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By:

Rhonda Trexler, BS RN COS-C CCP

Objectives Verbalize the ability to determine if a surgical wound

exists when documenting in OASIS-C

Describe would healing phases related to wounds healing by primary intention and secondary intention

Discuss the completion of OASIS–C items related to surgical wounds in home health patients

Why is this important? Accurate Assessments lead to appropriate

interventions for the patient and accurate data collection for OASIS-C -----leads to accurate payment and accurate measuring of outcomes

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Home Health Compare Improvement in Surgical Wounds is a publically

reported outcome on the home health compare website

http://medicare.gov/homehealthcompare/search.aspx

How often wounds improved or healed after an operation

Surgical Procedure/Surgical Wound • The Center for Medicare and Medicaid Services provides

guidance to Home Health regarding scoring for OASIS-C

• OASIS-C Guidance Manual – Chapter 3 http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/HHQIOASISUserManual.html

• CMS Q&As – link for OASIS Q&As – will take you to the OASIS Answers Website http://www.oasisanswers.com/aboutoas_links.htm

• Can also access the user manual from this site

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M1340 Does this patient have a Surgical Wound?

Integumentary System

Skin, hair, nails and sweat glands

Excludes mucous membranes, cataract surgery of the eye, surgeries via a vaginal approach

Centers for Medicare and Medicaid Services.

(2010). OASIS C guidnace manual.

Consider the Etiology Surgical interventions to treat already existing wounds

do not change the classification of the wound as surgical

Suture of laceration from trauma

Debridement of existing wound

Simple I&D of abscess/cyst

Skin graft over existing wound

Full thickness

Partial thickness

Suture of Laceration from Trauma • Classified as a trauma wound

• Debridement of a traumatic wound to remove debris or a foreign matter

• Traumatic wound requiring surgery to repair an internal organ or other internal structure is a surgical wound

– Repair of a torn tendon or a ruptured internal organ

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Pressure Ulcer with Sharp Debridement remains a pressure ulcer

Incision and Drainage Simple Incision and Drainage

Incision and drainage with removal of tissue or other structures

Drain placement = surgical wound

Wound remains surgical even after drain removal

Excision of an abscess or cyst

Skin Grafts Skin grafting is a

treatment of an existing wound

Full thickness

Partial thickness

Donor site is considered a surgical wound

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Muscle Flap/Skin Advancement Flap/Rotational Flap

Creates a surgical wound

Pressure ulcer that is muscle flapped will be classified as a surgical wound

If area breaks down again due to pressure – becomes a pressure ulcer

Skin Flap of a Pressure Ulcer becomes a Surgical Wound

Biopsy Sites Any wound created by needle puncture only is not a

surgical wound

Needle biopsy

Paracentesis with needle puncture only

Cardiac catheterization sites (even if stent placed)

Cut-Down procedure

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Biopsy Sites Excisional biopsy

Shave biopsy

Punch biopsy Surgical Wound for OASIS-C

Vascular Access Devices Central line sites

Implanted vascular access devices

Arterio-venous shunts

PICC lines

Peripheral IV sites

Ostomies All ostomies are excluded from consideration as

surgical wounds

Chest Tube sites

Take down procedure vs. Ostomy closing on own

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Sutures Sutures and Surgical Wounds

Peripheral IV sutured in place

ON-Q Pump

ON-Q C-bloc is a continuous peripheral

nerve block system that slowly infuses

local anesthetic near a nerve for effective

pain relief

Considered an implanted infusion device

Surgical wound if inserted separate from

wound

What is Not a Surgical Wound? VP shunt

Pacemaker

Toenail removed

Callous removed

Subcutaneous infusion

Enterocutaneous fistula

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What is a Surgical Wound? Orthopedic pin sites

Peritoneal dialysis catheter site

LVAD cannula exit site

When is a Surgical Wound No Longer Reported on OASIS-C? 30 Days After Epithelialization

Wound is considered a scar and no longer included in “M1340 Does this patient have a surgical wound?”

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What is Epithelialization?

National Institute of Health. (2010). Skin layers.

Retrieved from

http://www.nlm.nih.gov/medlineplus/ency/imagep

ages/8912.htm.

OASIS-C M1340: Does this patient have a surgical wound?

M1342: Status of the Most Problematic (Observable) Surgical Wound:

Outcome Based Quality Improvement

Outcome Based Quality Monitoring

Home Health Prospective Payment System

Risk Adjustment

Phases of Wound Healing

Hemostasis

Inflammation

Proliferation

Maturation

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Hemostasis Clotting cascade begins

Fibrinogen

Clot formation

Fibrinolysis

Inflammation

Inflammation WBCs enter the wound

Redness, swelling, warmth, and discomfort

Proliferation Granulation tissue

New blood supply develops

Epithelialization

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Epithelialization Healthy Wound Edges

Moist wound environment

Closed Wound Edges Epibole

Calloused

Hyperkeratonic

Maturation Day 7 up to 1 year

Contraction

Increased tensile strength

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Primary Intention Primary Intention

Surgically closed

Completely approximated

Less tissue loss

Do not granulate

Secondary Intention Open surgical wounds

Wound edges are open

Requires granulation tissue

Intentional and dehisced

Approximated Incisions Heal by Primary Intention

Any dehiscence of separation results in healing by Secondary Intention

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Terminology Avascular Tissue

Eschar

Slough

Dead Space

Granulation Tissue

Hyperkeratotic

Closed Wound Edges

M1342 Status of the Most Problematic Surgical Wound Newly Epithelialized

Fully Granulating

Early/Partial Granulation

Not Healing

WOCN Guidance on OASIS-C Items: Newly Epithelialized

Wound Bed completely covered with new epithelium

No exudate

No avascular tissue

No signs or symptoms of infection

Peirce, B., Mackey, D., & McNichol, L. (2009). Wound ostomy continence nurses society guidance on OASIS-C

integumentary items. Retrieved from http://www.wocn.org/pdfs/GuidanceOASIS-C.pdf

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Fully Granulating Wound bed filled with granulation tissue to the level

of the surrounding skin

No dead space

No avascular tissue

No signs or symptoms of infection

Early/Partial Granulation > 25% of the wound bed is covered with granulation

tissue

< 25% of the wound bed is covered with avascular tissue (eschar and/or slough)

No signs or symptoms of infection

Wound edges are open

Not Healing Wound with > 25% avascular tissue (eschar and/or

slough) OR

Signs/symptoms of infection OR

Clean but nongranulating wound bed OR

Closed/hyperkeratotic wound edges OR

Persistent failure to improve despite appropriate comprehensive wound management

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Primary Intention vs. Secondary Intention Do not granulate

Newly Epithelialized

Not healing

Granulation tissue

Newly Epithelialized

Fully Granulating

Early/Partial Granulation

Not Healing

Sutures / Staples Not considered part of the surgical wound when

determining the healing status

Include status of sites in comprehensive assessment documentation

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10 Days Post-Op

Scabs Presence of a scab is not automatically non-healing

Determine first is the wound is healing by Primary Intention or Secondary Intention

Primary Intention healing with scab = Not healing

Secondary Intention = Consider all 4 healing status choices

Implanted Port - Accessed “Some sites, because they are being held open by a line

or needle, cannot fully granulate and may remain ‘non-healing’ while the line or needle is in place”

CMS OOCS 04/10 Q&A #14

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Approximated Incision Separates in Several Areas If the wound is not completely epithelialized for 30

days – openings are considered part of the original surgical wound

Assess all areas following WOCN Guideline

If one area is not healing, report the status as “Not Healing” for M1342 Healing Status of the Most Problematic Surgical Wound

Improvement in Surgical Wounds Assessment Accuracy

Dehiscence

Infection

Delayed wound healing

Systemic Factors

Education

Prevention of Complications

Dehiscence Day 7

Drainage

Signs or symptoms of infection

Mechanical stress

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Infection Increased mortality

Longer hospitalizations

Higher healthcare costs

Drainage > 48 hours

Systemic Factors Circulatory Disorders

Diabetes

Malnutrition

Patient Education Prevent Dehiscence

Splint incisions

Prevent strain

Monitor for and report signs of complications

Prevent Infection

Educate patients

Hand hygiene

Wound care

Promote Healing

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References Baranoski, S., & Ayello, E. (2008). Wound care essentials: Practice principles (2nd ed.).

Philadelphia: Lippincott Williams & Wilkins.

Benbow, M. (2005). Evidence-based wound management. London: Whurr Publishing.

Benbow, M. (2007). Healing and wound classification. Journal of Community Nursing, 21(9), 26-30.

Centers for Disease Control and Prevention. (2009). Centers for disease control and prevention: Your online source for credible health information. Retrieved from http://www.cdc.gov/nutrition/everyone/basics/protein.html

Centers for Medicare & Medicaid Services. (2007). CMS OCCB Q&As – May 2007. Retrieved from http://www.oasisanswers.com/downloads/CMS_OCCB_1st_Qtr_QandAs_May_2007.pdf

Centers for Medicare & Medicaid Services. (2007). CMS OCCB Q&As – October 2007. Retrieved from http://oasisanswers.com/downloads/CMS_OCCB_3rd_Qtr_QandAs_Oct_2007.pdf

Centers for Medicare & Medicaid Services. (2010). OASIS-C guidance manual. Retrieved from http://www.cms.gov/HomeHealthQualityInits/14_HHQIOASISUserManual.asp

Centers for Medicare & Medicaid Services. (2010). CMS OCCB Q&As – April 2010. Retrieved from http://www.oasisanswers.com/downloads/CMS%20OCCB%201st%20Qtr%20QAs_04_20_201 0_508c.pdf

Centers for Medicare & Medicaid Services. (2010). CMS OCCB Q&As – July 2010. Retrieved from http://oasisanswers.com/downloads/CMS_OCCB_2nd_Qtr_QAs_07_20_2010.pdf

References Continued Centers for Medicare & Medicaid Services. (2010). CMS OCCB Q&As – October 2010. Retrieved from

http://oasisanswers.com/downloads/CMS-OCCB-3rd-Qtr-QAs_10_19_2010.pdf Centers for Medicare & Medicaid Services. (2011). CMS OCCB Q&As – January 2011. Retrieved from

http://oasisanswers.com/downloads/CMS%20OCCB%204th%20Qtr%20QAs_01_19_11_Final.pdf Doughty, D. B. (2005). Preventing and managing surgical wound dehiscence. Advances in Skin and Wound Care. 18(6),

319-322. Hampton, S. (2007). Bacteria and wound healing. Journal of Community Nursing, 21(10), 32-40. Hunter, S., Thompson, P., Langemo, D., Hanson, D., & Anderson, J. (2007). Wound & skin care. Understanding wound

dehiscence. Nursing, 37(9), 28-30. Kaye, K., Anderson, D., Sloane, R., Chen, L., Choi, Y., Link, K., Sexton, D., & Schmader, K.(2009). The effect of surgical

site infection on older operative patients. Journal of American Geriatrics Society, 57(1), 46-54. Lee, S. K., (2006). The role of nutrition in treating and healing wounds. Nursing Homes: Long Term Care Management,

55(11), 26-30. National Institute of Health. (2010). Skin layers. Retrieved from

http://www.nlm.nih.gov/medlineplus/ency/imagepages/8912.htm. Peirce, B., Mackey, D., & McNichol, L. (2009). Wound ostomy continence nurses society guidance on OASIS-C

integumentary items. Retrieved from http://www.wocn.org/pdfs/GuidanceOASIS-C.pdf Schwien, T., & Lang, C. (2008). Changes in wound care outcomes analysis: New home health compare measures.

Retrieved from http://www.ocshomecare.com/OCSHomeCare/media/OCSHomeCare/White%20papers/Wounds_08- 002.pdf.

Vuolo, J. C., (2006). Assessment and management of surgical wounds in clinical practice. Nursing Standard, 20(52), 46-56.