Sound Evidence - December 2008 - (Page 55) A B C D Figure 1. Sacral pressure ulcer in Patient 1 is unstageable before APWT (A); Stage IV with exposed bone after two APWT treatments over 2 days (B). Pressure ulcer of the left lateral ankle in Patient 2 is unstageable before APWT (C); Stage III with progress toward healing after 5 days of APWT (D). with substantial slough and/or eschar that obscures the true depth of the wound). In staging pressure ulcers, the key determinant for Stage III or Stage IV classification is depth of tissue damage.1 The National Pressure Ulcer Advisory Panel (NPUAP)1 guidelines for pressure ulcer staging are clear: until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Ulcers classified unstageable on admission could present a particular problem in acute care hospitals, where Stage III and Stage IV pressure ulcers not present on admission are considered by Medicare to be hospital-acquired conditions that “could reasonably have been prevented through the application of evidence-based guidelines”.2 If unstageable ulcers are later classified as Stage III or Stage IV after debridement has exposed true wound depth, they are considered hospital-acquired because they were not present on admission, and the added costs of care for these Stage III or Stage IV ulcers would not be eligible for reimbursement.2 Therefore, the new policy puts a premium on rapid and efficient debridement of unstageable pressure ulcers in order to identify Stage III and Stage IV ulcers “present on admission” and allow for Medicare reimbursement of the added costs associated with care of these advanced-stage ulcers. Wound care clinicians have a range of debridement options, including sharp or surgical, mechanical, enzymatic, and autolytic.4 Ultrasound therapies such as acoustic pressure wound therapy (APWT) are typically classified as mechanical. This case series describes the authors’ experience using APWT to help remove necrotic tissue from December 2008 Vol. 54 Issue 12 55
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