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 offer 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

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.

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. 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 
• 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

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 Patient and Wound Assessment and Documentation

• 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 
• Determining the potential for functional healing of the ulcer. 
• 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, appropriate diagnostic examination to 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] 

Care Planning – Healthcare Professional Responsibilities

Care Plan Development

• Develop a care plan in accordance with the clinic's approved Wound Care Standards.
• Ensure the care plan is based on findings from the comprehensive patient and wound assessment.
• Interventions should account for patient-specific risk factors affecting wound healing, such as vascular supply, nutrition, smoking, co-morbidities, and medications.
• Collaborate with the interprofessional healthcare team based on the patient's needs and care objectives.

Intervention Inclusion

• Include strategies to maintain skin integrity, reduce the risk of skin breakdown, and facilitate wound healing, taking into account client-specific factors.
• Unless there's a change in wound condition or patient concerns arise, aim to maintain the current care plan for a minimum of two weeks.
• A wound assessment must be completed and documented with every dressing change.

Comprehensive Patient and Wound Management

The institution endorses the use of the topics and procedures developed by Wound Reference, including the resources listed in the section 'Guidance and Resources' below.

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. 
• Selection of primary and secondary dressings should follow established wound bed preparation principles. [4][5][6] 
  
• 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][7]:
• 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 with standard of care may require a new approach, which may include a physician reassessment of underlying infection, off-loading, biofilm, metabolic, nutritional, vascular problems which may inhibit wound healing, and differential diagnosis. [1][2] 
• Re-evaluation of the patient and ulcer should be performed before use of adjuvant therapies.[8][9]

Direct Supervision

• 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.

Documentation – Healthcare Professional Responsibilities

DOCUMENTATION REQUIREMENTS

• Record all wound assessments using the clinic's designated Wound Assessment Documentation Forms or computer-based charting tools.
• Document care plans and treatment protocols in the patient's health record.
• Note any significant changes in wound status in the progress notes.
• Provide the rationale for any treatment plan alterations in the progress notes.
• Document all changes to the care plan in progress notes, including the rationale for such changes.
• Obtain and document patient consent for wound photography.

Transfer of Care

• Plan of care, previous treatment plans, and wound assessments must be provided upon transfer to another facility or service area (e.g., Continuing Care).

GUIDANCE AND RESOURCES 

Patient and Wound Assessment

Selected topics are listed below. Please refer to the Wound Care Knowledge Base for the full list:

• Global Surgical Transfer of Care to the Wound Clinic 
  
• How to Assess a Patient with Chronic Wounds
• Chronic Wounds Essentials - Quick Reference
• How to Determine Healability of a Chronic Wound
• How to Perform An Ankle Brachial Index
• How to Screen, Assess and Manage Nutrition in Patients with Wounds
• Wound Culture - Swabs, Biopsies, Needle Aspiration
• How to Collect a Wound Swab (Levine Technique) for Culture
• Diabetic Foot Ulcers - Classification Systems
• Pressure Ulcers/Injuries - Classification/Staging
  

Wound Management

Selected topics are listed below. Please refer to the Wound Care Knowledge Base for the full list:

• Standard of Care: Foundations for Wound Management
• Arterial Ulcers - Guidelines and Quality Measures
• Venous Ulcers - Overview
• Diabetic Foot Ulcers - Clinical Guidelines and Quality Measures
• Pressure Ulcers/Injuries - Overview
• Wound Infection - Overview
  
• Debridement, State-by-State Regulations on Conservative Sharp Debridement by Nurses in the United States, How to Perform Conservative Sharp Wound Debridement
• How to Administer Local Anesthesia for Wound Care Procedures
  
• Dressing Essentials
• How to Select Offloading Devices
• How to Select Adequate Compression Therapy Pressure Levels and Products
  
• How to Select and Apply Negative Pressure Wound Therapy Devices
• How to Apply Cellular and/or Tissue Based Products