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Incorporating Mid-level Providers into your Wound Care Team

Nancy Chatham RN,MSN,ANP BC,CCNS,CWOCN,CWS

Advanced Wound Healing and Hyperbaric Medicine

at Passavant Area Hospital

Incorporating Mid-levels in to your Wound Care Team

• What is a Mid-level Provider

• How to integrate Mid-level Providers into your wound care team

• Mid-level scope of practice

• Impact of Mid-level wound care specialist

• Opportunities for Mid-level’s in practice

What is a Mid-level Provider

• A medical professional who provides patient care generally under the supervision/collaboration of a physician.

• Nurse Practitioners (NP), Physician Assistants (PA), and CRNAs.

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Mid-level Scope of Practice

• Dependent on State Practice Act

• Related to the collaborative practice agreement between mid-level and supervising physician

• Practice setting

• Employer

Mid-level NP Scope of Practice

– ½ of the States require a Master’s in Nursing

– 42 States require National Certification

– 27 States require MD-NP collaboration

– 11 States permit independent practice

– 10 States require Direct Supervision

– 50 States and DC allow varying degrees of Prescriptive Authority

Mid-level = Navigator

• Specialized knowledge to direct tasks.• Maintaining the location of the patient status

compared to known normal patterns of wound healing.

• Monitoring and controlling the patient’s movement through the phases of wound healing.

• Notification of the team members when directional changes are required for the patients care.

• Keeping Medical director abreast of changes.

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Integrating Mid-level Providers

• Collaborative Agreement – Written within Midlevel providers state licensure – Level of prescriptive authority

• State notice of delegated prescriptive authority on file• Federal DEA number

– Identify practice guidelines – Reimbursement

• Incident to Physician or Midlevel’s NPI• Most States NP are not eligible for direct reimbursement

– Establish site of service– Establish collaborative practice coverage policy

Essentials of Collaboration• Clinical competence and

accountability• Common purpose• Interpersonal competence and

effective communication including assertiveness

• Trust and mutual respect • Recognition and valuing of diverse

complementary knowledge and skills

• Humor

Advanced Practice Nursing An Integrative Approach 4thed Hanson and Spross 2009

Team Collaboration

• Mid-level Providers based on State Practice Act Can Direct/Supervise:– Physical Therapist and PT Assistants

– Occupational Therapist and OT Assistants

– Registered Nurses

– Licensed Practical Nurses

– Nursing Assistants

– and other medical professionals

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Problem Focused Structural Design

• Algorithms– Cellulitis– Debridement– Dressing Guide Moist Wound Healing– Diagnostic

• Practice Guidelines– VLU, DM, PU, Arterial, Palliative Wounds

• Standard Order Set

Wound Infection AlgorithmIs Wound Infected?

Treat Infection: C&Sbefore starting antibiotics. (if MRSA suspected and no sulfa allergy,start Bactrim DS. + Sulfa allergy start Clindamycin or other antibiotic of providers choice.

Clean with sterilesaline or non cytotoxic wound cleanser

If extensive cellulitis is present. Consider admission or outpatient antibiotictherapy at providers discretion

Utilize Moist wound healing Algorithm

Is Cellulitis present?

Utilize Moist wound healing Algorithm

Yes No

YesNo

Edema Management

•Start appropriate diuretic if no Contraindications.•Obtain BMP prior to diuretic tx.•Mild compression (tensoflex)•Instruct on removal at HS•Elevate legs as much as possibleDO NOT START COMPRESSIONIF SIGNIFICANT ARTERIALDISEASE IS SUSPECTED

Abnormal findings

+C&S, S/S

soft tissue infection

Midlevel Diagnostic Algorithm

+S/S of infection,+ Co-morbidities,+ C&S, + CRP, Sed Rate, GFR,

+ X-Ray, Vascular Study

Initiate broad-spectrum antibiotic

&topical wound management

of microbial load.

NP Reevaluate5-7 days

Discuss with collaborativeOrder additional diagnosticsBone Scan, CT,CTA,

MRI,MRA

•Refer to Primary Wound Center

•Refer to Specialist

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Stage I Reddened Area

Stage II

Denuded Buttocks Skin Tear Blister Partial Thickness

Treatment Objectives

ProtectRemove cause

ProtectTreat

ProtectManage drainage

ProtectManage drainage

ProtectManage drainage

Topical Treatments (Dressing Change Intervals)

Pressure Thin film or (Q 3-5 days and PRN)OrSkin Prep (daily and PRN)Friction Thin film (Q 3-5 days) Or Skin Prep (QD)Incontinence Personal Cleanser(spray directly on skin, wait 10 seconds then remove with soft, dry cloth)/ Protective Ointment or Protective barrier cloths (Q episode)

Denuded skin: Personal Cleanser spray directly on skin, wait 10 seconds and remove, apply Zinc barrier Cream Q episode until healed. Then resume use of Protective Ointment or Protective barrier clothes.Denuded skin with Yeast infection: Cleanse with Personal Cleanser applyAntifungal Greaseless TX for 2 weeks after redness has resolved) **Must have MD order.**Pharmacy item.

Flap minimal drainageSteri-strip Cover w/ Thin film (Q 3-5 days) With or without Flap (light to moderate drainage)Thin film acrylic sheet change Q 5 days, or Thin foam adhesive change Q 3-5 day

Apply several coats of Skin Prep (QD) ORSkin Prep and cover with Thin film acrylic until blister fluid has reabsorbed, change Q7days and PRNORXeroform gauze kling change every other day.

Minimal Drainage—DRY WOUNDApply Hydro Gel, cover with a 4x4 gauze (QD)ORThin Film AcrylicChange Q 7 daysModerate to Heavy DrainageFoam adhesive change Q 3-5 days

Stage III Full Thickness

Stage IV Full Thickness

Unable to Stage Slough

Unable to Stage Eschar

Infected Wound

Treatment Objectives

ProtectManage drainage

ProtectManage drainageFill dead space

ProtectManage drainageFill dead space

DebrideManage drainage

Reduce BioburdenManage infection

Topical Treatments (Dressing Change Intervals)

Minimal to Moderate Drainage—DRY WOUNDApply Hydro Gel, cover with 4x4 gauze dressing, changing Q 1-3 daysModerate to Heavy DrainageFoam Adhesive change Q 3-5 days

Minimal to Moderate drainage, Cavity /tunneled Wound --DRY WOUNDHydro Gel saturated gauze fluffed loosely into wound bed, 4x4 Gauze and TapeModerate DrainageAlginate/ cover with 4x4 Gauze and tape Moderate to Heavy DrainageAlginate or Hydro fiber / Foam Adhesive (QD) Or Foam Plus Cavity*fill cavity only 50%

SloughCleanse w/ wound cleanser or saline. Apply Enzymatic ointment directly to the area of slough. Cover with appropriate dressing. Daily or twice daily applications are preferred. May cover with moisten gauze with normal saline to increase the effects of enzymatic agent**Must have MD order.**Pharmacy item.

Hard Dry Eschar: Apply Enzymatic ointment directly to the wound. Cover with appropriate dressing. Daily. May cover with moisten gauze with normal saline to potentiate the effects of enzymatic agent ** Must have MD order.**Pharmacy item.Exception: DO NOT Debride intact heels (Refer to AHRQ Guidelines)

Infected Wound1.Cleanse w/ wound cleanser or saline. Select appropriate Anti-microbial dressing:Dry to light drainage use (q 3 days) Iodosorb gel Pharmacy item or Silver gel, cover with 4x4 gauze dressing.Moderate to heavy drainage 1. use Ag+ Absorbent (q 3 days) or (q 7 days) OR Clorpactin moisten gauze.2. Apply cover dressing: 4x4 gauzeOR Hydrofera Blue foam

Venous Ulcer Initial Visit Follow-up Exit Visit

DiagnosticStudies

ABI wave form Refer for complete vascular study if indicated Duplex Doppler (looking for reflux, insufficiency,

venous htn) Culture if clinical s/s of infection are present CBC BMP Pre albumin Sed rate C-Reactive Protein x-ray with dx

Repeat abnormal labs 4-6weeks

Treatments H & PWound AssessmentPain AssessmentReduce EdemaCompression therapyTreat cellulitis and dermatitisTopical/Systemic therapyDebridementMoist Would Healing AlgorithmReduce Bacterial LoadSTSG

Wound assessmentEvaluate goals of wound healing.If no appreciable reduction in ulcersize is noted refer to QA for oversight.

WoundAssessmentEvaluate goals of woundhealing

Consults Vascular/Pain management

Medication/IV Assess medication ’s ’s

Nutrition Reg/Special - - - - - - - - - -

Activity WalkingElevate legs while sitting or laying

- - - - - - - - - -

Patient/FamilyTeaching

CausesTreatmentPrevention I/s on Calf pump exercises

ReinforceTreatmentSelf carePrevention

DischargeInstructions

DischargePlanning

Initial D/C planning discussed with pt/family Evaluate progress of D/C plans Discharge

Ca

re G

uid

elin

es

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WOUND CLASSIFICATION Acute or Chronic Surgical wound Primary Dx. (e.g., dehisced or infected surgical wounds, _____________________) Acute or Chronic Non-Surgical wound Primary Dx (e.g., abrasion, skin tear, burn, trauma, pressure ulcers, leg ulcers, foot ulcers,____________________) Secondary Diagnosis:_________________________________________________

Diagnostics: Culture if clinical s/s of infection are present CBC Sed Rate C-Reactive Protein BMP Pre-albumin HgA1C on confirmed/borderline diabetics if not performed in the past 3 mos. Fasting Lipid Profile X-ray dx.________________________________________________________ Venous Duplex Doppler scan for: (Venous insufficiency, reflux, venous HTN) Vascular Studies complete / with toe pressure Other___________________________________________________________ Consults_________________________________________________________

Pain management during wound care: Topical anesthetic cream (4% lidocaine) x 20min prn Topical anesthetic sol. lidocaine (1 % or 2%) x 5-10min prn

Skin Care: Topical therapeutic cream Protective barrier to peri wound prn Topical steroid cream 0.1% -0.05% Topical Antifungal powder or barrier cream prn

Wound Care: Cleanse with normal salineDebridement: Mechanical-whirlpool, gauze. Enzymatic_____________ Conservative sharps-tweezers, scissor prnAppropriate Dressing according to moist wound healing algorithm: Absorb/Contain drainage Manage bio-burdenCompression therapy appropriate based on current ABI: Multi-layer wrap Zinc base wrap Tubular wrap Off load device:_________________________________________________________________

Prescription:_____________________________________________________________________

Follow up clinic appointment with Dr/NP. ___________________________on___________Physician/Provider Signature _________________________________________Date____________ Revised 7-10

Standing Protocol for Initial Visit

Mid-level Provider Competency

• Establish Process in the Collaborative Agreement. – Method of competency

– Frequency of competency

– Procedural Competency check list signed by collaborative

– Maintain with collaborative agreement

Advanced Wound Care

• Sharps Debridement • Ultrasonic Debridement• Incision & Drainage • Punch Biopsy• Dermal Skin Substitutes• Offloading Total contact casting and modified

non contact casting. • Chemical Cauterization• Cryo treatment

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Competency Check ListAdvanced Practice Nurse Wound Care Procedure Competency check list

NumberPerformed Supervising Physicians Time

Frame

Sharp Debridement without anesthesia 1 year

Sharp Debridement with anesthesia 1 year

Suture of simple wounds and lacerations ( not requiring ligament or tendon repair) 1 year

Removal of ingrown nail, trimming nails 1 year

Cryo therapy 1 year

Chemical cauterization 1 year

Incision and drainage of abscesses 1 year

Dermal Skin Substitute 1 year

Punch Biopsy 1 year

Total Non-contact Casting 1 year

Ultrasonic Debridement

Midlevel Sig:

Collaborating physician sig:

Sharps Debridement

• Location of Wound– Ø Head, Hands,

Genitals

• Wound evaluation-s/s infection, vascular status, pain management

• Wound Bed preparation >25% devitalized tissue.

• Instruments of choice-15 blade scalpel, Adson multi tooth, Tissue nipper, Curette, Iris Scissors.

• Hemostasis

• Moist wound care

Acute and Chronic Debridement Algorithm

>25% Devitalized Tissue

Surgical Sharps

ScalpelScissors

Tissue nippers other

instruments

Proteolyticenzyme

Mechanicaldebridement

Hydration of devitalized

tissue, facilitating Phagocytic

cell and

protein digesting enzymes

HydrotherapyWhirl pool

woundirrigation

Enzymatic Autolyticdebridement Biological Chemical

Larval therapy

Silver Nitrate

Calcium orSodium

Hypochlorite solutions

Moist Wound Care Algorithm

Painless,time

consuming

Score EscharAnestheticHemostasis

QuickPainful

underlying Tissue

destruction

Not well

received

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Sharps Debridement

3mm curetteTissue Nippers 15 Blade Scalpel

Total Contact Casting and Modified Non-Contact Casting

• TCC remains the gold standard– Competency frequency proficiency

– Benefits • Weekly application

• Total off-loading pressure

• Increased compliance

– Cons• Learning curve

• Complications insensate population

Diabetic Foot Ulcer

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6mm adhesive felt cut to fit

Off-loading shoe with removable hexagons

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4mm adhesive felt

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Ultrasound Technologies

• What is the goal of debridement?

• Ultrasonic wound treatment devices

• Ultrasound transfer mist– Ultrasonic stimulation of

tissue

– Non-contact

– Non-thermal

• Ultrasound guided debridement– Deep tissue debridement

and micro cavitations

– Destruction of bacteria, viruses, fungi

Photo compliments of Dr. Niezgoda

I-&-D Procedures

• Sebaceous Cyst

• Boils

• Abscess

• Hematomas

• Appropriate antimicrobial therapy

• Moist wound healing algorithm

• Follow up

• Referrals

Punch Biopsy

• Failure to proceed through normal phase of wound healing

• Abnormal appearance

• Suspicious presentation malignancy

• Spontaneous presentation of ulcer

• Inflammatory presentation with bulla and ulceration

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Patient Considerations Biopsy

• Rights and informed consent

• Comfort

• Sight selection

• Appropriate biopsy technique

• Supplies needed

• Moist wound healing algorithm

• Follow up

Appropriate Wounds for Biopsy

Dermal Skin Substitutes

• Type of wound

– Diabetic

– Venous leg ulcer

– Traumatic wounds

– Pressure ulcer

• ECM extra cellular matrix

• Bio-engineered skin substitutes

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Dermal Skin Substitutes

• Product Preparation

Dermal Skin Substitutes

• Graft implantation

• Off-loading

• Dressing

• Follow up

Diabetic walking boot with removable hexagons

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• Compliance with Diagnostic Protocol

• Improved Financial Outcomes

• Improved Healing Rates

• Increased Marketability

Impact of Mid-level Wound Care Specialist

Compliance with Standard of Care

Admission and monthly diagnostics protocol

Clinical Outcomes

• Healing rates 2007-2010

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Improved Financial Benefit

Increased Marketability

• Development of Satellite clinic– Revenue source for rural hospitals

– Added revenue source to practice group• Contract Specialty Services

• Referral source to practice group

• Referral source to primary wound center for HBOT

Mid-level Providers

• Opportunities– Program Expansion

– Satellite Clinic Development

– Clinical Coverage

– Research

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Mid-level Providers…Navigators of the Future

Jon Smith

United States Navy

Intelligence

Specialist

References• Alavi A, Niakosari F, Sibbald R. When and How to Perform a Biopsy on a Chronic Wound. Advances in Skin and

Wound Care 2010 23 (3) 132-139• Christian S., JD, Dower C., JD Etal. Overview of Nurse Practitioner Scope of Practice in the United States-

Discussion, The Center for The Health Professions University of California, 2007• Espensen E H, DPM. Assessing Debridement Options for Diabetic Wounds 2007; 20(3), • Gray M, PhD. Is Total Contact Casting Effective for Treating Diabetic Foot Ulcers? J WOCN 2006,33(4):359-362• Hoffman K, DPM, Jensen J DPM, Jaakola E, DPM. Today’s Wound Clinic Aug 2010 4(4) 18-29• McGuire J, DPM. Transitional Off-loading: An Evidence-Based Approach to Pressure Redistribution in the Diabetic

Foot. Advances in Skin and Wound Care 2010 23(4)• Nabuurs-Franssen M, MD, Sleegers R, Huijberts, M, MD. et al. Total Contact Casting of the Diabetic Foot in Daily

Practice A prospective follow-up study. http://care.diabetesjournals.org/content/28/2/243.full Retrieved 8-25-2010 • National Guideline Clearinghouse www.guideline.gov wound care algorithm 2008. • National Guideline Clearinghouse www.guideline.gov wound care algorithm 2008. • Advanced Practice Nursing: An Integrative Approach 4th ed. Hamric A., Spross J., Hanson C. Sanders 2009• Assessing Debridement Options for Diabetic Wounds 2007; 20(3), E H. Espensen DPM • Niezgoda J , MD Integrating Ultrasound Guided Wound Debridement: Clinical Efficacy and return on investment,

Advancing Wound Healing www.worldrg.com/wound June 22nd-23rd, 2010 San Diego, CA• Wendelken, M, DPM, Markowitz, L, DPM, Oscar M. A., A closer Look At Debridement. Podiatry Today August

2010 23 (8)• Photos use in presentation were used with consent of participants or their guardians.