Mastering the OASIS Skin Assessment · include PPS and OASIS assessment skill building, documentation, intake and referral processes, care management, regulatory compliance, and policy

OASIS Complete Webinar Series

Mastering the OASIS Skin Assessment

Presented By: Rhonda Marie Will, RN, BS, HCS-D, COS-C

September 10, 2010

243 King Street, Suite 246 Northampton, MA 01060

413-584-5300 fax: 413-584-0220

e-mail: [email protected] www.fazzi.com

Instructions and Handouts for: Fall Risk Assessment

It is very important that you have these materials printed and ready to use prior to the start of the training. In order to participate in this training you will need to do the following:

1. Dial 1 (877) 615-4339 at least 10 minutes prior to the start of the webinar. 2. When asked, enter Conference ID 8160290#. 3. Give your agency’s name. 4. At this time you will be entered into the call and in “listen mode.” 5. If at any time you need assistance you may press *0 for the operator. 6. There will be a Q & A period toward the end of the session. Questions will be answered in the

order in which they are received. To ask a question, press *1. You will have the opportunity to ask your question and then be returned to “listen mode.” Do not press *1 prior to this time.

7. To view the presentation online you must click on the link sent to you from GoToWebinar. Nurses Only: Directions to receive contact hours for the training.

1. Each participant must complete an evaluation in order to receive contact hours. Click on the following link in order to access the online evaluation form:

https://www.surveymonkey.com/s/LTLPSPR *Please allow four weeks for processing. Rhonda Will, RN, BS, COS-C, HCS-D is a Senior Clinical Consultant and Assistant Director of the Home Care Quality Institute for Fazzi Associates, Inc. She has thirty eight years experience as a registered nurse and has worked in home health care since 1979 in various clinical, administrative and management roles. Rhonda has extensive experience in staff development and as a trainer. Her areas of expertise include PPS and OASIS assessment skill building, documentation, intake and referral processes, care management, regulatory compliance, and policy and procedure development. With Fazzi Associates Rhonda has developed and provides OASIS clinical training, audit and management training programs and basic ICD-9-CM Coding training. She oversees the team of professional associates who also provides clinical record audits and on site trainings. She presents OASIS and basic coding training on site and by audio conferencing for home health agencies, state home health associations and national professional and commercial organizations. Rhonda provided clinical leadership for the 2003 3M National OASIS Integrity Project. She has developed a reputation in the home health industry as an OASIS Expert and is often interviewed for home health care publications. Rhonda currently serves as a member of the Editorial Board for “Home Healthcare Nurse: The Journal for the Home Care and Hospice Professional.”

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Fazzi Associates, Inc. 1

Mastering the OASIS Skin

OASIS-Complete Webinar Series

Mastering the OASIS Skin Assessment

September 10, 2010

Rhonda Will RN BS COS C HCS D

©2010

Rhonda Will, RN, BS, COS-C, HCS-DAssistant Director of OASIS Competency Institute

[email protected]

©2010


Wound PrimerPressure Ulcers

Localized injury to the skin and/or underlyingLocalized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.

4 St S t d D Ti I j

©2010

4 Stages + Suspected Deep Tissue Injury

Wound Primer: DefinitionPressure Ulcers

Partial thickness tissue lossPartial thickness tissue loss– Involves epidermis and into but not through the

dermis– Superficial; presents as shallow crater, abrasion

or blisterHeals by epithelialization

©2010

– Heals by epithelialization• Regeneration of epidermis across a wound surface

– Includes Stage I and II pressure ulcers


Wound Primer: DefinitionPressure Ulcers

Full thickness tissue lossPenetrates thro gh the fat (s bc taneo s tiss e)– Penetrates through the fat (subcutaneous tissue) and may involve muscle, tendon, or bone

– Deep crater; may tunnel– Heals by granulation, contraction

and epithelializationNe er considered f ll healed

©2010

– Never considered fully healed– Closed when fully granulated and covered with

new epithelial tissue– Includes Stage III and IV pressure ulcers

Suspected Deep Tissue Injury (SDTI)

– Purple or maroon localized area of discolored intact skin OR a blood filled blister due to damage of underlying soft tissue from pressure and/or shear

©2010

(NPUAP 2007)


Degree/Status of HealingPressure Ulcer

Wound Status– Not healing

– Early/partial granulation

– Fully granulating

– Newly epithelialized

Wh ith li l ti h l t l d

©2010

• When epithelial tissue has completely covered the wound surface regardless of how long the pressure ulcer has been re-epithelialized.

• www.wocn.org Wound Guidance Document

WOCN Definitions Degree of Healing

• Not healing• Wound with ≥ 25% avascular tissue (eschar and/or slough) OR• Signs/symptoms of infection ORSigns/symptoms of infection OR• Clean but non-granulating wound bed OR• Closed/hyperkeratotic wound edges OR• Persistent failure to improve despite appropriate comprehensive

wounds management

• Early/partial granulation

©2010

• ≥ 25% of the wound bed is covered with granulation tissue• < 25% of the wound bed is covered with avascular tissue (eschar

and/or slough)• No signs or symptoms of infection• Wounds edges open


WOCN Definitions Degree of Healing

• Fully granulating• Wound bed filled with granulation tissue to the level of the

surrounding skin• No dead space• No avascular tissue (eschar and/or slough)• No signs or symptoms of infection• Wound edges are open

• Newly epithelialized

©2010

• Wound bed completely covered with new epithelium• No exudate• No avascular tissue (eschar and/or slough)• No signs or symptoms of infection

Definition

Unstageable pressure ulcersUnstageable pressure ulcers– Pressure ulcer under a dressing or device that

cannot be removed

– Full thickness tissue loss in which the true wound depth is obscured by slough and/or eschar in the wound bed

©2010

wound bed

– Suspected deep tissue injury in evolution


Alerts!

Stage II pressure ulcers and stasis ulcers thatStage II pressure ulcers and stasis ulcers that close/heal/fully epithelialize are not reportable on OASIS and will not be “newly epithelialized” for data collection.

Stage II pressure ulcers do not granulate and can l b “ t h li ” f d t ll ti

©2010

only be “not healing” for data collection.

M1306 Unhealed Pressure Ulcer Stage II or Higher

“Is there any kind of a pressure ulcer that is not a Stage I?”

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Time Points WOCN Guidelines NPUAP Staging


M1307 Oldest Non-epithelialized Stage II Pressure Ulcer - DC

Identifies:

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length of time a Stage II PU remained unhealed

patients who developed Stage II PU while receiving care from the HHA.

M1308 Current Number of Unhealed Pressure Ulcers/Stage

Number of ulcers present on the day of assessment

Number of ulcers in Column 1 that were also present at the most recent of SOC/ROC

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SOC/ROC


Patient 1 at SOC, has no unhealed Stage II Pressure Ulcer. There are no pressure ulcers.

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Patient 1 at Follow up he has one Unhealed Stage II PU.

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Patient 2 at SOC has one unhealed Stage III Pressure Ulcer.

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Patient 2 at Follow-up, the Stage III PU has progressed to a Stage IV PU.

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Patient 3 at SOC has 1 unhealed Stage II PU.

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Patient 3 at Discharge, the Stage II PU that was present at SOC has healed. A new Stage II PU developed and is present.

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Patient 4 at SOC has 1 unhealed Stage II PU and one closed Stage III PU .

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Patient 4 at Discharge, the Stage II PU that was present at SOC has healed. A new Stage II PU and the closed Stage III PU and is present.

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Patient 5 at SOC has 1 unhealed Stage II PU, 1 unhealed Stage III PU and one closed Stage III PU .

©2010


Patient 5 at Discharge, the Stage II PU that was open at SOC has healed. A different Stage II PU is open in another location. The Stage III PU remains unhealed and the other Stage III PU remains closed.

©2010



Patient 6 at SOC has 1 unhealed Stage II PU, 1 unhealed stage III PU and one closed Stage III PU.

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Patient 6 at recert, the Stage II PU that was open at SOC has fully reepithelialized. Another Stage II PU is open in a different location. The Stage III PU now has bone exposed and the other Stage III PU remains closed.

©2010



Patient 7 at SOC has 1 PU on the left heel covered with eschar and 1 blood filled blister on the right heel from pressure after many days of bed rest. There is a Stage III PU which closed in the hospital and remains closed.

©2010


Patient 7 at recert the 1 PU on the left heel remains covered with eschar. The blood filled blister on the right heel has broken open and is now a Stage III PU. The Stage III PU which closed in the hospital remains closed now.

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Patient 8 is bedbound. At SOC there is a skin graft on a Stage III PU with orders not to remove the pressure dressing until the physician's visit. There is a deep red, warm and boggy area noted on the right heel.

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Patient 8 at discharge the graft site has healed with some contracture and discoloration of the graft site and the deep red, warm and boggy area noted on the right heel is resolved.

©2010



M1310, M1312, M1314 - Unhealed Stage III or IV Pressure Ulcer with Largest Surface Dimension

SOC/ROC/DC©2010


Unhealed = non epithelialized (open) or closed

Consider all Stage III and IV pressure ulcers from M1308 Col.1 rows b, c, d.2

M1320 Status Most Problematic (Observable) Pressure Ulcer SOC/ROC/DC

Alert! Stage II pressure ulcers can only be “not healing”

©2010


Only closed Stage III and IV pressure ulcers can be newly epithelialized.

Most problematic is a clinical judgment.


M1322 Current Number of Stage I Pressure Ulcers

©2010


M1324 Stage Most Problematic (Observable) Pressure Ulcer SOC/ROC/FU/DC

Upon inspection, the patient has one PU on the left heel that is covered with eschar. There is one Stage 3 PU on his sacrum. Granulation tissue is present in the wound bed with areas of slough scattered over 10% of the wound bed.

Unhealed: Stage 1 open Stage II open or closed stage III

©2010


Unhealed: Stage 1, open Stage II, open or closed stage III or IV

(+)

Observable: visualized, able to stage

Most problematic is a clinical judgment.


M1330 Does this patient have a Stasis Ulcer?

Caused by inadequate venous circulation

©2010


Usually lower leg, often with stasis dermatitis

Exclude: arterial lesions and ulcers

M1332 Current Number of (Observable) Stasis Ulcers

Upon skin inspection, the patient has one stasis ulcer under an Unna Boot by physician and patient report with physician orders not to change the dressing for 4 days. The other leg has a stasis ulcer with beefy red granulation tissue filling 75% of the wound bed.

©2010


Observable: Can be visualized; not covered by non-removable dressing or device.


M1334 Status Most Problematic (Observable) Stasis Ulcer

Do not use! Not a response option!

Alert! A fully epithelialized stasis ulcer is healedand not reported in OASIS items!

©2010


Surgical Wounds

Frequently heal by Primary Intention– Wound edges are directly next to one anotherg y– Little tissue loss, no granulation occurs– Wound closure is performed with sutures, staples, or

adhesive

May heal by Secondary Intention– Wound is allowed to granulate

©2010

If there is any separation of the incision, then healing will be by secondary intention for data collection purposes.


Surgical Wound

SScar– Surgical wound that has been re-epithelialized

(epidermal resurfacing across the entire wound surface) for approximately 30 days or more without dehiscence or signs of infection.

• How will you know when the 30 days begins?

©2010

– A scar is not reportable for OASIS data collection.

Alert!

Surgical wounds healing by primary intention do not granulate and can only be “not healing” or “newly epithelialized” for data collection.

©2010


M1340 Have a Surgical Wound?

Unhealed wound resulting from a surgical procedure.

Include:

Stapled or sutured incisions

Wounds/I&D with drain placement except “ostomy”

O th di i it

©2010


Orthopedic pin sites

Muscle flap, skin advancement flap, or rotational flap to surgically replace a pressure ulcer

Excisions


Include:A “take down” of a previous ostomy

Central line sites

Medi-port and port-a-cath sites and other implanted infusion devices (e.g. On-Q pump/Q ball, etc.) and venous access devices regardless

©2010


( g p p , ) gof functionality (AV shunt, peritoneal dialysis catheter)

Shave, punch or excisional biopsy

Arthrocentesis

Left Ventricular Assist Device/HeartMate



Exclude:PICC line peripherally inserted and Peripheral IV

Pressure ulcer treated with surgical debridement

An existing wound treated by debridement or skin graft

Old surgical wound with scar or keloid formation

Ostomies even with drains (e g thoracostomy/chest tube etc )

©2010


Ostomies even with drains (e.g. thoracostomy/chest tube, etc.)

Cardiac catheterization and/or stent placement via a puncture with a needle

Needle aspiration without drain placement

Enterocutaneous fistula

Retention suture with a button

M1340 Have a Surgical Wound?The patient has a surgical wound with a dressing and an order not to change it until after the doctor’s appointment in 3 days. There is one other healing surgical wound from a drain that was removed and described as well approximated with some serous crusting.

Report surgical wounds that are unhealed and have not become a scar

©2010


Exception: implanted venous access and infusion devices


M1342 Status of Most Problematic (Observable) Surgical Wound

Covered with new epithelial tissue < 30 days

Select Response 0 for an implanted venous access or infusion device when it is the only surgical wound and the insertion site is

©2010


healed.

M1342 Status of Most Problematic (Observable) Surgical Wound

The patient had a hip replacement 4 weeks ago. One week ago the therapist noted that the surgical wound completely re-epithelialized without S/S of a complication. On this DC visit, the wound is described as well approximated, completely re-epithelialized with no scabbing or S/S of infection.

©2010



M1350 Have a Skin Lesion or Open Wound Receiving Intervention

Clinical intervention:

On-going clinical assessment or treatment as evidenced by orders

Select “YES” :Other wound types (burns, diabetic ulcers, cellulitis,

abscesses, wounds caused by trauma, etc) receiving clinical intervention

Non bowel ostomies receiving clinical intervention per the POC/485 (e.g., cleansing, dressing changes, etc) from the

©2010


treatment as evidenced by orders on the POCPOC/485 (e.g., cleansing, dressing changes, etc) from the home health agency

Select “NO”: pressure and stasis ulcers, surgical wounds;other types of skin lesions not receiving clinical intervention

Not healingEarly/partial granulation

Fully granulatingNewly

epithelialized

Scar/healed and not reported on

OASIS

Stage 1 PU √ √

Status of Healing Possible for OASIS Wound types

Stage 1 PU √ √

Stage 2 PU √ √

Stage 3 PU √ √ √ √

Stage 4 PU √ √ √ √

Closed Stage 3 or 4 PU

√

Stasis ulcer √ √ √ √

©2010

Surgical Wound Primary Intention

√ √ √

Surgical WoundSecondary Intention

√ √ √ √ √


Resources

National Pressure Ulcer Advisory Panel– www.npuap.orgp p g

Wound Ostomy Continence Nurses– www.wocn.org

S.Baranoski and E.A. Ayello, Wound Care Essentials: Practice Principles, Wolters Kluwer Lippincott Williams &Wilkins, Second edition 2008

©2010

Second edition, 2008

OASIS C Guidance ManualCMS OASIS Q and A

Fazzi Associates, Inc.243 King Street Suite 246243 King Street, Suite 246Northampton, MA 01060

413-584-5300www.fazzi.com

©2010

Documents

Mastering the OASIS Skin Assessment · include PPS and OASIS assessment skill building, documentation, intake and referral processes, care management, regulatory compliance, and policy