Fluorescence Imaging of Wounds in Nursing Homes
Can high-tech imaging prevent bedsores? Fluorescence imaging is changing how we see and treat wounds. In this week’s episode, nursing home abuse attorney Rob Schenk welcomes guest Martha Kelso to talk about how this technology is revolutionizing wound care in nursing homes.
Schenk: Fluorescence imaging of wounds in nursing homes. Stick around.
Hello out there and welcome back to the nursing home abuse podcast. My name is Rob. I will be your host for this particular episode, we’re going to be talking about fluorescence imaging of wounds for the purposes of detecting infection and bacteria. But certainly I’m not doing that by myself. I need help. And the help that I got is the absolute expert in this field. And that is Martha Kelso. So Martha is coming back on the episode or back on the podcast for the 150th time, but this time on this topic, which we’ve never talked about before on this podcast.
All right, let’s get into the meat and potatoes. Martha Kelso is the CEO of Wound Care Plus, a nationwide or close to nationwide leading mobile wound care group.
She’s renowned for her visionary leadership and post acute care. With a dedication to advancing wound healing, she excels as a published author, clinical editor, and expert witness for wound litigation, doing work for both plaintiffs and defendants. Martha’s contributions extend to national or national advisory boards, where her award winning expertise shapes the future of healthcare.
And we are so happy to have Martha on the show. Martha, welcome to the show.
Kelso:
Hi, Rob. Thanks for having me back.
Schenk:
Thanks. All right. I must admit that I know nothing about the topic that we’re going to talk about today, but you are the expert on this. So I want you to just talk to me in the audience, like we know nothing, which is probably accurate about fluorescence imaging of wounds.
In the long term care setting. So just I’ll let you start wherever you want to start.
What is fluorescence imaging?
Kelso:
Thank you. When I was first introduced to bacterial fluorescence there was a question on whether or not it was even covered. Nobody had done it in the post acute care space. So we’re going back to 2020. I ended up petitioning Medicare, specifically one of the Medicare administrative contractors known as WPS.
I sent an email to them, explained the technology, sent them some research behind it and asked them to cover it in the post acute care space. And within a few weeks they responded and agreed to cover it. So this was the first time that we could actually introduce this technology to our senior and aged population.
The reason why this is important is because, number one, we were in the middle of the pandemic, and the pandemic was raging. We didn’t even have the vaccine yet. Number two, we didn’t want to transport these people to the hospital for sepsis or wound related infections if we didn’t need to. So this is a non-invasive machine.
It means it doesn’t touch the patient. It doesn’t, the patient or resident, it doesn’t need to work. What happens is bacteria under this specific patented technology, when you fluoresce under this UV light, bacteria at 10 to the 4th power of colony forming units, which means true clinical infection, get excited and they’ll glow.
So for the first time in the history of man, we can now see bacteria in wounds with the naked eye real time using a non invasive device.
Schenk:
That’s amazing. So I guess the significance of this is that CMS covers this treatment. Wow.
Kelso:
They cover it for diagnostic clinicians. Nurse practitioners, physician assistants, MD, DO, DPM can use this modality to diagnose clinical infections in the wound.
It actually, it’s elevated bacterial burden is the appropriate terminology, and then we can do a targeted tissue culture and send that culture out to determine what type of bacteria it is.
What are the advantages of fluorescence imaging?
Schenk:
So tell me what are the advantages and obvious, there’s some that are obvious, but tell me about the advantages to this machine versus doing a culture and waiting for the results.
Kelso:
So traditional 1980s wound care prior to bacterial fluorescence, it would, we would have to guess, is this wound infected? Gosh, it doesn’t look infected to me. So maybe we wouldn’t culture, and then four or five days later, this person’s septic or has symptoms of sepsis or cognition changes, and we’re 9 1 1ing them out to the hospital.
They’re being admitted now for true sepsis and even some organ failure related to sepsis, and it could have totally been prevented. If we had this technology, the clinical signs and symptoms of wound infection, quite frankly, are unreliable, particularly in the elderly population, about 35 to 50 percent of the elderly population have a blunted immune system or immune response.
What that means is they don’t mount symptoms of infection, even when the presence of bacteremia is present. That’s scary, because it means our diagnostic criteria for clinical signs and symptoms is unreliable. It’s also incredibly unreliable in darker toned individuals. One of the clinical signs and symptoms we’re trained on in nursing school or doctor’s school is redness that is spreading.
In your darker toned individuals, like Fitzpatrick 4, you can’t see redness that is spreading. And yet, 95% of the textbooks discuss white or lighter toned people and redness that is spreading. Only 5% of images in medical and nursing textbooks even refer to darker toned individuals. So it sets up that population, that society for even more failure, more sepsis, more gangrene, more amputations, and more hospitalizations, which creates a massive imbalance in our racial disparities or inequities.
Schenk:
We had a very, we being me, had a very interesting conversation with Dr. Diane McAdams Jones about that exact topic about treating residents of color in the long term care setting and how just due to different training, different societal reasons, a lot of times residents of color follow the crack.
So I’m really happy that this is one avenue in which that disparity can be eliminated, or at least reduced. So okay, so all right, we have the little machine, it’s hovering over the wound. We’re determining whether or not there is a level of bacteria present that would qualify as an infection, for lack of a better word, how accurate is it versus the lab of doing a typical lab and how, and I get, and let me ask you another question.
This is a bad interview, but let me ask another question. I guess this is real time, right? Like you’re, you are seeing it’s, you’re going to get a readout in real time versus a lab, which might take hours or a day or two. Okay. So go back to that, address that and tell me how accurate is it?
Kelso:
It’s 95% accurate and it shows all bacterias known to man, porphyrin producing, and pseudomonas.
It will not show the caucuses, like enterococcus, for example, and it will not show fungus. So it shows all other bacterias, and it is 95% reliable, which by the way, most of our diagnostics are not that reliable. No other, the majority of diagnostic equipment on the market cannot purport or tout a 95% accuracy or reliability rating.
So what it does is show me where the bacteria is. If there’s porphyrin producing bacteria, it’ll glow red or pink. If it’s pseudomonas, it’ll grow, glow bright green, like lime, really bright fluorescent green. What that does then is allow my clinicians to say, my nurse practitioners or doctors to say, let me take a curette and see if I can scrape this unhealthy infected tissue out of the wound.
So once they sharp or target debris, they’re gonna fluoresce again. If it’s still fluorescing, Then they’re going to do a targeted tissue culture and culture where it’s fluorescing and send that out to the lab. So it’s not a replacement for tissue cultures or PCR testing or pathology testing to see what bacteria is growing.
What it does is show us where the chronic inhibitory bacteria load bacteria at 10 to the fourth power. That’s the magic number. Where is that bacteria harbored? Can I effectively remove it at the bedside? And if not, let me do a targeted tissue culture and send it in. So I know what bacteria is growing and therefore what antibiotic should I be treating with?
We have, I’ve published some research on this, both with the racial disparities. Yes. Because bacterial fluorescence ignores the melanin in the skin, it works on darker toned individuals all the way to lighter toned individuals. Additionally, we’ve published research on what happens when you incorporate this technology as a provider group with all of your patients.
So I can tell you that we’ve reduced systemic antibiotic prescribing by 33%. And I can also tell you that we eliminated hospitalization, sepsis, gangrene and amputations by 52% adopting this technology in the middle of the pandemic, when we had the worst staffing, the least amount of, availability to aggressive healthcare at the hospitals, so on and so forth.
So it definitely balances the equation.
Schenk:
Who have you heard you mentioned, I think a physician’s assistant and a physician who is qualified to use this machine and what kind of training do they need to undergo in order to use it?
Kelso:
I love that question. It can’t be a bedside nurse. It can’t be an LPN or an RN in the post acute care sector.
It does have to be a differential diagnostician. And the company itself, the bacterial fluorescence company, does the training for the providers because they have to learn how to interpret the different colors. If it’s pink, what does it mean? If it’s dark green, what does it mean? Versus green. And so the company itself puts the providers through the training with documented competencies.
And then we actually have my company Wound Care Plus, we have them go through retraining and retraining again, because the more trained your eye is, the more different things you’re going to see. In some cases, we’ve also identified subdermal abscesses that nobody could have seen with the naked eye and it’ll glow almost a pinkish hue or a rose colored hue and that means subdermal or below the skin abscess or infection.
When is fluorescence imaging appropriate for a wound?
Schenk:
When, if someone is qualified to use the machine.
When is it the standard? If there is a standard, when would it be normal to use it? What, at what point are we’re not just waving it in front of every resident as they will buy or walk by. When do we know? When to use the machine?
Kelso:
Yeah. Medicare defines that as when it’s medically necessary.
So there’s no what they call local coverage determination. There’s no governance by medicare, therefore it’s set to medical necessity. It’s interesting because there was a study that I was involved in as well where we did an international consensus panel on when this device should be used and based on the international consensus. We’ve defined it as wounds that have stalled for healing, wounds that may have symptoms of infection, people that are on immunosuppressants like prednisone or other immunosuppressants that may not show symptoms of infection.
So there’s a list of criteria that the international panel put together. And then decided this is when traditional clinicians should be considering the use of this device and that’s so far what medicare has been using to govern when they’re going to reimburse and when they’re not.
Schenk:
When do you think it should be used? What’s the earliest do you think that we should use this machine?
Kelso:
I, it’s interesting. Cause when we first rolled this device out, I went into the field myself as a nurse and I’ve been doing this, I’ve been doing advanced wound care, 20 years, I’ve been in healthcare 30. And when you’ve been at it as long as I have, you already have inherent beliefs about wounds that nobody else is going to tell you any different.
And so I can tell you a hundred percent myself when wounds are infected and when they’re not. And you’re not going to change my mind. I’ve seen literally a million wounds, overseen or treated literally a million wounds in 20 years time. So out in the field I go, and the very first person we fluorescence, I said, there’s no way that wound is infected.
And yet it was fluorescing. And I said, I don’t believe it. I don’t think the machine’s telling me. What I think it’s telling me, the data is wrong. It has to be wrong. And we cultured and sure enough, that wound was infected and we would have missed it. And that happened time and time again. And it was so shocking to me, a highly trained clinician specialized in wound care that has seen millions of wounds that my training, my eyesight was wrong.
And so in my belief, when you see a wound, a chronically stalled wound for the first time, you should absolutely fluoresce because chances are that chronic inhibitory bacterial load or wound infection is actually what’s keeping the wound from healing, it’s stalling it out. And worse, when you’re dealing with the sickest of the sick and the most polypharmacy, they don’t have a lot of buffer between when that wound gets infected until they get septic.
And so we now have a machine that doesn’t hurt. It’s non invasive. We have to turn the lights off. It’s got to be done in a completely dark environment. Okay. But you have access to this technology and the ability to prevent severe wound complications. Why wouldn’t you use it?
Schenk:
What you described, and thank you for sharing that I’m sure that was a very humbling experience.
It reminds me of that guy, Malcolm Gladwell, there’s a book he wrote called Blink, where experts in a field for a number of years can make a split second decision in a nanosecond, not understand why they’re making the decision, but the decision is correct. So that’s what that reminded me of.
And the example that he gave many examples, but the one that I remember offhand was art experts recognizing a fake within a nanosecond that fools everybody else. Okay. So tell me then. Walk me through you, you have a resident that’s qualified to receive this treatment. How does it, how long does it take?
What are we, I see we turned the lights off. Okay. Who else is in the room? How do we do it?
Kelso:
The main thing is, you walk in the room, you wash your hands, you explain to the resident or the patient what you’re going to do, get your gloves on, position the resident. We want to be able to see the wound fully.
We don’t want the wound obscured. Then we remove the dressing, cleanse the wound. You’re going to stop, change your gloves, wash your hands, wash your hands, change your gloves, come back over. We’re going to then explain to them what we’re doing. Here’s why we’re doing it. We want to see if the wound is infected.
We’re going to make the room thin and dark. Now traditionally in long term care, the windows are right there so you can’t get the room dark enough. We use a triple layer trash bag to make a black trash bag to make an area around the wound. Put a little hole in the trash bag, stick the device through. And any of the background, you can’t be laying on a white chuck or a white rubberized pad because that’ll revert the UV light back at us.
Then we want to make sure what’s underneath the person is completely black. Then you turn the device on, power it up, get the wound centered, Once the wound’s centered and you’re at the correct length away from the wound, there’s little lights that’ll come on the machine telling you that it’s correct, you then flip the UV filter on, capture the image, stop, look at the image, see what’s happening, interpret the device, then you would probably get out your curette to try to remove any glowing tissue.
Then you’re going to do it all over again.
Schenk:
So it’s a still, in my mind’s eye, it’s a still image, not a move. It’s not like you’re seeing bacteria run around.
Kelso:
You don’t see bacteria move, but you can do a video image too. So if I’m debreeding and I want to take a video of the debridement and do it real time, so I’m not having to re fluoresce.
So they have both, they have a still image and a video. You can do both.
How long does the process last?
Schenk:
And how long does a typical process last?
Kelso:
If they have multiple wounds, you would do this multiple times. So it could be a 30 to 40 minute procedure if you’re having to shift multiple wounds, if you’re having to then stop and do a tissue culture.
If the wound is not infected, it might be a 10 minute procedure where you’re stopping and looking at the interpretation of the image. But usually getting the patient ready, prepped, explained, getting the room completely dark, that’s usually what takes the longest. The image itself may be two to three minutes.
Schenk:
You mentioned in the times it has been used, the studies in which it’s been used has been highly successful. Why haven’t I heard of it? Like why is this not something that’s in every nursing home?
Kelso:
You must not be following me on social media because we’ve been talking about it for several years.
But no the true thing is when new technology is implemented, it takes time for that paradigm shift to happen. Additionally, the provider group has to purchase the machines, and they are not cheap. Additionally, the reimbursement from Medicare and other payers is not a lot. In my care setting, it’s typically 60, and yet, You’re having to purchase a 20, 30, 40, 000 piece of equipment, and then you get reimbursed a small amount over a slow period of time.
And so you have to be able to afford to invest in the technology if payers aren’t going to pay.
Schenk:
Is the, does it seem to you, and we’re nurses and attorneys, not scientists, but does it seem to you that the technology is advancing such that cost is going to come down?
Kelso:
Yes, always.
Schenk:
That’s good.
Yeah, that’s true. That’s true. That’s a dumb question. Martha, is there anything else that we should know about with fluorescence imaging?
Kelso:
It’s the ripple effect, right? So if we do, if we are putting people on antibiotics unnecessarily, you result in multi drug resistant organisms, and quite frankly, our elderly population end up with terrible side effects.
Sometimes antibiotics cause confusion and dizziness and falls with fractures. Sometimes antibiotics cause C. diff and they end up with perforated bowels or malabsorption syndrome or additional wounds from caustic diarrhea. And I chose as the CEO of Wound Care Plus to pay and implement and adopt this technology because it was the right thing to do.
Also, because there was reimbursement for it, but the outcome to our seniors has more than paid us back in dividends. The amount of wound infections we’ve stopped, the amount of hospitalizations we’ve stopped the amount of targeted tissue cultures. My point with that, if you have a wound like this, and there’s no bacteria here, but there is bacteria here.
Sometimes we were doing tissue cultures where there was no bacteria. So we were missing the infection. And so it’s a matter of fact, our clinicians actually get really upset if their machine stops working and they have to wait a week or two to get another machine or to figure out what’s going on with them. They’ve dropped it twice.
Down the hallway and we have to get a new replacement machine. They get upset when they don’t have the device now because it has literally changed the way we practice.
Schenk:
How many are there? Like how many machines are in use now in long term care?
Kelso:
I don’t know. We’re the biggest adopter and we probably have close to 40 machines at this point.
Every single one of our clinicians has one because we’re mobile. So I, Martha, can’t go out in the field today and then ship it to Rob and then Rob ship it back to Martha because we’re all seeing patients every day. So every single one of our clinicians has to have one.
Schenk:
Martha, this has been extremely educational for me, and I’m sure the audience as well, and I really appreciate you coming back on the show.
To share this knowledge with us.
Kelso:
Yeah, that’s an important topic. Thanks for having me.
Schenk:
Sure. Folks, I hope you found this episode educational. I most certainly did a lot of this stuff. I just have never heard of it. So I’m happy that she was able to come on and provide us with some information. If you would like to reach out to Martha, you can go to her website, which is mywoundcareplus.com.
Again, that’s mywoundcareplus.com. New episodes of the Nursing Home Abuse podcast come out every week on Monday. You can get them anywhere. You get your podcast from Spotify, Apple Podcasts, et cetera. But you can also find it, you can watch it on nursinghomeabusepodcast.com or on the YouTubes.
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