A Little Detective Work: Evaluating Continuity of Care Issues
Have you ever received a call from one of your referral sources about a patient that you have placed on a support surface and their wound is getting worse? And let me guess, they thought the mattress wasn't doing its job. If this sounds familiar, did you then make an unanticipated service call to the patient's house only to find everything in order? The correct equipment, properly set-up, can only do what it was intended to do. Therefore, where and how a patient spends their day plays a significant role in wound healing and equipment selection. The most therapeutic support surface mattresses on the market today are useless if the patient isn't in the bed. This dilemma is faced daily by clinicians and providers alike, and may be easily remedied. Understanding a patient's needs and daily schedule will allow you to choose appropriate equipment for specific activities of daily living (ADLs). Knowing how your patient spends his or her day and what surfaces he or she comes in contact with for extended periods can assist in wound healing as well as preventing wounds in the first place.
The Name of the Game is Re-distribution
To understand the scope of the problem, it is important to realize that up to 85 percent of seated dependent persons will develop some stage pressure ulcer in their lifetime. In the seated position, nearly 70 percent of your body weight is distributed through the pelvis and femurs. In a typical spinal cord injured patient, after five plus years of muscle atrophy --muscle wasting -- the ischial tuberosities, or sit bones, become more pronounced and are about the size of golf balls. Redistributing the pressure away from these bony prominences now becomes even more important. For the spinal cord-injured population, pressure ulcer care will account for 25 percent of their total health care costs. It can cost anywhere from $5000 to $40,000 to heal one pressure ulcer, and according to a study conducted for the Agency on Health Care Policy and Research, the total national cost for pressure ulcer treatment is estimated to exceed 1.3 billion dollars annually. This staggering statistic in and of itself should get clinicians and dealers alike involved in dealing with this problem proactively. After all, we all know where those billions come from, our paycheck.
Besides the mattress and wheelchair, other common continuity of care areas involve operating room tables, gurneys, shower benches, commode chairs, dialysis chairs, geri-chairs, sliding boards, heel protection and back rests. Any surface that comes into contact with the patient's damaged or fragile skin may become an impediment to healing. Extrinsically, we can really only manage four things: pressure, shear, friction, moisture and heat. Addressing these issues with support surfaces is a simple option. For example, studies have shown that incidence of intra-operative acquired pressure ulcers range anywhere from 12 percent to as high as 66 percent. As surgical advances continue to increase a patient's health, so does the length of the procedures and therefore the increased risk for development of pressure ulcers. Therefore, adopting pressure management strategies is becoming routine in surgical procedures exceeding four hours.
Wound clients with extended bowel routines that require one hour or more on a commode also will need a support surface to accommodate their commode seat or chair. Inexpensive pressure reducing support surfaces also are available for shower benches and transfer benches. The total time these patients spend in compromising positions on hard plastic may put them at further risk.
According to Medicare Part B Medical Policy Coverage and Payment Rules for support surfaces, Group II therapeutic support surfaces are only available to patients who have multiple stage II, or one large stage III or IV ulcer on the trunk or pelvis. Unfortunately, this means that bilateral stage II, III or IV heel wounds do not meet the qualifications for healing by means of a therapeutic support surface. And how did most of these patients get these wounds in the first place? They probably acquired them from excess pressure, shear or friction on their current mattress. As a result, we need to be proactive in treatment by providing devices and positioning to redistribute high peak pressures at the vulnerable tissues at and around the heels.
What about those patients who are limited to bed or a wheelchair and have adequate support surfaces in place? There is a litany of intrinsic risk factors such as age, nutrition, disease process, vascular issues, lack of sensation, and other issues that are difficult, if not impossible, to address with equipment selection.
Any surface that comes into contact with the patient's damaged or fragile skin may become an impediment to healing. |
Therefore it is imperative to choose equipment wisely, educate the client and caregivers extensively to their appropriate usage and why this is so important.
A common misconception is that once the patient obtains the therapeutic support surface, wheelchair cushion, or tilt-in-space wheelchair, turning, positioning and pressure relief techniques provided by the caregivers are no longer necessary. We are always under the influence of gravity, and therefore, we exert pressure on every surface we touch. To minimize the effect of gravity, we all could live underwater where the pressure on the body is equally distributed. Unless you are a fish, this is not a realistic option. To redistribute these peak pressures, support surfaces are designed to maximize the surface area around bony prominences. Unfortunately, even the best support surfaces are unable to completely eliminate ischemia, or lack of blood flow, in the skin and soft tissues. That is why weight shifts and turning and repositioning schedules are vital to complementing an appropriate use of support surfaces.
Reality Check
A wound care patient I have been involved with for more than a year-and-a-half told me that his wound was worsening after getting his new support surface mattress. He is a 9-year post L-3 complete spinal cord injured patient with a history of pressure ulcers and subsequent myocutaneous flap repair surgery to the left ischial tuberosity. He has multiple wheelchairs and cushions and is quite active in and around his home. He is independent with all of his personal care and transfers easily from one surface to another.
I arranged a time to meet at his home to do pressure mapping to double-check setup of his wheelchair, cushions and the support surface. Upon pulling onto his street, I notice a rather large billboard in his driveway. It is an advertisement saying "Re-elect Buddy Smith for Sheriff." I notice his pickup truck is attached to this rolling billboard. We start talking and he informs me that Buddy was a personal and business friend of his from way back and he has been driving his truck with this billboard so that he can get Buddy some added exposure. Curiously, he details how his wound has been getting a little worse since about June (three months prior to our discussion). He said he doesn't understand how this is happening. He said he has been driving about five to six hours a day, five days a week with the billboard. You are starting to get the picture now, aren't you?
With a little further questioning, he tells me it started getting worse, but he thought it would just heal once he got his new bed. He never really thought about using his wheelchair cushion in the truck because most of his driving until June had been just to the store and to the lake to go fishing. For education sake, we pressure mapped his truck seat and found that it was as about as pressure-relieving as the bleachers at the baseball diamond. With a resounding humph we placed his cushion in the truck and took another pressure mapping. He was amazed when he saw the difference. With that, he pledged to use his spare cushion in the truck from now on. And wouldn't you know, his wound began to heal.
In the process of this visit, we also looked at the other places he spends time during the day when he is not in his bed or in his wheelchair. His La-z-boy chair was a favorite spot late in the day, so he now uses his cushion there as well. This is just one example of how patient education and a little detective work can play a role in wound management.
Continuity of care is becoming the new buzzword for wound professionals. The age of understanding wound healing and how maximizing healing with wound dressings, topicals, and devices can only be effective if the root cause is addressed. With pressure and shear induced wounds, every surface the patient contacts during the day is a potential disruption in the wound healing continuum. To this end, long-term savings in a financially restrictive environment are necessary to control the costs involved to healing ischemic wounds. So the next time you get that call, do a little more detective work and try to get a better handle on the entire scenario. It will benefit everyone involved.
This article originally appeared in the April 2003 issue of HME Business.