Appropriateness of Long-Term Acute Care Hospital Transfer: A Multicenter Study of Medicare ACO Beneficiaries.

OBJECTIVES: There is wide variation in long-term acute care hospital (LTACH) use nationwide, the most intensive and expensive post-acute care setting, although appropriateness of use is uncertain. Therefore, we examined the appropriateness and reasons for transfer in a high-use region, and how Medicare criteria for LTACH payment identifies appropriate transfers. DESIGN: Multicenter retrospective observational cohort. SETTING AND PARTICIPANTS: Consecutive hospitalized Medicare beneficiaries transferred to an LTACH from 2017 to 2018 from an accountable care organization in Texas. METHODS: The primary outcome was clinical appropriateness of transfer ascertained by 2 physician reviewers. We abstracted patients' characteristics and primary reasons for transfer. We examined the positive predictive value (PPV) of meeting Medicare criteria for full LTACH payment [preceding intensive care unit (ICU) stay ≥3 days or prolonged mechanical ventilation] for identifying appropriate transfers, and how this differed if Medicare adopted an 8-day minimum ICU stay criterion recommended by the Medicare Payment Advisory Commission (MedPAC). RESULTS: Of 105 LTACH transfers, 33 (31.4%) were clinically appropriate. The most common reason among appropriate transfers was respiratory care (58%), but 42% had other indications. Inappropriate transfers most commonly were for wound care (28%), intravenous medication infusions (28%), or patient (17%) and physician preference (26%). The PPV for meeting Medicare LTACH payment criteria was 55%. The PPV improved to 77% if Medicare adopted the 8-day minimum ICU stay criterion, with only a modest absolute increase in appropriate transfers not meeting the more stringent criteria (12% to 17%). CONCLUSIONS AND IMPLICATIONS: Two-thirds of LTACH transfers in a high-LTACH-use region are clinically inappropriate, and are most commonly transferred for wound care, intravenous infusions, or patient and physician preference. Medicare payment criteria modestly distinguished between appropriate and inappropriate transfers. Adoption of MedPAC's recommended 8-day minimum ICU stay criterion could safely reduce inappropriate transfers, although generalizability to low LTACH-use regions is uncertain.

Oxidized Regenerated Cellulose/Collagen Dressings: Review of Evidence and Recommendations.

OBJECTIVE: Healthcare systems are being challenged to manage increasing numbers of nonhealing wounds. Wound dressings are one of the first lines of defense in wound management, and numerous options exist. The oxidized regenerated cellulose (ORC)/collagen dressing may offer healthcare providers a robust and cost-effective tool for use in a variety of wounds. DESIGN: A multidisciplinary panel meeting was convened to discuss the use of ORC/collagen dressings in wound care and provide practice recommendations. A literature search was conducted to provide a brief review of the peer-reviewed studies published between January 2000 and March 2016 to inform the meeting. SETTING: A 2-day panel meeting convened in February 2017. PARTICIPANTS: Healthcare providers with experience using ORC/collagen dressings. This multidisciplinary panel of 15 experts in wound healing included podiatrists, wound care specialists (doctors, certified wound care nurses, and research scientists), and an orthopedist. RESULTS: The literature search identified 58 articles, a majority of which were low levels of evidence (69.3% were level 3 or lower). Panel members identified wound types, such as abrasions, burns, stalled wounds, diabetic foot ulcers, and pressure injuries, where ORC/collagen dressing use could be beneficial. Panel members then provided recommendations and technical pearls for the use of ORC/collagen dressings in practice. Barriers to ORC/collagen dressing use were discussed, and potential resolutions were offered. CONCLUSIONS: An ORC/collagen dressing can be a critical tool for clinicians to help manage a variety of wounds. Clinical and economic studies comparing standard-of-care dressings and plain collagen dressings to ORC/collagen dressings are needed.

Management of Chronic Wounds: Diagnosis, Preparation, Treatment, and Follow-up.

Management of chronic wounds remains challenging in terms of prevalence and complexity. Considerable progress has been made in understanding the science of wound healing during the past decade, sparking volumes of publications and the development of hundreds of dressing and therapy options. There is a need for a simpli ed overview of evidence-based criteria to assist in the accurate diagnosis and appropriate management of chronic wounds in all care settings. An expert panel of 11 wound healing specialists experienced in various care settings convened to discuss best practices and recommended guidelines for managing major chronic wound types. Prior to the meeting, panel members reviewed 8 preselected peer-reviewed articles and 1 white paper containing treatment algorithms for all major chronic wound types. During the meeting, each panelist presented current evidence-based guidelines regarding a specific chronic wound type and case studies to illustrate concepts in the guidelines. This publication is a result of the panel discussion and presents an overview of literature- and experience- based criteria to help guide chronic wound diagnosis, assessment, treatment, and follow-up. A cycle of steps is presented as a framework to guide holistic care for all patients with chronic wounds, including de- hisced surgical wounds, diabetic foot ulcers, venous leg ulcers, arterial insu ciency ulcers, and pressure ulcers/injuries. Emphasis is placed on criteria to assist accurate diagnosis and dressing/therapy selection, holistic elements of patient and wound bed preparation, interventions to achieve patient adherence to a care plan, and follow-up to help prevent wound recurrence.

Wound Care Centers: Critical Thinking and Treatment Strategies for Wounds

Many wound care centers (WCCs) provide a specialized level of care using various wound care therapies and are managed by quali ed healthcare professionals (QHPs) from di erent specialty backgrounds such as family medicine, podiatry, and plastic surgery. However, these QHPs are sometimes challenged by reimbursement issues, limited therapy and dressing options, reduced access to multidisciplinary team members, and cost-driven factors unique to WCCs. To help address these issues, a meeting was convened by an expert panel of WCC physicians to discuss best practices for treating complex patients in a WCC. This publication presents an overview of WCC chal- lenges, describes a holistic approach to treating WCC patients, and provides clinical guidance on the decision-mak- ing process for selecting optimal treatment plans for the WCC patient. Clinical cases of atypical, surgical and chronic wounds seen in a WCC are also presented.

Novel techniques using negative pressure wound therapy for the management of wounds with enterocutaneous fistulas in a long-term acute care facility.

Patient status and wound condition are important factors to consider when developing an appropriate wound management plan. Comorbid conditions such as diabetes mellitus, obesity, and peripheral vascular disease affect wound healing, as do complications, such as fistulas and infections. This article describes 3 novel techniques, using negative pressure wound therapy with reticulated open-cell foam for managing patients with wounds containing an enterocutaneous fistula.

Analysis of run-in and treatment data in a wound outcomes registry: clinical impact of topical platelet-rich plasma gel on healing trajectory.

Randomised controlled trials in chronic wounds typically exclude patients with comorbidities and confounding factors. Well-designed observational studies can provide complementary clinical evidence that randomised trials cannot address. This study determined if wound care registry outcomes could be an alternative data source and if the results would be robust and valid. Changes in wound area and depth were hypothesised to be different between run-in therapies and platelet-rich plasma (AutoloGel™, Cytomedix, Inc) treatment. From a treatment registry of 285 chronic wounds, 46 had run-in and post-treatment data. Seven chronic wound categories were identified. Mean wound age at study start was 52·4 days. General linear model repeated measures showed a credible and robust data set. Statistically significant differences for wound area and depth were observed between run-in and post-treatment period at multiple time points. Wound area and depth ≥50% reduction were analysed using Kaplan-Meier methods. During run-in, 15% of wound area improved compared to 28% post-treatment and 11% of wound depth improved during run-in compared to 39% post-treatment. Significant clinical outcomes indicated many previously non responsive wounds began actively healing in response to platelet-rich plasma therapy, indicating that registry data can be used as a complementary source of evidence.

The clinical relevance of treating chronic wounds with an enhanced near-physiological concentration of platelet-rich plasma gel.

OBJECTIVE: This study investigated clinical outcomes in chronic nonhealing wounds following the short-term use of an enhanced, near-physiological concentration of platelet-rich plasma (PRP) gel (AutoloGel System, Cytomedix, Inc, Gaithersburg, Maryland). DESIGN: Study design was a large, observational case series using a multicenter registry database (all wounds included), which compared different populations within the database. SETTING: Thirty-nine centers contributed to the registry, including long-term acute-care centers, outpatient clinics, a durable medical equipment company, a home health agency, and a long-term-care center. PATIENTS: The target population included 285 chronic wounds (patient n = 200). Wound etiologies included diabetic, pressure, or venous ulcer; dehisced, surgical, or traumatic wound; and wounds of other etiologies. INTERVENTION: Therapeutic, PRP gel is produced from patient blood utilizing autologous platelets and plasma that contribute growth factors, cytokines, and chemokines, in a fibrin matrix. MAIN MEASURES: Area and volume of the wound and the linear total of undermining and sinus tracts/tunneling were calculated. Clinical relevance was determined by analyzing outcomes in wounds that responded to treatment. MAIN RESULTS: A positive response occurred in 96.5% of wounds within 2.2 weeks with 2.8 treatments. In 86.3% of wounds, 47.5% area reduction occurred, and 90.5% of wounds had a 63.6% volume reduction. In 89.4% undermined and 85.7% of sinus tracts/tunneling wounds, 71.9% and 49.3% reductions in linear total were observed, respectively. CONCLUSION: In chronic wounds recalcitrant to other treatments, utilization of PRP gel can restart the healing process. Rapid treatment response was observed in 275 of 285 wounds, and the magnitude of response was consistently high, with statistically significant outcomes reported for various subgroups.

A clinical review of infected wound treatment with Vacuum Assisted Closure (V.A.C.) therapy: experience and case series.

Over the last decade Vacuum Assisted Closure((R)) (KCI Licensing, Inc., San Antonio, TX) has been established as an effective wound care modality for managing complex acute and chronic wounds. The therapy has been widely adopted by many institutions to treat a variety of wound types. Increasingly, the therapy is being used to manage infected and critically colonized, difficult-to-treat wounds. This growing interest coupled with practitioner uncertainty in using the therapy in the presence of infection prompted the convening of an interprofessional expert advisory panel to determine appropriate use of the different modalities of negative pressure wound therapy (NPWT) as delivered by V.A.C.((R)) Therapy and V.A.C. Instill((R)) with either GranuFoam() or GranuFoam Silver() Dressings. The panel reviewed infected wound treatment methods within the context of evidence-based medicine coupled with experiential insight using V.A.C.((R)) Therapy Systems to manage a variety of infected wounds. The primary objectives of the panel were 1) to exchange state-of-practice evidence, 2) to review and evaluate the strength of existing data, and 3) to develop practice recommendations based on published evidence and clinical experience regarding use of the V.A.C.((R)) Therapy Systems in infected wounds. These recommendations are meant to identify which infected wounds will benefit from the most appropriate V.A.C.((R)) Therapy System modality and provide an infected wound treatment algorithm that may lead to a better understanding of optimal treatment strategies.

Cost-effectiveness of negative pressure wound therapy for postsurgical patients in long-term acute care.

OBJECTIVES: To evaluate the cost-effectiveness of negative pressure wound therapy (NPWT) using reticulated open-cell foam (NPWT/ROCF) as delivered by a Vacuum-Assisted Closure* (KCI Licensing, Inc, San Antonio, Texas) in patients with complex wounds in a long-term acute care (LTAC) setting. These patients are routinely discharged to LTAC hospitals with the goal of accelerating wound healing and timely transfer to a lower acuity care setting and are usually affected with serious comorbidities and deep, complex wounds with exposed anatomical structures, which require extended care (stay > 25 days). DESIGN: A retrospective chart review was conducted to determine the average daily wound volume reduction, average daily wound area reduction, and average cost per cubic centimeter of wound volume reduction for patients treated with NPWT/ROCF as compared with topical advanced moist healing strategies (non-NPWT). SETTING: All patients received treatment in an LTAC hospital. PARTICIPANTS: Patients admitted from November 2001 to August 2004 were identified using a computerized hospital database. The inclusion criteria were postsurgical patients of at least 18 years of age, with a single acute wound. INTERVENTION: Patients were treated with either NPWT/ROCF or advanced moist wound-healing therapies (non-NPWTs). MEASUREMENTS: Data collected included age, sex, wound measurements, Bates-Jensen Wound Assessment Tool severity score, procedures performed, wound care products and devices used, wound-healing outcomes, and costs associated with treatment. RESULTS: Fifty-one patients met the inclusion criteria: 36 were identified as NPWT/ROCF and 15 as non-NPWT. The NPWT/ROCF patients showed a statistically significantly higher average daily rate of volume reduction as compared with the advanced moist wound-healing group (5.02 +/- 13.36 vs 0.40 +/- 0.88 cm(3)/day; P = .046). The cost per cubic centimeter reduction was $11.90/cm(3) in the NPWT/ROCF group versus $30.92/cm in the moist wound-healing group. CONCLUSION: Postsurgical LTAC patients who were treated by NPWT/ROCF had a more accelerated rate of wound closure, compared with patients treated with advanced moist wound-healing therapy. These results suggest that, for this patient group, NPWT/ROCF may be more clinically effective in reducing wound volume, compared with advanced moist wound healing. Furthermore, the lower cost per cubic centimeter volume reduction suggests that NPWT/ROCF produces a more favorable cost-effective solution. Therefore, it is important when developing a wound-healing strategy that cost decisions be based on overall cost and not individual product cost when using advanced technology as part of the overall treatment plan. This study serves as a basis for further work in cost-benefit analysis when considering evidence-based outcomes in wound care.

Wound-healing outcomes using standardized assessment and care in clinical practice.

INTRODUCTION: Wound-healing outcomes applying standardized protocols have typically been measured within controlled clinical trials, not natural settings. Standardized protocols of wound care have been validated for clinical use, creating an opportunity to measure the resulting outcomes. PURPOSE: Wound-healing outcomes were explored during clinical use of standardized validated protocols of care based on patient and wound assessments. DESIGN: This was a prospective multicenter study of wound-healing outcomes management in real-world clinical practice. METHOD: Healing outcomes from March 26 to October 31, 2001, were recorded on patients in 3 long-term care facilities, 1 long-term acute care hospital, and 12 home care agencies for wounds selected by staff to receive care based on computer-generated validated wound care algorithms. After diagnosis, wound dimensions and status were assessed using a tool adapted from the Pressure Sore Status Toolfor use on all wounds. Wound, ostomy, and continence nursing professionals accessed consistent protocols of care, via telemedicine in home care or paper forms in long-term care. A physician entered assessments into a desktop computer in the wound clinic. Based on evidence that healing proceeds faster with fewer infections in environments without gauze, the protocols generally avoided gauze dressings. RESULTS: Most of the 767 wounds selected to receive the standardized-protocols of care were stage III-IV pressure ulcers (n = 373; mean healing time 62 days) or full-thickness venous ulcers (n = 124; mean healing time 57 days). Partial-thickness wounds healed faster than same-etiology full-thickness wounds. CONCLUSIONS: These results provide benchmarks for natural-setting healing outcomes and help to define and address wound care challenges. Outcomes primarily using nongauze protocols of care matched or surpassed best previously published results on similar wounds using gauze-based protocols of care, including protocols applying gauze impregnated with growth factors or other agents.

Guidelines for managing pressure ulcers with negative pressure wound therapy.

Pressure ulcers are a serious health issue, leading to clinical, financial, and emotional challenges. Numerous treatment modalities are available to promote wound healing, yet clinicians may be unsure how to incorporate these treatment options into an overall plan of care for the patient with a pressure ulcer. A consensus panel of experienced wound care clinicians convened in July 2004 to review the mechanisms of action and research basis for one such treatment modality: negative pressure wound therapy. After answering key questions about this modality, they developed an algorithm to assist the clinician in making decisions about using negative pressure wound therapy appropriately in patients with Stage III and Stage IV pressure ulcers.