Negative Pressure Wound Therapy

By Samantha Kuplicki, MSN, APRN-CNS, AGCNS-BC, CWS, CWCN, CFCN This is the account of a patient case in which technology, clinician experience, and patient adherence converged to save a limb.

By Samantha Kuplicki, MSN, APRN-CNS, AGCNS-BC, CWS, CWCN, CFCN Part 1 in a series exploring topics related to negative pressure wound therapy application. Negative Pressure Wound Therapy (NPWT), it's so simple, right? Everyone who knows anything about wound care knows how to apply it. Wait…YOU don't? No worries—we were all there at some point. In fact, for the first year or so of my wound care endeavors, I had very little insight as to how to apply NPWT. I understood the basic tenets of therapy: exudate management/removal, increased granulation tissue development, decreased frequency of dressing changes, and decreased cost of wound care, among others.

I was asked to perform a wound consult on a newly admitted resident to a post-acute unit of a nursing home. She rested quietly with a barely touched breakfast on her bedside table. Her aide had tried to feed her, but she accepted only small spoonfuls of oatmeal and a sip of orange juice. She came to our facility after a long hospitalization for COVID-19–related complications, including pneumonia, kidney failure, and septic shock that required pressor agents. While in the ICU on a ventilator, she developed a pressure injury. At 86 years old, her transfer papers revealed feeding tube refusal and a do-not-resuscitate (DNR) order.

The benefit of Negative Pressure Wound Therapy (NPWT) as an “active,” adjunctive treatment is well-established. Evidence has shown that wounds treated with negative pressure granulate faster than wounds managed with traditional dressings. There is ever-increasing literature to support the use of NPWT to treat wounds effectively and safely in even the youngest patients.1 Some specific benefits of NPWT for pediatric and adolescent patients include decreased frequency of dressing changes, as well as a dressing that is occlusive and unlikely to be removed by the patient.

Managing chronic wounds can be difficult and often includes multiple treatment strategies. Management techniques can vary depending on the size of the wound, comorbidities of the patient, and the underlying etiology. However, many chronic wounds benefit from the application of negative pressure wound therapy (NPWT). This treatment is known for improving healing conditions across a wide range of acute and chronic wounds.

By Beth Hawkins Bradley RN, MN, CWON Wounds treated with negative pressure wound therapy (NPWT) are not often straightforward. They occur in interesting places, have anything from slough to hardware visible in the bases, and have nooks and crannies that are not visible to the clinicians peering into the wound. A gentle probe is necessary during wound assessment to identify tunnels and undermined areas. I prefer to gently probe first with my gloved finger (I have small hands) because I can identify hidden structures and other oddities. Then I will use a swab to measure how far the tunnel or undermining extends. Once hidden dead spaces have been identified, clinicians can select the best strategy to bring them to closure. Herein are several techniques employed by clinicians to close undermined and tunneled areas.

Negative pressure wound therapy (NPWT) is a known adjunctive modality for healing wounds. The use of NPWT is well documented for the treatment of both acute and chronic wounds. NPWT is designed to remove fluid, decreasing the afterload to blood flow and resulting in increased localized tissue perfusion. Use of negative pressure may also enhance the formation of granulation tissue by secondary intention.

A fistula is a connection between two organs that are not normally connected, such as the stomach and the skin. Fistulas develop in various conditions and for a multitude of reasons, such as malignancy, Crohn’s disease, colitis, and others. Many times, fistulas occur after a surgical procedure. Goals of a care plan around a fistula focus on protection of the adjacent skin, containment of the effluent, nutrition, conditioning, and quality of life.

By: Dianne Rudolph, DNP, GNP-BC, CWOCN What are some ways to achieve insurance coverage for fistula pouches or to use ostomy supplies for a fistula? We often run into the issue of supplies not being covered for Medicare or Medicaid patients. Unfortunately, coverage is inadequate. CMS (Centers for Medicare & Medicaid Services) coverage for fistulas is limited for fistulas caused by or resulting from a surgical procedure, and even then, it may be difficult to get reimbursed. Spontaneous fistulas (15% to 25%) are generally not covered. The Wound, Ostomy and Continence Society is working on trying to effect a change in coverage. Some insurance companies may be more amenable to reimbursement, and it may require a case-by-case application or appeal. For patients being discharged home, it may be possible to secure a short-term supply of 10 to 14 days. The cost for the pouches may run $255 and up for a box of 10.

by Samantha Kuplicki, MSN, APRN-CNS, AGCNS-BC, CWS, CWCN, CFCN Recently, we've reviewed application and documentation strategies for negative pressure wound therapy (NPWT), but what about navigating the different systems currently on the market? We know all devices have the mechanism of negative pressure in common, but what other characteristics need to be considered when selecting the right device for your patient? In this installment, we will become better acquainted with the characteristics of NPWT devices and how they differ for various systems.