9/20/2013. Webinar Guidelines. September 26, :00 pm ET. 1 hour presentation by Dr. Elizabeth Ayello including a discussion period at the end.

Transcription

1 Medicaid Redesign Team Gold STAMP Project Webinar Staging, Measuring and Documenting Pressure Ulcers September 26, :00 pm ET This project is funded through a Memorandum of Understanding with the NYS Department of Health There is no commercial interest funding this program Webinar Guidelines 1 hour presentation by Dr. Elizabeth Ayello including a discussion period at the end. Send your questions at any time during the presentation via the chat box on your screen. Continuing Education Credit information will be available following the webinar. Webinar Guidelines This webinar will be recorded and available on demand for future viewing. Turn on your computer speakers for sound Handouts are available to download: Right side of your screen 1

2 Attendance Sheet Available to download: To the right of your screen Circulate the attendance sheet in your group Return to us: Fax or Include your (print clearly, please!) Your feedback is important! Medicaid Redesign Team Gold STAMP Project Webinar Staging, Measuring and Documenting Pressure Ulcers September 26, :00 pm ET This project is funded through a Memorandum of Understanding with the NYS Department of Health There is no commercial interest funding this program Staging, Measuring and Documenting Pressure Ulcers Elizabeth A. Ayello, PhD, RN, ACNS BC,CWON,MAPWCA, FAAN Faculty, Excelsior College School of Nursing Clinical Editor, Advances in Skin and Wound Care Executive Editor, WCET Journal Co Director and Course Coordinator, IIWCC NYU President, Ayello Harris and Associates, Inc. 26 September 2013 Webinar for Gold Stamp 2

3 Objectives Participants will: Differentiate the six pressure ulcer stages. Identify the steps in clinical measurement of pressure ulcers. Identify the key components of pressure ulcer documentation starting with the risk assessment. Ayello 2013 What is true today, may not be true tomorrow You must do the thing you think you cannot do. Eleanor Roosevelt Rethink Pressure Ulcer Risk Assessment because some clinicians: Believe its just a task Have lost the critical thinking piece Don t complete scale correctly Copy forward Ayello,

4 Braden Scale Levels of Pressure Ulcer Risk 19 to 23 = not at risk 15 to 18 = at risk = moderate risk 12 to 10 = high risk 9 or below = very high Advanced age Fever Poor dietary intake Protein Diastolic pressure below 60 Hemodynamic instability Ayello, 2007 Must address low subscale scores also Pressure ulcer clinical risk factors in older adults in home health Bowel incontinence Inability to transfer Ayello, 2012 Bergquist-Beringer, S., Gajewski, BJ. Outcome and assessment information set data that predict pressure ulcer development in older adults home health patients. Advances in Skin and Wound Care. 2011; 24(9): CMS MDS Data Set Source: National Healthcare Quality Report p. 126 available at Ayello

5 Disparities in Pressure Ulcer Care Source: National Healthcare Disparities Report, 2011p.129. Available at Ayello 2013 Determine the wound etiology Pressure Ulcers Vascular ulcers Venous Arterial Neuropathic/DM ulcers Other skin problems Skin tears MASD Ayello, 2010 Pressure ulcer or MASD? Pressure ulcer MASD (IAD) location Localized over Bony prominence diffuse color Non blanchable blanchable edges Distinct Irregular necrotic tissue Yes, possible no DeFloor, T. et al. Statement of the European Pressure Ulcer Advisory Panel-Pressure Ulcer Classification. J Wound Ostomy Continence Nurs. 2005; 32(5): Gray, M. et al. Incontinence-associated Dermatitis-A Consensus. J Wound Ostomy Continence Nurs. 2007; 34(1): Zulkowski, K. Perineal dermatitis versus pressure ulcer: Distinguishing characteristics. ASWC (8):382-8 Wolfman, A. Preventing incontinence-associated dermatitis and early stage pressure injury. WCET (1): Gray et al. Moisture associated skin damage-overview and pathophysiology. JWOCN. 2011;38(3): Ayello,

6 Pressure Ulcers Regulations don't always line up across settings *Home Care (OASIS C) *Long Term Care (MDS 3.0) *Acute Care (POA) *Long Term Acute Care Hospitals (LTCH CARE DATA) * In Patient Rehabilitation units (IRF PAI) Ayello 2012 Minimal pressure ulcer documentation S ize L ocation and staging E xudate E dge and surrounding tissue P ain Pain Bed color and type of wound tissue Ayello, 2007 From Tag F 314 Measuring Length Measure the longest length from head to toe using a disposable device. Head Toe CARE Data Sets 1.0 Section M 18 6

7 Measuring Width Measure widest width of the pressure ulcer side to side perpendicular (90 angle) to length. The width of this pressure ulcer is 6.2 cm. Head Toe CARE Data Sets 1.0 Section M 19 Measuring Depth Moisten a cotton-tipped applicator with 0.9% sodium chloride (NaCl) solution or sterile water. Place applicator tip in deepest aspect of the wound and measure distance to the skin level. CARE Data Sets 1.0 Section M 20 Pressure Ulcer Staging Partial Thickness Full Thickness Confirm the reliability of classifications among the professionals responsible for classifying pressure ulcers. (Strength of Evidence =B) Diagrams Copyright 2009 NPUAP 7

8 Category/Stage I Pressure Ulcer Definition Description Intact skin with nonblanchable erythema of of a localized area, usually over a bony prominence. Discoloration of the skin, warmth, edema, hardness, or pain may be present Darkly pigmented skin may not have visible blanching. The area may be more painful, firmer or softer, or warmer or cooler than adjacent tissue. Category/Stage I may be difficult to detect in individuals with dark skin tones. This may indicate an at-risk individual. Definition Copyright 2009 NPUAP Category/Stage II Definition Description Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. It may also present as an intact or open/ruptured serumfilled or serosanguineous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.* This category/stage should not be used to describe skin tears, tape burns, incontinenceassociated dermatitis, maceration or excoriation. Definition Copyright 2009 NPUAP Category/Stage III Definition Description Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Some slough may be present but does not obscure the depth of tissue loss. It may include undermining and tunneling. Definition Copyright 2009 NPUAP The depth of a category/stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and category/stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep category/stage III pressure ulcers. Bone/tendon is not visible or directly palpable. 8

9 Category/Stage IV Definition Description Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. It often includes undermining and tunneling. The depth of a category/stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis or osteitis likely to occur. Photo Ayello Definition Copyright 2009 NPUAP Exposed bone/tendon is visible or directly palpable. Unstageable Definition Description Full thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth cannot be determined but it will be either a category/stage III or IV. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body s natural (biological) cover and should not be removed. Definition Copyright 2009 NPUAP Suspected Deep Tissue Definition Description Purple or maroon localized area of discolored, intact skin or bloodfilled blister due to damage of underlying soft tissue from pressure and/or shear. Definition Copyright 2009 NPUAP Photo J. Cuddigan The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler than adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with treatment. 9

10 Pressure Ulcer Classification at a glance Ulcer Characteristics Category /stage Intact skin, non blanchable erythema I Open shallow ulcer with no slough or Serum, sero sanguinesous filled or ruptered blister full thickness ulcer can have necrotic tissue, but can see wound bed No bone, tendon,muscle visible Full thickness ulcer Can have necrotic tissue, but can see wound bed Bone, tendon, muscle visible Necrotic tissue covers wound bed II III IV Unstageable Purple, maroon discoloration of intact skin or Blood filled blister Ayello 2012 sdti What CMS says about Reverse Staging 2013 CMS LTC RAI Manual If the pressure ulcer has ever been classified at a deeper stage than what is observed now, it should continue to be classified at the deeper stage. Page M Revised CMS LTCH Quality Reporting Program Manual Version 2.0 If the pressure ulcer has ever been classified at a higher numerical stage than what is observed now, it should continue to be classified at the higher numerical stage. Page M 4 Are the definitions of all pressure ulcer stages clearly differentiated? Stage 1 Intact skin with non-blanchable redness of a localized area usually over a bony prominence Darkly pigmented skin may not have visible blanching: its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage I may be difficult to detect in individuals with dark skintones. May indicate at risk persons (a heralding sign of risk Deep Tissue Injury Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposed additional layers of tissue even with optimal treatment. 10

11 Stage II Blister Pressure Ulcers Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. It may also present as an intact or open/ruptured serumfilled or serosanguineous filled blister. Suspected Deep Tissue Injury Purple or maroon localized area of discolored, intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear. Definition Copyright 2009 NPUAP Photos courtesy of Dot Weir and Cindy Labish Revised Figure 4- Blistered Pressure ulcers and sdti (figure from Ayello, EA, Levine, JM, Roberson S. CMS updates on MDS 3.0 Section M:Skin Conditions. Change in coding of blister pressure ulcers. Advances in Skin and Wound Care. 2010:23(9):394,396 7.) Appearance Acute Care LTC MDS 3.0 (If signs of suspected deep tissue injury) Serous Filled Blister Blood filled Blister Intact purple maroon skin injury due to pressure Stage 2 Code sdti depth unknown sdti depth unkown Table Ayello 2010 Photos courtesy of Dot Weir and Cindy Labish Unstageable sdti Code under section M0300G LTC MDS 3.0 If (No signs of suspected deep tissue injury) Stage 2 Code under section M0300B Unstageable Stage 2 sdti Code under Code under section M0300B section M0300G Unstageable sdti Code under section M0300G Distribution of pressure ulcer staging 2006 to 2009 Stage I 31% 30% 28% 26% II 38% 37% 37% 36% III 8% 7% 7% 7% IV 7% 7% 6% 7% sdti 3% 4% 7% 9% Unstageable 13% 15% 15% 15% vangilder C, MacFarlane GD, Harrison P, Lachenbruch C, Meyer S. The demographics of suspected deep tissue injury in the United states: An analysis of the International Pressure Ulcer Prevalence Survey Advances in Skin and Wound Care. 2010, 23(6):

12 Where are most sdti ulcers located? ORANGE: Buttocks BLUE: Sacrum YELLOW: Heels GREEN: Ankles and foot?red: Elbow 12.9% 19.1% 41.4% 9.9% 2.5% vangilder C, MacFarlane GD, Harrison P, Lachenbruch C, Meyer S. The demographics of suspected deep tissue injury in the United states: An analysis of the International Pressure Ulcer Prevalence Survey Advances in Skin and Wound Care. 2010, 23(6): Acute Care CMS FY 2008 IPPS POA/HAC Announced Wednesday August 1, 2007; Implemented October 1, 2008 Pressure Ulcers are Reasonably Preventable MD or provider* must document pressure ulcers: location (707.0) stage ( ) on admission to hospital *(MD or any qualified healthcare practitioner legally accountable for establishing patient s diagnosis) Ayello, 2008 CMS data about accuracy of staging How does the distribution of the percentage of claims with a pressure ulcer site code with no accompanying pressure ulcer Sources: stage code vary by major hospital characteristics? Hospital Characteri stic Overall 68% AMC 58% Not 31% AMC Missing 50% Percentage of PU claims with out stage codes Hospital Bed Size <100 19% % % % % > % Missing 50% Percentage of pressure ulcer claims without any stage codes Examination of the accuracy of coding pressure ulcer stages Final Report to CMS. April By Nicole M. Coomer, Nancy T, McCall, RTI International. page 10 Ayello

13 Date August 7 August 8 19 Inconsistent Documentation Example from CMS Documentation Nursing Admission erythema of the buttocks, while not checking pressure ulcer ulcer. On the physician History and Physical, the Physical Exam document ϕ problems for skin, buttocks, and back. Erythema of the buttocks intermittently documented on nursing notes First mention of a skin tear in the nurse s notes on August 19 (twelve days after admission)). August 23 Stage II pressure ulcer documented in nurse s note Physician ordered a wound consult August 24 Stage III pressure ulcer on sacrum documented by wound care physician Disallowed by CMS Stage III was not present on admission Source: Accuracy of coding in the Hospital- Acquired Conditions-Present on Admission Program. Final Report to CMS. June Prepared for Susannah G. Cafardii by Snow, C.L., Holtzman, L, Waters, H., et al. RTI International. page 29 Ayello 2013 Percentage of Claims with a secondary diagnosis of pressure ulcer site not present on admission with and without a reported pressure ulcer stage code, FY2009 and FY 2010 Stage present? Number of claims with a PU site code FY 2009 Percentage of claims without a PU stage code FY 2009 Number of claims with a PU site code FY 2010 Percentage of claims without a PU stage code FY 2010 No 6,284 54% 6,159 61% Yes 5,365 46% 3,920 39% Source: Examination of the accuracy of coding pressure ulcer stages- Final Report to CMS. April By Nicole M. Coomer, Nancy T, McCall, RTI International. page 7. Ayello 2013 Pressure ulcers incorrectly coded Admitted via ED ED nurse documented pressure ulcer POA & notified ED physician Wound care consult ordered During hospitalization multiple notes: denuded areas, partial to full thickness skin loss partial thickness skin loss. Never used the term decubitus or pressure ulcer, nor stage On discharge : No stage of decubitus ulcer on buttock. CMS disallowed because stage of pressure ulcer on admission could not be confirmed Accuracy of coding in the Hospital- Acquired Conditions-Present on Admission Program. Final Report to CMS. June Prepared for Susannah G. Cafardii by Snow, C.L., Holtzman, L, Waters, H., et al. RTI International. Report.pdf. Page 26 13

14 CMS data about accuracy of staging Consider these questions: What are the CMS implications when the medical record documentation reports stage II III pressure ulcer? Sources: Examination of the accuracy of coding pressure ulcer stages Final Report to CMS. April By Nicole M. Coomer, Nancy T, McCall, RTI International. Accuracy of coding in the Hospital Acquired Conditions Present on Admission Program. Final Report to CMS. June Prepared for Susannah G. Cafardii by Snow, C.L., Holtzman, L, Waters, H., et al. RTI International. Fee for Service Payment/HospitalAcqCond/Downloads/Accuracy of coding Final Report.pdf Ayello 2013 Should all pressure ulcers be staged? Ayello & Sibbald, 2013 #1: Yes #2: No #3: It depends #4: if present on admission #5: I do not know Exposed Cartilage Pressure Ulcer NPUAP Position Statement August 27, 2012 Pressure Ulcers with Exposed Cartilage Are Stage IV Pressure Ulcers Although the presence of visible or palpable cartilage at the base of a pressure ulcer was not included in the stage IV terminology; it is the opinion of the NPUAP that cartilage serves the same anatomical function as bone. Therefore, pressure ulcers that have exposed cartilage should be classified as a Stage IV. 14

15 End of Life Kennedy Ulcers CMS LTCH Quality reporting Program Manual Skin ulcers that develop in patients who have terminal illness or are at the end of life should be assessed and staged as pressure ulcers until it is determined that the ulcer is part of the dying process (also known as Kennedy ulcers). Kennedy ulcers can develop from 6 weeks to 2 to 3 days before death. These ulcers present as pear-shaped purple areas of skin with irregular borders that are often found in the sacrococcygeal areas. When an ulcer has been determined to be a Kennedy Ulcer, it should not be coded as a pressure ulcer. Look at skin under tubes, drains, skin folds, other medical devices What s under this strap? Ayello, 2012 Mucosal Pressure Ulcers (MPrU) An NPUAP Position Statement Definition: MPrU are pressure ulcers found on mucous membranes with a history of a medical device in use at the location of the ulcer. Devices include oxygen tubing, endotracheal tubes, bite blocks, orogastric and nasogastric Epithelium of mucosa is not keratinized Pressure ulcers on mucosal surfaces are not to be staged using the pressure ulcer staging system. Furthermore, it is NPUAP s position that mucosal pressure ulcers not be classified as partial or full thickness, because the clinical assessment of the tissue does not allow the distinction. 15

16 CMS LTCH Quality Reporting Program Manual Mucosal Ulcers Mucosal pressure ulcers are not staged using the pressure ulcer staging system because anatomical tissue comparisons cannot be made. Therefore, mucosal ulcers (e.g. those related to rectal tubes) should not be coded on the LTCH CARE Data Set. Exudate Amount Exudate- Type and Amount None 0 NPUAP PUSH Tool Light 1 Moderate 2 Heavy 3 S. Baranoski Ayello, 2010 Pressure Ulcer Wound Edges Photos Ayello Ayello,

17 Pain Scales to Evaluate Pressure Ulcer Associated Pain Try This Speaker, Title, Hospital Pressure Ulcer Tissue Definitions Epithelial Granulation Slough Eschar MDS 3.0 LTCH CARE Data Set M0700 OASIS C M Newly epithelialized 1 Epithelial tissue 1 Fully granulating 2 Granulation 2 Early/partial granulation 3 Slough 3 Not healing 4 Necrotic (eschar) NA No observable pressure ulcer Ayello, 2012 Photos: D. Weir Minimal pressure ulcer documentation S ize L ocation and staging E xudate E dge and surrounding tissue P ain Pain Bed color and type of wound tissue Ayello, 2007 From Tag F

18 Objectives Participants have: Differentiated the six pressure ulcer stages. Identified the steps in clinical measurement of pressure ulcers. Identified the key components of pressure ulcer documentation starting with the risk assessment. Ayello 2013 What is true today, may not be true tomorrow Thank you! Continuing Education Credits CNE s, CME s and CHES : Please complete the post test and evaluation on School of Public Health, University at Albany is an approved provider of continuing nursing education by the Massachusetts Association of Registered Nurses, Inc., an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation. School of Public Health, University at Albany is accredited by the MSSNY to provide continuing medical education (CME) for physicians. The School designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit(s). Physicians should claim only credit commensurate with the extent of their participation in the activity. Nursing Home Administrators: Complete the post test and evaluation on www. goldstamp.org. Print the Continuing Education Form from the website and or fax it to us. This program has been approved by the NYS Board of Examiners of Nursing Home Administrators for 1.00 continuing education credit for nursing home administrators. Approval NY H This project is funded through a Memorandum of Understanding with the NYS Department of Health. There is no commercial interest funding this program. 18

19 Jackie Pappalardi, Director, Nursing Home and ICF Surveillance Paula Grogin, Project Coordinator Linda Laudato BSN, RN Gold STAMP Coordinator Dawn Bleyenburg, Director Lindsay Ruland, Assistant Director Jen Cioffi, Project Coordinator Susan Brooks, Web Producer 19