HowTo Use NPWT Successfully In The Home Care Setting

Discussing both clinical and practical aspects of using the technology, this author examines outpatient use of NPWT at home.

By Stephen Geller, DPM

I work at three hospital-based wound clinics and have a private practice office as well. Ninety-five percent of my practice is wound care. We see about 170 patients per week. There are a lot of choices that have to be made but I have a very simple and basic method for choosing the wound care products we use. The basic classifications start with wet, moist or dry wounds. If you can identity those, you can choose your products. It all starts with the wound.

The primary consideration in the wet wound is infection. Once you have a non-infected wet wound, you need to absorb the excessive drainage. Many products can absorb excessive drainage but the problem is they have a saturation point. Therefore, you need to know enough about these products to know when to change them.

The interesting thing about NP'i~'T is the canister is outside of the dressing system so it has no saturation point in theory. The early animal models have also showed that using NPvVT decreases bacterial bioburden." In order to maintain moist wounds, one may employ gels, creams, iodine and silver dressings.

Dry wounds also need moisture. The problem is the eschar but there are ways to get around this. One may fenestrate the eschar, use a debriding ointment and cover it with an occlusive layer like Vaseline gauze. This enables you to use the occlusive layer to drive the moisture through the eschar.

One patient had a wound with a Charcot prominence.

She had the wound for greater than one month and it pre~ sented acutely red and swollen. In order to know if you can use NPWT on a wound, you have to know the contraindications. It was a chronic wound so malignancy could be present. It was over a bony prominence and was acutely infected so osteomyelitis could be present. There was a significant amount of necrotic tissue, eschar and signs of acute infection.

This wound needed surgical debridement. Due to the chronicity of the wound, a biopsy was obtained during the

surgical debridement to rule out malignancy. The bone was clean. There was no osteomyelitis. We did not encounter any organs and there was no necrotic tissue left. 'Ale subsequently applied NPWT and after three weeks, the wound was filled to the surface with granulation tissue. At one month, we ceased using NPvv'T and used Promogran. The patient's wound healed in less than two months.

What You Should Know About Home Use of NPWT

The first and biggest advantage of NP'i~'T is the patient gets to go home. However, one cannot simply write the prescription for NPWT. One has to educate the patient and family on appropriate use ofNPWT. It is important to give patients a goal. One should also discuss how the dressings are going to be changed so there are no surprises. We give them the product information that they can take home and read. Then they come back with follow-up questions and they seem to be more fully prepared by that point in time.

Another advantage of NPWT is you do not pay for it.

The patient might have a co-pay but the hospital and home health agency do not pay for it. The insurance pays for NPWf. The supplies come with NP"VT so you and the home health agency are not paying for supplies. Normally, home health nurses visit the patient daily for dressing changes. With NPWT, the standard protocol is changing the dressing every 48 hours or every 12 hours for infected wounds. If the dressing is changed once by the physician or wound care clinic nurses, that leaves the home health nurse with two visit, per week. Reducing visits from seven to two every week is very beneficial to the home health agency. The nurses like it a lot and there is less infection, and less re-admission.

Communication is key and you have to talk to the nurses. Keep in mind that an excellent home health agency nurse who does very good wound care will likely g-et

moved up to management so he or she may not be the one seeing your patient for a long period of time. You have to continuously make sure the dressings are going well and they should also be able to call you if they have a problem.

Medicare pays for NPWT In 2000, Medicare gave NPvVT the following numbers: E2402 for the pump, A6550 for the dressings and A6551 for the canisters. Since NPWT is changing the standard of care, most of the other insurance companies are following suit and paying for it. The only problems we sometimes encounter are due to managed care. In dealing with managed care, you have to talk to a medical director and this is usually done doctor to doctor. When you speak to the medical director, the first and most important thing is to have a goal. Medical directors at the insurance companies want to know why you are using NPWT, whether it is to fill the wound with granulation tissue, to get enough granulation tissue to graft or flap the wound, to reduce edema or 'whatever reason you are using. You can point out what will happen if you cannot use NPWT. I think it is relatively easy to point this out with all the economic data.:J:J·1\·36

I am using total contact casting, delayed primary closure, skin equivalents or skin grafts, all in three to six weeks after NPWF.

Troubleshooting Problems With Home Care And NPWT

Whenever there is a system, something can go "'Tong. For one surgical wound, there was a large dead space, but no malignancy, no organ or major blood vessel involvement and there W<IS no necrotic tissue left. We applied NPWT. When I saw the wound after one week of NPVvT, it looked like nobody protected the skin from the foam beneath the track pad. Perhaps the nurse knew the sponge had to be the same size as the track pad but forgot the part about protecting the skin. NP'INT 'will pull granulation tissue through intact epidermis and that necrotic edge had to be debrided.

I kept the patient on NP'WT. The home health agency does not really care. It is not costing them any more. You get a wound that takes a little bit longer to heal, but after three weeks of NP,VT, the granulation tissue has filled to the surface. Now, I can use a total contact cast. The wound just took a little bit longer to heal. Even when bad things happen, they are correctable.

In Conclusion

Whenever you choose to use NPvVT, there is paperwork. Be sure to articulate your goal for the therapy and know the contraindications when you fill out the form. It. is an easy form to fill out It takes about two minutes to fill out the wound information (such as type of ulcer and going through the list of contraindications) and it takes the staff about five minutes to fill out the insurance information. We fax it in and it is done.

As far as the economic benefits of using NP\NT at home, it does not cost you anything for dressing supplies when you see the patients in your office. We know NPvVT helps promote wound healing. After three to six weeks of NPWT, I have seen an increase in my secondary procedures. I am using total contact casting, delayed primary closure, skin equivalents or skin grafts, all in three to six weeks after NPWT.

Patient satisfaction is up and this drives in more patients hom word of mouth. The home health care nurses are now seeing more of my patients because they are involved with the care and they send more patients to

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A Closer Look At NPWT

In The Wound Care Clinic Setting

This author examines the importance of referrals for wound care clinics and how NPWT helps facilitate the inflow of patients into these clinics. The author also shares a few case studies of complex wounds.

By Stephen Geller, DPM, FACFAS

I n order to understand how NPWT fits into a wound care center environment, it is important to understand how the hospital outpatient clinic is paid. It is essentially paid on ambulatory payment classifications (APes). These clinics get paid one price for a diagnosis. This reimbursement is supposed to cover the time the patients used the treatment room and the staff that runs the room as well as the equipment and instruments that were used. When it comes to dressing supplies, some are reimbursed separately by the insurance and some are bundled in. There is no predictable way to tell which products will be paid separately.

With NPvVT, you do not have the problem with the dressings because the dressing comes with the device and the wound care clinic is not paying for NPWT, making the device very favorable to the facility. The facility charges for complexity of care as well as the technical skill and time involved with NP"\¥T dressing changes. This leads to higher reimbursement as well.

The physicians at the wound care clinic are private contractors. This works out well for me. I have four offices but no overhead for three of those offices. I use a facility code to bill for what I do. This means the insurance companies take out a little bit because they know the supplies are coming from the hospital. I am not paying for any of those staff and there are usually a lot more staff than I have in my office.

In regard to applying technology like NPWT, when one gets a positive outcome, there is a tendency to apply the dressing to a broader array of wounds within the indications. A5 with any other technology, the more you do, the more likely you will see adverse events, Then you try to figure out what caused the adverse event, leading to a deeper understanding of this technology. Other physicians eventually hear about your successes, usually through the nurses, and they try it because there is this unsaid competition between wound care doctors, _As the nurses see more and more of NYVVT, they learn new

things that they impart upon other physicians. Eventually, everybody is using NPWT except a few and they feel so left out that they start using it.

The patients start telling people they were healed at a wound clinic and this word of mouth leads to other patients coming in specifically for NPWT. It is an interesting snowball effect.

Most hospitals own their own home health agencies.

This lends itself to more benefits for the wound care clinic as well. The home health agencies provide the skilled nursing visits to homebound patients and these nurses provide IV antibiotics and dressing changes. There is no cost to the wound care clinic for this. However, when these nurses see positive outcomes with NPvVT and then see other appropriate wounds that have not been treated with NPvVT, they may recommend that the physician refer the patient to a wound care clinic for NP\VT.

Building Referrals For A Wound Care Clinic

A~ I noted earlier, we are all private contractors in the wound care clinic so referrals are essential for us. To get referrals from the community, you have to make yourself available. I can function as a hospital liaison for community doctors who do not want to go to the hospital. It is also important to accept referrals for every wound, even the most complex wounds. Occasionally, this can be a problem as you have to know your own limitations. However, you can at least get the patient into the system for the other doctor. You write a very nice professional letter thanking the community doctor for the referral and telling him or her what you are going to do. When the patient is healed, you always want to send the patient back to the referring doctor unless the doctor does not want to see the patient back. This happens as well.

Another thing you want to avoid is blaming another doctor for a non-healing wound. Keep in mind there are basic levels of wound care and then there is advanced wound care.

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Nurses from home health agencies may suggest referring patients to wound care clinics for NPwr.

One can obtain referrals from the community and from within the team you work with on a regular basis, but how do you get referrals from people who are also wound care specialists? That is the hardest part. You have to be on just about every insurance plan you can. It may not be the smartest business decision as some people would tell me, but when you are on as many insurance plans as you can, you see more of the patients. You also have to be the clinician who never says no. If they call you at midnight and want your consultation, you go. When you are building a practice, you need referrals.

Case Study One: Using A Combination Of ApHgraf And NPWT

One patient was in the wound care clinic for 1"1'0 months with a non-healing surgical wound. The wound was deeper than it was wide. When surgically opened, the posterior tibial tendon was ruptured and no proximal end was found. There was degenerative joint disease of the ankle noted on MR!. She was eventually going to need an ankle fusion so I sutured the stump of the tibialis posterior into the flexor digitorum longus tendon. I knew it was not a long-term solution but I was hoping to get the patient through until she had the ankle fusion.

Three weeks out, the tendon was just about covered and there was granulation tissue to the surface. One may consider a skin graft at this point. However, this patient had diabetes and mental issues so I did not think she was a good candidate for a grafting procedure. I proceeded to use Apligraf and applied NPWT over top of it. When you use NPW'T over Apligrat, after one week, there are parts of Apligraf that look like it has just come out of the growth medium. For some reason, I get better results when I use NPVvT over Apligraf After five to seven days, T discontinued NP\VT as ner th« meshed vraft. nrotm:ol

and chose another dressing to support the ApligraL Four weeks after the Apligrafwas applied, the wound is nearly healed. Some people resume debridement at this point since the Apligraf has been absorbed by the wound but in this case, the patient's wound had just about healed.

Case Study Two: When A Patient Has Necrotizing Fasciitis

Another patient had gas in the soft tissues. We immediately took the patient to surgery in order to address the gas but unfortunately another patient was worse so we had to treat that patient first. This patient had necrotizing fasciitis, which caused the gas in the soft tissues. Everything was infected down to the fascia leaving his exposed tendon. We had to remove one necrotic tendon from the brevis. This was a good wound for NPWT.

We needed to get a seal by the toes so we used various products. I used Apligraf again. This was rather a large wound but he is not a very good skin donor. We applied NPWT over a Mepitel dressing, set the NPWT to 75 mm Hg and left it on for five to seven days. After six weeks, a second Apligraf was applied and the patient went on to complete healing.

Case Study Three: A Patient With A Posterior Heel Wound

Another patient had a posterior heel wound with osteomyelitis. He underwent a fernoropopliteal (fernpop) bypass because he had no circulation. v'-ie thought his circulation had improved and we subsequently performed a partial calcanectomy. He did not bleed one stitch. I punctured holes in the calcaneus to see if I could stimulate some bleeding from within the calcaneus and nothing came out. I applied NPWT anyvvay. We did see nice vascular tissue in the heel but the calcaneus was simply dead bone. The patient eventually underwent a below-knee (BK) amputation.

This was an example of needing to know what you can do versus what you cannot do. The patient was actually referred back to us in order to heal the BK dehiscence.

Keep in mind that we may never see another physician's good outcomes. This is important to remember. Another physician may be seeing your failures as well. Always treat the patients and the wound at the same lime. Understand and recognize your limitations. Don't be afraid to ask other team members for help. II

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