Use of an Ovine Collagen Dressing with Intact Extracellular Matrix To
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#834-Ferreras FINAL Advanced Wound Healing SURGICAL TECHNOLOGY INTERNATIONAL Volume 30 Use of an Ovine Collagen Dressing with Intact Extracellular Matrix to Improve Wound Closure Times and Reduce Expenditures in a US Military Veteran Hospital Outpatient Wound Center DANIEL T. FERRERAS, DPM, FAPWCA, AAWC CHIEF/LEAD PODIATRIST SURGICAL SERVICES CARL VINSON VA MEDICAL CENTER DUBLIN, GEORGIA SEAN CRAIG, RN, CWCN REBECCA MALCOMB, RN WOUND CARE NURSE RN CARE MANAGER FOR PRIMARY CARE NURSING NURSING ALEXANDRIA VA HEALTH CARE SYSTEM ALEXANDRIA VA HEALTH CARE SYSTEM PINEVILLE, LOUISIANA PINEVILLE, LOUISIANA ABSTRACT novel, comprehensive decision-making and treatment algorithm was established within a US govern- ment-run military veteran hospital in an attempt to standardize the process of outpatient wound care Aand streamline costs. All patients were systematically evaluated and treated using the comprehensive algorithm over a span of nine months. After three months of adherence to the algorithm, the algorithm was modified to include ovine-based collagen extracellular matrix (CECM) dressings as a first-line conventional treatment strategy for all appropriate wounds. The purpose of this retrospective analysis was to evaluate the hospital’s change in cellular and/or tissue-based graft usage and cost, as well as wound healing outcomes fol- lowing modification of the wound care standardization algorithm. Data from the first quarter (Q1; three months) of protocol implementation were compared to the subsequent two quarters (six months), during which time the first-line dressing modification of the protocol was implemented. Results showed that between quarters 1 and 3, the percentage of wounds healed increased by 95.5% (24/64 to 80/109), and the average time to heal each wound decreased by 22.6% (78.8 days to 61.0 days). Cellular and/or tissue-based - 1- #834-Ferreras FINAL Use of an Ovine Collagen Dressing with Intact Extracellular Matrix to Improve Wound Closure Times and Reduce Expenditures in a US Military Veteran Hospital Outpatient Wound Center FERRERAS/CRAIG/MALCOMB graft unit usage decreased by 59.7% (144 units to 58 units), and expenditures on cellular and/or tissue-based grafts decreased by 66.0% ($212,893 to $72,412). Results of this analysis displayed a trend toward decreased expenditures, faster healing times, and a greater number of healed wounds following modification of an evi- dence-based algorithm to incorporate CECM dressings as a first-line treatment strategy in managing chronic wounds. INTRODUCTION duced several sweeping cost saving mea- wound care efforts and product usage sures in 2014, and there is a major shift throughout the facility, to increase the underway toward value-based pay- rate of wound resolution, and to Chronic ulcers affect more than 6.5 ments, versus the present fee-for-ser- decrease overall expenditures on wound million people in the US and are a vice payments.10,11 care. After three months of adherence major growing health problem due to Along similar lines of quality to the algorithm, the algorithm was an aging population, increasing health improvement and cost savings, within modified to include an ovine-based col- care costs, and a steep rise in diabetes the US Veterans Affairs (VA) hospital lagen extracellular matrix dressing and obesity worldwide.1 The prevalence system, there has been a major push (CECM; Endoform® dermal template, of venous insufficiency ulcers in the US toward standardization since the August Hollister Incorporated, Libertyville, Illi- is approximately 600,000 annually,2 and 2001 launch of a Healthcare Failure nois) as a first-line treatment strategy venous leg ulcers (VLU) account for at Mode and Effect Analysis (HFMEA) for all appropriate wounds based on its least 70% of all chronic ulcers found on process.12 HFMEA is a five-step process understood effects in reducing elevated the lower leg.2,3 In 2014, approximately that uses an interdisciplinary team to metalloproteinases (MMPs)13 and its 22 million people in the US were living proactively evaluate a health care relatively low cost. The purpose of this with diagnosed diabetes,4 and, of these process. It involves process flow dia- retrospective analysis was to evaluate diabetics, an estimated 10–15% will gramming, a hazard scoring matrix, and the hospital’s change in cellular and/or develop a foot ulcer during their life- a decision tree to identify and assess tissue-based graft usage and cost, as well time.5 These foot ulcers represent a potential vulnerabilities. This standard- as wound healing outcomes following substantial cost burden, estimated at a ization process was originally designed modification of a wound care standard- one-year cost of over $9 billion among to assess and address prospective risk of ization algorithm to include CECM US Medicare beneficiaries with dia- a health care process to enhance safety, dressings as a first-line treatment strate- betes.6 In 2013, the average cost of but the process is now also used to gy. treating a diabetic foot ulcer (DFU) streamline cost. patient was approximately $49,209 for Basic tenets of HFMEA were used to the two-year period after diagnosis.5 standardize the process of wound care MaterialsMATERIALS and AND Methods METHODS Compared to matched non-VLU within a US VA hospital in an attempt to patients, a large database analysis improve outcomes and reduce cost. showed VLU patients incurred annual Prior to standardizing the wound care A 1,150 ft2 outpatient wound healing incremental medical costs of $6,391 in process in this VA hospital, inpatient center was established within the VA Medicare costs and $7,030 in private and outpatient wound care was per- hospital, and all ancillary departments insurance costs, suggesting an annual US formed on all floors and in all depart- were educated about the wound healing payer burden of $14.9 billion for ments by numerous physicians and center services and how to refer VLUs.7 clinicians with varying levels of wound patients to the center. A dual algorithm A focus on reductions in acute care care training. A substantial proportion that combined decision-making and spending has transferred care to the of hospital expenditures were spent on wound treatment protocols was devel- outpatient setting, and a growing num- wound care, outcomes were not oped and implemented by the wound ber of hospitals are offering outpatient tracked, and patients were regularly lost healing center program director (Daniel wound services as part of this cost shift- to follow-up. Diabetic foot and venous T. Ferreras) (Fig. 1). Wound healing ing. Currently, there are more than leg ulcers were reported causes of staff members were educated about the 1,000 outpatient wound care centers in extended lengths of stay and increased systematic use of the algorithm for each the United States8 with alarming esti- emergency department admissions. Fol- patient. mated annual expenditures on wound lowing committee analysis of the prob- care services of over $50 billion.9 These lem, a wound healing center was Decision protocol expenditures have captured the atten- established within the hospital and a Part one of the algorithm (Decision tion of US Centers for Medicare and two-part wound care standardization Protocol) is a decision tree honoring the Medicaid Services (CMS) administra- algorithm was developed and imple- fundamentals of wound care and was tors who have been moving to gain con- mented. used to determine that both the patient trol of the overwhelming costs of Goals of the wound healing center and wound bed were ready for treat- outpatient wound services. CMS intro- and the algorithm were to standardize ment. The Decision Protocol was based - 2- #834-Ferreras FINAL Advanced Wound Healing SURGICAL TECHNOLOGY INTERNATIONAL Volume 30 Figure 1. Dual protocol algorithm. - 3- #834-Ferreras FINAL Use of an Ovine Collagen Dressing with Intact Extracellular Matrix to Improve Wound Closure Times and Reduce Expenditures in a US Military Veteran Hospital Outpatient Wound Center FERRERAS/CRAIG/MALCOMB implementation, oxidized regenerated Table I cellulose (ORC)/collagen dressings Patient demographics and outcomes were used as first-line conventional Q1 Q2 Q3 treatment for all appropriate chronic Sept- Dec. 2014- Mar- wounds. Based on the needs of our Nov. 2014 Feb. 2015 May 2015 chronic wound population and grow- ing evidence implicating MMP imbal- Patients (n) 79 78 73 ances as a critical factor in stalled Male, n (%) 76 (96.2) 76 (97.4) 71 (97.2) wounds,20 a decision was made to Female, n (%) 3 (3.8) 2 (2.6) 2 (2.7) switch to CECM dressings as a first- line conventional treatment strategy Average age (years) 66.5 64.5 65.4 after three months (beginning of quar- Wounds treated (n) 64 84 109 ter 2). Silicone fenestrated gauze or an DFU, n (%) 35 (54.7) 65 (77.4) 82 (75.2) antibacterial foam dressing bound with gentian violet and methylene blue VLU, n (%) 25 (39.1) 17 (20.2) 21 (19.3) ® Heel PrU, n (%) 4 (6.2) 2 (2.4) 6 (5.5) (GV/MB) (Hydrofera Blue ; Hollister Incorporated, Libertyville, Illinois) Clinic visits (n) 274 343 336 was used as a cover over the CECM dressing, and paper tape was used to Healed wounds (n;%) 24 (37.5) 55 (65.5) 80 (73.3) secure the cover dressing. The area DFU, n (%) 18 (51.4) 44 (67.7) 61 (74.3) was wrapped with a latex-free con- VLU, n (%) 3 (12.0) 9 (52.9) 16 (76.2) forming stretch bandage and a light Heel PrU, n (%) 3 (75.0) 2 (100.0) 3 (50.0) four inch self-adherent elastic wrap as needed. Average time to heal, days 78.8 (11.3) 77.2 (11.0) 61.0 (8.7) Compression stockings and appro- (weeks) priate off-loading strategies (controlled DFU, n (%) (weeks) 74.2 (10.6) 67.9 (9.7) 52.5 (7.5) ankle movement walker boot, offload- VLU, n (%) (weeks) 86.1 (12.3) 115 (16.5) 99 (14.2) ing padding, and total contact cast) Heel PrU, n (%) (weeks) 73.5 (10.5) 57.4 (8.2) 44.1 (6.3) were used as needed.