Transcript
Speaker: Remember that that in in a way, give them giving skin failure the the label skin failure versus Kennedy terminal ulcer or skin changes that life's in helps us in our conversations with families because they're already aware of heart failure and kidney failure and liver failure. And so when you're able to teach families about and also our colleagues, that the skin is the body's largest organ and like other organs, the skin can fail, then that skin failure term turns out to be a really useful term.
Speaker: Max, did you just get that? That's a very good way to put it. That was really good. yeah yeah so Hello, everyone. Welcome to Healing by Design.
Speaker: the podcast where we amplify the voices that matter most in wound care. I'm Jen Bierup and I am here with my co-host, Therese Laub. We are so glad you found us and we can't wait to dig into today's conversation.
Speaker: Before we jump in, I do wanna take just a quick moment to cover a few things. Everything we talk about on this podcast is meant to educate and inform. It's not medical advice and it shouldn't be taken as a diagnosis or treatment recommendations. Your situation is unique and your healthcare care provider is always your best resource for decisions about your care.
Speaker: The opinions our guests share are their own. They don't speak for POSIC or our sponsors. And if any of our guests have professional or financial ties to products or companies we discuss, we'll always be upfront about that. One more thing, if you're ever dealing with a wound care emergency, please don't look to us for that. Go to a provider right away. Now that we have all of the disclaimers out of the way, let's dive right into our show.
Speaker: So we are very excited to have our group here today. um and we want everybody to introduce themselves and have this amazing discussion on the skin failure. So why don't you all tell us a little bit about yourselves and where you come from in regards to this?
Speaker: um First of all, so grateful to be here today. My name is Ginny McGuire. I'm a physical therapist, certified wound specialist, I also loved wound care, wound management so much that I decided to study it and get my PhD in building wound teams and scaling them with technology. So in health education and promotion.
Speaker: ah And then I also got a certification in AI and healthcare care implementation. I am the co-founder and current president of the Post-Acute Wound Skin Integrity Council. I'm also a consultant, advisor, and educator for different groups in post-acute care, including wound provider groups.
Speaker: That's it for me. So my name is Beatriz Cochera Ward. have been in advanced practice nurse practitioner and a certified wound healing specialist since 1999.
Speaker: ah Prior to that, I was a wound care nurse at a hospital setting in Miami. I have practiced in wound healing in the hospital and in the outpatient setting. for over 25 years and then in 2020 during the pandemic i decided to open on called wound care which is a mobile wound care company that we go to the homes assisted living facilities and skilled nursing facilities to basically bring the wound clinic without wheels basically like you know we call it we're bringing the wound clinic to the patients um and um i have been doing that for the last six years um
Speaker: I'm a very good wound healing specialist. I'm not anything else, but I try to tell people, you know if you need a real doctor that takes care of everything, you need another doctor. But I love what I do and I truly believe in having a multidisciplinary team approach.
Speaker: and I truly involved everyone ah from the CNAs all the way up to the vascular surgeons and everybody else that needs to be involved in order to care of for the wound. I am in Florida and I'm originally from Colombia in South America.
Speaker: So I'm Diane Krasner and I started as a wound ostomy continence nurse in 1985, attending the Harrisburg Hospital program.
Speaker: I went on to get my PhD and did my dissertation work on wound pain. And from there, I got very interested in end-of-life wounds and co-chaired the Skin Changes at Life's End panel or scale panel that um published its consensus document in 2008.
Speaker: two thousand and eight So I've had a long interest in end-of-life wounds and skin failure. I i currently work as a skin and wound care consultant and do expert witness work in York, Pennsylvania.
Speaker: And I am the past president of POSIC and the treasurer of the Coalition for At-Risk Skin. So, you know, I have to say I started my nursing journey 22 years ago and I started as an ICU nurse.
Speaker: And so obviously in ICU, right, people were very sick and they were on pressers and they had a lot of failure, respiratory failure, cardiac failure. um i mean, we had people on balloon pumps right back then um and coming back from cardiac caths, pretty, you know, extensive STEMIs. So what I saw as a new nurse um I started to see, oh gosh, wait a second, this skin is failing. this This is an organ and it is failing. And it had a very distinct ah difference than really, oh, this is a pressure injury. And even 22 years ago, um you know, my mentor nurses would say, the skin is an organ. The skin is failing here.
Speaker: You know, and we need to be careful. Or the patient is on a presser. Their blood pressure is nothing. We're really clamping down. And so we're going to not get the perfusion that we need to get. And so we need to watch our patients because their skin is going to fail.
Speaker: And so, you know, coming from an ICU perspective, this was something that we we were already, you know, thinking about in that particular setting. And so, you know, if we look at, okay, skin failure versus pressure injury, the great debate, let's let's talk a little bit about distinguishing between the pressure injur injuries, distinguishing between Kennedy scale. And then I really am excited to hear from you guys about unavoidable pressure injuries versus skin failure.
Speaker: So tell me a little bit about the differences because I can't wait to hear. And before we jump into that conversation, it's so hard for me not to interject on what you just said, because as an ICU nurse, boots on the ground, what you just expressed to us is what we have heard from nurses, from providers and from therapists in every setting around the world.
Speaker: And that's one of the reasons why we believe that this is so important to really make sure everybody understands what this phenomena is so we can really improve the care of our patients. So I just wanted to share with you that what you saw is echoed by people everywhere.
Speaker: That's good to know. That's great to know. we We know that we understand bits and pieces about this phenomena and what distinguishes pressure injury from skin failure.
Speaker: Clinicians at the bedside feel like they can know it. They look at the whole patient and they look at the wound or the wounds and they they feel like they know the difference. But for us to have a list of signs and symptoms that you can just check off and say, this, this, this, it's skin failure. We're we're not there yet.
Speaker: And we we need, you know, we're going to need a whole lot of research and we're going to need research on, on population-based research on big data sets. But, know, there's some, there's so small studies that have been done that show us things like you've mentioned, Jen, that, um, you know, perfusion plays a part, pressers play a part, um, the critical multi-organ system failure, critical status, end of life, all those things. So, you know, what, what we're trying to do is paint a a big picture where all of the things we know are accepted into our understanding and we're not throwing anything out.
Speaker: So we're still saying to people, you know, if, if your facility is calling it a Kennedy terminal ulcer, still call that a Kennedy terminal ulcer, but you may be coding it as stage skin failure or, you know,
Speaker: still call it Tromboli-Brennan terminal tissue injury. And Mary just published in her group, just published a great new study. So there's going to be more and more information coming um that'll help us understand the, it's a complicated phenomenon.
Speaker: it is and it's that It's an umbrella term to Diane's point that encompasses skin changes at life's end and Kennedy terminal ulcer and so on and so forth. but it's also a phenomena that's recognized by CMS for many, many years now.
Speaker: And so our work, Pulse 6 work in this endeavor is really to help patients in nursing homes and all settings then understand exactly what CMS said since 2022 or 2023. Thank you. When it is indeed a skin breakdown,
Speaker: thank you when it is indeed a skin breakdown a wound or other from skin failure, then it is not coded as a pressure injury and should not be documented as such.
Speaker: However, what we're trying to do is give some guidance because what this is, is a physician, a provider diagnosis, looking at all those aspects that Diane just mentioned from perfusion to organ failure and so on.
Speaker: But it really is that provider who's going to work with the team to do that assessment and then make that diagnosis. That is exactly right. You hit it right on. I can think of a patient that ah recently I took upon our care. The patient was referred to us with a diagnosis of a bilateral heel stage three pressure injuries.
Speaker: And this is a lady that had dementia, that her dementia had gotten worse. She had urinary incontinence, fecal incontinence. So she had significant risk factors for wound healing and she had the decreased mobility as well. So initially the person that referred that patient to us diagnosed as a stage three pressure injuries. When I started looking at the entire patient, I realized that they're telling me that this patient had stopped eating solid foods for like four weeks um that her dementia had gotten worse.
Speaker: So I said, okay, so let me just look at this whole patient. I'm going to stay with this diagnosis of a stage three. And I started instituting everything I know,
Speaker: how to treat a stage three pressure injury. I did the offloading, the nutrition optimization, the turning schedule. We tried to help as much as we can in terms of the dementia, came back the week later. And now this patient not only had wounds on the heels, but now she had wounds on the medial aspect of both of her feet. And when she was completely offloaded, there was no friction, there was no shearing, there was no trauma. And I'm thinking, why would she develop these new wounds? She has no reason why to develop new wounds in terms of pressure because she's not getting pressure from anywhere. So now the picture started changing and and i have been documenting this progression and I have already did my differential diagnosis and I've already spoke to the family and the caregivers about the fact that this patient is actually showing signs of skin failure. So after my second week, I started just change my diagnosis from a pressure injury to a skin failure diagnosis. So this is not a diagnosis that you can just make from day one. Sometimes you need a little bit more time. There are some acute changes that can happen very acutely. For example, I've seen changes that can happen within hours and the patients pass away within 24 to 48 hours. But there are some chronic signs of skin failure that can last for several weeks, but the patient continues to decline. They eat less and less and less. Their mentation is less and less.
Speaker: So I do believe that it is very important to recognize that and ask providers to keep that in mind and don't just make that diagnosis right away.
Speaker: That's a really good point. And we see that with wound care all the time because a wound is truly an expression of what's going on in that person internally, externally, and so on. And so skin failure is not unique in sometimes it takes a while to get the diagnosis right.
Speaker: So think about how many times you might've seen a new patient or a new admission with a wound on the gator area. They have some issues with mobility. Maybe they have some edema. Maybe they have some hemocytorin. And you think, logically, Venus. And then you find out later, after more information becomes ah aware to ah more awareness to more information, you find out about comorbid conditions, maybe Crohn's disease, and so on and so forth.
Speaker: And you find out that it's actually pyroderma. And so this is not uncommon. that as we get to understand the patient and all their other conditions, then the diagnosis becomes clear.
Speaker: That's a great point. On that specific patient that we were talking about, I forgot to tell you that immediately when I saw her, I didn't have my ABI machine. But the next week I came back, I came back with my ABI machine. I did a complete ABI. It was completely normal. But then she had new wounds. So then that's when the whole picture started becoming more clear. I said, well, this is not... a poor perfusion issue. This is not that we're not offloading. She's failing. The body is failing. The skin, which is our largest organ, is also failing.
Speaker: It is not that we're not providing good care, which is very important to explain it to the patient and the family members and the caregivers, because there is sometimes that feeling of guilt. What are we doing wrong? you know and it's very important to recognize that.
Speaker: I think as you guys are talking too, um it's it's starting to become clear that documentation is going to be huge when we talk about this diagnosis, right? Because it's not something you walk into and you say, this is what's going on. it's it's It's a conglomeration of everything that's going on with that patient that you have to show. is in your documentation that supports as you're going towards that diagnosis, why you did and how you came to that conclusion. Does that? Absolutely. Yeah. So if I may add, you need to a lot of people focus on documenting the wound.
Speaker: And I think that's when they fail. They need to document their differential diagnosis, their reasoning, the patient's trajectory. The patient has been offloading properly for this amount of time. An ABI was completed. You know, everything so that the trajectory can show that, yes, you have done all a B, and C, and still the skin is fading. And with...
Speaker: I'm sorry, the archetype of the human that is at risk for skin failure is the same as the human at risk for a pressure injury. So, you know, certainly somebody at the end of life with multi-organ failure, perfusion issues is also likely to have mobility issues and sensory issues.
Speaker: And so we want to make sure that we're recognizing there's risk for pressure injury and there's also risk for skin failure. And many of those interventions are the same.
Speaker: We definitely have to document that we're doing the offloading, the turning, the nutrition, the skincare, the skin check. But we also need to, to Beatrice's point, have conversations with the patient and or the family, whatever's appropriate, what is skin failure and what are the risk factors?
Speaker: Because when somebody does develop skin failure, It's not the skin failure necessarily that causes a lot of upset. It can. It's very upsetting to look at when it's your loved one.
Speaker: But it's really upsetting if it's a surprise, making sure that that family is aware that this is a possibility. We're still going to do all these things. But even in some cases, when it is indeed skin failure, organ failure, we can't prevent this.
Speaker: But we will catch it early and make your loved one as comfortable as possible. Exactly. And that is so important. I've had these conversations many, many times. And it's great because the patient's families are not surprised. They actually maybe start calling their family members that live up north. In my case, you're in Florida. You know what? Mom is actually getting worse, she's not eating, her wounds are getting worse, and maybe as they start bringing people along, and they actually appreciate that communication, as opposed to being punitive. Well, their she's not being turned, and that's what, you know what I'm saying? So it's very, very important that we look at the whole patient, and we bring all these things that are failing. Well, it's also her kidneys. She's not urinating as much. Her mentation, she's not, you know, responding as much. So I think that is so important, Janine.
Speaker: Tell me now a little bit, because I think we've all kind of touched on this, and you know, this is a huge deal, right? And especially in the SNF and long-term care world. Help our listeners understand the difference now between avoidable, unavoidable. How does skin failure play into that? How does the documentation need to look? Because I think this, ah this you know, as Placid kind of really brings us to the forefront, and we'll talk about those codes in a little bit, it's really going to become huge here, right? Because a lot of our facilities get dinged for things that truly were unavoidable because they were misdiagnosed. So I guess tell me about that a little bit.
Speaker: Well, yeah i want to I want to go back to Therese's comment about documentation because I think that that's really important to speak to. And we've we've heard, we have a ah group called the Skin Failure Shared Interest Group of POSIC.
Speaker: And in discussions with members of the SF-SIG, We've heard about a number of different facilities.
Speaker: um Mostly we've heard from those in in ah the northeast of the United States that have implemented skin failure protocols in their hospital systems or their SNF systems. And one of the most important things they do is standardize the approach to documentation of skin failure and ah the what the womb nurses may be documenting. And then the consults they give to their um consulting physician
Speaker: Many of them have one physician who oversees the skin failure program and who who writes a very specific kind of note that addresses those issues that are going to highlight the distinction between skin failure and pressure injury. So you've got providers and wound expert nurses who have have been trained and have standardized the language that they're using in their facilities to make those distinctions clear.
Speaker: and they've got kind of template verbiage that they're using. And I think that's the approach that we'll see taken more and more as more and more hospital systems implement the skin failure protocols within their hospitals.
Speaker: They're doing that before we even have codes because they they feel a need for ah um a million reasons um to be able to distinguish this in their patients across the continuum, be they patients in ICU or patients you know in their hospice unit. But they they they see it clinically and they need to address it even if it takes us another year or two to get coats.
Speaker: That is so important, Diane. And I'll add on one more thing about that Skin Failure Shared Interest Group. Their next project is to work on a patient education guide for skin failure.
Speaker: So definitely check out those resources. And then Jen, I want to bounce back to your question then. So what's the difference between avoidable, unavoidable and skin failure?
Speaker: And this is one thing that Drives me a little bit crazy because regulatory on a regulatory defines avoidable, unavoidable. Avoidable, unavoidable is a regulatory construct.
Speaker: It is not a medical diagnosis. And if you want to read about it, look at FTAG 686, the surveyor guidance tool. Look at the critical element pathway for FTAG 686, and you'll see that it has four things.
Speaker: You have to evaluate for all the risk factors. They don't care about a score, the specific risk factors. Then you have to implement interventions for each risk factor 24-7. Then you have to evaluate those interventions and then revise them.
Speaker: The reason why I'm spelling that out is if you are a mobile wound group, a provider, there is no way you can attest to those four pieces. You are not in that facility 24-7. yeah.
Speaker: the nursing staff is. So avoidable, unavoidable is a team approach in that facility led by a nurse leader, usually signed off, usually by a DON using the critical element pathway.
Speaker: That is not at all skin failure. Skin failure is a medical diagnosis. So although it is also In theory, unavoidable, it's not part of the regulatory term for a pressure injury.
Speaker: so I hope i clarified that. so providers, don't write avoidable, unavoidable, please. You could be part of that root cause analysis and you should be, but it's your role.
Speaker: If it is indeed organ failure, skin failure, you are providing that diagnosis. And as Diane said, in a standardized way, that assessment, And how that gets communicated to the team.
Speaker: Thank you, Janine, because that was always my question. You know, I'm like, OK, is it are all unavoidable pressure injury skin failure? like know you know No. No. But some are. But I mean, that's the question that we're going to get, right? We're going to get those types of questions. And so I'm happy that we are really kind of hitting this head on because, you know, and you're right, Diane, we have to have the same language across the board and we have to have the same ah algorithms, if you will, or clinical decision making tools, because if we don't, then we are going to be all over the place.
Speaker: And i do want to kind of talk a little bit. I have a couple of things. But first, I really kind of want to dive into the POSIC code situation in that there's more than just the acute code. And I think I want, Diane, if you can kind of touch upon some of the different codes just a little bit so we can kind of understand those just little And these are, I want to put a little asterisk, is that these are not current codes. These are these are codes that POSIC is championing and hoping to um to be able to to acquire so that way we can start to identify these patients. So I guess, Diane, kind of give us a little background about that. So I'll give you a quick summary. So we've been putting forth codes since 2023 when we first heard that CMS made that ruling.
Speaker: um And it's been an evolution. um And we have our latest code proposal called a tabular modification before the ICD-CM committee now.
Speaker: Essentially, we use Diane Langamo's conceptual framework as the basis for our code proposal. So we've divided the codes into acute, chronic, and end-stage, as defined by Langomo in our article. And that's a whole conversation that we're not going to get into. no But it's not, acute doesn't mean acute care.
Speaker: Acute means the underlying, acute underlying condition that causes the hypoperfusion. So everyone's going to have to read Diane's article, um,
Speaker: in order to to really understand this. so That was published in 2006, She did that work. Oh, wow. Okay. You know, it's it's amazing. um So within each classification, there are six or seven right now, six or seven different codes.
Speaker: And for each one, they go by skin intact, partial thickness, full thickness, or unspecified. And so that enables us, I'll just give you one example for end-stage skin failure. It enables us to, let's say, we see a trombolibrenin terminal tissue injury where the skin's intact.
Speaker: That would be end-stage skin intact versus a Kennedy lesion. That's partial thickness. That would be end-stage partial thickness versus a full-blown malignant wound, skin changes at life's end, that would be end-stage skin failure, end-stage skin failure, full thickness.
Speaker: So sometimes the provider doesn't really talk about depth. They just say,
Speaker: Skin failure, end stage, no depth. That's where the coder would be using those unspecified codes. So we're looking at something like 25 to codes within the skin failure or tabular modification at the present time.
Speaker: But it might change. So we're we're going through at least one more round with the ICD-10 committee. um And that's for the U.S. And then...
Speaker: Of course, there's a whole international effort that will have to happen, both for ICD-11 um and for other countries, that many of whom have their own unique ICD coding, like us in the United States. you know We're the only ones that use the ICD-10-CM. Australia has one. Germany has one. So it's going to go...
Speaker: bit by bit, taking lots of time, unfortunately, but that's just how the system is. But at least if if we clinicians know about it, that that's the most important thing.
Speaker: um Because at the end of the day, we'll be delivering the right care for the patients. And to your point, that that is very important that as clinicians and providers, we learn to recognize that.
Speaker: I have seen some people that they, then when the nurses come, for example, I usually go to this facility, skilled nursing facility on Tuesdays, and I've been approached by nursing and they tell me, Dr. B, please, I have a doctor in nursing, so they call me Dr. B. So Dr. B, please come to see this patient. She only had like a little skin discoloration.
Speaker: on her tailbone you know she's been eating less and less and we know she's you know she's in hospice but you know can you please take a look at it and and then i look at the patient and then i'm i kid you not within hours that patient started deteriorating then that's when you start calling everybody in their families because you want them to know what is going on In case they want to come because you know this is going to be that acute type of skin failure as opposed to the other one that you've been very slowly like my other lady that I was telling you with the heels that has been very progressive. It's been almost three and a half weeks and now I saw her yesterday. She's actually even worse. So very slow.
Speaker: So there is a difference between that acute presentation and the chronic and your interventions, even when he comes to maybe not doing anything in terms of medicine, but the educating the staff and the family of what to expect is important to recognize the difference.
Speaker: So I have a crazy question. Oh, sorry. Because if if if patients and families don't know What happens? yeah Then they they get angry and they assume that something must have been done done wrong if my mother got wound that looked like this.
Speaker: and And oftentimes we really fail by not explaining what is happening. And then that's when people sue.
Speaker: And read those lawsuits hurt everybody. they They don't resolve the issue, the unexplained understandings for families. They make the caregivers feel guilty or inadequate when if it is in fact skin failure, this is nobody's fault.
Speaker: And it's no no more anybody's negligence than is you know heart failure or kidney failure. I mean, it just is. It's not anyone's fault. But because we haven't explained things well to patients, families, caregivers, and to ourselves,
Speaker: we get in these terrible binds and you know, I do a lot of legal consulting and i would say that at least 90% of the cases that I've been reviewing in the last decade are related to end of life skin failure.
Speaker: Wow. And it, it, it, they, they shouldn't even be brought as lawsuits. Wow. But they're, they become lawsuits because of our, our inability to um
Speaker: diagnose what's happening and have an understanding. So that that's why this understanding skin failure is so important.
Speaker: I agree, I agree. And I think it it comes exactly from at the provider level, because if the provider diagnoses the patient with the pressure injury, That's where it starts as opposed to maybe mentioning the pressure injury, but identifying the multiple risk factors for wound healing that that person identified upon that diagnosis and maybe throwing in the documentation, the fact that this patient has been already provided with all the evidence-based practice approaches to prevent or treat pressure injuries. And in spite of these, we're not treating we're not responding and blah, blah, blah. So these actually beefs up your documentation to show that you already spoke to the family, you already spoke to everybody.
Speaker: And as opposed to just calling it a pressure injury without really showing the rest of the picture or all the other interventions that you have instituted and that you have been documenting and that you've been educating the patient, the family and the staff about it.
Speaker: It starts at a provider level. Well, I think the nurses have some responsibility to that, that ICU nurse who admits a patient who's in acute respiratory failure,
Speaker: and is on pressers and um gets ah automatically gets the diagnosis of risk for skin failure, ah risk for pressure risk for pressure injury.
Speaker: i mean, they always do that. They put in the pressure injury prevention bundle, but that patient should be also getting the diagnosis risk for skin failure because they're probably more at risk for skin failure than they are for pressure because the pressure injury prevention bundles already in place.
Speaker: That's a great point. sos It's a paradigm shift. It's a paradigm shift. It's taking off your old lenses that saw everything as a pressure injury and and beginning to say, wait a minute, you know, it might not be so. And in some of the some of the hospitals that are looking at their preliminary data from the implementation of the skin failure protocols,
Speaker: 50% of the patients that had been labeled pressure injury were really skin failure. So this begs the question, and I'm going to throw it right out there because we have, and we've talked about this, I think there's a common theme in all of our podcasts. It's we're not a specialty.
Speaker: We don't have the education. We have... a So many charts that we look through that we can't even stage a real pressure injury correctly most of the time. And what, Janine, we can only get it right 70% of the time, overall diagnoses. So if if if we can't even like do the basic stuff right, correct, we can't even do that. Now we're bringing in whole whole... whole new concept and a whole new group of things to learn.
Speaker: You know, Beatrice, I want to hear from you. Where is this going to go? Because I see a mass amount of confusion because we can't even stage a three right at this point.
Speaker: I think it comes down to empowering our nurses with the critical thinking that they need to start not looking like Diane said, just one diagnosis, one nursing diagnosis, but looking at the entire patient, not just the hole in the patient like we call it. Don't look at the hole in the patient, look at the whole patient. And I feel that we need to really shift our paradigm to not only look at the skin, but the entire patient. What is going on with this patient's heart? Is his heart actually pumping enough blood to bring to the oxygen, to the to the sacral area?
Speaker: We always think about the blood needing to pump to the feet, but what about the other areas that need to be perfused? So when we stay away from just looking at the skin and wound care and all that, and we look at the organs, the kidneys, are the kidneys filtering the urine? are you know All of these things is when we really need to start empowering our nurses and shifting our paradigm to and start looking at assessing risk factors for wound healing from the moment the patient walks through that door into the hospital, into the leave into the assisted living facility. And when we have that identification of the risk factors for wound healing, Then we start implementing all of our interventions, nursing diagnoses and all of that prevention protocols, but looking at everything. So I agree with you. I feel that there is much more to be done, but it all starts with our nurses, education and with our providers. The fact of the matter is that our physicians, too, what do they get, like 20 percent of wound healing education? even then they think Not even that. And they think it is actually, right. And they think it is wound care.
Speaker: But when they so when you start actually telling them, hey, it's it's actually when when you're looking at that patient with heart failure, are you thinking already that they could get a pressure injury because they're hypoperfusing?
Speaker: That is when we need to start changing, shifting our paradigm like Diane was mentioning. That almost goes back. Oh, sorry. chera by No, I just going to say that that kind of goes back to looking at us as as wound care as a specialty so we can have all of those those things in place.
Speaker: You know, so that's what was going say. Yeah, that's and I was going to add to that in the same vein, almost in that. you know, historically wounds were really viewed as it's the nurse's fault, it's the nurse's problem, and they need to find this specialty band-aid or ointment or gel. This skin failure is really just helping us look at the patient much deeper.
Speaker: to every to your point, Beatrice, you know, whole person evaluating them in context to mobility, nutrition, chronic disease, vascularity, and so on and so forth.
Speaker: And not only could it be a pressure injury or a skin failure or a DFU or a VLU or pyriderma or a hundred other things, if we don't have a specialty that identifies the roles of the different disciplines, because I will argue for the physical therapist as well right in this setting, if that PT is calling it pressure,
Speaker: And the physician's calling it skin failure and the nurse is calling it DFU. Diane, how's that going to look in litigation? Right, exactly. So we all have to be on the same page. And for that, it really does need to be a specialty with algorithms that are consistent and standardized.
Speaker: No, absolutely, because we're not there yet. Yeah. Sorry. Yeah, go ahead. No, I just had a quick question because this is so interesting. You're talking about, you know, other diagnoses in conjunction with, right, the skin failure, like the pressure injury or the foot ulcer or whatever. um Are you thinking as this moves forward that it's going to be in conjunction with another diagnosis, like it's going to be skin failure with pressure injury, because there is a down downward effect when you look at like even products that are ordered for the patient, because our our our DME, the way it's set up with ordering and LCDs and everything, it's very targeted at the diagnosis of the wound, right? Some of the some of the products. So I'm curious how that would fit in. And if you're looking at that in that light.
Speaker: Well, and and that's that's why it takes so long to get a code through and and then to, once it's passed and approved by the ICD-10 committee, it takes another year for the trickle-down effect to go to all the DME and across the continuum. because And right now...
Speaker: we've got all these disconnects when there are transitions of care. And we know that's happening and it's unfortunate, so that if it ah but there's no there's no answer yet.
Speaker: And there's gonna be a difficult transition period when an acute care facility, for example, diagnosis a wound as skin failure um and the patient ends up being transferred to a skilled nursing facility.
Speaker: And they can't get the products they need because they would only provide them if it were the diagnosis was pressure injury. So they can't get specialty bed and they can't get the dressings. And so we we have you know made the powers that be aware of this, um the urgency of getting this fixed because it's happening every single day that across the continuum,
Speaker: you've got these patients falling through the cracks. So they're aware of it, but it there's not an easy fix here. Right. And i'll I'll add to that, Therese, you know, there's a lot of wounds that are from multiple etiologies. You know, think about how many people with a VLU also have arterial insufficiency. And the guidance has always been, well, what's the primary cause, which isn't always easy to figure out. Right. But I think to Diane's point, you know, there needs to be one overarching. And that I think was also CMS's point when they said that, you know, if it's from skin failure, don't code it as pressure ah because that's not the primary cause. It doesn't necessarily mean that there's the the human body is void of pressure altogether. Mm-hmm.
Speaker: Could you theoretically, because I will say this, i mean, I've often thought of this, mean, forever. So I'm just gonna throw this out here. So like, so we have a patient, right? And they really, they they do have multiple comorbidities. um And this is to your point, Janine, is okay, we have somebody with a VLU. We know for a fact it's a VLU. They have, um you know, venous studies that come back that we have reflux, they have hemocedrine staining, they they have all the classic symptoms.
Speaker: they' Their perfusion is okay enough. Like it's okay. But they have – let's just say they have an underlying cancer. They have an underlying – they have all these other things that are going on, right? So is it theoretically possible – and I have said this. I've said this is a venous leg ulcer, right?
Speaker: But this is also skin failure. The skin as an organ is struggling to heal. Like it can't do what it – we're doing everything we can, Right. And in all intents and purposes, we should be making progress, but we're not making, and we've even ruled out atypical here, right? But we have all these other comorbidities that this patient is struggling with. I have said this this skin is not responding like it's supposed to because the skin is is really starting to fail. Could we have a secondary diagnosis? Could we have a VLU as a primary? And then could we have... chronic skin failure as a secondary? and And would that help define then some algorithms and where we need to go and help understand, you know, maybe what trajectory that patient should be in? So that way we set the right expectations, we have the right communication, and that way we're using supplies and products appropriately and and all of that. So, you know, that that is always in the back of my mind.
Speaker: I'm going to tell you what I i do. And please, Janine, let me know if if this is okay. But what I usually do is that, let's say, for example, I have a non-healing wound. I'm just going to make a hypothetical ex example. I have ah a patient with a chronic disease.
Speaker: because it has been there more than four weeks, a chronic non-healing wound at the right distal medial lower leg. Typical location for a venous stasis also, right? And then I am going to say that my multiple risk factors for wound healing are advanced age, decreased mobility, immunocompromised status due to cancer diagnosis with bone metastasis,
Speaker: venous insufficiency, urinary incontinence, malnutrition with decreased intake of solid and food. So all of those basically support the fact that this probably this is a skin failure. So along with that, I am going to put in another diagnosis that says failure to thrive.
Speaker: So I'm having my initial diagnosis of the right distal medial lower leg. venous insufficiency, ulcer, my failure to thrive diagnosis, and then my multiple risk factors for wound healing, the immunocompromised status, the nutrition, the venous insufficiency, and all of that. On my documentation, I'm going to say I discuss with the patient, the family, the caregivers, the significant risk factors for wound healing. I am concerned about the fact that the patient as show is showing signs of
Speaker: worsening malnutrition with decreased food intake and some signs of skin failure. So I throw it in there. So I think that is what I am doing to show that basically we're doing we're doing the elevation, we're doing the compression. i already did my ABI. We're trying to optimize the nutrition, but the patient is not eating. We already gave him the appetite to the stimulant and the patient is not eating.
Speaker: So all of my my notes are huge and people that know me know, my notes are huge but I paint this story. So when you paint this story, when you read it, you're like, OK, OK, I explain. You know what I'm saying? um Is that Janine? I would love to hear from you because. This is just my opinion. My opinion is, yes, you're painting the human story and it gives good rationale as to what's happening. And as a e um clinician,
Speaker: when I'm looking at somebody and having that conversation with myself, one of the things I ask is, if we have opportunity to do the most aggressive measures with this person, revascularization procedure, maybe some serious debridement, and so on and so forth,
Speaker: are they capable of surviving those procedures? That's great point. That's a great point. If they are capable of surviving, would their quality of life be better or worse because of those procedures?
Speaker: And that really helps have the team. I'm a physical therapist. I'm not a physician. it helps a team conversation around what's possible and kind of helps me land in the place of understanding that this is indeed a palliative trajector trajectory in some circumstances. And it helps kind of guide that conversation with the family as well.
Speaker: Because most families, obviously skin is upsetting to see, it's visible, it's emotional. You want to throw everything in the kitchen sink at that person for that wound to heal. But it's so important to understand that those interventions could cause mom or dad a lot more pain and they might be in a worse situation, not better.
Speaker: And again, your documentation, your transparent documentation stating, I discussed with the patient and the family the fact that ah the patient is very frail and will not be able to you know go through any type of vascular surgical intervention. And at this point, we're trying to do a palliative approach, understanding that the wound may not heal, but we're preventing from getting infected, pain, having pain and being hospitalized.
Speaker: That documentation and that transparency and the time that you take matters. And when when I'm a reviewing a record and it has the sort of information that you've just talked about, Bea, and it's documented, you know I can go to the attorney and say,
Speaker: the the The picture's been painted. It is clear from the record that's that all the appropriate things were done, that the standard of care was met, and that this is documented skin failure.
Speaker: And the at that point, the attorney can go and he can settle this case. he can Or he can even make it go away completely. um and And that that's what it takes to help defend ourselves and protect ourselves in this environment. the The real dilemma occurs when there's no documentation at all or minimal documentation. And we don't have any understanding or rationale about for why things were done and what the, what the wound really was. And that's, you know, that's when we get into trouble legally.
Speaker: and And two things to add on that from a provider perspective. So working with provider first providers for 20 years in wound management, what I've learned is it's not one conversation and be, you probably can attest to that, that often it takes families time to digest this information and understand it psychologically.
Speaker: The second thing is it has to be a provider having this conversation with the family. okay They're not going to accept that from anybody else on the team. So it needs to be the provider leading it.
Speaker: And you don't want anybody else. You don't want the pesky PT walking in after and calling it some other wound type. So the provider should also sit with the team and make sure everybody's on the same page So none of us are giving the family mixed messages.
Speaker: Yep. I agree 100%. You need to have a leader. You need to have somebody that can be approaching the family and explaining everything to them as it is happening weekly or daily so they are not surprised.
Speaker: and they need to document it properly so it doesn't happen like what Diane was saying that then you come back into finding out that they're suing and then you look at the record and there is nothing documented about it except for the fact that maybe you put the lower loss mattress or whatever that doesn't mean just because you're doing a turning schedule doesn't mean that the tissue but is going to be viable just because you're doing the you know put it you know you has has to be everything And Diane, so I need to i need to understand that. are we i a I am very skeptical.
Speaker: And I don't mean to be skeptical. I don't mean to be negative. I really don't. But it's only because, you know, I continue to look at charts and I continue to look at things. And Bea, if we could like reproduce 6,000 of you across the country, that would be absolutely amazing. Can we like can we just like copy, like clone you? was trying to clone myself to help myself in the business. and that be like I mean, like if if if I could have one wish, it would be to have 50 of you here, like like in my part of Ohio.
Speaker: um um But, you know, but we don't. And that's the reality. And so my question is, is are we going to have providers that just say, oh, it's skin failure? And then we're just going to default to that because that's fine that's the easy way out, because our documentation in wound care is dismal.
Speaker: It's absolutely dismal and it's getting worse. Now, we have AI around the corner. We have technology around the corner that I think can really, really help us with this. But it's still such a lack of knowledge and it's still such a lack of thoroughness. And we still, we in wound care, we're supposed to look at the whole patient, right, for every diagnosis, right? And we don't do that at all. So in this, we're we're forced to do it now in skin failure. But my question is, is that legally, you know, are we going to just put people in the bucket of skin failure and walk away and go, oh, we tried?
Speaker: Well, there certainly are are people that are afraid of that. um and And some of the people who oppose and groups that oppose the the codes for skin failure are worried about that.
Speaker: But... um There's no doubt fat that this is this is going to be a challenging journey. We've been challenged with just getting codes.
Speaker: But once the codes get passed, then we've got the big, enormous challenge of educating and implementing and putting these symptoms sick symptom systems in place.
Speaker: But what what certainly it's pointed out as we've looked at what it takes to put skin failure in place, that a lot of things are being done done wrong with wound care across the board.
Speaker: pressure Pressure injuries, for example, are are not being diagnosed by providers the way Medicare and Medicaid require. They're being diagnosed by you know LPNs and CFS because there's no one else who's interested in doing it. So all all of that is going to get eventually fixed as all of this goes into play.
Speaker: And, but we're, you know, POSC is has committed to taking the lead in the education on this, but it's going to require the involvement of all of our endorsing organizations and other partners, um,
Speaker: to put this into place. The big organizations like the American Hospital Association and ACA and you know ah big groups because wound care is teeny.
Speaker: And this this goes across the continuum of care. ah All patient populations from ICU to The home health. Yeah. the home health yeah home and house I mean, home health, that's a whole nother animal to train. was just going to say, there's so many patients at home in hospice that they have it. And um I think putting an algorithm ah like like I know you've been thinking about and differentiating and does the patient has this, this, this, but it's still, it comes down to education, not only at the provider level, but at the nursing level, at the CNA level.
Speaker: um it it It's a big endeavor. So Janine, tell me a little bit about what POSIC has committed to on the education side of this, because I think it's important, you know, what what where POSIC is at, understanding the level of education needed. Kind of fill us in a little bit about that just quickly, if you can. So POSIC's vision and mission is to be the source and advocate for all those at risk of skin impairment and wounds and who have skin impairment and wounds. And skin failure fits perfectly in our whole our whole endeavor for advocacy for that very reason. And so we've been working with different organizations from around the globe.
Speaker: We are committed to working with them, to collaborating with them, to really spearheading the educational efforts for skin failure, as well as other wound types. Because misdiagnosis, Jen, as you pointed out earlier, is not just skin failure. Misdiagnosis of all wounds is a tremendous issue that affects patients and their caregivers in all settings. And so skin failure is really almost low-hanging fruit because CMS had already acknowledged it.
Speaker: And we see a lot of people today who are not being diagnosed who should be. They're on the wrong path of care. And so for me personally, I'm highly motivated to support this. And I can say on behalf of the entire board, we feel the same way. This is the right thing to do at the right time.
Speaker: So as we get to a close, tell me, let's let's talk a little bit about the position paper and and and what next steps are are with POSIC. So everybody just kind of give me your give me your thoughts and and kind of announce a little bit about what's going on with that.
Speaker: Well, I'll start. So um we've been working for the last four months um on what I call our magnum opus. It is the um ah paper that explains our position with regard to the necessity for coats for skin failure.
Speaker: um And we have produced a document which will be released ah September 15th, will be available on the POSIC website to download and we'll make it available to all our endorsing organizations and partner organizations and sponsors and members and anyone who wants it. um It's a self-published PDF that's been that's copyrighted to POSIC and will give organizations permission to reprint it and distribute it. And so it is the synthesis of all of our best thinking on, um you know, why skin failure codes are important, why getting the diagnosis right is important and the ramifications for um getting the right diagnosis across
Speaker: the continuum of care, regulatory, legal, and so on. So we were, you know, the, the documents over 40 pages long, we were able to put into this document, all the things that you can't just put in a sound bite with an extensive annotated bibliography.
Speaker: who i I'll just add to that first and foremost, you know, to give credit, tremendous credit to Dr. Diane Krasner for leading this work and leading us down this journey and this path with this really amazing publication.
Speaker: In addition to Dr. Krasner, we have Dr. Ron Rosen, we have Dr. Scott Bullhack, then we have our SIG chairs, we have Heidi Cross, Cindy Sylthia, Pamela Scarbaro, we've had our entire board of directors as reviewers.
Speaker: And Diane, I'm forgetting some names because there are so many people, but anybody else we want to shout out for all their work? Well, Janine herself, um who has also been one of the one of the primary authors and many others um who've been part of this journey um from from the beginning. But we felt, you know, we really felt the need to, to be able to respond to some of the editorials that have been written, some of the letters to the editor, ah but respond comprehensively.
Speaker: And that's what what this document's gonna do. And we will have this- Power story. Yes. And we will have this available, not right yet, correct? It's not gonna be available, but we will have it available um for our members? Is that something that will happen?
Speaker: Absolutely. So our ah read our anticipated release date is September 15th. And we will, within the document, there is a QR code opportunity for you to endorse the proposal.
Speaker: And that's going to be very important for us as we move forward on this advocacy path to show that we have um people who support what the document says.
Speaker: So look for that. Yeah. This is amazing. And, you know, ah on behalf of Therese and i we are excited to be in in the POSIC journey on this. And we're excited that we had you guys today to discuss this. Beatriz, to have Janine, to have Dr. Diane here with us today. Actually, we have all three doctors here today. So it has been you know all three doctors here today. um to have all of you here to have this incredibly important discussion, which needs to be had and we need to continue to talk about it. ah But again, on behalf of Healing by Design, thank you so much for joining us today. And I am looking forward to maybe a part two and season two of Healing by Design because I think we have a lot more to talk about. So thank you so much, guys, for being with us today. very welcome.
Speaker: Thank you you. Thank you. Thank you. and you I have to tell you, this is my, I had a podcast once when I started the company that somebody called me and they wanted to do a podcast with me to tell my story. And this is my second podcast in my entire career. So this is very, very fun. And I feel, I feel completely excited because this panel is amazing.
Speaker: Especially, I have to say, Dr. Kreisner, to have you here is like, wow, this is incredible. Well, we really was so thankful you joined us, be because, yeah you know, we we felt like we had a missing her leg of our stool. And we did. And we needed, you know, neither of us are an active clinical practice. And for you to tell your stories,
Speaker: Thank you. Thank you. This really means a lot. And adding credibility. It did. It was really good. So we're so thankful that we met you. Thank you. And actually, Beatriz, you're definitely like my new go-to person. And I think Therese and I, we're going to have a meeting with you because i have I want to talk about some things. And like you are amazing.
Speaker: Amazing. no i Amazing. And I like you we need to put you on a pedestal. And and and it's just so I am so, so thankful to to to meet you because um just like I love it. I love it. So um I'm here for you guys. just it i I feel very, very happy. I am just so happy that I reached out. I really i need I asked Janine. was like, I need to talk to you guys because I've been having all this.
Speaker: Patience and I just, you know, I'm not doing it right. i keep on saying the right words, but what Dr. Kreisner said is vital. You need to have the proper templates and documentation in order to just easily put them on your documentation when it's needed, though.
Speaker: I feel that what you said about the fact that we don't want everybody to start calling it a skin failure when it's not, it would be a huge problem. yeah But if you know that it is skin failure and you have done your differential diagnosis and you have looked at all your you know other issues that could be causing this, you really need to have your documentation ready in template forms and education and all that.
Speaker: Again, that's podcast number two, number three, and number four.
Speaker: And that's a wrap on today's episode. Thank you so much for spending time with us. These conversations are why we do this, and we don't take it lightly that you chose to listen to us today. Before we head out, just a reminder. Everything you heard today is meant to educate, not to replace the advice of your own healthcare care provider. Please don't make medical decisions based on what you hear on this show. Your provider is the right person for that.
Speaker: Our guests share their own opinions and experiences, not the official positions of POSIC or anyone who supports this show. If you're dealing with a wound care emergency, please get to someone who can help you right away.
Speaker: And if today's episode was useful, subscribe and share it with someone in your corner of wound care. It helps us reach the people who need it the most.
