Susan E. Duffield, BSN, RN, CWOCN

1. VACUUM ASSISTED CLOSURE (V.A.C.) THERAPY: An Advanced System for Wound Healing in the Home Setting Susan E. Duffield, BSN, RN, CWOCN

2. Learning Objectives • Define Negative Pressure Wound Therapy (NPWT) • Discuss guidelines for the appropriate use of NPWT • Identify patients with wounds who would benefit from NPWT and patients for who this modality would be contraindicated. • Discuss guidelines for the application of NPWT. • Explain the basic steps in obtaining insurance reimbursement for NPWT in the home care setting.

3. V.A.C. Therapy a.k.a. NPWT • NPWT applies continuous or intermittent sub-atmospheric pressure, or suction, to the wound bed via a computerized vacuum pump attached to an open-cell foam sponge that is placed in the wound and secured with an adhesive semi-occlusive dressing. Wound fluids are evacuated via a tubing system placed on the foam at one end and connected to a disposable canister housed in the therapy unit on the opposite end.

4. The V.A.C. System • Manufactured by Kinetic Concepts, Inc., San Antonio, TX.

5. Clinical Benefits of V.A.C. Therapy • Maintenance of moist, protected environment • Removal of excess interstitial fluid from the wound periphery • Increased local vascularity • Decreased bacterial colonization • Quantification/qualification of wound drainage • Increased rate of granulation tissue formation • Increased rate of contraction • Increased rate of epithelialization

6. V.A.C. Therapy Indications • Acute wounds • Full-thickness surgical wounds • Chronic wounds • Stage 3 pressure ulcers • Stage 4 pressure ulcers • Diabetic ulcers • Venous stasis ulcers • Traumatic wounds • Dehisced wounds

7. Stage 3 Pressure Ulcer • Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to (but not through) the underlying fascia. The ulcer presents clinically as a deep crater with or without undermining adjacent tissue. Kinetic Concepts, Inc.

8. Stage 4 Pressure Ulcer • Full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bone or supporting structures (e.g. tendon, joint capsule). Note: Undermining and sinus tracts may also be associated with Stage IV pressure ulcers. Kinetic Concepts, Inc.

9. Venous Stasis Ulcer • Ulceration associated with venous hypertension • Johns Hopkins Medical Images

10. Diabetic Foot Ulcer • Diabetics are prone to foot ulcerations due to both neurologic and vascular complications Wound Care Information Network

11. V.A.C. Therapy Precautions • Acute bleeding, patients on anticoagulants, or difficult wound homeostasis. • Ensure all vessels are adequately protected with overlying fascia, tissue, or other protective barrier. • Greater care should be taken with respect to weakened, irradiated, or sutured blood vessels.

12. V.A.C. Therapy Contraindications • Malignancy in wound • Necrotic tissue with eschar • Untreated osteomyelitis • Fistulas to organs or body cavities • Do not place V.A.C. dressing over exposed arteries or veins

13. Clinical Efficacy • 300 wounds treated (acute, subacute, and chronic) • 296 wounds improved with an  rate of granulation tissue formation • Wounds were treated until completely closed, split-thickness skin graft applied, or flap rotated Annals of Plastic Surgery, 1997

14. Cost Effectiveness of V.A.C. Therapy • Retrospective chart review of 1032 Medicare home care patients • 61% faster healing rate • 38% less cost Ostomy/Wound Management, 1999

15. APN Orders for V.A.C. Therapy • Location of wound • Size of foam dressing (S, M, L, XL) • V.A.C. Therapy setting (usually 125 mm Hg continuously or intermittently 5 min on/2 min off) • Frequency of dressing changes – usually every 48 hours

16. Application of the V.A.C. • Visiting Nurse • Home caregivers and patients able to apply and remove V.A.C.

17. Dressing Application Overview • Place foam in wound • Cover with semi-occlusive dressing • Secure tubing • Connect tubing to the V.A.C. therapy unit

18. Operating the V.A.C. Unit • Insert canister securely in unit • Connect dressing tubing to canister tubing • Press power button ON • Follow prompts • Start therapy • Therapy should be on 24 hours each day

19. Alarms • Therapy OFF • Canister is full • Air leak

20. Monitoring and Progression of Wound Healing • Weekly wound measurements • Signs of healing • Oozing of blood as granulation occurs • Wound bed becomes redder • Gradual  in wound drainage •  in dimensions of wound • Average length of treatment is 4-6 weeks

21. Ambulatory Options • For the patient who is goes to work or school, a battery powered model is available. • Wound must be minimally draining.

22. Termination of V.A.C. Therapy • Adequate granulation base achieved allowing for: • Changing to conventional dressing changes • Split-thickness skin graft • Flap closure

23. Reimbursement Guidelines for Home V.A.C. Therapy • Medicare B • Complete Initial Statement of Ordering Physician (ISOP)(available at www.woundvac.com) • Fax ISOP to KCI • Mail completed original ISOP to KCI • Private Insurance • Complete above steps • Some insurers may require additional information, such as clinical notes, before issuing authorization for coverage • Medicaid • Not currently covered in NJ

24. Additional Information • 1-877-WOUNDVAC • www.woundvac.com • V.A.C. Recommended Guidelines for Use: Physician and Caregiver Reference Manual (Kinetic Concepts, Inc.)

25. Key Points • Non-invasive active therapy for wound healing • Indicated to treat a variety of acute & chronic wounds • Dressing changes every 48 hours • Reimbursable under Medicare B & most private insurers