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Chronic Ulcers


Ramzy Salama PA-C, CWS.

Today’s Agenda
• Chronic Ulcers: Pressure, venous, Arterial, Diabetic,
and Unusual ulcers.
• Wound Assessment & documentation
• Pressure &Non-pressure related Ulcers.
• Pressure ulcer Staging.
• Non- pressure ulcer classifications
• Acute & chronic healing process.
• Chronic nature of ulcers.
• Chronic Ulcers treatment.
• Types of wound dressings.
• Hospital Acquired condition & CMS payment.
Wound Assessment
• Location of the ulcer. • Exudates;
• Pressure related • Amount ( mild, moderate, heavy)
• None pressure related; • Color; strew colorless ( serous)
• Arterial, Venous, mixed etiology, pink( serosanganeous) Yellow
Diabetic, unusual or factitial cheesy color ( purulent)
ulcers. • Odor
• Size& Shape • Foul smelling indicate Infection
• Peri wound condition • Pain
• Wound bed; • Increase in case of infection
• Granulation%: beefy red.
• Necrotic% :any other color.
• Eschar% : Black, gray, or brown.
• Fibrosis%: white.
• Slough%: yellow.
Types of tissues in the ulcer bed
• Granulation; beefy red color that described as
bumpy road.
Left arm wound that showed good
granulation& reepithalization
Left arm wound healed by
secondary intention( Scar tissue)
Types of tissues in the ulcer bed
• Necrotic tissues; Non- • Slough; fibrin,
viable tissues, Colors; proteinaceous material
black, yellow, white, any and Pus.
other color but red.
Types of tissues in the ulcer bed
Eschar: necrotic, black,
grey lethery layer that • Fibrosis: scar like tissues
firmly attached to the
underlining tissues.
(National pressure ulcer advisory panel)
Pressure ulcer Staging system

. In February 2007; the NPUAP has revised the

definition and the stages of pressure ulcers.
. Deep tissue injury & unstageable were added
the original 4 stages.
. Definition of pressure ulcer; It is localized
injury to the skin and / or underlying tissue
usually over a bony prominence, as a result of
pressure, or pressure in combination with
shear and/ or friction and also moisture.
International NPUAP-EPUAP
Pressure Ulcer Definition, 2009
A pressure ulcer is localized injury to the skin
and/or underlying tissue usually over a bony
prominence, as a result of pressure, or ressure
in combination with shear. A number of
contributing or confounding factors are also
associated with pressure ulcers; the
significance of these factors is yet to be
Pressure ulcer Definition 2016
• Pressure injury • Localized damage to the skin and
underlying soft tissue • Usually over a bony
prominence or related to a medical or other device –
Injury can present as intact skin or an open ulcer –
May be painful • Injury occurs as result of intense
and/or prolonged pressure or pressure in
combination with shear • Tolerance of soft tissue for
pressure and shear may also be affected by –
Microclimate – Nutrition – Perfusion – Comorbid
conditions – Condition of soft tissue.
• Edsberg LE, et al. J Wound Ostomy Continence Nurs.
Common pressure ulcer sites
• Usual Pressure Ulcer Locations
• Over Bony Prominences
• 1-Occiput
• 2-Ears
• 3- Scapula
• 4-Spinous Processes
• 5-Shoulder
• 6-Elbow
• 7-Iliac Crest
• 8-Sacrum/Coccyx
• 9-Ischial Tuberosity
• 10-Trochanter
• 11-Knee
• 12-Malleolus
• 13-Heel
• 14-Toes
Pressure ulcer stages
• Stage1
• Stage 2
• Stage 3
• Stage 4
• Suspected deep tissue injury
• Unstageable ( Eschar)
Stage 1

• Non blanch able redness ( Erythema) over a

pressure point with intact skin. No skin break
• In case of dark skin patient; it is a bit darker
skin area than the surrounding area
• The area may be painful, firm, soft warmer or
cooler as compared with the adjacent tissue.
Stage 1
Left heel pressure ulcer 1
Stage 1/R/O Moist related
Stage 1
Stage one treatment
• TX: Off loading protocol using pillows and Air
mattress ( order, Turn – Q-Mattress) +
Cushioning using Mepilex ( Foam wound
• Free text nurse order: continue Off loading
protocol using pillows and Air mattress ( order
Turn – Q-Mattress) + Cushioning using
Mepilex ( Foam wound dressing). Continue
pressure ulcer prevention protocol. Continue
reposition the patient on different sides every
2 hours using 30 degree technique.
Deep Tissue Injury
• A 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.
• It may be difficult to detect in dark skin
• It may evolve and become covered by thin
eschar in a very short time.
Left buttock suspected DTI
Sacral suspected DTI
Right heel suspected DTI
DTI treatment
• TX: Off loading protocol using pillows and Air
mattress ( order, Turn – Q-Mattress) +
Cushioning using Mepilex ( Foam wound
dressing). Monitoring the ulcer closely for
getting worse or better.
• The same free text nurse order that was for
stage one pressure ulcer.
Stage 2
• Skin break down over a pressure point with
red wound bed . No slough
• It is a partial thickness wound that include
epidermis and dermis but not through the
dermis layer.
• Also, it can presented as a blister that is filled
with serum; opened or intact skin.
Right hip stage 2 x2ulcers
Stage 2
Right buttock stage 2
Stage 2 Treatment
• Tx: The same off loading protocol and nurse
free text order as it was ordered in case of
stage one + Hydrogel or hydrocolloid or
Mepilex ( foam dressing).
Stage 3
• Full- thickness tissue loss with s/c fat visible
but not through the s/c fascia.
• Bone, tendon , or muscle is not exposed.
• Slough may be present but does not obscure
the depth of tissue loss. Undermining &
tunneling may be included.
• There is no S/C tissues on the bride of the
nose, ear, occipital and malleolus. So, Stage 3
ulcer in these area can be shallow.
Stage 3 pressure ulcer
Pressure ulcer stage 3
Sacral ulcer stage 3
Right heel pressure ulcer stage 3
Stage 3
Stage 3
Stage 3
Stage 3 Treatment
• TX: The same off loading protocol and the same
nurse free text order as in case of stage one.
• Excisional debridement of necrotic tissues if it is > 30
% of the size of the wound. If patient is not a surgical
candidate you can always use collagenase ointment
for enzymatic debridement as your secondary
choice, Or hydrogel/ hydrocolloid for autolytic
debridement. You can also use wound vac dressing
on clean and viable wound base to promote
granulation tissue. Wound vac setting at 125 mmhg
continuous treatment at low intensity.
Stage 4
• Full thickness tissue loss with exposed bone,
tendon, or muscle.
• Slough or Eschar may be present on some
parts of the wound bed.
• Undermining & tunneling often present.
Necrotic/ Undermining Sacral
pressure ulcer stage 4 with
exposed bone
Sacral pressure ulcer stage 4
Sacral pressure ulcer stage 4
Necrotic sacral pressure ulcer with
exposed bone
Sacral pressure ulcer stage 4
Stage 4
Stage 4
Stage 4 Treatment
• TX: The same treatment as it was mentioned
for stage 3.
• Full –Thickness tissue loss in which the base of
the ulcer is covered by slough ( yellow, tan,
gray, green, brown) and /or Eschar ( tan,
brown, or black).
• The only case the debridement is
contraindicated when eschar is dry, intact, and
hard without erythema or fluctuance on the
heel only
• In case of erythema and feels soft on
palpation; debridement is indicated.
Unstageable left 5 th metatarsal
Unstageable heel pressure ulcer
left hip unstageable pressure ulcer
Left hip unstageable pressure ulcer
Unstageable Sacral pressure ulcer
Sacral unstageable pressure ulcer
Sacral and left buttock unstageable
pressure ulcer.
Unstageable Ulcer Treatment
• Tx: Excisional sharp debridement of Escher
anywhere in the body. The only exception to
the debridement rule is when Escher is dry
stable ( Hard like a rock) on the heels only.
But once the eschar started to become soft
and and showed sign of infection,
debridement is indicated then.
Braden Scale
Braden Scale
• Braden Risk Assessment Scale for developing pressure.
• A highest score person can get is 23.
• The highest the score = the less the risk for developing
pressure ulcer.
• Less < 9 = very high risk. 10-12 =high risk. 13-
14=moderate risk. 15-18= mild risk. >18= No risk.
• NOTE: Bed and chair bound individuals or those with
impaired ability to reposition should be assessed upon
admission for their risk of developing pressure ulcers.
Patients with established pressure ulcers should be
reassessed periodically.
Braden Scale continue
• In general, Nursing home patient who is not
communicating and only respond to painful
stimuli gets 9/23 or less , so patient is at a very
high risk for developing pressure ulcer.
• Usually these pts. Get 2 pts for sensory
perception, 2 for moisture, 1 for activity
(bedfast), 1 for mobility, 2 for nutrition ( peg
tube), and 1 for friction and shear. Total 9.
Wound classification
• Wounds not related to pressure
• Also, in
• Some ref.
• Wound
• With expo.
• Bone called
• Complex
• Wound .
Example of superficial thickness
loss (Skin Tear)
Right hip partial thickness wound
Full thickness surgical wound with
exposed subcutaneous adipose
Example of a full thickness loss
ulcer on the leg.
Another example of a full thickness
loss abdominal wound that shows
good granulation tissues
Sacral Full Thickness wound shows
good granulation tissues in a young
patient who had an I&D of infected
pilonidal cyst
Full thickness fasciotomy surgical
Full thickness surgical wound with
bone exposed (Complex Wound)
Venous Ulcer
• 70 %-90% of chronic leg ulcers are venous stasis ulcers.
• Location: Gaiter area above the malleolus (Medial)
• Size& Shape: Edge may be irregular with depth limited to dermis
or shallow subcutaneous tissue.
• Wound bed: Ruddy red, yellow, slough may be present.
Tunneling & undermining are very uncommon.
• Exudates: Copious, serous unless infection is present.
• Surrounding skin: may appear macerated, crusted, or scaling.
• DX. Venous duplex, venous mapping.
• TX. Compression ( in case ABI > .8), elevation above the heart
level. Local wound care. Exercise to increase venous return.
(CEAP) Classifications of Venous
• Class O: No visible or palpable signs of venous disease
• Class 1: Telengectasis, reticular veins, malleolar flare.
(Noted below the malleolus)
• Class 2: Varicose Veins
• Class 3: Edema without skin changes
• Class 4: Skin changes ascribed to venous disease
(pigmentation, eczema, lipodermatosclerosis)
• Class 5: Skin changes as defined above with healed
• Class 6: Skin Changes as defined above with active ulcers
• Compress from behind the toes up to below
the knee
• From the metatarsal to below the patellar
• 30-40 mm Hg at the ankle
• Compression functions: compress the
superficial system and to assist for venous
return to the deep system (which will prevent
leakage and support calf muscles.)
Compression Continued
• Type of Compression:
1. Rigid/ inelastic/ short stretch. e.g. Unna’s boot. Requires
ambulated patients for calf muscle to press tissue on
2. Elastic/ long stretch. Good for ambulated and non
ambulated patients. Multiple layer wraps: 4 layer wraps,
3 layer wraps. e.g. Profore
• 3. Compression Stockings ( Come in different sizes)
• < 20 mm Hg for prevention (over the counter)
1. Class 1: 20-30 mm Hg
2. Class 2: 30-40 mm Hg
3. Class 3: 40-50 mm Hg
4. >60 mm Hg
Venous Ulcers
Venous stasis ulcer
Arterial Ulcer
• Location: Tips of toes, bet. The toes, on pressure point
of foot ( heel or lateral foot)
• Size & shape: Small creates with well defined borders.
• Wound bed: Pale or necrotic
• Exudates: mild due to poor blood supply.
• Surrounding skin: Erythema or slight fluctuance (
• Dx. Arterial duplex. ABI; 0.91- 1.3= normal, 0.7-0.9 =
mild obstruction. 0.4-0.69= moderate. Less than 0.4 =
sever obstruction. More than 1.3 = Artrial calcification.
• Tx. Revascularization, Debridement, ABX.
Arterial ulcers
Arterial ulcer
Arterial ulcer
Diabetic foot ulcer
• Location: Plantar surface of the foot especially over the
metatarsal heads , toes & heels.
• Size & shape: Even wound margins with callus.
• Wound bed: Granular tissue unless PAD present.
• Exudates: Variable serous unless infection is present (
• Surrounding skin : Normal
• Tx: Surgical debridement of devitalized tissue, and off
loading using a special shoes. Tx osteomylitis in case of
bone exposed (Clinical osteomylitis) with 6 weeks of IV ABX.
foot ulcer( Wagner Classification)
• Grade 0: pre ulcer lesion, healed ulcer, presence
of bony deformity
• Grade 1: Superficial ulcer without S/C tissue
• Grade 2: Through the S/C tissue; may expose
bone, tendon, ligament, or joint capsule
• Grade 3: Ostitis, abscess, or osteomylitis.
• Grade 4: Gangrene of a digit
• Grade 5: Gangrene requiring foot amputation
Diabetic foot Ulcers
Pyoderma Gangrenosum
• Uncommon non-infectious neutrophiloic
dermatosis that is of uncertain etiology.
• Starts off as small painful papule or nodule
• The lesion enlarges and ulcerates
• Overhanging violaceous borders
• History of systemic conditions i.e. IBD, SLE

Pyoderma Gangrenosum
• Dx – Biopsy – histologic findings often non-
• Diagnosis of exclusion
• Pathergy – Paradoxical response to
debridement (may get worse) particularly in
proximity to the areas debrided.
• Tx – Protective dressings, topical steroid

Pyoderma gangrenosum of the RLE
Pyoderma Gangrenosum
• Associated with high levels of calcium
• Leads to calcification of the small arteries .
• Associated with intimal fibrosis and thrombus
• Hx – ESRD on HD, hyperparathyroidism,
sudden weight loss or gain.

• Distribution can include peripheral locations
on the body including fingers, toes, tongue,
penis, and torso.
• Very painful.
• Localized tender lesions start as light violet
mottling, evolving to pruritic patches and
plaques, vesicles or irregularly shaped ulcers.
• Necrosis and black eschar develop in
subcutaneous tissue in a few days.
LLE at the lateral aspect
RLE at the medial aspect
A bedridden patient with PMH;DM,
ESRD on HD, and Calciphylaxis
• Dx – Elevated calcium/phosphorus levels.
• Tx
– Lower-serum calcium and serum phosphorus
serial debridement
– parathyroidectomy
– skin graft
– anticoagulation
– antibiotics
– amputation
– renal transplant
Healing phases in acute wound
• Hemostasis: 0- 3 hrs. platelets –blood clotting
• Inflammatory : 0- 3 days. Leukocytes&
Macrophages are the key cells to destroy bacteria
& clean cellular debrie.
• Proliferative : 3-21 days. Epitheliazation,
angiogenesis ; granulation tissue formation&
collagen deposition are the key steps to this
• Maturation : 21days- 1.5 year. Contraction, scar
tissue formation.
Types of Wound Healing
• Primary intension: e.g, surgical wound, evenly
edges laceration that was sutures within less
than 8 hrs.
• Secondary intension: Infected surgical wound
that is not healing properly within 21 days,
Chronic, non-healing ulcers, Full thickness loss
opened abscess (Surgical Wound).
• Tertiary intension: It is a delayed closure of a
wound, e.g Fasciotomy wound. Less than
50,000 colonies
Types of Wound Healing Continued
• Partial thickness wound; healed by re-
• Full thickness wound; healed by
1. Granulation
2. Contraction
3. Re-epithalization
Type of Abdominal Wounds
• Infected surgical wound; fascia is intact.
• Dehisced Wound; fascia is not intact.
• Eviscerated Wound; Abdominal content is
outside the abdominal wound edges.
Midline Abdominal infected
surgical wound
Chronic wound
• In case of chronic wound, the biological character
of wound bed is different than that in case of the
acute wound. There is:
• Increase amount of MMPs ( Matrix
Metalloproteases .
• Increase pro inflammatory cytokine
• Decrease amount tissue inhibitors protease
• Decrease amount of growth factors.
Chronic wound exudates
• Chronic wounds stall in the inflammatory phase.
• Chronic wound exudates slows down or blocks the
proliferation of cells such as keratinocytes, fibroblasts
and endothelial cells, all of which are important in the
repair process. Wound exudates contains a number of
matrix metalloproteinases and serine proteases that
can break down or damage essential extracellular
matrix materials. These are vital for cell movement and
re-epithelialization. Growth factors, which are essential
for optimal wound closure, are also inhibited by
macromolecules found in chronic wound exudates.
Bacterial Burden in the Wound
• Bacteria present within a wound can be divided into four distinct
• Contamination - defined as the presence of non-replicating
microorganisms within the wound.
• Colonization - defined as the presence of replicating
microorganisms, which do not cause injury to the host. Examples of
bacterial wound colonization would be Staphylococcus epidermis
and Corynebacterium sp. whose presence have been shown to
increase the rate of wound closure(37).
• Critical colonization - defined as the presence of replicating
microorganisms, which are beginning to cause local tissue damage.
• The concept of critical colonization has recently been introduced to
describe wounds with an increased bacterial burden, moving
between the category of colonization and local infection. During
critical colonization, subtle clinical signs of infection may be present
before the classical signs associated with infection appear(38, 39).
Bacterial Burden in the Wound
• These clinical signs and symptoms of local infection are listed below.
• Delayed healing
• Change in color of the wound bed
• Friable granulation tissue
• Absent or abnormal granulation tissue
• Abnormal odor
• Increased serous exudates
• Increased pain at the wound site
• Infection - defined as the presence of replicating microorganisms in the wound, which cause
injury to the host.
• This type of infection is regarded as systemic infection and the traditional signs and symptoms
are listed below.
• Advancing redness (erythema)
• Fever a (swelling)
• Pain
• Foul odor
• Pus
Chronic Wound Treatment
• Debridement; Debridement; Debridement.
• Complete debridement of devitalized and
poorly functioning tissues.
• Restoration of bacterial balance.
• Maintenance of optimal moisture balance.
• Control of edema/ lymphedema.
Chronic Wound Treatment
• *Remove devitalized tissues and surface contaminants;
Debridement: There are 5 types of debridement;
• Surgical: Sharp & Excisional Debridement. In the OR & bed
side. “Selective”
• Mechanical: eg. Wet to dry dressing, Puls-lavage (Water
under pressure). “Non-selective”
• Enzymatic: Collagenase (santyl).”Selective”
• Autolytic: Wound dressing that stimulate patient own body
enzymes to debride the wound. “Selective”
• Eg; Hydrogel , Hydrocolloid (Replicare, DuoDerm/
• Biological ; ( Maggot) Debride only the necrotic
Chronic Wound Treatment
• *Control bacterial burden of wound
• Monitor for signs of infection.
• Debride all necrotic tissue.
• No topical antibiotics due to risk of developing
resistant organisms.
• Topical antimicrobial dressing; eg Silver dressing; (
Acticoat, Silver alginate, Aquacel AG) Iodosorb gel (
Cadexomer iodine ). Methylene blue(Hydrofera Blue)
• Use systemic antibiotic only in presence of spreading
cellulites, sepsis , or osteomylitis
Chronic Wound Treatment
• *Provide moist wound environment and control exudates
with Alginate, Foams, moist plain packing.
• Prevent further injury; relief pressure by changing body
position Q2 hrs. Using; Low air loss mattress
• Support repair process;
• Protein and calories( protein 1.25- 1.5 g/kg/d: calories 30-
35 calories/kg/d)
• Vitamin &mineral supplement e.g; 500 mg of Vit. C, MVI 1
tab daily, and 220 mg zinc sulphate daily for 2 weeks.
• Avoid exposure to cold.
Contraindication of Debridement
• Three Conditions
1. Dry, stable( Showed no sign of infection) eschar
on the heel.
2. Fungating mass (bleeding issue)
3. Pyoderma gangrenosun; (Pathergy)
Advanced/ Adjunctive Wound
Healing Therapies
1. Hyperbaric Oxygen Therapy. (HBOT)
2. Electrical stimulation
3. Negative pressure (V.A.C). (NPWT)
4. Growth Factors (regranex) FDA approved for DFU.
5. Skin Equivalents (Apligraph) For DFU& VSU
6. Advanced Dressing for chronic wounds such as
collagen, promogram, integra, oasis, etc.
*A chronic non-healing wound for more than 3-6
months in which it is not responding to standard
of care treatment requires a biopsy to rule out
(NPWT)Negative Pressure Wound
• Indication claimed by manufacturing company: All different
kinds of wounds/ ulcers. However, I use it for stage 3 and 4;
full thickness wound.
• Contraindication: Bleeding ulcers, cancer in the ulcer,
untreated osteomylitis, and not on any organs
• V.A.C therapy promotes healing by stimulating granulation
through cell division, cell expansion, and new vascularization
• Negative pressure is 125 mm Hg continuous in the first 48
hours. Then intermittent (5 minutes on and 2 minutes off)
• Wound should show improvement in the characteristic and
the depth within 9 days of therapy
(HBOT) Hyperbaric Oxygen Therapy
• 100% oxygen therapy under pressure.
• Patient stays in the oxygen chamber for 90
• Very expensive treatment modality.
• Long list of indications and contraindications.
(Ask Ms. Monica from hyperbaric chamber)
• Patient can benefit from HBOT. i.e; Diabetic
foot ulcer grade 3, patient with traumatic
wounds, necrotizing fasciitis
Skin Substitutes
Monitoring Wound Healing
• Mostly for pressure ulcers; weekly measurements and
documenting changes in the wound bed
• PSST tool Pressure Sore status tool
13 assessment parameters
– Size, depth, edges, undermining, necrotic tissue types,
necrotic tissue amount, exudate types and amount, skin
color surrounding wound, peripheral tissue edema and
indurations, granulation tissue, and epithelization
• PUSH tool  Pressure ulcer Scale for healing
– Ulcers are categorized with respect to surface area
(LxW), exudate and type of wound tissues
Types of wound dressing
• *Alginate; seaweed. Soft, nonwoven fiber. Shaped as ropes, pads.
• Moderate to heavy exudate. In stage 3 &4
• Contraindication; in case of mild- dry wound.
• E.G. Sorbsan, Kaltostat, Maxsorb extra AG
• * Antimicrobial ; wound care product derived from agent such as silver, iodine, and
polyhexaethylene biguanide.
• Silver dressing; e.g. Acticoat absorbent, burn , 3 ,7. silvasorb. Aquacell AG. Silvercel. 2- 7 days.
• Iodosorb gel, Cadexomer iodine 0.9% Q 48 hrs.
• * Collagen; used as a primary dressing. Absorbent, maintain a moist wound healing
• E.G BGC matrix, cellerate RX gel & powder, Kollagen Medifil 2 particles.
• *Contact Layer; Woven net acts as a low- adherence material to protect the wound bed from
trauma during dressing changes.
• E.G conformant 2 wound veil, Mepitel, Adaptic, oil emulsion
• * Composites; combine two or more products
• E.G. Alldress, Compdress island dressing, MPM multi layered dressing (Bordered).
Types of wound dressing
• *Foams; absorbent. Light – heavy exudate.
• Disadvantage; Not for eschar, may macerate periwound skin.
• E.G. Allevyn Adhesive ( Hydrocellular polyurethane) stage 2,3,4. Curafoam
plus,Hydrasorb foam, hydrocell foam, Mepilex border.
• * Hydrocolloids: Occlusive or semiocclusive – gelatin, pectin, and
• Autolytic debridement, absorption. Not for heavy exudate. Not for fragil skin.
• E.G. DuoDERM, VGF border, Exuderm, Replicare.
• * Hydrogels; Water- or glycerin based amorphous gel, impregnated gauzes, or
sheet. Soothing reduce pain, Rehydrate the wound bed, Autolytic debridement.
Not in heavy exudate.
• E.G. CarraGauge Pad, Clearsite hydrogel , Hydrogel spray. Solosite wound Gel.
• * Tranparent films; Adhesive , Semipermeable, Polyurethane membrane.
• E.G. OP Site, Bioclusive, Carra Smart Film, ClearSite transparent membrane.
Hospital-Acquired Conditions
• On February 8, 2006, the President signed the Deficit
Reduction Act (DRA) of 2005. Section 5001(c) of DRA
requires the Secretary to identify conditions that are:
(a) high cost or high volume or both, (b) result in the
assignment of a case to a DRG that has a higher
payment when present as a secondary diagnosis, and
(c) could reasonably have been prevented through the
application of evidence-based guidelines.
• Started on October 1, 2008 hospital will not receive
additional payment for cases in which one of the
selected conditions was not present on admission.
Hospital-Acquired Conditions
• The 10 categories of HACs include: • Catheter-Associated Urinary Tract Infection (UTI)
• Foreign Object Retained After Surgery • Vascular Catheter-Associated Infection
• Air Embolism • Surgical Site Infection Following:
• Blood Incompatibility – Coronary Artery Bypass Graft (CABG) - Mediastinitis
• Stage III and IV Pressure Ulcers – Bariatric Surgery
• Falls and Trauma • Laparoscopic Gastric Bypass
– Fractures • Gastroenterostomy
– Dislocations • Laparoscopic Gastric Restrictive Surgery
– Intracranial Injuries – Orthopedic Procedures
– Crushing Injuries • Spine
– Burns • Neck
– Electric Shock • Shoulder
• Manifestations of Poor Glycemic Control • Elbow
– Diabetic Ketoacidosis • Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)
– Nonketotic Hyperosmolar Coma • Total Knee Replacement
– Hypoglycemic Coma • Hip Replacement
– Secondary Diabetes with Ketoacidosis
– Secondary Diabetes with Hyperosmolarity
• To group diagnoses into the proper DRG, CMS
needs to capture a Present on Admission (POA)
Indicator for all claims involving inpatient
admissions to general acute care hospitals.
• The POA Indicator guidelines are not intended to
provide guidance on when a condition should be
coded, rather to provide guidance on how to
apply the POA Indicator to the final set of
diagnosis codes that have been assigned in
accordance with Sections I, II, and III of the
official coding guidelines.
CMS POA Indicator Options and Definitions

• Code
• Reason for Code
• Y
• Diagnosis was present at time of inpatient admission.
• CMS will pay the CC/MCC DRG for those selected HACs that are coded as "Y" for the POA Indicator.
• N
• Diagnosis was not present at time of inpatient admission.
• CMS will not pay the CC/MCC DRG for those selected HACs that are coded as "N" for the POA Indicator.
• U
• Documentation insufficient to determine if the condition was present at the time of inpatient admission.
• CMS will not pay the CC/MCC DRG for those selected HACs that are coded as "U" for the POA Indicator.
• W
• Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of
inpatient admission.
• CMS will pay the CC/MCC DRG for those selected HACs that are coded as "W" for the POA Indicator.
• 1
• Unreported/Not used. Exempt from POA reporting. This code is equivalent to a blank on the UB-04, however; it
was determined that blanks are undesirable when submitting this data via the 4010A.
• CMS will not pay the CC/MCC DRG for those selected HACs that are coded as "1" for the POA Indicator. The "1" POA
Indicator should not be applied to any codes on the HAC list. For a complete list of codes on the POA exempt list,
see page 110 of the Official Coding Guidelines for ICD-9-CM.
Examples for MS-DRG
• Primary and Secondary Diagnoses Service: MS-DRG Assignment
• (Examples below are for a single secondary diagnosis only)
• Principal Diagnosis
• Present on Admission (Status of Secondary Diagnosis) • Intracranial hemorrhage or cerebral infarction (stroke)
• Average Payment* (Based on 50th percentile for FY 2008)
• Principal Diagnosis with CC - MS-DRG 066
• Intracranial hemorrhage or cerebral infarction (stroke) without CC/MCC - MS-DRG
066 • Example Secondary Diagnosis
• --
• $5,347.98 • Dislocation of patella-open due to a fall (code 836.4
• Principal Diagnosis (CC))
• Intracranial hemorrhage or cerebral infarction (stroke) with CC - MS-DRG 065
• Example Secondary Diagnosis • N
• Dislocation of patella-open due to a fall (code 836.4 (CC))
• Y • $5,347.98
• $6,177.43
• Principal Diagnosis
• Principal Diagnosis
• Intracranial hemorrhage or cerebral infarction (stroke) with CC - MS-DRG 066 • Intracranial hemorrhage or cerebral infarction (stroke)
• Example Secondary Diagnosis
• Dislocation of patella-open due to a fall (code 836.4 (CC)) with MCC - MS-DRG 064
• N
• $5,347.98 • Example Secondary Diagnosis

Principal Diagnosis
Intracranial hemorrhage or cerebral infarction (stroke) with MCC - MS-DRG 064
• Stage III pressure ulcer (code 707.23 (MCC))
• Example Secondary Diagnosis • Y
• Stage III pressure ulcer (code 707.23 (MCC))
• Y • $8,030.28
• $8,030.28
• Principal Diagnosis • Principal Diagnosis
• Intracranial hemorrhage or cerebral infarction (stroke) with MCC - MS-DRG 066
• Example Secondary Diagnosis • Intracranial hemorrhage or cerebral infarction (stroke)
• Stage III pressure ulcer (code 707.23 (MCC)) with MCC - MS-DRG 066
• N
• $5,347.98 • Example Secondary Diagnosis
• Stage III pressure ulcer (code 707.23 (MCC))
• N
• $5,347.98
Documentation & Payment
• If pressure ulcer is documented as (present on
Admission) ; a higher ICD-9 code may be
assigned resulting in higher payments.
• Documentation of pressure ulcer location is
critical as it impacts DRG assigned.
• Ankle, buttock, heel, trochanter, sacrum,
lower back, provide higher DRG.
• Elbow, upper back, etc may not.
Prevent pressure ulcer development
• If a pressure ulcer develops during
hospitalization, there will be no payment .
• All stages 1,2,3,4, and unstageable.
• So, hospital must implement early prevention
strategies and monitor frequently.
• If patient admitted with an unstageable
pressure ulcer and it opens to stage 3 or 4
during admission, no extra payment will be
Prevent pressure ulcer development
• If patient admitted with a documented stage 1
or 2 pressure ulcer and it deteriorates to stage
3 or 4; no extra payment will be received .
• If a stage 1,2, or unstageable pressure ulcer is
documented as secondary diagnosis (POA) will
not result in higher payments.
• Only stage 3 and stage 4 present on admission
as a secondary diagnosis will result in higher
Proper documentation
• Pressure ulcers have to be documented on admission
by PCP (MD, NP, PA etc.)
• All documentation has to be consistent with the stage,
location, wound bed condition & infection.
• If you can not do staging , please describe the wound.
• Source of POA documentation;
• - Emergency Dept.
• -H&P .
• - Progress notes
• - Admitting notes
Affected Hospital
• The Present on Admission (POA) Indicator requirement and
Hospital-Acquired Conditions (HAC) payment provision only apply
to Inpatient Prospective Payment Systems (IPPS) Hospitals.
• At this time, the following hospitals are EXEMPT from the POA
Indicator and HAC:
• 1. Critical Access Hospitals (CAHs)
2. Long-term Care Hospitals (LTCHs)
3. Maryland Waiver Hospitals
4. Cancer Hospitals
5. Children's Inpatient Facilities
6. Rural Health Clinics
7. Federally Qualified Health Centers
8. Religious Non-Medical Health Care Institutions
9. Inpatient Psychiatric Hospitals
10.Inpatient Rehabilitation Facilities
11. Veterans Administration/Depart of Defense Hospitals
• http://global.smith-
• Dr. Falanga, Vincent: Boston University; Skin substitutes.
• Geriatrics at your Fingertips: David B. Reuben, MD; 2004
• Clinical Guide Wound Care : Fifth Edition; Cathy Thomas Hess,
At the end of the day that’s what
keeps me going