March/April 2014

Wound Care Management

By Jeanine Maguire, MPT, CWS
Today’s Geriatric Medicine
Vol. 7 No. 2 P. 14

Long term care facilities must adhere to the basics in wound care management while embracing an interdisciplinary approach that advances best practices to attract partnerships with referral sources and decrease the potential for wound-related litigation.

Pressure ulcers, neuropathic ulcers, and chronic wound conditions pose a continuing challenge in long term care (LTC) and skilled nursing facilities. Most experts agree that a majority of pressure ulcers can be avoided, and the advent of an avoidable pressure ulcer often is perceived as resulting from poor quality care. Facilities that strictly adhere to the basics of pressure ulcer prevention have proven their ability to decrease facility-acquired pressure ulcers.

However, the health care system is evolving, and a focus on reducing rehospitalizations is an essential piece of LTC facilities’ partnerships with referral sources. As this relates to wound management, preventing rehospitalizations means not only preventing pressure ulcers but also healing and/or effectively managing existing community-acquired pressure ulcers, neuropathic ulcers, chronic wounds, and even surgical incisions. Additionally, as litigation involving pressure ulcers and chronic wounds continues to increase, an interdisciplinary approach that moves beyond the basics is key to survival.

Revisiting the Basics
The basics in pressure ulcer prevention have been well established in a multitude of publications and national guidelines, including those from the National Pressure Ulcer Advisory Panel; the Centers for Medicare & Medicaid Services; the Wound, Ostomy, and Continence Nurses Society; and the American Medical Directors Association. Research indicates that adhering to these standards results in decreased numbers of facility-acquired pressure ulcers. Increasing exercise at any level benefits wound prevention and healing as well as stress management, musculoskeletal pain reduction, blood pressure, weight control, blood sugar maintenance, and general well-being.

Strict adherence to risk assessment protocol (eg, Braden, Norton) and the provision of individualized interventions that focus on nutrition, moisture management, pressure redistribution, turning, repositioning, and mobility are the mainstay of care.

Facilities that have failed to establish sound and consistent processes regarding wound prevention and care likely will struggle with regulatory issues, litigation, the perception of poor care, and costly fixes, although those that have established such processes are better off but not completely in the clear. As the health care landscape moves forward with new technology, the advanced processes for overall wound management and outcomes, beyond pressure ulcer prevention, will be of greater interest to referral sources, litigators, and regulators.

Advancing pressure ulcer and wound management in LTC and skilled nursing facility environments includes performing the following:

• utilizing electronic medical record (EMR), telehealth, and virtual medicine options;

• standardizing treatment and surface options for a variety of patient needs;

• incorporating strategies to reduce the risk of staff injury while providing care to high-risk residents; and

• advancing wound management by establishing an interdisciplinary approach, including active participation of physicians and/or physician extenders.

Technological Evolution
It is essential for LTC and skilled nursing facilities to evaluate the numerous technology choices available to enhance wound management. Newer options may include using technology to access a wound specialist for virtual consultation or wound rounds, conduct virtual education, make virtual treatment selections, conduct virtual Medicare Part B billing, use EMR wound modules for data collection and assessment, or incorporate wound photographs into the EMR.

These options ultimately will provide improved communications throughout the continuum of care, more transparency and less redundancy of paperwork for caregivers, and potentially more access to certified wound specialists, even in remote locations. But as these newer technologies advance, there are barriers and glitches to work out, as with any trial or implementation. For the caregiver at the bedside, whose tech skills could widely vary, this can be a frustrating time.

Some issues and challenges related to technological advancements include programs that are not always user friendly or easy to navigate; wound programs that may be too complicated and take more time vs. old-fashioned paper and basic Excel grids; an inability to connect wound modules to primary EMR programs; wireless connection issues; and privacy issues that range from protection/encryption of the actual programs to bedside privacy issues using EMRs and other new virtual technologies. A key to successful technology use involves collaborating with vendors to work through these issues.

In light of technology’s evolution, facilities should develop a task force to review, evaluate, and select technology solutions. Team members should include IT and legal consultants, an outcomes specialist, a facility administrator, the director of nursing, a staff nurse, a wound specialist, and an education specialist.

The task force should define the facility’s goals regarding wound management and refine its focus. It should identify needs, whether they include a single EMR for the entire medical record documentation, the ability to generate reports, a wound module, or photography capabilities. The task force should measure time consumption for data entry, downloading needs, and other tasks to note time added or saved. If there are multiple technologies, the facility’s ability to interact and/or easily connect among them must be determined.

It’s also essential to consider patient protection, such as photo encryption as well as patient consent needs, privacy concerns, care goals, and expectations along with the necessary documentation. Other considerations include assessing devices such as iPads and tablets, the availability of wireless connectivity, the metrics on ease of use, management of IT issues, the education required for use, and staff competency with using them.

Choosing Appropriate Products
With thousands of wound-related products on the market, facilities can become overwhelmed when trying to narrow choices and select the best options for patients’ wounds, the facility’s stock, and/or an organization’s formulary, particularly in view of the time-consuming process of sifting through the options and investigating FDA approvals and supportive research.

Despite the difficulty, nurses must understand the whys and hows of using and applying skin and wound products to their patients. Nurses most often are the primary clinicians evaluating patients’ wounds with every dressing change and then communicating changes and topical product recommendations to prescribers. The treating nurse requires an understanding of treatment indications and contraindications to ensure product appropriateness, as with any other medication. Failure to select the right option or incorrectly using it can negatively impact clinical outcomes. Additionally, having too many product varieties and options is unnecessary and can increase the potential for errors while driving up facility costs.

In addition to the overwhelming number of skin and wound product treatment options, there are myriad options related to therapeutic surfaces. Foam? Memory foam? Low air loss? Alternating pressure? Foam and air hybrids? Rotating, static, dynamic? Rent or purchase? How long will a certain product last? What are the benefits and risks of each product? Again, failure to select the right options for patients’ needs can be just as detrimental as having too many, resulting in selection confusion and potential errors.

Interdisciplinary Approach
To attract partnerships with referral sources and decrease wound-related litigation and regulatory issues, facilities must focus on wound management basics while advancing management principles via an interdisciplinary approach. Recognizing and implementing best practices to promote the healing and/or management of community-acquired pressure ulcers, neuropathic ulcers, chronic wounds, and surgical incisions is key to minimizing the risk of rehospitalizations as well as minimizing the scrutiny of surveyors and litigators.

Achieving successful wound outcomes falls beyond the basics in pressure ulcer prevention. Facilities that admit patients with wound and skin conditions need an interdisciplinary team approach to manage them, with clearly stated expectations and a plan of care. Facilities with a well-prepared internal team will be best suited to maximize positive outcomes and avoid costly errors.

The admitting nurse must be able to recognize common wound types and atypical characteristics in order to collaborate with providers to identify the right treatment guidelines and the associated interventions without delay. Too often patients are admitted with a wound that is incorrectly labeled, often as pressure, leading to the wrong treatment path.

Educational deficits in basic wound assessment can result in the failure to recognize early signs of infection or wound decline, resulting in the need for more expensive treatments, use of antibiotics, and rehospitaliziations. Even the seemingly simple mistake of not understanding that a stage II pressure ulcer cannot have slough can result in incorrect treatments and interventions and subsequent wound decline, followed by regulatory and legal repercussions.

Also important is the patient’s and family’s perception of wound care and what may have been a missed opportunity to allow them to psychologically adapt to a clinically unavoidable situation. Even in cases where a patient’s medical status is so compromised that wound healing is not probable, well-intentioned clinicians may incorrectly give these patients and their family members unrealistic expectations. The inability of a facility’s team to properly manage a patient’s wound and/or effectively communicate all risk factors that may impact the patient’s ability to heal can lead to frustration, poor satisfaction, and legal and regulatory issues.

Despite the many challenges, there are opportunities as well as the potential for newly identified solutions that can have positive results for internal process improvement; potential cost reductions; improved relationships with patients, families, and referral sources; reduction in staff injury; and improved outcomes in terms of patient satisfaction and regulatory and legal survival.

Change is never easy. However, with clearly defined goals, strong leadership, thoughtful strategy, and preference, the efforts are well worth any struggles.

Caring for Caregivers
Nurses and direct care staff can suffer injuries related to wound management and treating pressure ulcers because many of these injuries occur when turning and repositioning highly dependent patients. Turning and repositioning is an expected standard of care for the prevention and management of pressure ulcers, yet facilities often find it difficult to maintain it in an ongoing, consistent fashion.

Articles in many publications have suggested that the difficulty in maintaining consistent turning regimens lies in the large numbers of patients who either are dependent on or require extensive assistance to reposition. Adding to that difficulty, according to the Centers for Disease Control and Prevention, recent literature has estimated that nearly 70% of adults in the United States are overweight, potentially adding to the physical demands on caregivers.

An additional challenge is created by the increasing number of aging staff members who may not be physically capable of routinely and safely turning and repositioning dependent patients, as indicated by the number of injured nurses and nursing assistants noted by the US Bureau of Labor Statistics.

Wound Management Beyond the Basics
Clinicians, including medical directors, physicians, physician extenders, nurses, and therapists, all have received varying degrees of education regarding wound management. Too often, however, clinicians avoid practicing wound management because they may lack specialized training or wound care itself has evolved beyond what they were taught years ago. Regardless, clinicians who are willing to incorporate their area of expertise and work with the health care team can contribute to significant improvement in outcomes.

Additionally, the availability of wound journals, wound workshops, national wound symposiums, national wound certifications, and online training make advancing clinical education easily obtainable for all disciplines. The interdisciplinary team can maximize outcomes by collaborating with weekly wound rounds, education, and overall process improvement. Below are descriptions of the roles various professionals play in advancing wound care management:

• The medical director provides oversight and support of the wound management program from prevention to treatment, supports and directs the physician or extender who attends rounds, and oversees and directs wound management process improvement efforts.

• The facility administrator ensures the availability of guideline treatments and provision of therapeutic surfaces immediately on patient admission, oversees process improvement and audits, and collaborates with the medical director to establish any staffing changes to accommodate efficient wound rounds.

• The director of nursing enforces consistency in wound rounds and turning programs; oversees audits; collaborates with the administrator regarding the needs for new admissions at risk of or with wounds; collaborates with the facility staff to establish a process for procurement from central supply to the patient, including weekends and holidays; mentors the unit manger in root cause analysis of any wound patterns; collaborates with certified wound specialists to determine any facilitywide wound-specific needs or areas for process improvement; monitors wound management outcomes; and reviews monthly unit wound logs.

• A certified wound specialist collaborates routinely with the wound team for all chronic ulcers and full-thickness ulcers; coordinates and leads interdisciplinary wound rounds; provides wound prevention and management education to clinicians, patients, families, and the community; provides ongoing wound product and surface selection, education, and competency; analyzes root cause reporting and oversees wound outcome reporting; supports and educates staff regarding wound-type policy, procedures, guidelines, and algorithms; and collaborates across the continuum of care.

• The physician or physician extender establishes wound-type diagnosis; determines anticipated wound-type prognosis; and intervenes, recognizes, and educates the team regarding any medical conditions and medication that may impair healing. In cases where healing is unlikely, he or she ensures that the patient, family, and care team receive an explanation and details regarding emphasis on the goal of comfort and infection prevention, including debridement, bedside tests (eg, ankle brachial index), referrals to appropriate specialists (eg, vascular, infectious disease), and appropriate test utilization (eg, MRI, biopsy).

• The education specialist or nurse practice educator attends rounds to recognize educational opportunities; collaborates with the certified wound specialist for wound-specific education; educates the team on infection control, treatment applications, guideline utilization, communication skills, surface utilization, turning and repositioning, risk assessment, skin assessment, body mechanics, wound characteristics, and pressure ulcer staging; and provides bedside education, if appropriate.

• The unit manager reviews care plans and interventions weekly and assesses overall patient progress toward his or her goals, determines any other relevant aspects that may impact a patient’s wound (eg, positioning during dialysis), ensures access to and availability of guideline wound products, maintains the unit wound log, and assists with root cause analysis for any wound-type trends.

• Nursing staff recommends topical treatment options based on the facility’s established guidelines; provides education to patients, families, and the wound team; and provides treatments according to policy to minimize infection risk. (All nurses who provide treatments must be competent in treatment recommendations and appropriate application.)

• Physical therapists restore function, including mobility, and lead strengthening and conditioning programs; restore and/or increase safe bed and chair mobility to prevent skin breakdown or promote healing; provide family and staff education on proper body mechanics for patients who need turning or repositioning; manage contracture; intervene with unique positioning needs in a bed or chair; debride wounds (per state practice act and facility policy); evaluate for modalities to increase circulation to chronic wounds; and establish gait training.

• Occupational therapists evaluate for complex seating and positioning needs, manage contracture, monitor scar management, restore independent bed and transfer mobility, and provide instructions regarding use of adaptive equipment.

• Speech therapists evaluate for swallowing disorders.

• Dietitians evaluate residents at risk of pressure ulcers as well as those with pressure ulcers and other chronic wounds and provide education to patients, family members, and the interdisciplinary team regarding any nutritional risk factors and/or interventions.

• Nursing assistants attend to patients and assist with positioning for wound rounds and report to the nursing director any issues with interventions (eg, heel lift boots, turning devices, wedges).

• Social services guides the care team in effective communication with patients and family members, helps patients and their families to adapt to and cope with a chronic wound diagnosis and/or adapt to, accept, and cope with palliative wound management goals.

Final Thoughts
Pressure ulcer prevention basics are the expected standard across the continuum of care. The LTC and skilled nursing facilities most efficient and consistent with the basics have a tremendous opportunity to offer advanced wound management for individuals with existing wounds of various etiologies. The on-site availability of the entire interdisciplinary team and, in some cases, even the family, allows this type of setting to offer a holistic approach to wound care.

The use of advancing technologies, standardized treatments, and standardized therapeutic surfaces and interventions positions facilities as the optimal settings to maximize skin and wound outcomes. However, providing care to institutionalized older adults is not without some challenges. Advancing wound education and routine access to a certified wound specialist will assist in building the interdisciplinary team and lend to more credibility among peers and referral sources.

In addition to that challenge, the physical demands of caring for this high-risk population, with and without wounds, is resulting in higher staff injury rates. Incorporating the use of carefully selected devices along with education about body mechanics can result in a future LTC and skilled nursing facility care that not only excels in wound management outcomes but also becomes a more attractive place for those caregivers who have the desire and compassion to care for this population.

— Jeanine Maguire, MPT, CWS, serves as a clinical director for skin integrity and wound management and chair of product selection for Genesis HealthCare. As a physical therapist and nationally certified wound specialist, she has dedicated the last 20 years to improving outcomes for patients who suffer with wounds. As an educator, she provides wound-related lectures at colleges and at state and national venues for physician groups, therapists, dietitians, nurses, and students.