Protecting the Epidermis and the Bottom Line

In August, the Centers for Medicare and Medicaid Services (CMS) said hospitals will not receive payments for healthcare-acquired pressure ulcers. The final rule for changes to the Medicare programs hospital inpatient prospective payment system (IPPS) for 2008, effective Oct. 1, 2008 also, mandates no reimbursement for several other healthcare-acquired conditions, infections and adverse events.

The final rule, which can be accessed at:, says treatment for pressure ulcers that were acquired while hospitalized will no longer be reimbursed because CMS lawmakers believe these types of outcomes should be avoided. The final rule text reads: By selecting this condition, we would provide hospitals the incentive to perform careful examination of the skin of patients on admission to identify decubitus ulcers. If the condition is present on admission, the provision will not apply.

According to CMSs research, pressure ulcers are both a high cost and high volume adverse event. In fact, in 2006, there were 322,946 reported cases of Medicare patients who had a pressure ulcer as a secondary diagnosis, and CMS notes that these cases had an average charge of $40,381. Thats an annual total cost of $13 billion. Furthermore, a 2003 JAMA article cites additional costs of $10,845 per each healthcare acquired pressure ulcer (which would total $3.5 billion annually).

The CMS statute indicates that the provision should apply to conditions that could reasonably have been prevented through the application of evidence-based guidelines. Prevention guidelines for pressure ulcers exist at the following Web sites: and 

The following HAIs are also mentioned in the CMS document:

  • surgical site infections 

  • ventilator-associated pneumonias 

  • catheter associated bloodstream infections hospital falls 

  • bloodstream infections/septicemia pneumonia vascular catheter associated infections 

  • Clostridium difficile-associated disease (CDAD) methicillin-resistant Staphylococcus aureus (MRSA) catheter-associated urinary tract infection

The final rule has an additional inclusion of three serious preventable events which will no longer receive payment as in the past. They include leaving an object in during surgery; air embolism as a result of surgery; and providing incompatible blood or blood products.

Assess to Prevent and Prevent to Protect

It is possible to halve the incidence of pressure ulcers in the acute care setting, according to the 10th Annual International Pressure Ulcer Prevalence Survey (IPUPS) released by Hill-Rom in September. Furthermore, the survey, compiled from data gathered from 653 healthcare facilities and more than 82,000 patients, documents that nearly half of all adult patients in acute care facilities are at high risk for developing pressure ulcers. The study notes that although hospitals are beginning to incorporate comprehensive pressure ulcer prevention programs, still over 75 percent of high risk patients do not receive such a program. The Hill-Rom report also estimates that more than 900,000 Medicare patients will develop pressure ulcers annually.

Skin integrity is of utmost importance in this playing field, and assessment is the key to success, according to Bill Brandon, BSN, RN, WOCN, product manager of the specialty wound care division of Covidien. One cannot treat the wound until an accurate assessment is done and its imperative to not miss clues as it could delay wound closure, he asserts.

Brandon offers some assessment points:

At a minimum, visualize all bony prominences in any patient that may have an altered perception of pain. One must assess for underlying skin damage by visually inspecting the skin. Review the notes from the field or facility. Look for any reason the patient may have unknown breakdown. If there are potential reasons, be sure to perform a full evaluation.

Many at-risk patients will arrive via the emergency department (ED), but there are currently no evidence-based or scope-of-practice mandates for the ED related to best practices for reducing the incidence of pressure ulcers.

Many times, the ED represents the first place for breakdown to occur, so careful examination at this stage of a patients care can prove imperative.

A head-to-toe approach to skin assessment in the ED is of utmost importance, points out Cynthia A. Fleck, RN, BSN, MBA, ET/WOCN, CWS, DNC, DAPWCA, FACCWS, a certified wound specialist and dermatology advanced practice nurse. Fleck, who serves as president of the American Academy of Wound Management (AAWM), is a member of the board of directors for the Association for the Advancement of Wound Care (AAWC), and is vice president of clinical marketing for Medline Industries, Inc.s Advanced Skin and Wound Care, says it is important to check behind a patients ears, between deep skin folds, between toes and in contracted fists and joints. Having the correct personnel and examining any patient entering the ED with wounds or questionable skin appearance will decrease the incidence of incorrectly identified wounds or skin manifestations. This will become even more important with the changes that CMS will put into play with the new IPPS, she adds.

As Brandon points out, maintaining skin integrity is a continual process that is dependent upon constant monitoring for breakdown with active preventative measures along with implemented advanced treatments. He suggests every healthcare professional be on constant lookout and take action when needed. If an area of compromised tissue is identified (for example, from pressure), then everyone from the assistant to the physician should be able to order a better support surface or request an evaluation be completed. By empowering all of those involved in providing care for the patient, better outcomes can be realized.

Fleck says sometimes the most remedial, yet imperative aspects can be overlooked when it comes to protecting skin integrity, assessing risk and working to prevent further breakdown. I believe the most overlooked issue is not treating the host first or expecting a wound to heal thats connected to an infirmed individual, she shares. Underlying diseases such as diabetes mellitus, lower extremity arterial disease (LEAD), venous hypertension and insufficiency, malnutrition and poor mobility can cause chronic wounds to stall.

Oftentimes taking a holistic view of the patient and giving their body a tune-up can assist the bodys natural healing ability, she continues. For example, the wound cannot heal if it doesnt have the oxygen and nutrient delivery system (arterial blood flow). This is one of the first things I inquire about when I consult on a case. Taking a team approach and involving all the right members to ascertain the patients problems is the best approach. When in doubt, refer!

Proper support surface selection is another big issue that needs to be addressed in order to keep skin intact, Fleck adds. At risk individuals, especially the immobile need pressure redistribution surfaces wherever their skin comes in contact be it a bed, chair, gurney, Geri-chair, OR table, etc. This is of prime importance around bony prominences so the pelvis, heels and ankles are all areas at jeopardy. Most patients who come into facilities are automatically at risk so offering all patients some measure of pressure redistribution even before they trigger a Braden score that demonstrates risk is recommended. There are many high density or multi-density mattress replacements available to take the place of innerspring mattresses that can cause pressure ulcers.

How Infection Control Can Help

Infection control practitioners (ICPs) can help to implement a solid course of action and an improved standard of care for wound care throughout their facility in countless ways. Brandon points out that teamwork is key. Infection control and wound care clinicians should work together for the patients ultimate gain. To the best of my knowledge, there are no ICP or wound care clinicians (WOCN or WCS) that are perfect and know everything about the others specialty. We can all learn from each other and the better we do that the more effective we are.

He suggests frequent meetings among clinical review committees where members can openly discuss cases, treatments and outcomes. Do not be afraid to implement additional interventions. The goal for infection control is to drive the infection rate to zero and until one reaches that goal, there is work to be done.

One such area to work on, according to Fleck, is the use of community tools that move from one patient to another. A great example is the bandage scissors that reside in many practitioners pockets, she explains. Simple, yet often neglected issues such as this can wreak havoc on wound management and infection control practice. With regard to supplies, keep them to a minimum in the exam room as the key factor is contact with the client. Ask yourself, Did it touch the client? Did someone who touched the client, touch the item without washing? All reusable equipment must be cleaned and disinfected before use on the next patient. If individual nurse servers are available at each point of care or patient room, use of a Ziploc baggie with the patients individual supplies such as bandage scissors should be placed and only used for that patient.

Hands continue to be the biggest culprit for spreading infection, including such detrimental wound infiltrates as methicillin-resistant Staphylococcus aureus (MRSA). When I lecture or educate clinicians, I use the analogy that their hands are probably dirtier than their toilet seats, Fleck says. That usually gets some gasps! We have to make sure that we are offering the right products along with the right programs (education campaigns, etc.). If your facility is using harsh soaps that strip the epidermis of its protective mechanism, a vicious cycle begins with the hands drying, becoming uncomfortable, cracking and causing the user to avoid the cause washing their hands.

I find that keeping it simple helps clinicians understand the importance of infection control issues. Since we cant see microbes, they are sometimes forgotten. In other words, how does infection control affect clinicians and their world? For example, they wouldnt want to take a case of MRSA home to their children or become infected themselves.

The Culprits are Aplenty

Many may think only of bacterial-related infiltrates when referring to skin infections, but other organisms also are to blame.

For home health, Candida (the organism that causes thrush) seems to be one of the most problematic infections outside of bacterial infections, says Fleck. She shares other common offenders:

Incontinent perineal dermatitis manifests as cutaneous eruptions caused by the interaction of several factors: frequent and prolonged skin wetness from occlusion and urine caught in close approximation to the skin; friction by movement of skin against skin, diaper, or plastic leg gatherings or fastening tape; or fecal enzymes that cause cutaneous irritation coupled with bacterial or yeast growth in a dark, moist environment on inflamed, damaged skin. When present for longer than three days, there is likely to be secondary Candida albicans (C albicans) infection. Perineal dermatitis occurs on the lower abdomen, groin, perineum, buttocks, labia majora, scrotum, penis, or upper thigh. It presents clinically as bright red, painful erythema with or without papules, erosions, scale, or maceration. A related condition is denudation. This is a partial-thickness injury caused by friction and shearing forces and chemical and enzyme irritation resulting from incontinence.

Candidiasis infection is caused by an overgrowth of C albicans, a yeast-like fungus. It typically occurs in individuals who are pregnant, diabetic, or immunocompromised; who have endocrinopathies or skin maceration; or those who use oral contraceptives or hormone replacement therapy, antibiotics, or topical steroids. Candidiasis occurs in areas of moisture, heat, and darkness, such as the mouth, vaginal tract, and gut. Clinically, there may be edema, erythema, and erosion, and patients may report pruritus.

Intertrigo is a candida expression of the integument that occurs in large skin folds. Heat and moisture provide the environment for proliferation of organisms. Poor hygiene and inflammatory diseases increase the risk of this infection. Fissuring is common. Intertrigo looks angry and is often painful.

Tineas are a group of superficial fungi or dermatophytes responsible for most skin, hair and nail infections. Tineas invade the skin and survive on dead stratum corneum keratin; they cannot live on mucosal surfaces devoid of keratin. They rarely undergo deep invasion except in immunocompromised patients. Tineas are classified by body region-scalp (tinea capitis), hands (tinea manuum), body (tinea corporis), feet (tinea pedis), and nails (tinea unguium). They are characterized by an active border of infection and central clearing. Vesicles are seen in severe inflammation, except for the palms and soles. In any folds of tissue be sure to eliminate the moisture and corn starch, Brandon recommends. The two topical powders Mycostatin or Nystatin seem to provide adequate coverage for most of these infections. It is possible to utilize gauze products in the folds to help keep the folds dry. However, it is imperative that these dressings be changed when they become moistened.

Future Outlook

Brandon says progress in wound care is not tremendously quick but there are many active therapies that are new to the market now. Growth factors of differing origins, peptides, dermal replacements, as well as systemic medications, are in the works and are driving changes in the industry, he says. Over the next few years, I believe there will be additional technologies that will simplify both wound care and infection control.

As it stands now, most day-to-day wound care is implemented through a combination of experience and education. No laboratory tests will tell you what foam dressing is best or if you should use a calcium alginate vs. a composite dressing. Wound care, today, is an artful science.

The financial outlook outside the hospitals looks pretty solid. According to the third edition of Wound Care Markets: Volume I: Skin Ulcers the market for skin ulcer treatments will soar to $6.2 billion in 2011. The report, released by Kalorama Information, says overall steady growth in the worldwide skin ulcer treatment market will likely come from new therapies that result in decreasing healing times and subsequent cost savings; a growing focus on special populations such as diabetics and the obese; the increasing elderly population; availability of new therapeutic techniques; and the recent focus on wound care products and prevention.

Mature skin treatment products such as anti-infectives, skin ulcer management and pressure relief devices will continue to generate the majority of sales, the report reads, but advancements in biotechnology, biomaterials, and tissue engineering are expected to drive growth during the forecast period. Negative pressure wound therapy will also see estimated growth of 11.6 percent.

Developments in treatments of skin ulcers have made tremendous strides in the last decade, says Mary Anne Crandall, author of the report, in a recent press release. New developments are providing the healthcare arena with some truly sophisticated, highly effective skin ulcer treatments. Revolutionary advances using tissue engineering, growth factors, animal-fetal cell research, stem cell research, and gene therapy may offer new hope to patients who experience acute and chronic skin ulcers.

Fleck agrees that the outlook for wound care looks exciting. As far as research goes, we have made incredible advances and giant steps to understanding road blocks to healing and correcting them from a micro and macro standpoint.

The future of wound management is very exciting!, she concludes. 

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