solving the compliance riddle with compression garments compliance compression... · 2018-08-07 ·...

Solving the Compliance Riddle with Compression Garments

Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC

Advisor, APMA Coding Committee

Advisor, APMA MACRA Task Force

Expert Panelist, Codingline

Fellow, American Academy of Podiatric Practice Management

Board of Directors, American Society of Podiatric Surgeons

Board of Directors, American Professional Wound Care Association

Editorial Advisory Board, WOUNDS

Twitter: @DrLehrman

FACTS: CHRONIC VENOUS ULCERS

Venous Ulcers account for 60-90% of leg ulcers

More common in women: 3X

Difficult to heal: 50% > 9 months/20% > 2 years

High rate of reccurrence: Up to 69%

Advances in Skin & Wound Care: August 2009 - Volume 22 - Issue 8 - p 384

http://journals.lww.com/aswcjournal/toc/2009/08000




VASCULAR MECHANICS

DEEP VEINS

SUPERFICIAL VEINS

COMMUNICATING VEINS (PERFORATORS)

VALVES

CALF PUMP

Hegarty M,: Am Overview of Compression Therapy. Today’s Wound Clinic vol 4 issue

10-Oct 2010.

NORMAL ANATOMY

VENOUS SYSTEM

DEEP VEINS SUPERFICIAL VEINS PERFORATORS

Semin Intervent Radiol. Sep 2005; 22(3): 147–156.

http://konstati.co/venous-anatomy-of-the-arm/venous-anatomy-of-the-arm-and-figure-1-anatomy-of-the-venous-system-of-the-

http://konstati.co/venous-anatomy-of-the-arm/venous-anatomy-of-the-arm-and-figure-1-anatomy-of-the-venous-system-of-the-neck-thoracic-inlet/

ARTERY

PROVIDES OXYGENATED

BLOOD TO THE LIMB

IS A FACTOR IN VENOUS

DISEASE 20% OF THE

TIME

http://legacy.owensboro.kctcs.edu/gcaplan/anat2/notes/APIINotes5%20Circulatory%20Anatomy.htm

http://legacy.owensboro.kctcs.edu/gcaplan/anat2/notes/APIINotes5 Circulatory Anatomy.htm

•Hypoxia in areas of venous congestion

•Growth factors get trapped

ANATOMICAL FAILURE

Venous Wall Physical Properties: Reduced Strength

Venous Valves

Primary Venous Disease: degenerative damage

Secondary Venous Disease: DVT

Calf Pump

90% of venous return is through these 3

Fletcher, Moffatt, Partsch, Vowden, Vowden: Principles of Compression in venous disease, a practitioner's guide to treatment andprevention of venous leg ulcers; Wounds International: 2013

LYMPHEDEMA

An abnormal collection of excessive tissue proteins, edema, chronic inflammation and fibrosis in the interstitial space.

Blockage in the lymphatic system

CHRONIC PROBLEM

EDEMA AND WOUND HEALING

Inflammation

Fibrosis

Induration

Elevated Proteases

Ischemia

ORGANIZED APPROACH TO WOUND CARE

1. Is there adequate perfusion

and/or oxygenation?

2. Is non-viable tissue present?

3. Are signs/symptoms of infection and/or inflammation present?

4. Is offloading or pressure relief appropriate?

5. Is edema controlled?

6. Is tissue growth optimized?

7. Is the wound microenvironment

conducive to healing?

8. Is pain controlled?

9. Are host factors optimized?

Disease Process

Controlled

Advanced ModalBalance

ities

Patient Centered Pain

Wound Moisture

Edema

Offloading

BioBurden

Debridement

Blood Flow

TREATMENTS

COUNTERACT GRAVITY EXERCISE

COMPRESSION

THERAPY

SURGERY

COMPRESSION THERAPY

• Application of pressure to the lower extremities.

• Recognized treatment of choice for venous leg ulcers.

• Systems include hose, tubular bandages, bungee systems, and bandage systems of two or morecomponents.

• These systems aim to provide graduated compression to the lower limb in order to improve venous return and to reduce edema.

http://wwundsinternational.com/pdf/content_10802.pdfw.wo

http://wwundsinternational.com/pdf/content_10802.pdfw.wo

HOW DO WE DEFINE THIS IN PRACTICE??????

TYPES OF COMPRESSION

ELASTIC

INELASTIC

STATIC

DYNAMIC

WRAPS

HOSE

TYPES

COMPRESSION WRAPS

COMRESSION HOSIERY

INTERMITTENT PNEUMATIC

COMPRESSION (IPC)

BUNGEE + ZIPPER

WHAT TO DO BEFORE COMPRESSION

VASCULAR SCREENING

Venous studies

• Duplex ultrasound

Arterial Doppler

PURPOSE OF COMPRESSION

1. Counteract the force of gravity and promote

the normal flow of venous blood up the leg

2. Acts on the venous and lymphatic systems to

improve venous and lymph return and reduce

edema

3. Causes narrowing of the superficial veins

Meissner,M, Lower Extremity Venous Anatomy, Interventional Radiology, Sept. 2005, ; 22(3): 147-158

WHAT IS ADAQUATE COMPRESSION

Overcomes intravenous pressure

Exerts a sub-bandage resting pressure that is well tolerated in a resting position

Provides a pressure increase when the patient

rises to a standing position: (50-70mmHG)

Provides external compression improving venousreflux during walking

Fletcher, Moffatt, Partsch, Vowden, Vowden: Principles of Compression in venous disease, a practitioner's guide to treatment and prevention of venous leg ulcers; Wounds International: 2013

Partsch, H; compression therapy of venous ulcers;, Hemodynamic effects depend on interface pressure and stiffness; EWMA Journal 2006, vol 6 NO2.

TYPES OF BANDAGES

Non-Stretch

Short –Stretch

Long -Stretch

NON-STRETCH

ZINC PASTE BANDAGES

SHORT STRETCH

Bandages that stretch to less than 100% of

their original length: minimal extensibility

High Working Pressure/Low Resting Pressure

LONG STRETCH

LONG STRETCH

Expands over 100% of its original length

Low Working Pressure/High Resting

Pressure

Contains Elastomeric Fibers: fibers that are able

to stretch and return to almost their original size.

World Union of Wound Healing societies (WUWHS). Principles of best practice: Compression in venous leg ulcers. A consensus document. London: MEP Ltd,2008

• Assess whether home care nurses achieve adequate subbandage pressure when treating patients with venous leg ulcers

• 13 months• 68 nurses

Delivery of compression therapy for venous leg ulcers AMA Dermatol. 2014 doi: 10.10010amadermatol.2013.7962 Zarchi Kl, Jemec GBI

Delivery of Compression Therapy for Venous Leg Ulcers



• Participant-masked measurements of subbandage pressure

• Three bandage types:

1. an elastic, long-stretch,

single-component bandage

2. an inelastic, short-stretch, single-component bandage

3. a multilayer, 2-component bandage



• Association between achievement of optimal pressure and

– Years in the profession

– Attendance at wound care

educational programs

– Previous work experience

– Confidence in bandaging ability



• A substantial variation in exerted pressures was found

11mm Hg exerted by an inelastic bandage80mm Hg exerted by a 2-component bandage



• The optimal subbandage pressure range, defined as 30 to 50 mm– 39 of 62 nurses (63%) applying the 2-

component bandage

– 28 of 68 nurses (41%) applying the

elastic bandage

– 27 of 68 nurses (40%) applying the

inelastic bandage



Pressures less than 30 mmHg

• Inelastic – 56%

• Elastic – 53%

• 2 component – 27%



• None of the investigated factors was associated with the ability to apply a bandage with optimal pressure.

Compliant Compression!

• Instead of Velcro, Bungee system to adjust compression

• No neoprene = no stretching out

• Breathable


• 10 DIFFERENT SIZES

• 30-50 mmHg

• Garment, Liner, Bag

• Different Lengths

• 15mmHg just from zipping

• Must have a venous stasis ulcer

• A6545

Recurrence

60% - 70%

• Below-knee graduated compression stockings or hosiery likely to prevent recurrence of venous leg ulcers

• Application of external pressure with compression to calf muscle raises interstitial pressure resulting in improved venous return and reduction in the venous hypertension

Compression for preventing recurrence of venous ulcers. Nelson EA, Bell-Syer SE, Cullum NACochrane Database Syst Rev. 2000; (4):CD002303.

Options

THINGS TO CONSIDERWHEN CHOOSING COMPRESSION

ETIOLOGY OF WOUND

PATIENT’S MOBILITY

PATIENT’S ACCESS TO CARE

ULCER SITE

PATIENT’S TOLERANCE

CLINICIANS LEVEL OF EXPERIENCE

COSTSullivan V: Compression Pitfalls: improving patient Adherence with Compression Therapy.

Today’s Wound Clinic. Vol 4 Issue 12-Dec 2010

HOSE/SUPPORT STOCKINGS

Made of elasticated textile

Styles: knee, thigh, pantyhose lengths

Custom or off-the-shelf

Can be used as first line treatment in

patients with small ulcers

2-component systems

LEVELS OF COMPRESSION

Class I: 14-18 mmHg: Anti-Embolism hose

Not a therapeutic level of compression

Class II: 18-24 mmHg: dependent edema,

non-ambulatory, CHF

Class III: 25-35mmHg: Venous Insufficiency

Class IV: Lymphedema, need to have active

muscle movement

EXERCISE!!

CALF RAISES CALF STRETCHES

MARCHES

DAILY WALKING

UP AND DOWN STAIRS

SWIMMING

Compliance

• Can’t get them on

• Uncomfortable

• Cannot tolerate level of compression required

Not using compression = High degree of recurrence

Compression for preventing recurrence of venous ulcers. Nelson EA, Bell-Syer SE, Cullum NA Cochrane Database Syst Rev. 2000; (4):CD002303.

•58% non-compliance failure in Class 3 stockings

Prevention of recurrence of venous ulceration: randomized controlled trial of class 2 and class 3 elastic compression. Nelson EA, Harper DR, Prescott RJ, Gibson B, Brown D, Ruckley CVJ Vasc Surg. 2006 Oct; 44(4):803-8

• Recurrence is common

• Recurrence is more common in patients who are noncompliant with compression therapy

Healing of venous ulcers in an ambulatory care program: the roles of chronic venous insufficiency and patient compliance JOURNAL OF VASCULAR SURGERY November[1995 Curtis A. Erickson, MD, Debbie J. Lanza, BSN, RVT, Donna L. Karp, BSN, RVT, Janice W. Edwards, RN, RVT, Gary R. Seabrook, MD, Robert A. Cambria, MD, Julie A. Freischlag, MD, and Jonathan B. Towne, MD, Milwaukee, Wis.

Healing of venous ulcers in an ambulatory care program: the roles of chronic venous insufficiency and patient compliance JOURNAL OF VASCULAR SURGERY November[1995 Curtis A. Erickson, MD, Debbie J. Lanza, BSN, RVT, Donna L. Karp, BSN, RVT, Janice W. Edwards, RN, RVT, Gary R. Seabrook, MD, Robert A. Cambria, MD, Julie A. Freischlag, MD, and Jonathan B. Towne, MD, Milwaukee, Wis.

• Compliance is dependent on compression garment


• Instead of Velcro, Bungee system to adjust compression

• No neoprene = no stretching out

• Breathable


• 10 DIFFERENT SIZES

• 30-50 mmHg

• Garment, Liner, Bag

• Different Lengths

• 15mmHg just from zipping

• Must have a venous stasis ulcer

• A6545

Conclusion

Solving the Compliance Riddle with Compression Garments

Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC

Advisor, APMA Coding Committee

Advisor, APMA MACRA Task Force

Expert Panelist, Codingline

Fellow, American Academy of Podiatric Practice Management

Board of Directors, American Society of Podiatric Surgeons

Board of Directors, American Professional Wound Care Association

Editorial Advisory Board, WOUNDS

Twitter: @DrLehrman

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