Professional Documents
Culture Documents
BY
85
Pyoderma Gangrenosum
• Dx – Biopsy – histologic findings often non-
specific
• Diagnosis of exclusion
• Pathergy – Paradoxical response to
debridement (may get worse) particularly in
proximity to the areas debrided.
• Tx – Protective dressings, topical steroid
cream
86
Pyoderma gangrenosum of the RLE
Pyoderma Gangrenosum
Calciphylaxis
• Associated with high levels of calcium
phosphate.
• Leads to calcification of the small arteries .
• Associated with intimal fibrosis and thrombus
formation.
• Hx – ESRD on HD, hyperparathyroidism,
sudden weight loss or gain.
89
Calciphylaxis
• Distribution can include peripheral locations
on the body including fingers, toes, tongue,
penis, and torso.
• Very painful.
• Localized tender lesions start as light violet
mottling, evolving to pruritic patches and
plaques, vesicles or irregularly shaped ulcers.
• Necrosis and black eschar develop in
subcutaneous tissue in a few days.
90
LLE at the lateral aspect
calciphylaxis
RLE at the medial aspect
Calciphylaxis
A bedridden patient with PMH;DM,
ESRD on HD, and Calciphylaxis
Calciphyalxis
• Dx – Elevated calcium/phosphorus levels.
• Tx
– Lower-serum calcium and serum phosphorus
serial debridement
– parathyroidectomy
– skin graft
– anticoagulation
– antibiotics
– amputation
– renal transplant
94
Healing phases in acute wound
• Hemostasis: 0- 3 hrs. platelets –blood clotting
process.
• Inflammatory : 0- 3 days. Leukocytes&
Macrophages are the key cells to destroy bacteria
& clean cellular debrie.
• Proliferative : 3-21 days. Epitheliazation,
angiogenesis ; granulation tissue formation&
collagen deposition are the key steps to this
phase.
• Maturation : 21days- 1.5 year. Contraction, scar
tissue formation.
Types of Wound Healing
• Primary intension: e.g, surgical wound, evenly
edges laceration that was sutures within less
than 8 hrs.
• Secondary intension: Infected surgical wound
that is not healing properly within 21 days,
Chronic, non-healing ulcers, Full thickness loss
opened abscess (Surgical Wound).
• Tertiary intension: It is a delayed closure of a
wound, e.g Fasciotomy wound. Less than
50,000 colonies
Types of Wound Healing Continued
• Partial thickness wound; healed by re-
epithalization.
• Full thickness wound; healed by
1. Granulation
2. Contraction
3. Re-epithalization
Type of Abdominal Wounds
• Infected surgical wound; fascia is intact.
• Dehisced Wound; fascia is not intact.
• Eviscerated Wound; Abdominal content is
outside the abdominal wound edges.
Midline Abdominal infected
surgical wound
Chronic wound
• www.thewoundinstitute.com/
• In case of chronic wound, the biological character
of wound bed is different than that in case of the
acute wound. There is:
• Increase amount of MMPs ( Matrix
Metalloproteases .
• Increase pro inflammatory cytokine
• Decrease amount tissue inhibitors protease
• Decrease amount of growth factors.
Chronic wound exudates
• Chronic wounds stall in the inflammatory phase.
• Chronic wound exudates slows down or blocks the
proliferation of cells such as keratinocytes, fibroblasts
and endothelial cells, all of which are important in the
repair process. Wound exudates contains a number of
matrix metalloproteinases and serine proteases that
can break down or damage essential extracellular
matrix materials. These are vital for cell movement and
re-epithelialization. Growth factors, which are essential
for optimal wound closure, are also inhibited by
macromolecules found in chronic wound exudates.
Bacterial Burden in the Wound
• Bacteria present within a wound can be divided into four distinct
categories.
• Contamination - defined as the presence of non-replicating
microorganisms within the wound.
• Colonization - defined as the presence of replicating
microorganisms, which do not cause injury to the host. Examples of
bacterial wound colonization would be Staphylococcus epidermis
and Corynebacterium sp. whose presence have been shown to
increase the rate of wound closure(37).
• Critical colonization - defined as the presence of replicating
microorganisms, which are beginning to cause local tissue damage.
• The concept of critical colonization has recently been introduced to
describe wounds with an increased bacterial burden, moving
between the category of colonization and local infection. During
critical colonization, subtle clinical signs of infection may be present
before the classical signs associated with infection appear(38, 39).
Bacterial Burden in the Wound
continued
• These clinical signs and symptoms of local infection are listed below.
• Delayed healing
• Change in color of the wound bed
• Friable granulation tissue
• Absent or abnormal granulation tissue
• Abnormal odor
• Increased serous exudates
• Increased pain at the wound site
• Infection - defined as the presence of replicating microorganisms in the wound, which cause
injury to the host.
• This type of infection is regarded as systemic infection and the traditional signs and symptoms
are listed below.
• Advancing redness (erythema)
• Fever a (swelling)
• Pain
• Foul odor
• Pus
Chronic Wound Treatment
• Debridement; Debridement; Debridement.
• Complete debridement of devitalized and
poorly functioning tissues.
• Restoration of bacterial balance.
• Maintenance of optimal moisture balance.
• Control of edema/ lymphedema.
Chronic Wound Treatment
Continued
• *Remove devitalized tissues and surface contaminants;
Debridement: There are 5 types of debridement;
• Surgical: Sharp & Excisional Debridement. In the OR & bed
side. “Selective”
• Mechanical: eg. Wet to dry dressing, Puls-lavage (Water
under pressure). “Non-selective”
• Enzymatic: Collagenase (santyl).”Selective”
• Autolytic: Wound dressing that stimulate patient own body
enzymes to debride the wound. “Selective”
• Eg; Hydrogel , Hydrocolloid (Replicare, DuoDerm/
Exuderm)
• Biological ; ( Maggot) Debride only the necrotic
tissue.”Selective”
Chronic Wound Treatment
Continued
• *Control bacterial burden of wound
• Monitor for signs of infection.
• Debride all necrotic tissue.
• No topical antibiotics due to risk of developing
resistant organisms.
• Topical antimicrobial dressing; eg Silver dressing; (
Acticoat, Silver alginate, Aquacel AG) Iodosorb gel (
Cadexomer iodine ). Methylene blue(Hydrofera Blue)
• Use systemic antibiotic only in presence of spreading
cellulites, sepsis , or osteomylitis
Chronic Wound Treatment
Continued
• *Provide moist wound environment and control exudates
with Alginate, Foams, moist plain packing.
• Prevent further injury; relief pressure by changing body
position Q2 hrs. Using; Low air loss mattress
• Support repair process;
• Protein and calories( protein 1.25- 1.5 g/kg/d: calories 30-
35 calories/kg/d)
• Vitamin &mineral supplement e.g; 500 mg of Vit. C, MVI 1
tab daily, and 220 mg zinc sulphate daily for 2 weeks.
• Avoid exposure to cold.
Contraindication of Debridement
• Three Conditions
1. Dry, stable( Showed no sign of infection) eschar
on the heel.
2. Fungating mass (bleeding issue)
3. Pyoderma gangrenosun; (Pathergy)
Advanced/ Adjunctive Wound
Healing Therapies
1. Hyperbaric Oxygen Therapy. (HBOT)
2. Electrical stimulation
3. Negative pressure (V.A.C). (NPWT)
4. Growth Factors (regranex) FDA approved for DFU.
5. Skin Equivalents (Apligraph) For DFU& VSU
Dermograph
6. Advanced Dressing for chronic wounds such as
collagen, promogram, integra, oasis, etc.
*A chronic non-healing wound for more than 3-6
months in which it is not responding to standard
of care treatment requires a biopsy to rule out
(NPWT)Negative Pressure Wound
Therapy
• Indication claimed by manufacturing company: All different
kinds of wounds/ ulcers. However, I use it for stage 3 and 4;
full thickness wound.
• Contraindication: Bleeding ulcers, cancer in the ulcer,
untreated osteomylitis, and not on any organs
• V.A.C therapy promotes healing by stimulating granulation
through cell division, cell expansion, and new vascularization
• Negative pressure is 125 mm Hg continuous in the first 48
hours. Then intermittent (5 minutes on and 2 minutes off)
afterward.
• Wound should show improvement in the characteristic and
the depth within 9 days of therapy
(HBOT) Hyperbaric Oxygen Therapy
• 100% oxygen therapy under pressure.
• Patient stays in the oxygen chamber for 90
minutes.
• Very expensive treatment modality.
• Long list of indications and contraindications.
(Ask Ms. Monica from hyperbaric chamber)
• Patient can benefit from HBOT. i.e; Diabetic
foot ulcer grade 3, patient with traumatic
wounds, necrotizing fasciitis
Skin Substitutes
Monitoring Wound Healing
• Mostly for pressure ulcers; weekly measurements and
documenting changes in the wound bed
• PSST tool Pressure Sore status tool
13 assessment parameters
– Size, depth, edges, undermining, necrotic tissue types,
necrotic tissue amount, exudate types and amount, skin
color surrounding wound, peripheral tissue edema and
indurations, granulation tissue, and epithelization
• PUSH tool Pressure ulcer Scale for healing
– Ulcers are categorized with respect to surface area
(LxW), exudate and type of wound tissues
Types of wound dressing
• *Alginate; seaweed. Soft, nonwoven fiber. Shaped as ropes, pads.
• Moderate to heavy exudate. In stage 3 &4
• Contraindication; in case of mild- dry wound.
• E.G. Sorbsan, Kaltostat, Maxsorb extra AG
• * Antimicrobial ; wound care product derived from agent such as silver, iodine, and
polyhexaethylene biguanide.
• Silver dressing; e.g. Acticoat absorbent, burn , 3 ,7. silvasorb. Aquacell AG. Silvercel. 2- 7 days.
• Iodosorb gel, Cadexomer iodine 0.9% Q 48 hrs.
• * Collagen; used as a primary dressing. Absorbent, maintain a moist wound healing
environment.
• E.G BGC matrix, cellerate RX gel & powder, Kollagen Medifil 2 particles.
• *Contact Layer; Woven net acts as a low- adherence material to protect the wound bed from
trauma during dressing changes.
• E.G conformant 2 wound veil, Mepitel, Adaptic, oil emulsion
• * Composites; combine two or more products
• E.G. Alldress, Compdress island dressing, MPM multi layered dressing (Bordered).
Types of wound dressing
• *Foams; absorbent. Light – heavy exudate.
• Disadvantage; Not for eschar, may macerate periwound skin.
• E.G. Allevyn Adhesive ( Hydrocellular polyurethane) stage 2,3,4. Curafoam
plus,Hydrasorb foam, hydrocell foam, Mepilex border.
• * Hydrocolloids: Occlusive or semiocclusive – gelatin, pectin, and
carboxymethylcellulose.
• Autolytic debridement, absorption. Not for heavy exudate. Not for fragil skin.
• E.G. DuoDERM, VGF border, Exuderm, Replicare.
• * Hydrogels; Water- or glycerin based amorphous gel, impregnated gauzes, or
sheet. Soothing reduce pain, Rehydrate the wound bed, Autolytic debridement.
Not in heavy exudate.
• E.G. CarraGauge Pad, Clearsite hydrogel , Hydrogel spray. Solosite wound Gel.
• * Tranparent films; Adhesive , Semipermeable, Polyurethane membrane.
• E.G. OP Site, Bioclusive, Carra Smart Film, ClearSite transparent membrane.
Hospital-Acquired Conditions
• On February 8, 2006, the President signed the Deficit
Reduction Act (DRA) of 2005. Section 5001(c) of DRA
requires the Secretary to identify conditions that are:
(a) high cost or high volume or both, (b) result in the
assignment of a case to a DRG that has a higher
payment when present as a secondary diagnosis, and
(c) could reasonably have been prevented through the
application of evidence-based guidelines.
• Started on October 1, 2008 hospital will not receive
additional payment for cases in which one of the
selected conditions was not present on admission.
Hospital-Acquired Conditions
• The 10 categories of HACs include: • Catheter-Associated Urinary Tract Infection (UTI)
• Foreign Object Retained After Surgery • Vascular Catheter-Associated Infection
• Air Embolism • Surgical Site Infection Following:
• Blood Incompatibility – Coronary Artery Bypass Graft (CABG) - Mediastinitis
• Stage III and IV Pressure Ulcers – Bariatric Surgery
• Falls and Trauma • Laparoscopic Gastric Bypass
– Fractures • Gastroenterostomy
– Dislocations • Laparoscopic Gastric Restrictive Surgery
– Intracranial Injuries – Orthopedic Procedures
– Crushing Injuries • Spine
– Burns • Neck
– Electric Shock • Shoulder
• Manifestations of Poor Glycemic Control • Elbow
– Diabetic Ketoacidosis • Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)
– Nonketotic Hyperosmolar Coma • Total Knee Replacement
– Hypoglycemic Coma • Hip Replacement
– Secondary Diabetes with Ketoacidosis
– Secondary Diabetes with Hyperosmolarity
Coding
• To group diagnoses into the proper DRG, CMS
needs to capture a Present on Admission (POA)
Indicator for all claims involving inpatient
admissions to general acute care hospitals.
• The POA Indicator guidelines are not intended to
provide guidance on when a condition should be
coded, rather to provide guidance on how to
apply the POA Indicator to the final set of
diagnosis codes that have been assigned in
accordance with Sections I, II, and III of the
official coding guidelines.
CMS POA Indicator Options and Definitions
• Code
• Reason for Code
• Y
• Diagnosis was present at time of inpatient admission.
• CMS will pay the CC/MCC DRG for those selected HACs that are coded as "Y" for the POA Indicator.
• N
• Diagnosis was not present at time of inpatient admission.
• CMS will not pay the CC/MCC DRG for those selected HACs that are coded as "N" for the POA Indicator.
• U
• Documentation insufficient to determine if the condition was present at the time of inpatient admission.
• CMS will not pay the CC/MCC DRG for those selected HACs that are coded as "U" for the POA Indicator.
• W
• Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of
inpatient admission.
• CMS will pay the CC/MCC DRG for those selected HACs that are coded as "W" for the POA Indicator.
• 1
• Unreported/Not used. Exempt from POA reporting. This code is equivalent to a blank on the UB-04, however; it
was determined that blanks are undesirable when submitting this data via the 4010A.
• CMS will not pay the CC/MCC DRG for those selected HACs that are coded as "1" for the POA Indicator. The "1" POA
Indicator should not be applied to any codes on the HAC list. For a complete list of codes on the POA exempt list,
see page 110 of the Official Coding Guidelines for ICD-9-CM.
http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide08.pdf
Examples for MS-DRG
• Primary and Secondary Diagnoses Service: MS-DRG Assignment
• (Examples below are for a single secondary diagnosis only)
• Principal Diagnosis
• Present on Admission (Status of Secondary Diagnosis) • Intracranial hemorrhage or cerebral infarction (stroke)
• Average Payment* (Based on 50th percentile for FY 2008)
• Principal Diagnosis with CC - MS-DRG 066
• Intracranial hemorrhage or cerebral infarction (stroke) without CC/MCC - MS-DRG
066 • Example Secondary Diagnosis
• --
• $5,347.98 • Dislocation of patella-open due to a fall (code 836.4
• Principal Diagnosis (CC))
• Intracranial hemorrhage or cerebral infarction (stroke) with CC - MS-DRG 065
• Example Secondary Diagnosis • N
• Dislocation of patella-open due to a fall (code 836.4 (CC))
• Y • $5,347.98
• $6,177.43
• Principal Diagnosis
• Principal Diagnosis
• Intracranial hemorrhage or cerebral infarction (stroke) with CC - MS-DRG 066 • Intracranial hemorrhage or cerebral infarction (stroke)
• Example Secondary Diagnosis
• Dislocation of patella-open due to a fall (code 836.4 (CC)) with MCC - MS-DRG 064
• N
• $5,347.98 • Example Secondary Diagnosis
•
•
Principal Diagnosis
Intracranial hemorrhage or cerebral infarction (stroke) with MCC - MS-DRG 064
• Stage III pressure ulcer (code 707.23 (MCC))
• Example Secondary Diagnosis • Y
• Stage III pressure ulcer (code 707.23 (MCC))
• Y • $8,030.28
• $8,030.28
• Principal Diagnosis • Principal Diagnosis
• Intracranial hemorrhage or cerebral infarction (stroke) with MCC - MS-DRG 066
• Example Secondary Diagnosis • Intracranial hemorrhage or cerebral infarction (stroke)
• Stage III pressure ulcer (code 707.23 (MCC)) with MCC - MS-DRG 066
• N
• $5,347.98 • Example Secondary Diagnosis
• Stage III pressure ulcer (code 707.23 (MCC))
• N
• $5,347.98
Documentation & Payment
• If pressure ulcer is documented as (present on
Admission) ; a higher ICD-9 code may be
assigned resulting in higher payments.
• Documentation of pressure ulcer location is
critical as it impacts DRG assigned.
• Ankle, buttock, heel, trochanter, sacrum,
lower back, provide higher DRG.
• Elbow, upper back, etc may not.
Prevent pressure ulcer development
• If a pressure ulcer develops during
hospitalization, there will be no payment .
• All stages 1,2,3,4, and unstageable.
• So, hospital must implement early prevention
strategies and monitor frequently.
• If patient admitted with an unstageable
pressure ulcer and it opens to stage 3 or 4
during admission, no extra payment will be
received.
Prevent pressure ulcer development
• If patient admitted with a documented stage 1
or 2 pressure ulcer and it deteriorates to stage
3 or 4; no extra payment will be received .
• If a stage 1,2, or unstageable pressure ulcer is
documented as secondary diagnosis (POA) will
not result in higher payments.
• Only stage 3 and stage 4 present on admission
as a secondary diagnosis will result in higher
payments
Proper documentation
• Pressure ulcers have to be documented on admission
by PCP (MD, NP, PA etc.)
• All documentation has to be consistent with the stage,
location, wound bed condition & infection.
• If you can not do staging , please describe the wound.
• Source of POA documentation;
• - Emergency Dept.
• -H&P .
• - Progress notes
• - Admitting notes
Affected Hospital
• The Present on Admission (POA) Indicator requirement and
Hospital-Acquired Conditions (HAC) payment provision only apply
to Inpatient Prospective Payment Systems (IPPS) Hospitals.
• At this time, the following hospitals are EXEMPT from the POA
Indicator and HAC:
• 1. Critical Access Hospitals (CAHs)
2. Long-term Care Hospitals (LTCHs)
3. Maryland Waiver Hospitals
4. Cancer Hospitals
5. Children's Inpatient Facilities
6. Rural Health Clinics
7. Federally Qualified Health Centers
8. Religious Non-Medical Health Care Institutions
9. Inpatient Psychiatric Hospitals
10.Inpatient Rehabilitation Facilities
11. Veterans Administration/Depart of Defense Hospitals
References
• http://www.TheWoundInstitute.com/
• http://global.smith-
nephew.com/us/WOUND_BED_PREP_EXU_MGMT_17170.htm
• http://streamingpowerpoint.com/pres/hohabarchive/pres/index
.htm
• http://www.naccme.com/program/n-517/page/716/
• http://www.cms.hhs.gov/HospitalAcqCond/01_Overview.asphtt
p://www.nursingquality.org/NDNQIPressureUlcerTraining/modul
e1/default.aspx
• Dr. Falanga, Vincent: Boston University; Skin substitutes.
• Geriatrics at your Fingertips: David B. Reuben, MD; 2004
• Clinical Guide Wound Care : Fifth Edition; Cathy Thomas Hess,
RN,BSN,CWOCN,2005
At the end of the day that’s what
keeps me going