Archive for the ‘Wound Assessment & Documentation’ Category

Prior Authorization: New Rule in Effect for Pressure Reducing Support Surfaces

Wednesday, February 26th, 2020

Clinicians caring for Medicare beneficiaries who need pressure reducing support surfaces when discharged home are adapting to a new rule.

Those clinicians now need to submit a Prior Authorization Request for Pressure-Reducing Support Surfaces, said Cynthia Broadus, BSHA, RN, CHCRM, LNHA, CLNC, WCC, DWC, OMS, executive director at the National Alliance of Wound Care and Ostomy (NAWCO) in Somonauk, Ill.

The Prior Authorization Request for Pressure Reducing Support Surfaces is a rule established by the Centers for Medicare and Medicaid Services (CMS) that took effect Oct. 21, 2019.

Submitting the preauthorization documentation will identify the need for the pressure reducing support surface and provide the supporting documentation, according to Broadus.

“The authorization must be submitted before the support surface is supplied to the patient and before a claim can be submitted for payment,” she said.


The Head to Toe Search for Wounds

Tuesday, June 12th, 2018

A comprehensive skin assessment should look for more than just wounds because many medical problems have telltale signs that are easy to see if you know what to look for.

POA. These three little letters have become very important in wound care because we must document any wounds present on admission (POA). By doing so, we are saying that these wounds began somewhere else—maybe at home, maybe in another care setting, but definitely not while under the present facility’s care. This distinction of origin has great implications both financially and legally.


Stinging. Burning. Painful. Wounds Hurt!

Saturday, March 10th, 2018

Wound pain is sometimes difficult to quantify, but if a patient complains of pain, this requires effective and timely pain management. In the midst of the war on narcotics, that might mean looking for alternative pain management techniques and learning new approaches.

Several months ago, I was attacked by the most venomous scorpion in North America, the Arizona bark scorpion. This stealth attack happened while I slept in my own bed at home in our southern Nevada desert home. I woke up with a jolt knowing that something was terribly wrong with me, but not quite sure what was happening. I felt a fiery tingling pain in both my hands and my abdomen, yet at the same time I also had a total loss of feeling in those areas. I remember yelling to my family that I was paralyzed, but they were confused because I was running around and frantically waving my arms obviously not paralyzed at all. We only figured out what had happened when I tried to crawl back into bed and saw the scorpion on my pillow.

My scorpion stings were an indescribable sensation and unlike any type of pain I had ever experienced. Even today, I am struggling to find the words to tell you what it felt like. All I knew was that it hurt and was unlike any pain I had previously experienced or could even compare it to. For the record, I did some research afterward—people describe it as feeling quite similar to being electrocuted. Luckily, I can say that I was never electrocuted, but that is how people describe it.

Just as luckily, I have never had a pressure injury or a diabetic foot ulcer, so I am not really sure what those feel like either. My patients tell me they hurt. Some patients seem like they are in extreme pain, while others seem to have only mild pain. How do we quantify wound pain, and more importantly, how do we manage it effectively?


Lower Extremity Ulcers and the Toe Brachial Pressure Index

Friday, January 19th, 2018

To treat patients with lower extremity ulcers, you need to find out if there’s impaired arterial blood flow. For some patients, however, the standard Ankle Brachial Index (ABI) yields misleading results. Fortunately, there’s an easy alternative: the Toe Brachial Pressure Index (TBPI).  Here’s when and how to perform this simple test.

When confronting a lower extremity ulcer, we know that the usual wound assessment isn’t enough. Standards of care guide us to perform an Ankle Brachial Index (ABI) to calculate blood flow. By doing so, you can rule out significant arterial disease and determine the amount of venous compression you can safely apply.

The ABI compares the systolic blood pressure of the ankle to that of the arm (brachial) with the following formula:


Calculating Ankle Brachial Index


Values between 0.41-0.91 represent peripheral arterial disease (PAD) sufficient to cause claudication. Meanwhile, values of 0.00-0.40 reflect severe PAD sufficient to cause resting pain or gangrene. Refer the patient to a vascular specialist for further assessment.

When the ABI Falls Short:  Hardened Arteries

If your patient has a long history of diabetes, severe neuropathy, or kidney disease, the ABI diagnostic may yield misleading results because of calcified arteries.  In other words, If the blood pressure cuff cannot adequately compress the arteries, your ABI will be falsely inflated.

If you already know your that your patient has calcified arteries or an ABI comes back with an abnormally high value (>1.3), you need an alternative approach.  That’s where the Toe Brachial Pressure Index (TBPI) enters the picture.

How to Perform a Toe Brachial Pressure Index

The Toe Brachial Pressure Index is a non-invasive method of determining blood flow through the arteries in the feet and toes, which seldom calcify. The procedure resembles the more familiar ABI. If you have solid blood pressure skills, you will master the TBPI with ease.

TBPI Equipment

First, gather the items you’ll need on hand to complete the TBPI measurements:

  • A blood pressure meter with an arm cuff and toe cuff
  • A handheld Doppler ultrasound device
  • Ultrasound transmission gel
  • Tissue or gauze
  • Damp cloth or alcohol wipes

Measuring Brachial Systolic Pressure

  1. Have the patient remove shoes and stockings and lie down for at least 10 minutes prior to obtaining blood pressure measurement.
  2. Apply the blood pressure cuff snugly on the upper arm with the lower edge of the cuff 1 inch above the antecubital fossa (pit of the elbow) and palpate for the brachial pulse.
  3. Apply conductivity gel over the brachial artery. Turn on the Doppler device and place the tip of the probe at the antecubital area at approximately a 60-degree angle to the surface of the skin.
  4. Move the probe around until you hear the clearest arterial pulse sounds. Keep the probe at that position.
  5. Inflate the blood pressure cuff to approximately 20mm Hg above the numerical reading where the pulse sounds cease.
  6. Slowly deflate the cuff at a rate of 2 mm Hg per second until you hear the first arterial pulse sound. When this number is determined, deflate the cuff completely and record this systolic reading.
  7. Remove the gel from the patient’s skin with a tissue or gauze
  8. Repeat the procedure in the other arm and record the reading.

Measuring Toe Systolic Pressure

  1. Place the toe cuff around the base of the great toe. Use the second toe if the great toe can’t be used.
  2. Palpate the pulse signal on the toe’s distal pad area. Apply transmission gel to the pulse site.
  3. Place the tip of the Doppler probe onto the gel at a 45-degree angle to the skin surface. Direct the probe toward the patient’s head to detect the pulse signal.
  4. Slowly inflate the toe cuff until you no longer hear the pulse signal (to a maximum of 200 mm Hg). A partial squeeze should adequately inflate the cuff.
  5. Slowly deflate the toe cuff until the point at which the pulse signal returns. This is the toe’s systolic pressure.
  6. Remove the toe cuff. Use tissue or gauze to remove the leftover gel from the patient’s skin and from the Doppler probe. Gently clean the Doppler probe with a damp cloth or alcohol wipe.
  7. Calculate and document the results with the Toe Brachial Pressure Index formula, using the brachial systolic pressure in the arm with the highest pressure:


Calculating Toe Brachial Index


Understanding Toe Brachial Index Results

How do you interpret the number that results from your measurements and calculation?

TBPI > 0.7    Normal, suggests no arterial disease

TBPI = 0.64 – 0.7   Borderline

TBPI < 0.64    Abnormal, suggests arterial disease

If the absolute Toe Pressure (mm Hg) ≤30, this indicates Lower Extremity Arterial Disease and predicts a failure to heal.

Do you already see widespread adoption of the ABI and the TBPI in your facility? If so, do you have any handy tips for your fellow clinicians? Can you offer recommendations for your favorite equipment? We welcome you to share your knowledge and help elevate the skills of your fellow healers.


Wound Care Education Institute® provides online and onsite courses in Skin, WoundDiabetic and Ostomy Management. Eligible clinicians may sit for the prestigious WCC®, DWC® and OMS national board certification exams through the National Alliance of Wound Care and Ostomy®(NAWCO®). For details, see

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to the care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.


Wound Care and Epibole: It’s All About the Edge

Thursday, May 18th, 2017

How do you spot an unhealthy wound edge? Learn more about the causes, prevention and treatment of epibole.

When it comes to treating epibole, it’s all about knowing what a healthy wound edge looks like – and being able to spot signs of trouble. This basic overview includes epibole causes, prevention and treatment. We’ll have you ready to meet this condition head-on and get your patients on their way to recovery.


9 Wound Care Documentation Pitfalls to Avoid

Friday, May 12th, 2017

Lawsuits often are settled out of court because the medical record documentation is not defensible. Incomplete, illogical, and inconsistent records are far too common, so it is important to avoid the common pitfalls.

After reviewing hundreds of medical charts involved in litigation, I noticed many of the same problems occurring in the wound care documentation over and over again. From New York to Florida to California, it is remarkable how the same inconsistencies, errors, and oversights tend to stymie the defense of a case. The goal of every healthcare practitioner is to have complete, accurate, and timely documentation of the medical care given to each and every patient. Here are nine wound care documentation pitfalls to avoid.


The Great (Legal) Debate About Turn and Reposition Documentation

Friday, April 7th, 2017

Documentation of turning and repositioning often leads to legal problems as some healthcare providers chart by exception and others chart at the point of care.

“The hospital never turned the patient, and therefore the patient suffered a serious pressure injury,” declared the plaintiff attorney. The defense team shot back, “Whoa. Slow down. Never is long time, and of course we turned the patient.” How can a basic care intervention such as turning and repositioning have two totally opposing views?


Wound Detective Series: Is It (Or Is It Not) Infected?

Friday, January 13th, 2017

How can you tell if a wound is really infected? Learn how to spot the signs of infection and be a skilled wound investigator.

Are you ready, wound detectives, to tackle a new case? This time, we’re learning how to spot the signs of infection. Remember, the wound will tell us what we need to know, we just have to pay careful attention and know what to look for. After all, treatment depends primarily on our clinical assessment (and then a wound culture, if indicated). Sharpen up those investigative skills, and let’s get to work.


Ankle-Brachial Index? It’s Easier Than You Think

Wednesday, December 7th, 2016

Determining a patient’s ABI is a vital part of wound care, but unfortunately this step is often avoided … or even omitted. Here’s why this happens, and how you can change it.

Have you ever faced a seemingly daunting task, and so you do everything in your power to avoid it? Like renewing a driver’s license, for example. Or maybe cleaning out the refrigerator. But then once it’s done, you look back and say, “Hey, that wasn’t so bad!”

That’s kind of how it is when it comes to determining a patient’s ankle-brachial index (ABI). While this is a key component of the lower-extremity vascular exam, it’s often overlooked – and even omitted – just because it seems so overwhelming. Hang in there, folks: we’re here to help make it easier.


Wound Detective Series: How to Get Away with Killing Biofilm

Friday, October 21st, 2016

Even the best wound care detectives are challenged by this sneaky culprit that delays healing. Here’s how to identify biofilm bacteria and solve the case.

Ready for some serious detective work? In this wound-care case, we will try to find and invade the elusive biofilm bacterial hide-out. So the questions are: where are those microbes holed up, how do I know if they are even there, and how do I get rid of them?

Put on your Wound Detective hat – this one’s going to be tough. Even with your trusty magnifying glass, it’s not easy to spot the signs and symptoms of biofilm in your patients’ wounds.