Invia Wound Therapy NPWT Order Form Page 1 of 3 Who should Medela, Inc. contact for questions regarding this order? Contact Name: Direct Fax: PATIENT INFORMATION [Complete this section ONLY if you will not be supplying a Face Sheet that contains this information.] Patient s Name (Last, First, MI): Patient s DOB: / / Patient s Permanent Address: SS# - - o Male o Female Height: Weight: (ft., in.) (lbs.) City: State: Zip: Invia Wound Therapy will be used in what type of setting: o Private Residence o Assisted Living Please contact Medela if in: o Skilled Nursing Facility o Rehabilitation Center o Acute Care Facility o LTACH Delivery Address: If a facility, Name: City: State: Zip: Delivery Contact: Direct INSURANCE INFORMATION [Provide a copy of insurance card(s)] Is the financial obligation for the patient s NPWT the responsibility of a party other than the patient or the patient s insurance (i.e., workman s comp, litigation, etc.)? o No o Yes a If Yes: Name of responsible party Contact PRIMARY INSURANCE: o Medicare o Private Insurance o Medicaid Group #: Insurance Name: Policy/ID #: Insurance Address: Primary Care Physician if not Prescriber: SECONDARY INSURANCE: o Medicare o Private Insurance o Medicaid Group #: Insurance Name: Policy/ID #: Insurance Address: TERTIARY INSURANCE: Insurance Name: Group #: Policy/ID #: CLINICAL CARE PROVIDER INFORMATION [The organization that will be providing the patient s wound care.] Name of Organization: Address: City: State: Zip: Organization Organization Contact Name: Organization Fax: Direct Please fax documents to 866-494-6231. Medela, Inc., 1101 Corporate Drive, McHenry, IL 60050-7006 877-MY INVIA (877-694-6842) Email: myinvia@medela.com www.myinvia.com FAC004HCI Rev C 7/16/08 2008 Medela, Inc. All Rights Reserved. Invia and Medela are registered trademarks of Medela, Inc.
Invia Wound Therapy NPWT Order Form Page 2 of 3 Please include copies of all pertinent information from patient s medical record to validate the information provided here. WOUND TYPE [Check only one wound type below. Complete a separate Secondary Wound Assessment Form for each additional wound.] o 1. SURGICALLY CREATED or DEHISCED WOUND o 2. TRAUMATIC WOUND A) Is the patient being appropriately turned/positioned? o Yes o No o 3. PRESSURE ULCER: o Stage III o Stage IV a B) If patient s pressure ulcer is on the posterior trunk or pelvis, has a group 2 or 3 support service been used? o Yes o No o N/A C) Is moisture/incontinence being managed? o Yes o No o 4. VENOUS/ARTERIAL ULCER a A) Are compression bandages and/or garments being consistently applied? o Yes o No B) Is leg elevation/ambulation being encouraged? o Yes o No o 5. NEUROPATHIC ULCER (e.g., diabetic ulcer) a A) Has pressure on the foot ulcer been reduced with appropriate modalities? o Yes o No o 6. CHRONIC ULCER/MIXED ETIOLOGY (present at least 30 days) a A) Is pressure over the wound being relieved? o Yes o No o N/A B) Is moisture/incontinence being managed? o Yes o No WOUND HISTORY 1) Which therapies have been previously utilized to maintain a moist wound environment? [Check all that apply.] o Saline/Gauze o Hydrogel o Alginate o Hydrocolloid o Absorptive o Other: 2) Is the patient s nutritional status compromised? o No o Yes a If Yes, check the actions taken: o Protein Supplements o Enteral/NG Feeding o TPN o Vitamin Therapy o Other: 3) Was NPWT utilized within the last 90 days? o No o Yes a If Yes: o Inpatient o Outpatient If Yes, Date initiated: / / Facility Name: 4) Does patient have diabetes? o No o Yes a If Yes, is patient on a comprehensive diabetic management program? o No o Yes 5) Is there osteomyelitis present in the wound? o No o Yes a If Yes, treated with: 6) If wound is > 90 days, has a biopsy been done? o No o Yes a If Yes, is cancer in the wound? o No o Yes a (contraindicated) 7) Is there a fistula to an organ or body cavity within vicinity of the wound? o No o Yes a If Yes: o Enteric o Non-enteric a (contraindicated) Additional medical documentation may be requested. Please fax documents to 866-494-6231. Medela, Inc., 1101 Corporate Drive, McHenry, IL 60050-7006 877-MY INVIA (877-694-6842) Email: myinvia@medela.com www.myinvia.com FAC004HCI Rev C 7/16/08 2008 Medela, Inc. All Rights Reserved. Invia and Medela are registered trademarks of Medela, Inc.
Invia Wound Therapy NPWT Order Form Page 3 of 3 Please include copies of all pertinent information from patient s medical record to validate the information provided here. WOUND MEASUREMENTS [Complete a separate Secondary Wound Assessment Form for each additional wound.] Wound Location: Wound Age in Months: Presence of necrotic tissue with eschar? o No o Yes* [Please obtain measurements after debridement.] * If yes, type of debridement: o Mechanical o Chemical o Sharp/Surgical a If Sharp/Surgical, date: / / Length: cm Width: cm Depth*: cm * If depth is less than or equal to 0.5 cm, please provide documentation whether underlying structures (such as bone, muscle, fascia) are exposed. Measurement Date: / / Is there undermining? o No o Yes a If Yes, complete details below. Location #1: cm, from to o clock Location #2: cm, from to o clock Is there tunneling/sinus? o No o Yes a If Yes, complete details below. Location #1: cm, @ o clock Location #2: cm, @ o clock Exudate Type: o Serous o Serosanginous o Other Exudate Amount: o < 100 ml / day o > 100 ml / day TO BE COMPLETED BY PRESCRIBER PRESCRIPTION, ATTESTATION AND PRESCRIBER INFORMATION Patient Name [print] (last) (first) (mi) I prescribe Invia Wound Therapy. This includes: an Invia Wound Therapy suction pump, up to 15 wound dressing sets/per wound/per month and up to 10 canisters per month. The anticipated length of therapy is month(s) starting on / / for the following diagnosis (ICD-9-CM diagnosis code specific to 4th or 5th digit or narrative): Goal at the completion of Invia Wound Therapy: o Assist granulation tissue formation o Delayed primary closure (tertiary) Prescriber s Signature Date / / Prescriber s Name [print] (last) (first) (mi) Address: City: State: Zip: Fax: NPI: PRODUCTS PROVIDED Upon establishment of medical necessity, Medela will ship an Invia Wound Therapy suction pump, 15 wound dressing sets per wound per month and 10 canisters per month. If you would like to make a special request for other supplies, please check here o and a Medela customer service representative will contact you regarding this. Requested delivery date: / / [Please allow at least 24 hours following review of completed form.] Please fax documents to 866-494-6231. Medela, Inc., 1101 Corporate Drive, McHenry, IL 60050-7006 877-MY INVIA (877-694-6842) Email: myinvia@medela.com www.myinvia.com FAC004HCI Rev C 7/16/08 2008 Medela, Inc. All Rights Reserved. Invia and Medela are registered trademarks of Medela, Inc.
One Nolte Drive ~ Kittanning, PA 16201 724-545-3200 ~ Toll Free: 888-545-4949 Instruction for Completion of Negative Pressure Wound Therapy (NPWT) Prescription and Clinical Information Forms Section I Prescription To be completed by the physician. 1. Only complete this prescription form if you will not be providing a separated prescription or written order. 2. Sign and date the Prescription and Attestation, no stamped signatures. 3. Include a letter of Medical Necessity and request for additional supplies. A. NPWT is required for greater than 4 months and/or B. The clinical condition of the wound requires more than 15 dressings per wound and/ or more than 10 canisters per month. Section II Patient s Wound History To be completed by licensed professionals only. 1. Answer questions 1-5 or fax the applicable documentation from the patient s medical record to (724) 543-2718 2. If the information is faxed, data must include: A. Wound history and any operative reports B. Wound measurements C. Nutritional status Section III Additional Information by Wound Type To be completed by licensed professional only. 1. Answer only the question that relate to the patient s specific wound type. Section IV Wound Measurement To be completed by licensed professional only. 1. Complete all items 2. Record the measurements for each wound being treated with NPWT. NPWT Order Form Completed by licensed professionals, for initial order, and faxed to (724)543-2718 Monthly Wound Progress Documentation Form Completed by licensed professionals and faxed monthly to (724)543-2718 All information must be completed in order for the beneficiary to qualify for Medicare. If more than one wound is being treated, a prescription is needed for each wound. Failure to follow all instructions for use can lead to improper product performance and serious or fatal injury; consult a physician prior to initiation of treatment with NPWT. Clinical and technical support is available through contacting Armscare Medical Supply at (888)545-4949, or the on call service 24/7 at (866)603-6598.
Who should Armscare contact for question regarding this order? Contact Name: Direct Negative Pressure Wound Therapy PATIENT INFORMATION [Complete this section ONLY if you will not be supplying a Face Sheet that contains this information.] Patient s Name (Last, First, MI) Patient s DOB: (mm/dd/yyyy) / / SS# - - Height: Weight: Patient s Permanent Address: City: State: Zip: Armscare Wound Therapy will be used in what type of setting: Private Residence Assisted Living Please contact Armscare if in: Skilled Nursing Facility Rehabilitation Center Acute Care Facility LTCH Delivery Address: If a facility, Name: City: State: Zip: Delivery Contact: Direct INSURANCE INFORMATION [Provide a copy of insurance card(s)] Is the financial obligation for the patient s NPWT the responsibility of a party of other than the patients of the patients insurance (i.e. workman s comp, litigation, ect.)? No Yes If Yes: Name the responsible party: Contact PRIMARY INSURANCE: Medicare Private Insurance Medicaid Group# Insurance Name: Policy/ID #: Insurance Address: Primary Care Physician if not Prescriber: SECONDARY INSURANCE: Medicare Private Insurance Medicaid Group# Insurance Name: Policy/ID# Insurance Address: TERTIARY INSURANCE: Insurance Name: Group#: Policy/ID# CLINICAL CARE PROVIDER INFORMATION [The organization that will be providing the patient s wound care.] Name of Organization: Address: City: State: Zip: Organization Organization Contact Name: Organization Fax: Direct One Nolte Drive, Kittanning, PA 16201 724-545-3200 / 888-545-4949 Fox: 724-543-2718
General Protocols for Negative Pressure Wound Therapy System Compiled by Jen Agosti, RN, CWCA, FACCWS, President, Nurse Sharks Introduction: Negative Pressure Wound Therapy (NPWT) is indicated for the types of wounds which may benefit from an environment encouraging removal of fluids and drainage from the wound bed and enhancing circulation to the wound surface to promote healing. Treatment goals include: management of exudate; controlling infection; promoting tissue granulation; contraction of wound edges; angiogenesis; and remodeling of tissue matrix. Indication for use of NPWT: Stage III and IV pressure ulcers Surgical and acute wounds Neuropathic and venous insufficiency ulcers Traumatic wounds Chronic wounds Contraindications/Precautions for NPWT: Malignant wounds Areas where major organs, bone, or blood vessels are exposed Untreated osteomyelitis Multi-system failure (Failure to Thrive) Wounds with eschar Uncooperative patient Anticoagulant use Malnutrition Immunocompromised When to Stop NPWT: Wound it too dry Wound is superficial Pain at wound site with application of NPWT Wound has achieved adequate granulation tissue for alternate therapy or surgical interventions
Dressing Application and Change Procedures: Before initiating dressing procedure, turn the pump on to ensure that the unit is functioning, and then turn it back off. Open the canister set package and place the bacterial filter* in the top left corner of the unit (it only fits one way), attach the 12 clear tubing to the 90 degree white elbow connector and insert the elbow connector into the filter and attach the other end of tubing to the canister lid labeled vacuum. Thoroughly cleanse the wound with NSS and gently pat dry the peri-wound skin Apply skin barrier to peri-wound skin and allow to air dry Line the wound bed with the non-adherent contact layer, cut to mimic wound bed size Saturate the AMD gauze with saline Place the clamp on the drain tubing and sandwich the drain between saline moistened gauze, pack any remaining depth with saline soaked gauze 4x4 s The gauze should be on top of/surrounding the drain tubing Protect the peri-wound skin where the drain will draped to prevent additional skin breakdown (may use hydrogel or hydrocolloid Cover the entire wound with transparent occlusive dressing, make sure the dressing surrounds the wound edges by 1-2 inches Seal the suction catheter with the transparent film by squeezing the film around the suction catheter Attach the suction catheter to the male adapter on the drain tubing Close the clamp Turn pump on to continuous suction therapy and dial setting to between 60-80mmHg Release the clamp, you should hear a sucking down noise and be able to visualize the dressing suck down as well Listen for air leaks and patch any leaks with transparent dressings Inspect the dressing for a complete seal at least every 4 hours and reinforce as necessary Check the pressure setting at least every shift to maintain proper suction
Initial dressing, drain, and tubing changes in 48 hours then 3 times weekly (depending upon length of seal and amount of drainage), after two weeks, the dressing changes may be decreased to 2x weekly if the physician feels that is indicated based on wound drainage and longevity of seal Pressure settings may also be increased in increments of 10mmHg weekly if the physician feels that this is indicated to expedite fluids drainage Technical Tips: Change the dressing, drain, and tubing 3x a week Change the canister every 2 weeks and as needed for full container Change the bacterial filter with each canister change and if overflow occurs Setting up and managing the Pump: Plug into outlet Set black button on the front of the machine to continuous mode Adjust the blue dial to between 60-80 mmhg, push dial in and turn to adjust rate Insert the bacterial filter with the elbow connector and short tubing into the left opening Connect the tubing to the bacterial filter Canister Management: Connect the blue end of the tubing to the canister; the white male end is connected to the drain which is placed in the wound bed Battery Management: The internal battery has a 30-45 minute lifespan To recharge the battery, plug into outlet, for at least 2 hours and turn the pump off (clamp tubing while recharging the unit) *The bacterial filter must be used at all times, failure to use this filter may result in overflow passing into the internal parts of the pump, causing the pump to become contaminated and therefore requiring the unit to be taken out of service. Failure to use the bacterial filter may result in a charge to the facility for the internal replacement parts. These instructions are intended to be utilized as a guide according to the manufacturer s recommended protocols for use: Nurse Sharks, Inc. is not responsible for individual interpretation of these guidelines. Please contact either Armscare at (724)545-3200 / 888-545-4949 or Nurse Sharks, Inc. at (814)787-7365 for troubleshooting and/or clinical concerns.
Negative Pressure Education I / We have been given instructions and training on the Negative Pressure Wound Therapy System, as documented below: Instructor / title: Date: Person(s) receiving education / title: Date: Clinical Instruction Authorization Delivery Slip