Sound Evidence - December 2008 - (Page 57) Discussion With the recent change in Medicare reimbursement policy for pressure ulcers, debridement that facilitates accurate pressure ulcer stage on admission in the acute care setting has become a priority. In these three patients, using APWT to assist with debridement of unstageable pressure ulcers allowed for staging of the wounds as Stage III and Stage IV within 2 days of admission, which should maximize the MS/DRG and potential for reimbursement appropriate to the severity of these wounds. In their “Guidelines for the Treatment of Pressure Ulcers”, the Wound Healing Society4 lists several debridement modalities, including sharp or surgical, mechanical, enzymatic, and autolytic. Based on a review of the evidence and expert consensus, these guidelines describe the following benefits and drawbacks to these debridement methods. Surgical/sharp debridement is indicated for fast and effective removal of large amounts of necrotic tissue. However, these techniques require significant expertise, adequate vascular supply to the wound, and systemic antibacterial coverage in cases of systemic sepsis. Additionally, sharp debridement is contraindicated in patients with bleeding disorders or on anticoagulation therapy. Finally, the pain associated with surgical/sharp debridement often requires narcotic pain medication and can be intolerable despite use of narcotic agents.4 Mechanical debridement (using wet-to-dry dressings, wound irrigation, and whirlpool techniques) physically removes necrotic tissue. Although effective in some cases, such strategies also have their drawbacks. Wet-to-dry dressings can be painful and may damage viable newly formed tissue. High- or low pressure streams or pulsed lavage can cause trauma to the wound bed as well as pain for the patient. Whirlpools may be helpful initially to loosen and remove debris and necrotic tissue but are associated with risk of tissue maceration and bacterial contamination.4 Using dressings with endogenous (autolytic debridement) or exogenous enzymes (enzymatic debridement) to soften and remove necrotic tissue can take up to 2 weeks or more. Furthermore, this method is not recommended for infected wounds or very deep wounds that require packing.4 To date, the only known contraindications for use of APWT are those common to other ultrasound therapies — ie, areas near electronic implants/prostheses, on the lower back during pregnancy or over a pregnant uterus, and over areas of malignancy must be avoided.5 Although a range of biophysical effects of APWT on the wound healing process have been described in a recent literature review by Unger6 (eg, activation of inflammatory cells and fibroblasts; promotion of collagen synthesis, cell division, angiogenesis, and growth factors; and inhibition of matrix metalloproteinase activity), APWT qualifies as a debridement option owing to its indication for “removal of yellow slough, fibrin, tissue exudates, and bacteria”.5 However, clinical studies to date have not evaluated APWT specifically as a debridement modality. Rather, the randomized and nonrandomized studies have shown a benefit of adjuvant APWT (primarily in lower-extremity ulcers) on healing outcomes, such as proportion of wounds healed, volume reduction, and healing rate, relative to conventional wound therapies alone.7-11 Conclusion Ultimately, the recent change in Medicare reimbursement policy with regard to pressure ulcer care has put a premium on the rapidity with which acute care clinicians establish the stage of pressure ulcers, including ulcers unstageable on admission. This report of an early experience using APWT to expedite slough/eschar removal and allow for accurate staging of pressure ulcers suggests that APWT may be a clinically useful tool for acute care wound clinicians. Further research into the fastest, most efficient ways to clear necrotic tissue from unstageable pressure ulcers would be of particular value to wound care clinicians in the acute care setting. - OWM References 1. Black J, Baharestani M, Cuddigan J, et al. National Pressure Ulcer Advisory Panel’s updated pressure ulcer staging system. Urol Nurs. 2007;27(2):144–156. 2. Medicare Program: Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates. Federal Register. Part II. Vol 72: Center for Medicare and Medicaid Services; 2007:47200–47201. December 2008 Vol. 54 Issue 12 57
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