Objectives. Why is this important? 5/1/2012. By: Rhonda Trexler, BS RN COS-C CCP

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1 By: Rhonda Trexler, BS RN COS-C CCP Objectives Verbalize the ability to determine if a surgical wound exists when documenting in OASIS-C Describe would healing phases related to wounds healing by primary intention and secondary intention Discuss the completion of OASIS C items related to surgical wounds in home health patients Why is this important? Accurate Assessments lead to appropriate interventions for the patient and accurate data collection for OASIS-C -----leads to accurate payment and accurate measuring of outcomes 1

2 Home Health Compare Improvement in Surgical Wounds is a publically reported outcome on the home health compare website How often wounds improved or healed after an operation Surgical Procedure/Surgical Wound The Center for Medicare and Medicaid Services provides guidance to Home Health regarding scoring for OASIS-C OASIS-C Guidance Manual Chapter 3 Assessment- Instruments/HomeHealthQualityInits/HHQIOASISUserM anual.html CMS Q&As link for OASIS Q&As will take you to the OASIS Answers Website Can also access the user manual from this site 2

3 M1340 Does this patient have a Surgical Wound? Integumentary System Skin, hair, nails and sweat glands Excludes mucous membranes, cataract surgery of the eye, surgeries via a vaginal approach Centers for Medicare and Medicaid Services. (2010). OASIS C guidnace manual. Consider the Etiology Surgical interventions to treat already existing wounds do not change the classification of the wound as surgical Suture of laceration from trauma Debridement of existing wound Simple I&D of abscess/cyst Skin graft over existing wound Full thickness Partial thickness Suture of Laceration from Trauma Classified as a trauma wound Debridement of a traumatic wound to remove debris or a foreign matter Traumatic wound requiring surgery to repair an internal organ or other internal structure is a surgical wound Repair of a torn tendon or a ruptured internal organ 3

4 Pressure Ulcer with Sharp Debridement remains a pressure ulcer Incision and Drainage Simple Incision and Drainage Incision and drainage with removal of tissue or other structures Drain placement = surgical wound Wound remains surgical even after drain removal Excision of an abscess or cyst Skin Grafts Skin grafting is a treatment of an existing wound Donor site is considered a surgical wound Full thickness Partial thickness 4

5 Muscle Flap/Skin Advancement Flap/Rotational Flap Creates a surgical wound Pressure ulcer that is muscle flapped will be classified as a surgical wound If area breaks down again due to pressure becomes a pressure ulcer Skin Flap of a Pressure Ulcer becomes a Surgical Wound Biopsy Sites Any wound created by needle puncture only is not a surgical wound Needle biopsy Paracentesis with needle puncture only Cardiac catheterization sites (even if stent placed) Cut-Down procedure 5

6 Biopsy Sites Excisional biopsy Shave biopsy Punch biopsy Surgical Wound for OASIS-C Vascular Access Devices Central line sites Implanted vascular access devices Arterio-venous shunts PICC lines Peripheral IV sites Ostomies All ostomies are excluded from consideration as surgical wounds Chest Tube sites Take down procedure vs. Ostomy closing on own 6

7 Sutures Sutures and Surgical Wounds Peripheral IV sutured in place ON-Q Pump ON-Q C-bloc is a continuous peripheral nerve block system that slowly infuses local anesthetic near a nerve for effective pain relief Considered an implanted infusion device Surgical wound if inserted separate from wound What is Not a Surgical Wound? VP shunt Pacemaker Toenail removed Callous removed Subcutaneous infusion Enterocutaneous fistula 7

8 What is a Surgical Wound? Orthopedic pin sites Peritoneal dialysis catheter site LVAD cannula exit site When is a Surgical Wound No Longer Reported on OASIS-C? 30 Days After Epithelialization Wound is considered a scar and no longer included in M1340 Does this patient have a surgical wound? 8

9 What is Epithelialization? National Institute of Health. (2010). Skin layers. Retrieved from ages/8912.htm. OASIS-C M1340: Does this patient have a surgical wound? M1342: Status of the Most Problematic (Observable) Surgical Wound: Outcome Based Quality Improvement Outcome Based Quality Monitoring Home Health Prospective Payment System Risk Adjustment Phases of Wound Healing Hemostasis Inflammation Proliferation Maturation 9

10 Hemostasis Clotting cascade begins Fibrinogen Clot formation Fibrinolysis Inflammation Inflammation WBCs enter the wound Redness, swelling, warmth, and discomfort Proliferation Granulation tissue New blood supply develops Epithelialization 10

11 Epithelialization Healthy Wound Edges Moist wound environment Closed Wound Edges Epibole Calloused Hyperkeratonic Maturation Day 7 up to 1 year Contraction Increased tensile strength 11

12 Primary Intention Primary Intention Surgically closed Completely approximated Less tissue loss Do not granulate Secondary Intention Open surgical wounds Wound edges are open Requires granulation tissue Intentional and dehisced Approximated Incisions Heal by Primary Intention Any dehiscence of separation results in healing by Secondary Intention 12

13 Terminology Avascular Tissue Eschar Slough Dead Space Granulation Tissue Hyperkeratotic Closed Wound Edges M1342 Status of the Most Problematic Surgical Wound Newly Epithelialized Fully Granulating Early/Partial Granulation Not Healing WOCN Guidance on OASIS-C Items: Newly Epithelialized Wound Bed completely covered with new epithelium No exudate No avascular tissue No signs or symptoms of infection Peirce, B., Mackey, D., & McNichol, L. (2009). Wound ostomy continence nurses society guidance on OASIS-C integumentary items. Retrieved from 13

14 Fully Granulating Wound bed filled with granulation tissue to the level of the surrounding skin No dead space No avascular tissue No signs or symptoms of infection Early/Partial Granulation > 25% of the wound bed is covered with granulation tissue < 25% of the wound bed is covered with avascular tissue (eschar and/or slough) No signs or symptoms of infection Wound edges are open Not Healing Wound with > 25% avascular tissue (eschar and/or slough) OR Signs/symptoms of infection OR Clean but nongranulating wound bed OR Closed/hyperkeratotic wound edges OR Persistent failure to improve despite appropriate comprehensive wound management 14

15 Primary Intention vs. Secondary Intention Do not granulate Newly Epithelialized Not healing Granulation tissue Newly Epithelialized Fully Granulating Early/Partial Granulation Not Healing Sutures / Staples Not considered part of the surgical wound when determining the healing status Include status of sites in comprehensive assessment documentation 15

16 10 Days Post-Op Scabs Presence of a scab is not automatically non-healing Determine first is the wound is healing by Primary Intention or Secondary Intention Primary Intention healing with scab = Not healing Secondary Intention = Consider all 4 healing status choices Implanted Port - Accessed Some sites, because they are being held open by a line or needle, cannot fully granulate and may remain non-healing while the line or needle is in place CMS OOCS 04/10 Q&A #14 16

17 Approximated Incision Separates in Several Areas If the wound is not completely epithelialized for 30 days openings are considered part of the original surgical wound Assess all areas following WOCN Guideline If one area is not healing, report the status as Not Healing for M1342 Healing Status of the Most Problematic Surgical Wound Improvement in Surgical Wounds Assessment Accuracy Dehiscence Infection Delayed wound healing Systemic Factors Education Prevention of Complications Dehiscence Day 7 Drainage Signs or symptoms of infection Mechanical stress 17

18 Infection Increased mortality Longer hospitalizations Higher healthcare costs Drainage > 48 hours Systemic Factors Circulatory Disorders Diabetes Malnutrition Patient Education Prevent Dehiscence Splint incisions Prevent strain Monitor for and report signs of complications Prevent Infection Educate patients Hand hygiene Wound care Promote Healing 18

19 References Baranoski, S., & Ayello, E. (2008). Wound care essentials: Practice principles (2 nd ed.). Philadelphia: Lippincott Williams & Wilkins. Benbow, M. (2005). Evidence-based wound management. London: Whurr Publishing. Benbow, M. (2007). Healing and wound classification. Journal of Community Nursing, 21(9), Centers for Disease Control and Prevention. (2009). Centers for disease control and prevention: Your online source for credible health information. Retrieved from Centers for Medicare & Medicaid Services. (2007). CMS OCCB Q&As May Retrieved from Centers for Medicare & Medicaid Services. (2007). CMS OCCB Q&As October Retrieved from Centers for Medicare & Medicaid Services. (2010). OASIS-C guidance manual. Retrieved from Centers for Medicare & Medicaid Services. (2010). CMS OCCB Q&As April Retrieved from 0_508c.pdf Centers for Medicare & Medicaid Services. (2010). CMS OCCB Q&As July Retrieved from References Continued Centers for Medicare & Medicaid Services. (2010). CMS OCCB Q&As October Retrieved from Centers for Medicare & Medicaid Services. (2011). CMS OCCB Q&As January Retrieved from Doughty, D. B. (2005). Preventing and managing surgical wound dehiscence. Advances in Skin and Wound Care. 18(6), Hampton, S. (2007). Bacteria and wound healing. Journal of Community Nursing, 21(10), Hunter, S., Thompson, P., Langemo, D., Hanson, D., & Anderson, J. (2007). Wound & skin care. Understanding wound dehiscence. Nursing, 37(9), Kaye, K., Anderson, D., Sloane, R., Chen, L., Choi, Y., Link, K., Sexton, D., & Schmader, K.(2009). The effect of surgical site infection on older operative patients. Journal of American Geriatrics Society, 57(1), Lee, S. K., (2006). The role of nutrition in treating and healing wounds. Nursing Homes: Long Term Care Management, 55(11), National Institute of Health. (2010). Skin layers. Retrieved from Peirce, B., Mackey, D., & McNichol, L. (2009). Wound ostomy continence nurses society guidance on OASIS-C integumentary items. Retrieved from Schwien, T., & Lang, C. (2008). Changes in wound care outcomes analysis: New home health compare measures. Retrieved from Vuolo, J. C., (2006). Assessment and management of surgical wounds in clinical practice. Nursing Standard, 20(52),