OASIS Alert

Published on Thu Oct 03, 2013 PDF

Look to WOCN guidance for healing specifics.

Make an error documenting the healing status of wounds on the OASIS and you’ll impact your reimbursement as well as your data accuracy. But selecting a healing status isn’t always intuitive. Make sure you know which type of wound has limited options in M1342.

OASIS item M1342 asks you to identify the status of the patient’s most problematic (observable) surgical wound. New guidance from the Centers for Medicare & Medicaid Services helps you choose the best response.

Establish the Basics

Your response options for M1342 — Status of the patient’s most problematic (observable) surgical wound are:

0 — Newly epithelialized;

1 — Fully granulating;

2 — Early/partial granulation; and

3 — Not healing.

This item identifies the degree of healing present in the most problematic, observable surgical wound.

Timepoints: You’ll complete M1342 at start of care, resumption of care, follow-up, and discharge from the agency — not to an inpatient facility.

Know How the Wound is Healing

Surgical wounds can heal in one of two ways: either by primary intention or by secondary intention, says Judy Adams, RN, BSN, HCS-D, HCS-O, with Adams Home Care Consulting in Asheville, N.C. You’ll need to know which healing process the wound is going through before you can select an answer for M1342.

Wounds healing by primary intention heal through a process of epithelialization which involves regeneration of the epidermis across the wound surface. These wounds are closed by sutures, staples, or adhesive tape.

When your patient’s wound is healing by primary intention and the edges are approximated, you’re limited to only two healing scoring options for M1342, Adams says. You’ll choose between “0 — Newly epithelialized” and “3 — Not healing” for these patients. This is because wounds healing by primary intention heal through epithelialization and do not go through the granulation process.

“Guidance states that a wound where the edges are approximated epithelializes within hours to three days most of the time,” Adams says. Select Response “0” for surgical wounds that are healing by primary intention with no signs of complication.

If a wound is healing by primary intention and there is any drainage seeping though the edges of it, or if there is a scab adhered to the underneath of the wound that comes through the incision line, the wound is considered non-healing. “If anything is able to come through the incision, the edges cannot be epithelialized,” Adams explains. For these wounds, list response “3.”

Confusing: These limited choices don’t always feel comfortable for clinicians. “We can assess that a surgical wound is healing beautifully, but if it is not fully epithelialized, we are forced to choose response ‘3 — Not healing,’” says Sue Hull, MSN, RN, CWOCN with WoundConsultations.com in Craig, Alaska. “It just doesn’t feel right, does it? But, go ahead, choose it. It is what we have to work with in home health. You can describe the wound better in your documentation.”

“If there is not full epithelial resurfacing such as in the case of a scab adhering to underlying tissue, the correct response would be ‘Not healing’ for the wound healing by primary intention,” CMS says in an OASIS Q&A.

But how can you tell if the scab is adhering to underlying tissue? “If you cleanse the wound and the scab is solidly attached, it is adhering to underlying tissue,” Hull says. In that situation, you would choose “3 — Not healing” as your response, she says. “Don’t even argue with yourself that the wound is healing beautifully. Just choose it.”

Caution: If a wound originally closed by primary intention with sutures, staples or glue, has any areas of separation along the incision line, it is no longer healing by primary intention, but is now considered healing by secondary intention, Adams says.

Wounds healing by secondary intention heal through granulation. A patient with a wound healing by secondary intention may have a drainage system or his wound may be packed with gauze. With these wounds, your M1342 response options expand, because the criteria for all of the healing status stages are applicable, Adams explains.

Wounds healing by secondary intention do not have their edges approximated and heal from the “bottom up” through a process of contraction, granulation, and then epithelialization, Adams says. The criteria for each of these stages as defined by the Wound, Ostomy and Continence Society in 2009 are as follows:

(M1342) Status of Most Problematic (Observable) Surgical Wound:

• 0 — Newly epithelialized
  
• 1 — Fully granulating
  
• 2 — Early/partial granulation
  
• 3 — Not healing
  
• NA — No observable surgical wound

Definitions:

0 — Newly epithelialized

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

1 — 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

2 — Early/partial granulation

• 25 percent of the wound bed is covered with granulation tissue
• < 25 percent of the wound bed is covered with avascular tissue (eschar and/or slough)
• No signs or symptoms of infection
• Wound edges open

3 — Not healing

• Wound with 25 percent avascular tissue (eschar and/or slough) OR
• Signs/symptoms of infection OR
• Clean but non-granulating wound bed OR
• Closed/hyperkeratotic wound edges OR
• Persistent failure to improve despite appropriate comprehensive wound management

Take care: “Clinicians must observe the wound carefully to determine what stage of healing the wound has achieved as determined by the WOCN Guidelines,” Adams says.

Once a surgical wound has been newly epithelialized for 30 days, it becomes a scar and is no longer considered a surgical wound, Adams says. The only exception to this rule is for an implanted vascular access device, such as a mediport. These wounds remain newly epithelialized once the initial incision (to insert the device) is fully closed for however long the port remains in the body whether it is used or not and whether it is still functional or not, she says.