By Lauren Lazarevski, RN, BSN, CWOCN
As summer begins to wind down and we look ahead to Halloween, let’s discuss some “creepy crawlies” we may encounter in wound care that may cause apprehension in even the most seasoned health care staff.
By Christine Shettel, RN, BSN, WCC, DAPWCA, PWRC
Hyperbaric medicine has been used in wound care for over 50 years. As wound care professionals, we are saving patient’s lives, and preserving limbs utilizing Hyperbaric Oxygen Therapy (HBO). As health care professionals we understand the indications and benefits of HBO therapy, however, it’s important to follow clinical pathways and your local coverage determinations to ensure that we are placing the clinically appropriate patients in the chambers. It’s also important to understand what clinical documentation is required in order to qualify your patients for treatments to achieve optimal outcomes.
Currently, the majority of wounds we are treating at Mercy Jefferson, Crystal City, MO, outpatient wound care center include but are not limited to Diabetic Foot Ulcers, Soft Tissue Radionecrosis, Failed Flaps and Grafts, Chronic Refractory Osteomyelitis, Clostridial Myonecrosis (Gas Gangrene), and Necrotizing Soft Tissue Injuries. On initial assessment you must complete a thorough history and physical. Based on findings, wound classification, co-morbidities, and wound appearance; determine if the patient requires vascular studies, imaging, or laboratory evaluation. Based on results and documentation you can then determine if your patient is an appropriate candidate for hyperbaric treatments.
Below are the diagnoses, requirements, necessary assessment, and documentation to qualify your patient for Hyperbaric Therapy.
Diabetic Foot Ulcer (Neuropathic Wounds)
During the patient's initial assessment, document any history of infection, oral or intravenous antibiotic therapy, abscess, osteomyelitis, or cellulitis. CMS Guidelines mandate that the patient is a Wagner Grade 3 DFU (Diabetic Foot Ulcer) and demonstrates lack of wound healing after 30 days of optimal standard basic wound care before becoming a candidate for HBO therapy. This basic treatment must include nutritional support and glycemic control, vascular maximization, control of infection, offloading, and wound care. If improvement goals have not been met after 30 days, consideration of Hyperbaric Oxygen Treatments is indicated. Prior to Hyperbaric treatment the patient needs to be assessed for osteomyelitis and adequate blood flow. Studies should include one of each of the following: Images require an X-ray, MRI, or 3 phase bone scan; Vascular workup requires a TCOM, ABI, or Vascular studies. Also, after 30 days re-assess Wagner Grade 2 DFUs. A Wagner Grade 2 should heal within 30 days. There is a good chance the wound is not a simple Wagner Grade 2 and may be complicated by underlying bone or soft tissue infection if it is not healing. Wagner Grade 2's and 3's require different management protocols. Make sure on admission you are assessing the factors listed above. If you need to change a diagnosis from Wagner Grade 2 to Grade 3, please have the physician add an addendum to the original admission diagnoses.
Soft Tissue Radionecrosis
When performing system reviews and assessing the patient's past medical history, document if the patient has a past medical history of a form of cancer, and assess for a history of radiation therapy. For example, a patient could appear to have a pressure ulcer, but the wound may have resulted from complications of prior radiation therapy. Document the timeframe the patient received radiation, dose, duration, as well as the number of treatments. Patients with radionecrosis appropriate for hyperbaric oxygen therapy include those with complications from early effects, late effects, and osteoradionecrosis of the jaw.
Failed Flaps and Grafts
A flap is defined as tissue surgically manipulated from its original location. Failed flaps include amputation sites which are compromised and non-healing or dehisced, including BKA, AKA, TMA, or digit amputation. A graft could either be split-thickness or full-thickness. A patient with either early post-surgical or delayed flap compromise can be considered a failed flap or graft. Consider why the patient is not healing. Assess their nutritional and vascular status, or for underlying osteomyelitis or infection. Remember it is important to document surgical interventions, wound care, and antibiotic therapies.
Chronic Refractory Osteomyelitis
If the patient has a history of osteomyelitis, document and obtain records of the surgical interventions, previous treatments including oral or intravenous antibiotic therapy including medication dose and duration of therapy. In addition, obtain records of any images (X-ray, MRI, or 3 phase bone scans).
Clostridial Myeonecrosis (Gas Gangrene)
If a patient is suspected to have Gas Gangrene, surgical confirmation is important for both diagnosis as well as management. Intraoperative tissue cultures are also helpful to additionally confirm the diagnosis. Also document any conjunctive therapies including parenteral antibiotics.
About The ACHM
The American College of Hyperbaric Medicine (ACHM) was formed by a group of physicians practicing the developing specialty of hyperbaric medicine who noticed the need for a national professional organization dedicated to serving as a medical specialty society. The ACHM has worked to develop an image of hyperbaric oxygen therapy as a distinct medical specialty, often requiring full-time practice.
If you are a member of the ACHM and would be like to be featured as a guest blogger, please contact firstname.lastname@example.org.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.