Podcast Addresses Prevention, Treatment, More

October 24, 2019
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Decubiti, pressure ulcer, pressure injury, decubitus ulcer. Call it what you will, as long as the emphasis is on quality care. During an AMDA On-The-Go podcast earlier this month on this important topic, Jeffrey Levine, MD, CMD, co-author of the Pocket Guide to Pressure Ulcers, took the focus from terminology to treatment and other challenges facing post-acute and long-term care (PALTC).

Host Wayne Saltsman, MD, PhD, CMD, observed that in 2016 the National Pressure Ulcer Advisory Panel (NPUAP) introduced the term “injury” rather than “ulcer.” Dr. Levine observed that the NCUAP decided on the terminology change for “a number of reasons.” However, he said, “The main reason is that Stage 1 is not a skin break at all; therefore, Stage 1 isn’t an ulcer. This unfortunately caused a tempest in the wound care world with the main consideration that it was a gift to plaintiff attorneys.” Despite this tempest, he noted, the new terminology has had “good penetration in the wound care and regulatory communities,” and he pointed out that the Centers for Medicare & Medicaid Services (CMS) has used the term in its verbiage.

In the end, Dr. Levine said, “We at the front lines shouldn’t be wasting time arguing about the terminology.” Plaintiff lawyers will always find ways to attribute negligence to physicians and facilities, but, as he explained, “We need to look toward providing proactive quality care by developing working systems for wound care as mandated by CMS interpretive guidelines in F-Tag 686.”

This means, he said, that “we need wound care knowledge among our medical directors, physicians, and other primary care providers, along with qualified wound care practitioners who are skilled in both communicating with nurses, doctors, nutritionists, and families, as well as judicious decision-making for wound care.” This knowledge base should include such issues as prevention modalities, wound assessment, recognition and treatment of infections, recognition and identification of other conditions such as moisture-associated skin damage and fungal infections, the importance of nutrition, palliative care principles, proper product choice, and when to refer the patient to a surgeon and sharply debride the wound.

CMS has long recognized that pressure injuries might reflect on quality, Dr. Levine noted. He also said that PALTC facilities have been ahead of the curve in acknowledging this, while hospitals have only recently come into the fold. He explained, “This really got a boost in 2008 as part of a pay-for-performance initiative promulgated by CMS when they brought hospitals into the picture.” More recently, the agency has created the Electronic Clinical Quality Measure (ECQM) in which “hospital harm pressure injuries” are specifically designated.

Sometimes pressure injuries are unavoidable. Dr. Levine said, “We on the front lines have long recognized that there are patients with intrinsic characteristics that engender pressure injuries that are unavoidable even though we’ve administered care that incorporates all components of clinical practice guidelines for prevention.” Unfortunately, he added, “Research has not yet given us a bullet-proof algorithm that predicts pressure injury avoidability or unavoidability.” Nonetheless, he stressed, “We shouldn’t let our guard down with regard to provision of preventive techniques and proactive quality care.”

Another major consideration, Dr. Levine said, is that with the transformation of nursing homes into subacute facilities, practitioners are seeing more wounds that aren’t pressure injuries. These include, he said, surgical, arterial, or trauma wounds; venous ulcers; burns; and wounds related to malignancies: “This is all the more reason that medical directors and others in PALTC need education and training in managing complex, chronically ill patients with all kinds of wounds. The challenge is huge, and I applaud the Society for being on the front lines in presenting education and resources on this topic.”

The ideal wound care system, Dr. Levine said, “starts at the top with knowledgeable and involved administrators and medical directors, involved primary care physicians who take the time to examine all wounds and document what they see, competent wound care personnel and consultants, and the involvement of all disciplines in skin assessment, pressure relief interventions, nutrition, and information choices regarding treatment. “We in the PALTC community know about all these parameters. It’s nothing new, and it’s not rocket science. The key is getting the administrative commitment to back us up and provide appropriate resources, along with medical directors and primary care practitioners who are familiar with basic concepts.”

Click here to listen to the full podcast and hear much more of Dr. Levine’s interview. Check out a full list of archived episodes you can listen to at your convenience. CME is available for these programs.