Managing Pressure Ulcers In The Lower Extremity

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Author(s): 
Clinical Editor: Kazu Suzuki, DPM, CWS

   Depending on the stage of the ulcer, Dr. Wendelken prescribes a number of offloading boots for pressure redistribution. He has lately had “great results” with the Waffle Heel Elevator Custom (EHOB).

   Dr. Suzuki doesn’t think “heel cradle cushions” are effective for pressure ulcers.

   “I despise those heel cradle cushions,” says Dr. Suzuki. “They are widely used pillow boots that are attached directly to the heel itself. They add bulk to the heel and do nothing to prevent or offload heel pressure ulcers.”

Q:

Do you recommend or prescribe a bed or mattress for their pressure issues?

A:

Dr. Suzuki routinely recommends beds and mattresses. As he notes, the general recommendation on beds is that patients with minor pressure ulcers (stage 1 or 2) should have a memory foam mattress or mattress topper (overlay) a minimum of 3 inches high, which patients can buy without prescriptions in most bedding stores and in larger markets at stores like Costco or Target. Dr. Suzuki says patients with more substantial pressure ulcers (stage 3 or 4) will most likely need a powered air bed (i.e. low air loss, air fluidized, etc.), saying that will require prescriptions, detailed medical records for submission, and help from a local medical supply durable medical equipment company.

   Dr. Wendelken notes a group 1 mattress overlay may be indicated and is covered by the Centers for Medicare and Medicaid Services (CMS) if the mattress meets the following conditions:
• the patient is completely immobile (i.e., the patient cannot make changes in body position without assistance); or
• the patient has limited mobility (i.e., the patient cannot independently make changes in body position significant enough to alleviate pressure and at least one of the conditions A-D below); or
• the patient has any stage pressure ulcer on the trunk or pelvis, and at least one of the conditions A-D below.

A. Impaired nutritional status
B. Fecal or urinary incontinence
C. Altered sensory perception
D. Compromised circulatory status

   Dr. Wendelken notes that in each case, the medical record must document the severity of the condition sufficiently to demonstrate the medical necessity for a pressure reducing support surface.

   After trying to get insurance to reimburse for these items with a medical supply store and being unable to get timely reimbursement, Dr. Suzuki advises patients to purchase mattresses with a small expectation that they may be reimbursed by their insurance later.

   Dr. Sage notes that occasionally a patient may require an air mattress to treat or prevent decubitus ulcers at multiple sites, but he notes the primary medical or surgical service generally prescribes this. He notes a patient with multiple decubitus ulcers is rarely, if ever, admitted to the podiatry service alone.

   Dr. Sage is a Professor and the Chief of the Section of Podiatry at the Department of Orthopaedic Surgery and Rehabilitation at the Loyola University Stritch School of Medicine in Maywood, Ill.

   Dr. Suzuki is the Medical Director of the Tower Wound Care Center at the Cedars-Sinai Medical Towers. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles, and is a Visiting Professor at the Tokyo Medical and Dental University in Tokyo.

   Dr. Wendelken is a licensed RN who specializes in emergency medicine. He is affiliated with the Calvary Hospital Center for Palliative and Curative Wound Care in Bronx, NY. He is an Adjunct Professor in the Department of Radiology at the Temple University School of Podiatric Medicine in Philadelphia. Dr. Wendelken is a principal in BioVisual Technologies, LLC, and is the inventor of PictZar® Digital Planimetry software program.

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