contributed to the success of this first use of maggot therapy in our facility. After the first dressing change, Mr. Green’s wound improvement was so dramatic that it made a vivid impact on staff. This motivated them to discuss the results with their coworkers. Soon, staff from other disciplines began to approach me with questions and ask if they could attend the next scheduled dressing change.

Thanks to the success of our experience, we introduced maggot therapy throughout the Select Specialty Hospitals’ network of facilities in January 2016. Since then, we’ve treated at least a dozen patients.

Sally Anne Jewell is manager of wound care at Select Specialty Hospital Houston in Texas. (Mr. Green’s name in the case study was fictitious.)

Selected references

Cazander G, van Veen KE, Bouwman LH, et al. The influence of maggot excretions on PA01 biofilm formation on different biomaterials. Clin Orthop Relat Res. 2009;467(2):536-45.

Cowan LJ, Stechmiller JK, Phillips P, et al. Chronic wounds, biofilms and use of medicinal larvae. Ulcers. 2013.

Geary MJ, Smith A, Russell RC. Maggots down underWound Pract Res. 2009;17(1):38.

Steenvoorde P, Jacobi CE, Oskam J. Maggot debridement therapy: free-range or contained? An in-vivo  study. Adv Skin Wound Care. 2005;18(8):430-5.

The Buzz Report: A wound care clinician’s best friend

By Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS

In 2014, more than 8,000 new articles related to wound healing were added to the PubMed online database and hundreds of new patents for topical wound formulations were filed. Staying up-to-date with the latest and greatest findings and products can be challenging. We all lead busy lives, and our demanding work schedules and home responsibilities can thwart our best intentions. Although we know it’s our responsibility to stay abreast of changes in our field, we may feel overwhelmed trying to make that happen.

Keeping clinicians up-to-date on clinical knowledge is one of the main goals of the Wild On Wounds (WOW) conference, held each September in Las Vegas. Each year,
I present the opening session of this conference, called “The Buzz Report,” which focuses on the latest-breaking wound care news—what’s new, what’s now, and what’s coming up. I discuss innovative new products, practice guidelines, resources, and tools from the last 12 months in skin, wound, and ostomy management.

This article highlights the hottest topics from my 2014 Buzz Report, with appropriate updates since the September WOW conference.

Pressure ulcer prevention and treatment

2014 was an active year in the area of pressure ulcer prevention. The latest practice guideline on pressure ulcers, released last September, was a joint collaboration of the National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance. The intent of the guideline, titled “Clinical Practice Guideline for Pressure Ulcer Prevention and Treatment,” was to advance international consensus on pressure ulcer prevention and management. This document is a must-read for all clinicians practicing wound care today.

Also, NPUAP updated its Registered Nurse Competency-Based Curriculum: Pressure Ulcer Prevention. The curriculum now includes major competencies, content objectives, content topics, suggestions for varied teaching methods, and references.

Are some pressure ulcers unavoidable? This continues to be a hot topic. At a February 2014 multidisciplinary conference hosted by NPUAP, participants reached a consensus on these key points:

  • Some pressure ulcers are unavoidable.
  • Patients at increased risk for developing unavoidable ulcers are those with malnutrition and multiple comorbidities, those with extensive body edema, and those who must keep the head of the bed elevated more than 30 degrees for medical reasons. It’s in every wound clinician’s best interest to stay abreast of NPUAP’s position on unavoidable pressure ulcers. The report was published in the Journal of Wound, Ostomy and Continence Nursing.


According to the 2014 National Diabetes Statistics Report, more than 21 million people in the United States have diabetes, and an estimated 8 million of them are undiagnosed. Diabetes raises the risk of cardiovascular disease because of common concurrent conditions, such as hypertension, obesity, abnormal cholesterol and triglyceride levels, and poorly controlled glucose levels. Help your patients reduce their risk by referring them to the free “Diabetes and Coronary Artery Disease ‘Make the Link’ Toolkit” from the American Diabetes Association.

Compression therapy

Do you use compression therapy to treat patients with venous ulcers? I reviewed three documents on this topic. (See the selected references at the end of this article.) The most compelling was a study published in JAMA Dermatology titled “Delivery of Compression Therapy for Venous Leg Ulcers.” It found more than half the nurses who applied either inelastic or elastic bandages obtained sub-bandage pressures below the 30 mm Hg required for therapeutic compression. The authors concluded that training programs focused on practical bandaging skills are needed to improve management of venous leg ulcers.

Wound care and infection

Infected wounds pose a challenge for even the most seasoned practitioners, who may have difficulty determining the recommended course of action. The Infectious Diseases Society of America published an updated guideline, “Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014.” It covers both diagnosis and ongoing management recommendations for a wide variety of infections, ranging from minor to life-threatening. Although practice varies, clinicians should use evidence-based
interventions to identify and manage wound infections; failing to do so could lead to death.

Resources and new products

Need more resources? See Clinician Resources on page 35 for valuable links. Also, check out new products that might be useful for your patients (See New products in wound care.)

The world of wound care is always changing and evolving. We all need to develop a plan for staying current so we’re not using outdated modalities. I’m already gathering the latest and greatest for the 2015 Buzz Report. One thing is certain—there’s never a lack of issues to review when it comes to wound care.

Selected references

Principles of compression in venous disease: a practitioner’s guide to treatment and prevention of venous leg ulcers. Wounds International, 2013. www.woundsinternational.com/pdf/content_10802.pdf. Accessed December 10, 2014.

Zarchi K, Jemec GB. Delivery of compression therapy for venous leg ulcers. JAMA Dermatol. 2014;150(7):730-6.

Zenilman J, Valle MF, Malas MB, et al. Chronic Venous Ulcers: A Comparative Effectiveness Review of Treatment Modalities. Comparative Effectiveness
Review No. 127. Prepared by Johns Hopkins Evidence-Based Practice Center. AHRQ Publication No. 13(14)-EHC121-EF. Rockville, MD: Agency for Healthcare Research & Quality; December 2013. www.effectivehealthcare.ahrq.gov/ehc/products/
. Accessed December 10, 2014.

Donna Sardina is editor-in-chief of Wound Care Advisor and cofounder of the Wound Care Education Institute in Plainfield, Illinois.

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

An easy tool for tracking pressure ulcer data

By David L. Johnson, NHA, RAC-CT

As a senior quality improvement specialist with IPRO, the Quality Improvement Organization for New York State over the past 11 years, I’ve been tasked with helping skilled nursing facilities (SNFs) embrace the process of continuous quality improvement. A necessary component of this effort has been to collect, understand, and analyze timely and accurate data. This article discusses a free tool I developed to help SNFs track their data related to pressure ulcers and focus their quality improvement efforts for the greatest impact.

The beginning

Since 2002, the quality initiatives administered by CMS have included the prevention and treatment of pressure ulcers as a focus topic for SNFs across the country. The challenge has been to guide identified facilities to collect their own data, in real time, and drill down into that data to identify trends and opportunities for improvement.

In 2002, I decided to develop a tracking tool to help SNFs with the timely collection of their pressure ulcer data. The tool had to be in a format that could be easily used by most providers, including those with basic computer equipment and operating skills. The purpose of this tracking tool was not to replace the necessary clinical documentation of the pressure ulcers, but to offer a focused document with pertinent statistical information for all cases of pressure ulcers in the SNFs at any point in time.

The current Monthly Pressure Ulcer Tracking Form is in its fifth generation. First developed in an Excel 2003 format, the original tracking tool was very functional, but basic. However, Excel 2007 enabled me to add functionality that launched the originally developed tool into a format offering not only a detailed summary and graphs for the entire SNF but also instant access to individual summaries and related graphs for up to 15 separate user-defined locations. For example, those designated locations could be as general as individual units or as detailed as specific care assignments.

How it works

The current version of the Monthly Pressure Ulcer Tracking Form offers the convenience of an Excel spreadsheet to instantly summarize and graph your pressure ulcer data by such categories as site, origin, stage, age of wound (auto-calculated), days to heal (auto-calculated), and weekly response to treatment. The tracking form also summarizes all wounds that are new for the month, by both site and stage and by whether they developed in-house or were present on admission. (See Sample data calculation and graph for all acquired in-house pressure ulcers by stage.)

All of the printed summaries and graphs are clearly identified by their user-defined facility location. Users can quickly identify the data source with the opportunity to easily detect both adverse trends and their own program successes.

Built-in macros for the tracking form walk the user through everything from adding a new case to an end-of-month routine that conveniently saves the data in the current monthly file. The macros then remove the information for all healed or discharged pressure ulcer cases before carrying over all of the data on existing pressure ulcers for the start of a new month of tracking.

All wounds are entered only once, and the weekly status update is as simple as a single letter code for “new,” “improved,” “same,” “worsened,” or “healed.” The data format was intentionally built to allow these factual entries to be clerically entered after collection and assessment by the appropriate professional.

The user is guided through the data entry process with helpful hints in cell drop-down menus as well as embedded data validation rules to restrict what is entered, thereby offering a summary and analysis true to the expectations and spirit of the tracking form.

Efficient data collection in real time is invaluable to wound care teams, offering them the potential to immediately identify adverse trends or celebrate small successes in their wound care program. Take, for example, a calculated increase in facility-acquired stage 2 pressure ulcers. Is there a common site? Is the increase isolated to one designated location or unit? Are there opportunities for focused education efforts, such as early identification or proper prevention practices? The ability to drill down into your data will allow you to focus your limited resources in the areas of identified documented need. (See Sample data calculation and graph for all healed pressure ulcers by site.)

In another example, the data analysis offered instantaneously through this tracking form can easily compare data among designated units within your facility. Is there a unit experiencing better healing times? Has there been a unit experiencing no facility-acquired pressure ulcers? What does that tell you about its prevention practices? How can those practices be spread?

A free resource

In summary, the timely collection, analysis, and attention to your facility’s pressure ulcer data can be invaluable in your internal quality improvement efforts.

These tracking forms are available for download free of charge at nursing
under “Clinical Topics, Pressure Ulcer Clinical Tools and Resources.” You can download a tracking tool with sample data (for demonstration and training purposes), a master blank file for immediate facility implementation, and a multipage PDF desk-side instructional booklet. The instructional booklet offers simple, clear instruction with actual screen prints to help guide the user through the tracking tool functionality. The original tracking tool written in Excel 2003 is still available for those providers with Excel versions earlier than 2007. However, the functionality of the latest generation, which is available to anyone with Excel 2007 or newer, is far superior and highly recommended.

For additional information, please e-mail me at david.johnson@hcqis.org.

Note: This material was prepared by IPRO, the Medicare Quality Improvement Organization for New York State, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 10SOW-NY-AIM7.2-14-24.

David L. Johnson is a senior quality improvement specialist with IPRO, the Quality Innovation Network-Quality Improvement Organization for New York State.

Disclaimer: The views expressed in this article are those of the author and do not necessarily represent the views of, and should not be attributed to, Wound Care Advisor. All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

Using maggots in wound care: Part 2

By Ronald A. Sherman, MD; Sharon Mendez, RN, CWS; and Catherine McMillan, BA

Note From the Editor: This is the second of two articles on maggot therapy. The first article appeared in our July/August 2014 issue, Read part 1 here.

Whether your practice is an acute-care setting, a clinic, home care, or elsewhere, maggot debridement therapy (MDT) can prove to be a useful tool in wound care. But setting up any new program can meet resistance—and if you seek to establish a maggot therapy program, expect to meet significant resistance. By arming yourself in advance, you can achieve your goal more easily. This article covers all the bases to help you get your maggot therapy program off the ground.

Know what you’re getting into

Be knowledgeable. Do your homework and learn all you can about maggot therapy. Know what it can and can’t do, how it works, and the lifecycle of flies and maggots. Learn about the most common complications and how to avoid them.  To gain knowledge, use the wealth of instructional resources in journals, on the Internet, and at conferences. Be aware that the Biotherapeutics, Education, and Research (BTER) Foundation (www.BTER
) has many resources devoted to maggot therapy; most are available for free. You can contact the foundation directly to arrange lectures, workshops, and webinars. Also consider attending a professional wound care conference, such as Wild on Wounds, which usually features a maggot therapy workshop. (See Maggot therapy resources.)

Recruit allies

A common obstacle to an MDT program is inability to find others who want to get involved. But try to get at least one other person on your side (more if possible), and make sure this person is an influential member of the wound care team. The strongest ally may be the head of the wound care or skin integrity team, a surgeon, or the infection prevention officer. These individuals not only can lend support for an MDT program but also fend off such excuses as, “Maggots are an infection risk,” or “The Joint Commission will never approve.” If you don’t reach out to these individuals and convince them of the merits of your vision, the opposition may recruit them to block your efforts to establish a program.

Be prepared

Once you decide an MDT service can yield a net benefit for your facility’s wound care program, you’ll still need to convince colleagues and administrators of its merits. Don’t be scared; be prepared by working out everything in advance. Develop policies and procedures for the use of MDT in wound care. (On the BTER website, registered users can download a policy and procedure template at www.bterfoundation.org/policytemplates.)
Create a plan for patient and therapist education. The BTER Foundation’s patient education brochure “Is MDT for Me?” is a valuable educational resource available on the foundation’s website, along with recorded patient interviews.

Developing a notebook of peer-reviewed clinical studies also can help you prove MDT is effective in treating pressure ulcers, venous stasis ulcers, diabetic foot
ulcers, postoperative ulcers, or other specific conditions. Be sure this notebook includes documents indicating that the maggots your clinic will use are cleared for marketing by the Food and Drug Administration. (The BTER Foundation maintains a library of such literature, available to members.) By addressing these and other likely problems or obstacles in advance, you won’t have to spend the next year searching for solutions.

Be flexible

Ultimately, your MDT program will need to fit into your facility’s wound care program. Prepare for the possibility that your facility might impose certain requirements—insisting, for instance, that your patients be treated as in-patients or that all maggot dressings are applied by medical staff. To get your program off the ground, keep an open mind and consider meeting such requirements and making compromises. Remember: it will be easier to renegotiate for the policies you want once others see firsthand that your program is running well.

Dealing with administrators and the “NIMBY” mindset

Anticipate questions by administrators, and have on hand the data or publications that support your answers. Address the areas of concern to those who are responsible for patient safety, financial solvency, and public relations. Present your plan for patient and staff education and safety.

Many healthcare administrators acknowledge that maggot therapy is effective, safe, and cost effective, but they don’t want it in their facility. This is the “not in my backyard” (NIMBY) mindset. If you don’t have buy-in from the administration, your program will be a nonstarter. So when looking for allies to join your effort, consider approaching a hospital administrator or someone who works closely with the administration, such as a department head (chief of orthopedic, reconstructive, or podiatric surgery), chief of nursing or rehabilitation medicine, leader of the infection-prevention team, or chair of the skin integrity committee. Don’t choose someone you don’t know; instead, select someone you’re comfortable with, who will respect you and listen to you.

To communicate more effectively with administrators, try to see the issue from their viewpoint. Some administrators are concerned about flies getting loose in the hospital, passing the next inspection by The Joint Commission, hospital-acquired myiasis (parasitic infestation), negative media attention, and poor public perception. Be prepared to explain why each of these concerns is unfounded. To do this, perhaps you can arrange a chat between your administrators and an administrator from another healthcare facility that has an MDT program in place. Or ask a maggot-therapy experienced administrator from another facility to write a letter to your administrators. Be sure to emphasize that maggot therapy can bring positive local media attention and decrease costs for inpatients, uninsured patients, and anyone else on a capitated or fixed-fee reimbursement scheme.

You’ll have an easier time getting the administration to sign off on an MDT service if you can demonstrate that maggot therapy is cost-effective and reimbursable. Ask your coding department or maggot suppliers for help in this area, if necessary. You might want to download maggot-therapy reimbursement statements from your facility’s common insurers, or access the reimbursement information available on the BTER Foundation website. The Foundation even provides patient assistance grants for patients without insurance or whose insurance declines to pay.

Recruiting and educating patients

Most wound care patients don’t have trouble accepting maggot therapy—especially those with foul-smelling, draining, activity-impairing, limb-threatening wounds. Many have endured or may be facing surgery or even amputation. For them, wearing a dressing with maggots for 2 days may be no big deal, particularly if they understand the potential benefits.

Play down the negative

One of the keys to interacting with patients successfully is to show you’re comfortable with maggot therapy yourself. Don’t tell a patient, “I know this sounds gross, and you’re probably not going to like what I’m about to suggest, but…” If you do this, the patient is likely to respond, “Maggot therapy? That sounds gross and I don‘t like what you’re suggesting.”

Don’t put a “nonbeliever” in charge of discussing maggot therapy with patients, and don’t give patients the idea that you expect them to find it repulsive. Instead, present the option matter-of-factly or even enthusiastically, as you would any other medical option: “I think maggot therapy might help. Let me explain the benefits, risks, and alternatives.”

Anticipate that most patients will have questions, and be prepared to answer them. (See How to answer commonly asked patient questions.) An effective means of education is to have former MDT patients speak to MDT candidates. A registry of former patients willing to volunteer as educators or interviewees can be a valuable adjunct to your maggot therapy service. Brochures, video testimonials, and other materials also can aid patient education.

A few weeks of solid preparation up front can save you months of drawn-out discussions about the benefits of an MDT program with administrations. Instead, you’ll be able to spend this time providing patients with the benefits of maggot debridement.

Selected references

Sherman RA. Maggot therapy takes us back to the future of wound care: new and improved maggot therapy for the 21st century. J Diabetes Sci Technol. 2009;3(2):336-44.

Sherman RA. Mechanisms of maggot-induced wound healing: what do we know, and where do we go from here? Evid Based Complement Alternat Med. 2014;2014:592419. www.hindawi.com/journals/ecam/2014/592419/. Accessed October 5, 2014.

Wayman J, Nirojogi V, Walker A, et al. The cost effectiveness of larval therapy in venous ulcers. J Tissue Viability. 2000;10(3):91-4.

The authors work at the BioTherapeutics, Education & Research (BTER) Foundation in Irvine, California. Ronald A. Sherman is director. Sharon Mendez is a member of the board of directors. Catherine McMillan is a research intern.

Disclaimer: The views expressed in this article are those of the author and do not necessarily represent the views of, and should not be attributed to, Wound Care Advisor. All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

Device–related pressure ulcers: Avoidable or not?

By: Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS

A medical device–related pressure ulcer (MDRPU) is defined as a localized injury to the skin or underlying tissue resulting from sustained pressure caused by a medical device, such as a brace; splint; cast; respiratory mask or tubing; tracheostomy tube, collar, or strap; feeding tube; or a negative-pressure wound therapy device. The golden rule of pressure ulcer treatment is to identify the cause of pressure and remove it. Unfortunately, many of the medical devices are needed to sustain the patient’s life, so they can’t be removed.

But does that mean MDRPUs aren’t avoidable? Yes—and no. Some aren’t avoidable, but not as many as you might think. Many result not from the device itself but from poor device positioning or securement. Some result from simple failure to check under the tubing or device. These causes are avoidable. Preventive practices include frequently evaluating device positioning and securement. Also, if possible, loosen the device at least once per shift to check for skin problems.

The National Pressure Ulcer Advisory Panel has created four “Best Practices for Prevention of Medical Device–Related Pressure Ulcers” posters, which can be downloaded for free. Besides a general poster, you’ll find posters for the specialties of critical care, pediatrics, and long-term care. Each poster features photos of MDRPU-related injuries and prevention strategies such as:

  • Choose the correctly sized medical device for the individual.
  • Cushion and protect the skin with dressings in high-risk areas.
  • Remove or move the device daily to assess skin.
  • Avoid placing the device over the site of a previous or existing pressure ulcer.
  • Educate staff on the correct use of devices and prevention of skin breakdown.
  • Be aware of edema under the device and the potential for skin breakdown.
  • Confirm that the device isn’t placed directly under a patient who’s bedridden or immobile.

Of course, even when caregivers focus on prevention, mistakes can happen. Unfortunately, mistakes are a part of life. But that doesn’t mean we can’t learn from our mistakes to better protect our patients. When a mistake occurs, determine what happened, correct it, and take steps to prevent it from happening again. That’s our job as clinicians and as patient advocates.

Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS
Wound Care Advisor
Cofounder, Wound Care Education Institute
Plainfield, Illinois

Selected references

Black JM, Cuddigan JE, Walko MA, Didier LA, Lander
MJ, Kelpe MR. Medical device related pressure
ulcers in hospitalized patients. Int Wound J.

Fletcher J. Device related pressure ulcers made easy.
Wounds UK. 2012;8(2). www.woundsinternational
. Accessed June 23, 2014.

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

A Saudi rehabilitation facility fights pressure ulcers

By Joanne Aspiras Jovero, BSEd, BSN, RN; Hussam Al-Nusair, MSc Critical Care, ANP, RN; and Marilou Manarang, BSN, RN

A common problem in long-term care facilities, pressure ulcers are linked to prolonged hospitalization, pain, social isolation, sepsis, and death. This article explains how a Middle East rehabilitation facility battles pressure ulcers with the latest evidence-based practices, continual staff education, and policy and procedure updates. Sultan Bin Abdulaziz Humanitarian City (SBAHC) in Riyadh, Saudi Arabia, uses an interdisciplinary approach to address pressure-ulcer prevention and management. This article describes the programs, strategies, and preventive measures that have reduced pressure-ulcer incidence.

Committed to excellence

With 409 beds, SBAHC is the largest rehabilitation facility in the Middle East; it treats both inpatients and outpatients. Therapeutic, supportive, and educational services are designed to restore patients’ health and function after acute illness and promote their safe return to the home and community. SBAHC admits adult and pediatric patients who have suffered brain injuries, spinal-cord injuries (SCIs), stroke, and limb loss. The facility also offers other services (such as prosthetics, orthotics, and wound care) at clinics that operate 5 days a week.

SBAHC launched its wound care service in late 2007, with the mission of becoming a center for wound care excellence. To prevent and manage pressure ulcers, it uses guidelines from the National Pressure Ulcer Advisory Panel (NPUAP) (www.npuap.org) and the European National Pressure Ulcer Panel. From the onset, the SBAHC administration has fully supported efforts to eradicate pressure ulcers. It has a well-defined process, studied thoroughly and approved by an interdisciplinary team, for identifying, preventing, and managing pressure ulcers.

Initial evaluation

Before admission, patients are screened with special attention to their rehabilitation potential. (Patients who need acute medical care are transferred to an acute-care facility.) Those admitted with community-acquired pressure ulcers are distinguished from those with hospital-acquired pressure ulcers (HAPUs). Within 2 to 6 hours of admission, all patients undergo a comprehensive, front-to-back and head-to-toe skin assessment to check for wounds. Within 24 hours, a pressure ulcer or other wound must be documented; pressure ulcers found later than 24 hours after admission are considered HAPUs.

Also on admission, patients undergo a risk assessment using the Braden scale, a standardized assessment tool for evaluating pressure-ulcer risk. Early identification of at-risk patients is crucial for early implementation of preventive measures and to establish a baseline for later comparison, as when patients sustain new wounds in the facility. The Braden score corresponds to a prevention protocol that varies with the patient’s risk level. A change in the patient’s condition calls for reevaluation with the Braden scale. All direct-care staff are involved in the process and take an active role in the protocol. Pressure ulcers of all stages are referred to the wound care specialist, who in turn may refer the patient to the consultant surgeon, if needed.

Pink clover status

A communication process alerts all SBAHC care providers that a patient has developed a pressure ulcer or is at increased risk. A rotating pink clover icon (chosen to symbolize that healthy skin is pink and that the patient requires repositioning and checking of the skin) is activated for patients with Braden scores of 18 or below. This alert icon appears across the patient’s name and medical-record number in the electronic system, signaling caregivers to use caution because certain types of care or other activities may cause or exacerbate existing pressure ulcers in at-risk patients.

Campaign to lower HAPU rates

The alarming rate of pressure ulcers impelled the SBAHC wound care team to
review and revise existing preventive measures, develop new policies and procedures (which are reviewed annually and revised every 3 years or as necessary), and fine-tune its prevention and management protocols. HAPU incidence became an internal quality indicator. In 2012, an initiative was implemented to reduce HAPU incidence to less than 1% of the monthly total average census. The project had three goals:

  • to educate at least 80% of all direct-care staff (including nursing, medical, and rehabilitation staff) on pressure-ulcer identification and prevention
  • to reduce pressure-ulcer incidence in patients with SCIs to less than 27% of the total incidence (monthly report trends and data from other hospitals worldwide indicate most pressure ulcers occur in SCI patients)
  • to reduce the number of pressure ulcers in patients permitted to go on therapeutic-leave pass to 50% or fewer monthly, within 1 year.

The HAPU prevention team took on the challenge of lowering the incidence. At monthly meetings, staff receive updates on issues related to pressure ulcers. The team addresses these issues, identifies factors that contribute to pressure ulcers, discusses updated evidence-based practices in areas that may need improvement, and provides input on implementation with team members’ consensus.

By the end of 2012, about 82% of direct-care staff had received education. From 2011 to 2012, pressure-ulcer incidence in SCI patients dropped significantly to 18.6%. Also that year, no pressure ulcers were reported in patients who had therapeutic-leave passes. Overall, the project has achieved its goals. Average HAPU incidence for 2012 was 1.8%. Incidence for 2013 was 1.05%—a 41.6% decrease.

Because a lower HAPU incidence reflects a facility’s high standards of care, these initiatives have placed SBAHC’s quality of care in the spotlight. In published data, HAPU rates in long-term care facilities range from 2.2% to 23.9%. At SBAHC, the goal is a rate below 1%.

Pressure-ulcer surveys

Monthly HAPU incidence reports are compiled for monitoring and reference. The
facility also conducts a quarterly point-prevalence survey. The survey measures the proportion of individuals in a defined population who have a pressure ulcer at a given time, such as a particular date.

For the second year, a hospital-wide prevalence survey was conducted simultaneously in all in-patient units, with a thorough skin check of all patients admitted on a designated day. Total prevalence included all patients with preexisting pressure ulcers and those with HAPUs. (However, not all patients could participate. Some were in therapy sessions or undergoing procedures outside the unit; others simply refused to be assessed.) Inter-rater reliability testing using kappa statistics has been adopted and results are submitted quarterly, with the goal of comparing reliability of pressure-ulcer identification by the nursing and medical staff to that of SBAHC wound care specialists.

Staff training and testing

As part of our continual staff education on pressure ulcers, all newly hired direct-care staff receive initial training and competency testing in wound care procedures. Topics include frequency of skin inspections and reinspection in patients at risk for pressure ulcers, use and implementation of pressure-ulcer prevention plans and protocols, identification of pressure-ulcer stages based on NPUAP guidelines, and completion of the comprehensive wound-assessment tool. Annual competency checks are done for staff who have been with SBAHC for more than 1 year to ensure their current practice is evidence-based and doesn’t deviate from standards. Nursing staff (including nurses’ aides) re­ceive weekly wound care education sessions, with greater emphasis on pressure-ulcer prevention and identification. Physicians and rehabilitation staff are educated in separate sessions. The goal is to ensure that at least 80% of all direct-care staff receive education aimed at reducing or eliminating pressure ulcers.

Expanding the wound care service

Currently, the wound care unit at SBAHC has four beds and admits patients with stage 3 or 4 pressure ulcers or unstageable ulcers who have rehabilitation potential. The goal is to treat patients capable of sustaining an optimal functioning level after their debilitating pressure ulcers heal. Later, the service will expand to up to 11 beds, with patient stays of at least 6 weeks.

The first patient admitted to the service had a stage 4 pressure ulcer on the right trochanter; after 1 month of wound management, he was discharged with the ulcer healed and was able to participate in intensive rehabilitation sessions. Other patients have been admitted with multiple and more severe pressure ulcers; their wounds have improved significantly. (See Photos tell the story.)

Some patients’ wounds aren’t totally healed at discharge because of expired fund­ing, noncompliance with management, or refusal to cooperate. They are advised to return to the wound care clinic to ensure continuity of care. SBAHC plans to implement benchmarking to compare its performance against that of other facilities and help gauge the success of its pressure-ulcer practices.

100 Days campaign

Around the same time SBAHC opened its wound care unit, the hospital launched the “100 Days—100% HAPU Free” Campaign. The goal was to reach zero HAPUs in all hospital units for 100 days and to empower all healthcare providers in all disciplines to use effective pressure-ulcer prevention strategies. This campaign was the first of its kind in the Middle East. Spearheaded by the SBAHC wound care team, the campaign spotlights our facility as a role model for evidence-based, innovative wound care.

The authors work at Sultan Bin Abdulaziz Humanitarian City in Riyadh, Saudi Arabia. Joanne Aspiras Jovero is a wound and stoma care specialist and educator. Hussam Al-Nusair is director of nursing. Marilou Manarang is a senior wound and stoma care specialist and educator.

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

Guidelines for safe negative-pressure wound therapy

By Ron Rock MSN, RN, ACNS-BC

Since its introduction almost 20 years ago, negative-pressure wound therapy (NPWT) has become a leading technology in the care and management of acute, chronic, dehisced, traumatic wounds; pressure ulcers; diabetic ulcers; orthopedic trauma; skin flaps; and grafts. NPWT applies controlled suction to a wound using a suction pump that delivers intermittent, continuous, or variable negative pressure evenly through a wound filler (foam or gauze). Drainage tubing adheres to an occlusive transparent dressing; drainage is removed through the tubing into a collection canister. NWPT increases local vascularity and oxygenation of the wound bed and reduces edema by removing wound fluid, exudate, and bacteria.

Every day, countless healthcare providers apply NPWT devices during patient care. More than 25 FDA Class II approved NPWT devices are available commercially. If used safely in conjunction with a comprehensive wound treatment program, NPWT supports wound healing. But improper use may cause harm to patients. (See Risk factors and contraindications for NPWT.)

Lawsuits involving NPWT are increasing. The chance of error rises when inexperienced caregivers use NPWT. Simply applying an NPWT dressing without critically thinking your way through the process or understanding contraindications for and potential complications of NPWT may put your patients at risk and increase your exposure to litigation.

Proper patient selection, appropriate dressing material, correct device settings, frequent patient monitoring, and closely managed care help minimize risks. So before you flip the switch to initiate NPWT, read on to learn how you can use NPWT safely.

Understand the equipment and its use

Consult your facility’s NPWT protocols, policies, and procedures. If your facility lacks these, consult the device manufacturer’s guidelines and review NPWT indications, contraindications, and how to recognize and manage potential complications. Ideally, facilities should establish training programs to evaluate clinicians’ skills. Enhanced training should include comprehension of training materials, troubleshooting, and correct operation of the device, as shown by return demonstration of the specific NPWT device used in the facility.

Assess the patient thoroughly

The prescribing provider is responsible for ensuring patients are assessed thoroughly to confirm they’re appropriate NPWT candidates. Aspects to consider include comorbidities, contraindicated wound types, high-risk conditions, bleeding disorders, nutritional status, medications that prolong bleeding, and relevant laboratory values. The pain management plan also should be evaluated and addressed.

Assess the order

Before NPWT begins, make sure you have a proper written order. The order should specify:

  • wound filling material (foam or gauze dressing and any wound adjunct, such as a protective nonadherent, petrolatum, or silver dressing)
  • negative pressure setting (from -20 to-200 mm Hg)
  • therapy setting (continuous, intermittent, or variable)
  • frequency of dressing changes.

Follow all parts of the order as prescribed. Otherwise, you may be held responsible if a complication arises—for example, if you apply a nonadherent dressing when none is ordered and this dressing becomes retained, requiring surgery for removal; or if you set a default pressure when none is ordered and the patient suffers severe bleeding or fistula formation as a result.

Assess the wound

If you know what your patient’s wound needs, you can take proactive measures. What is the wound “telling” you? With adept assessment, you can become a “wound whisperer”—a clinician who understands wound-healing dynamics and can interpret what the wound is “saying.” This allows you to see the wound as a whole rather than just maintaining it as a “hole.”

  • If the wound tells you it’s too wet, take steps to absorb fluid or consider increasing negative pressure, as ordered.
  • If it’s telling you it’s dry, consider decreasing negative pressure, as ordered. If the wound bed remains dry, you might want to take a NPWT “time out”. Apply a moisture dressing for several days and assess the patient’s hydration status before restarting NPWT.
  • If the wound says it’s moist, maintain the negative pressure.
  • If it tells you it’s infected, treat the infection.
  • If it tells you it’s dirty, debride it.
  • If it says it’s malnourished, feed it.

The DIM approach

To establish a baseline evaluation, develop a systematic approach for assessing
the wound before NPWT. This will help optimize wound-bed preparation, enhance NPWT efficacy, and prevent delayed wound healing. (See Assessing with DIM.)

Take a time-out
Before you apply the NPWT dressing, be a STARStop, Think, Act, and Review your action. This time-out allows you to critically think your way through the application process and consider potential consequences of your actions.

Ongoing patient assessment and monitoring

Follow these guidelines to help ensure safe and effective NPWT:

  • Follow the device manufacturer’s instructions and your facility’s NPWT protocol, policy, and procedures.
  • Identify and eliminate factors that can impede wound healing (poor nutritional status, limited oxygen supply, poor circulation, diabetes, smoking, obesity, foreign bodies, infection, and low blood counts).
  • Evaluate the patient’s nutritional status to ensure protein stores are adequate for healing.
  • Assess and manage the patient’s pain accordingly.
  • Protect the periwound from direct contact with foam or gauze.
  • Prevent stretching or pulling of the transparent drape to secure the seal and avoid shear trauma to surrounding tissue.
  • Prevent stripping of fragile skin by minimizing shear forces from repetitive or forceful removal of transparent drapes.
  • Use protective barriers, such as multiple layers of nonadherent or petrolatum gauze, to protect sutured blood vessels or organs near areas being treated with NPWT.
  • Don’t overpack the wound too tightly with foam. Compressing the foam prevents negative pressure from reaching the wound bed, causing exudate to accumulate.
  • Position drainage tubing to avoid bony prominences, skinfolds, creases, and weight-bearing surfaces. Otherwise, a drainage tubing related pressure wound may develop.
  • Bridge posterior wounds to the lateral or anterior surface to minimize drainage tubing related pressure wounds to the surrounding tissue.
  • Count and document all pieces of foam, gauze, or adjunctive materials on the outer dressing and in the medical record, to help prevent retention of materials in the wound.
  • Ensure the foam is collapsed and the NPWT device is maintaining the prescribed therapy and pressure at the time of initial patient assessment and when rounding.
  • Address and resolve alarm issues. If you can’t resolve these issues and the device needs to be turned off, don’t let it stay off more than 2 hours. While the device is off, apply a moist-to-dry dressing.
  • With a heavily colonized or infected wound, consider changing the dressing every 12 to 24 hours.
  • Monitor the patient frequently for signs and symptoms of complications.

Evaluate patient comprehension of teaching

A proactive approach to education can ease the patient’s anxiety about NPWT. Unfamiliar sounds and alarms may heighten anxiety and cause unwarranted concerns, so inform patients in advance that the device may make noise and cause some discomfort. An educated and empowered patient can participate actively in treatment. Improved communication may enhance outcomes and help identify errors in technique before they cause complications.

Be prepared to answer patients’ questions, which may include:

  • Am I using the device correctly?
  • How long will I have to use it?
  • What serious complications could occur?
  • What should I do if a complication occurs? Whom should I contact?
  • How do I recognize bleeding?
  • How do I recognize a serious infection?
  • How do I tell if the wound’s condition is worsening?
  • Do I need to stop taking aspirin or other medicines that affect my bleeding system or platelet function? What are the possible risks of stopping or avoiding these medicines?
  • Can you give me written patient instructions or tell me where I can find them?

View: Patient Education


To avoid patient harm and potential litigation, be a STAR and a wound whisperer. If you’re in doubt about potential complications of NPWT or how to assess and monitor patients, stop the therapy and seek expert guidance. “Listen” to the wound and assess your patient. This may take a little time, but remember—monitoring NPWT, the wound, and the patient is an ongoing process. You can’t rush it. Sometimes, to go fast, you need to go slowly.

Access more information about NPWT.

Selected references
Agency for Healthcare Research and Quality. Technology Assessment: Negative Pressure Wound Therapy Devices. Original: May 26, 2009; corrected November 12, 2009. Available online at: www.ahrq.gov/research/findings/ta/negative-pressure-wound-
f. Accessed January 30, 2014.

Daeschlein G. Antimicrobial and antiseptic strategies in wound management. Int Wound J. 2013; 10(Suppl 1):9-14.

Food and Drug Administration. Guidance for Industry and FDA Staff—Class II Special Controls Guidance Document: Non-powered Suction Apparatus Device Intended for Negative Pressure Wound Therapy. November 10, 2010. Available at: www.fda.gov/MedicalDevices/DeviceRegulationand
. Accessed January 30, 2014.

Food and Drug Administration. FDA Preliminary Public Health Notification: Serious Complications Associated with Negative Pressure Wound Therapy Systems. November 13, 2009. Available at: www
. Accessed January 30, 2014.

FDA Safety Communication: UPDATE on Serious Complications Associated with Negative Pressure Wound Therapy Systems. February 24, 2011. Available at: /www.fda.gov/MedicalDevices/Safety/
. Accessed January 30, 2014.

Fife CE, Yankowsky KW, Ayello EA, et al. Legal issues in the care of pressure ulcer patients: key concepts for healthcare providers—a consensus
paper from the International Expert Wound Care Advisory Panel©. Adv Skin Wound Care. 2010;23(11):493-507.

Improving the Safety of Negative-Pressure Wound Therapy. Pa Patient Saf Advis. 2011;8(1):18-25. Available at: http://patientsafetyauthority.org/
. Accessed January 29, 2014.

Krasner D. Why is litigation related to negative pressure wound therapy (NPWT) on the rise? Wound Source. Posted November 11, 2010. Available at: www.woundsource.com/article/why-litigation-related-negative-pressure-wound-therapy-npwt-rise. Accessed January 30, 2014.

Lansdown AB. A pharmacological and toxicological profile of silver as an antimicrobial agent in medical devices. Adv Pharmacol Sci. 2010; Article ID 910686. Available at: www.hindawi.com/journals/aps/2010/910686/

Lipsky BA, Hoey C. Topical antimicrobial therapy for treating chronic wounds. Clin Infect Dis. 2009;49(10):1541-9.

RG, Goodman L, Woo KY, et al. Special considerations in wound bed preparation 2011: An update©. Adv Skin Wound Care. 2011;24(9):415–36.

Sibbald RG, Woo KY, Ayello EA. Clinical Practice Report Card: A Survey of Wound Care Practices in the U.S.A. Ostomy Wound Manage. April 2009 Suppl:12-22.

Ron Rock is the nurse manager and clinical nurse specialist for the WOC nursing team in the Digestive Disease Institute of the Cleveland Clinic in Cleveland, Ohio.

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

Clinician Resources


Take a few minutes to check out this potpourri of resources.

International Ostomy Association

The International Ostomy Association is an association of regional ostomy associations that is committed to improving the lives of ostomates. Resources on the association’s website include:

  • a variety of discussion groups
  • information for patients
  • list of helpful links.

The site also provides contact information for the regional associations.

Substance use disorder in nursing

Substance use disorder (SUD) can have a profound effect not only on patients but also on the nursing profession. “What You Need to Know About Substance Use Disorder in Nursing,” a brochure from the National Council of State Boards of Nursing, discusses SUD, including how to recognize the warning signs and what to do to get a colleague help.

Enhancing patient and family engagement

The Agency for Healthcare Research and Quality has released the “Guide to Patient and Family Engagement in Hospital Quality and Safety,” an evidence-based resource to help hospitals work as partners with patients and families to improve quality and safety. The guide includes the following:

  • Strategy 1: Working With Patients and Families as Advisors shows how hospitals can work with patients and family members as advisors at the organizational level.
  • Strategy 2: Communicating to Improve Quality helps improve communication among patients, family members, clinicians, and hospital staff from the point of admission.
  • Strategy 3: Nurse Bedside Shift Report supports the safe handoff of care between nurses by involving the patient and family in the change-of-shift report.
  • Strategy 4: IDEAL Discharge Planning helps reduce preventable readmissions by engaging patients and family members in the transition from hospital to home.

Download the entire guide.

Lymphedema Treatment Act

The Lymphedema Treatment Act (HR 3877) is intended to improve coverage for the treatment of lymphedema from any cause. You can visit the Act’s website to learn how to contact your members of Congress about the Act and join your state’s advocacy team. Consider these six easy ways to increase awareness:

  • Distribute information cards.
  • Distribute or post fact sheets.
  • Like the Act’s Facebook page.
  • Follow the act on Twitter and re-tweet tweets.
  • Include information on your website or blog.
  • Use a tell-a-friend form to quickly tell up to 10 people at a time about the website.

You can also access an update on the Act on the National Lymphedema Network’s website.

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

Medicare reimbursement for hyperbaric oxygen therapy

By Carrie Carls, BSN, RN, CWOCN, CHRN, and Sherry Clayton, RHIA

In an atmosphere of changing reimbursement, it’s important to understand indications and utilization guidelines for healthcare services. Otherwise, facilities won’t receive appropriate reimbursement for provided services. This article focuses on Medicare reimbursement for hyperbaric oxygen therapy (HBOT). (See What is hyperbaric oxygen therapy?)

Indications and documentation requirements

The Centers for Medicare & Medicaid Services (CMS) National Coverage Determination for HBOT lists covered conditions for HBOT, as do the individual Medicare Administrative Contractor’s (MAC) Local Coverage Determination policies and/or articles. (See Conditions for which CMS approves use of HBOT.) Providers should thoroughly review the indications and utilization guidelines to ensure coverage criteria are met for each clinical condition.

It’s important that the documentation in the patient’s medical record supports the medical necessity for HBOT. Reimbursement hinges on documenting all services performed. For example, diabetic wounds of the lower extremity will first require the assessment of the patient’s vascular status with correction of any problems found, optimization of nutritional status and glucose control, removal of nonviable tissue, appropriate offloading of the ulcer, treatment and resolution of infection, and maintenance of a clean, moist wound bed.

HBOT is indicated if all of the above have been done and the ulcer doesn’t show measurable signs of healing after 30 days of standard wound care.

Provider requirements

For HBOT to be reimbursed, a facility must ensure the provider supervising the treatment meets CMS requirements. Physicians who supervise HBOT should be certified in Undersea and Hyperbaric Medicine or must have completed a 40-hour, in-person training program by an approved entity. In addition, if HBOT is performed off-site from a hospital campus or in a physician’s office, Advanced Cardiac Life Support training and certification of the supervising physician are required.

CMS also requires appropriate direct physician supervision for coverage, meaning that the physician must be present on the premises and immediately available to furnish assistance and direction throughout the performance of the procedure.

Billing and coding

In a hospital outpatient setting, the correct code is C1300, hyperbaric oxygen under pressure, full body chamber, per 30-minute interval. Physician supervision of HBOT is reported with CPT code 99183, physician attendance and supervision of hyperbaric oxygen therapy, per session. It’s important to note that the physician supervision code should be reported in a unit of 1, and the hospital outpatient procedure code of C1300 will be in multiple units, typically 4 units.

Prepay probes

Providers may be asked to submit medical documentation for specific claims identified by the MAC prior to payment (“prepay probes”). These Additional Development Requests require a response within 30 days and generally involve 20 to 40 claims per provider. Such requests occur in both inpatient and outpatient settings, and some MACs are starting to use prepay probes in skilled nursing facilities as well.

After review of the documentation, providers receive notification of the results. Further reviews are based on the provider error rate calculated.

Skilled nursing facility, inpatients, critical access hospitals

In a skilled nursing facility, HBOT is part of the facility Prospective Payment System (PPS) payment in Medicare part A stays. For hospital inpatients, HBOT is reported under revenue code 940. For critical access hospitals, a reasonable cost-based system is used.

Ensuring reimbursement

To ensure reimbursement of HBOT, check CMS policies and articles for indications, utilization guidelines, and provider requirements. In addition, ensure that documentation clearly supports the need for HBOT and follows the billing and coding requirements.

Both authors work at Passavant Area Hospital in Jacksonville, Illinois. Carrie Carls is the nursing director of advanced wound healing and hyperbaric medicine and Sherry Clayton is the director of managed care and revenue integrity.

Selected references
Centers for Medicare & Medicaid Services. Hyperbaric oxygen therapy (HBO) supplemental article (A52118). http://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52118. Accessed February 19, 2014.

Centers for Medicare & Medicaid Services. National coverage decision for hyperbaric oxygen therapy (20.29). Publication No. 100-3. http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx. Accessed February 19, 2014.

Clarke D. Economics of hyperbaric medicine. In: Kindwall E, Whelan H, eds. Hyperbaric Medicine Practice. 3rd ed. Flagstaff, AZ: Best Publishing Company; 2008;275-288.

Gesell L. Hyperbaric Oxygen Therapy Indications. 12th ed. Durham, NC: Undersea and Hyperbaric Medical Society; 2008.

Kranke P, Bennett MH, Roecki-Wiedmann I, Debus S. Hyperbaric oxygen for chronic wounds. Cochrane Database Syst Rev. http://www.ncbi.nlm.nih.gov/pubmed/22513920. Updated 2012. Accessed February 19, 2014.

National Government Services. Article for hyperbaric oxygen (HBO) therapy—medical policy (A52174). http://www.ngsmedicare.com. Accessed February 19, 2014.

National Government Services. Part B medical review: the medical review process. http://www.ngsmedicare.com. Accessed February 19, 2014.

Schaum K. Hyperbaric oxygen therapy reimbursement reminders for a successful 2010. Today’s Wound Clinic. 2010;4:9-14.

Tuner T. The coming audit storm. Today’s Wound Clinic. 2012;6:18-20, 38.

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.