Wound Care in Crisis – Have we Rebuilt the Tower of “Babble” for Pressure Ulcers?
by Michael Miller DO, FACOS, FAPWCA
“…(7) Go to, let us go down, and there confound their language, that they may not understand one another's speech.(8) So the Lord scattered them abroad from thence upon the face of all the earth: and they left off to build the city. (9)Therefore is the name of it called Babel..." (Genesis, Chap. 11).
Like most of you, I work in a variety of practice locations including Long-Term Acute Care, my own non-hospital affiliated wound care center (too much bureaucracy can cause mental constipation), as well as house calls. For the sake of clarity, I want it known that I speak English (the East coast variety with some slurring and rapidity), a moderate amount of Spanish, some Mandarin Chinese (Hoorah for Putonghua), some Yiddish, and a smidgen of German and Japanese (more than just “Sushi” and “Bento Box”). The ability to communicate is essential when talking to nurses, other doctors, and people in general.
For those of you who have rambled with me month after month, I have recovered nicely from last month’s knee replacement (my pain was well-controlled, thank you) and resumed work perhaps a bit too quickly but nonetheless, I am back at it fast and furious. While in the rehab, the MDS coordinator was kind enough to visit and while chatting, asked if I had seen the newest upcoming MDS set for 2012. For those of you not in the long-term care business, this is basically an extraordinarily complex and detailed how-to guide on wounds and other issues in nursing homes.
As an avid reader of many journals, articles and other sources of information for wound care, I pride myself on keeping abreast of the hottest new wound care topics. I forgot to add that I also have a fairly busy practice as a medico-legal expert in wound care litigation. I will tell you that business in this particular arena has expanded exponentially, but for reasons that have more to do with ego and stupidity and less with simple naiveté. When the CMS “Never Events” concepts for acute care facilities came into existence, I struggled to understand how they would be “punished” for the creation of pressure-based tissue injuries. For example, if an inpatient develops pneumonia, or a DVT, or an exacerbation of CHF, they have no choice but to stay in the hospital and my understanding is that care for this complication is not reimbursed as a separate diagnosis but rather, must be cared for out of the reimbursement the hospital received for the initial diagnostic set. In other words, the facilities get paid nothing extra for the complication, but have to care for it out of their reimbursement for the original admitting diagnoses. Since these “Never Event” complications mandate ongoing hospitalization, the process is self contained. However, when the complication is the creation of a pressure-based tissue injury, there really is no reason for the patient to stay in the hospital and so the patient can go to a long-term care facility or discharged to home. The question then becomes, if the hospital is liable for the care referable to that injury, will they reimburse the home health care agency or the long-term care facility for care rendered for that hospital acquired problem, and if so, how will this reimbursement scheme be instituted? I can only state that to date, no facility in which I work, nor any of my partner home heath care agencies that have received a hospital acquired pressure sore patient, have received any form of reimbursement from the initiating hospital.
To be fair, reasons other than the desire for hospitals to preserve their reputations (and cash flow) by failing to, or underreporting these injuries, needs to be considered. To my mind, the simplest and most obvious is related to the most basic of all pressure-based tissue injury wound care problems, namely, “definition”.
The astute MDS coordinator at the nursing care facility where I did my knee rehabilitation was kind enough to provide me the newest guidelines for long-term care facilities. In addition, I have had extensive discussions with hospital coding specialists, long-term care coding specialists, as well as many years of teaching pressure ulcer physiology and basics to numerous levels of audiences. I would dare any of you to argue with me that 10 wound care specialists examining a single pressure-based tissue injury in a patient could conceivably propose 10 different diagnoses of stage (yes I know there are only 4 + deep tissue injury (DTI) currently accepted) based on the accepted wound care literature, and that based on the lighting in the room, what they had for lunch, and the color of the paint on the walls in the room, their staging of that same wound might change over the next 1 to 2 hours.
The problem is not so much with consistency, but rather definitions. The NPUAP and their “across the pond” relative, the EPUAP, as well as the many “Expert Panels”, have both done yeoman’s jobs trying to service several masters including CMS, the many insurance companies, the many different care settings, and last and certainly least, the patient’s and we caregivers. In simplest terms, what has transpired is that we have essentially re-created the biblical Tower of Babel. The only entities that seem to be happy about this are, of course, the plaintiff’s attorneys because they are smart enough to realize that:
1. The vast majority of physicians are not trained in wound care;
2. By virtue of licensing and training requirements, nurses are not allowed to diagnose specific disease entities (tell that to several nursing home chains who have instituted wound treatment protocols based solely on nursing wound diagnoses);
3. Persistent and consistent misunderstanding, or lack of understanding of the pathophysiologic origins of many different pressure-based tissue injuries (such as why coccygeal-based wounds are different than sacral or ischial);
4. Persistent use of not just unsupported, but condemned treatments like Dakin’s solution, Topical Gentamicin, frequent debridements of non-diabetic wounds, etc.;
5. MOST SIGNIFICANTLY, there is little-to-no consistency in the staging of pressure-based tissue injuries across the spectrum of occurrence and evaluation.
For those of you who ramble the same wound care roads that I do, this modern-day Tower of Babel unquestionably creates an untenable situation in which patient care is suffering, make no bones about it.
However, lest I be accused of identifying a problem without offering my usual intellectually sound, elegantly simple solutions, you may rest assured that “I got the answer”.
If you remember that the skin’s major function is protection of the delicate internal environment, then loss of this protective environment places the delicate internal environment at risk. The problem with playing the “loss of epidermis to deep dermis” game, or evaluating injuries which expose any of the layers which make up our skin, is the misconception that these injuries are static and that “what you see is what you get”. In fact, the truth of the matter is that you are simply watching a single frame of a movie that at any given time can be running either forward or backward based on a myriad of factors. And so to my mind, for all of the reasons listed above and the infinite number of reasons for which I have neither the time nor the wherewithal to list, here are the solutions to this problem, humbly offered:
1. When evaluating a wound, or any injury to the tissues, it should be determined whether or not it is due to pressure either primarily or in part (such as friction and shear). Let us not forget that for the most part, diabetic neuropathic injuries are in fact pressure-based tissue injuries which are exacerbated by lack of sensation. The same goes for spinal cord injury based.
2. If indeed the etiology is pressure based, than either the skin is present (DTI) or not PERIOD! Of course, regardless of whether skin is present or not, the definitive treatment is always pressure relief (not reduction, which is a myth in my book) and must be always initiated as the most fundamental treatment (this single act would mitigate the vast majority of pressure-based lawsuits).
3. Since the skin is intact in what we presently call stage I and DTI, then no dressings, or ointments, unguents are required. Of course, differing between stage I pressure ulcers and DTI would be the aggressive initiation of prayer that the DTI would not progress and open since once DTI is present, am not aware of anything that can reconstitute damaged or dying tissue.
4. If the pressure-based tissue injury has lost its epithelial/protective covering and hence is “open”, then the clinician should institute the dressing du jour - based on the myriad of factors that the wound care companies parade in front of our eyes like the Leonid Meteor showers in November.
To recap in the simplest terms, the wound, injury, etc. is either due to pressure or not. If so, pressure relief is immediately instituted. If the skin is intact, no further treatment is warranted. If not, then the appropriate dressing and adjunctive treatments are instituted. Simple, sensible, pathophysiologically appropriate, and most important reproducible regardless of level of training, facility, insurance company or bureaucrat.
In this era of mandated electronic medical records, the infinite interpretations of HIPPA, mandatory insurance coverage, and other pro-complexity initiatives, I respectfully swim against the tide by offering something equally scientific, less complex, more black and white, and most importantly, universally understandable.
Until the next time we ramble together…
About The Author
Michael Miller DO, FACOS, FAPWCA is the Founder and Medical Director of The Wound Healing Centers of Indiana and IndyLymphedema, as well as a clinical consultant, teacher, inventor, and published author.
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.