POLICY HEADER

• Document Name: Operational Policy:   Advanced Wound Care Program Scope of Service   
• Document Number: WC-1
• Effective Date: __/__/__     Date of last revision:   __/__/__
• Administrator responsible:_________________________

PURPOSE

The purpose of this Policy is to enable the Wound Care Program that adopts it to o ffer its services to patients whose medical needs can be met within the capability of the Wound Care Program's staff and facilities, and to ensure that all patients treated will receive high  quality care in an expedient and professional manner.

POLICY

1. Patients: the Wound Care Program provides wound care consultation and related case management on an outpatient and inpatient basis to individuals without regard to their age, race, color, national origin, or ability to pay.
2. Medical Necessity Requirements for Wound Care Services and Procedures: Wound Care services will be provided to patients with wounds refractory to healing or that have complicated healing cycles either because of the nature of the wound itself or because of complicating metabolic and/or physiological factors. Post-operative wound care services may be provided to Medicare beneficiaries subject to the Global Surgical package, provided transfer of care to the wound clinic has been documented (see topic " Global Surgical Transfer of Care to the Wound Clinic"). The types of wounds expected to be included in this Policy are as listed, but not limited to the following  [1] [2]:
• 2nd and 3rd degree burns (see topic " Acute Burns")
• Surgical wounds that must be left open to heal by secondary intention
• Wound with biofilm
• Wounds associated with complicating autoimmune, metabolic, vascular, or pressure factors
• Open or closed wounds complicated by necrotic tissue and/or eschar
• Wounds that have various factors that complicate normal healing, such as subcutaneous  fluid and blood collections that require specialized drains or devices
• Pressure ulcers/injuries, venous ulcers, arterial ulcers, diabetic foot ulcers, traumatic wounds, inflammatory, vasculopathic, neoplastic ulcers, ulcers due to metabolic disorders
  
3. Wound Care Services: Wound care requires an initial evaluation and treatment by a physician or qualified non-physician provider, with subsequent regular follow up visits for re-evaluation.
• Wound care services thus involve identifying potential causes of delayed wound healing and modification of treatment as directed by a physician.
• Comprehensive assessment:
• Goals for assessment include:
• Determining the underlying cause(s) of delayed wound healing such as vascular disease, infection, diabetes or other metabolic disorders, immunosuppression, unrelieved pressure, radiation injury and malnutrition.  
• Determining risk factors for the underlying cause(s) and for potential associated complications
• If appropriate, classifying the ulcer(s) according to specific classification systems (e.g., for a diabetic foot ulcer, see topic " Diabetic Foot Ulcers - Classification Systems")
• Determining the potential for functional healing of the ulcer. See topic " How to Determine Healability of a Chronic Wound"
• Comprehensive patient evaluation to include pertinent medical and wound history, comorbidities, past medical history, social history, patient and caregiver's concerns, nutritional assessment, review of systems, physical examination
  
• Comprehensive wound assessment to include history and physical exam, wound exam with documentation of type of tissue, tissue percent (viable, necrotic, etc.), dimensions, shape, base, exudate, wound edges, undermining, periwound skin, absence/presence of infection, digital photograph  [3]  
• If applicable, a ppropriate diagnostic  examination t o  include (but not limited to) ankle brachial index, laboratory tests, nutritional parameters, hydration status, diabetes screen/control,  anemia evaluation, infection/osteomyelitis work-up, radiology body imaging, computer tomography, magnetic resonance imaging, and others  [3]  
• Comprehensive wound management to include: 
• Evidence-based, patient-centric treatment plans based on appropriate algorithms, focusing on control of complicating factors such as:
• Unrelieved pressure
• Infection
• Vascular compromise
• Uncontrolled metabolic derangement
• Nutritional deficiency
• Presence of necrotic tissue and debris 
• Patient  education  materials  that  describe  wound causes, relieving factors, treatment options, skin and wound care instructions, proper nutrition, and pressure-relieving measures [3]
• Selection of  appropriate compression therapy, offloading devices,  pressure-relief  seating and resting-support surfaces
• Debridement of ulcers as indicated, performed by professionals within their scope of practice. See topics " Debridement",  " State-by-State Regulations on Conservative Sharp Debridement by Nurses in the United States", " How to Perform Conservative Sharp Wound Debridement"
• Appropriate  referral to  other  specialties  as  necessary such as dermatology, dietary, endocrinology, infectious disease, occupational  therapy, orthopedics, orthotics, physical  therapy, plastics, podiatry, prosthetics, rheumatology, or vascular surgery  [3]
• Regular follow-up visits  at  strategic  intervals
• Reassessment of the patient and wound to assess whether the individualized treatment goals are being met, and whether  signs of improvement in response to the wound care service being provided are present. Evidence of improvement may include measurable changes in the following  [1] [2] [4]:
• Drainage
• Inflammation
• Swelling
• Pain and/or tenderness
• Wound dimensions (surface measurements, depth)
• Granulation tissue
• Necrotic tissue/slough
• Tunneling or undermining
• A wound that shows no improvement after 30 days may require a new approach, which may include a physician reassessment of underlying infection, off-loading, biofilm, metabolic, nutritional, or vascular problems which may inhibit wound healing. [1] [2]
• Direct supervision by a physician or qualified healthcare professional (depending on state regulations) is required at all times while patients receive wound care services at the Wound Care Program.