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 Building the Best Wound Programs

New technologies and products are advancing pressure ulcer treatment, but caregivers in sync with their residents are the critical element.

 

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Americans are obsessed with their skin. They spend billions of dollars every year to keep it young, firm, and healthy. When people age and they enter a long term care center, concerns about skin continue, but the priorities shift. The focus is on keeping skin intact; preventing wounds; and when they occur, treating them; warding off complications such as infections; and managing pain. In recent years, there have been some innovations in wound care prevention and management, but communication and teamwork remain the ultimate key to success.

Front and Center

Preventing wounds has always been a top concern of nursing center staff. Wounds also have been a source of fears of survey citations and even litigation. Then back in 2001, Stage 3 and 4 pressure ulcers that occur after admission to a health care facility were included on a list of “never” events, something considered to be a medical error that should never happen, by the National Quality Forum. While this term is no longer used, facility-acquired wounds remain stigmatized.

“Family members hear this and think that wounds should never occur, and they are angry and upset when one does,” says Lee Rogers, MD, DPM, wound researcher and medical director of quality for Advanced Tissue.

In truth, “although pressure injuries are sometimes associated with factors such as inadequate staffing and nutritional care, the preventability of all pressure ulcers has never been proven, and most caregivers agree that they can occur even in the best of circumstances,” says Jeffrey Levine, a New York-based geriatrician, board member of the National Pressure Ulcer Advisory Panel, and co-author of “Pocket Guide to Pressure Ulcers.”

Nonetheless, the formation of a wound can strike terror in the hearts of team members and suspicion in the minds of family members. Because of this, it should be no surprise that terminology surrounding wounds is of great interest and controversy.

Changing Terminology

In an effort to accurately describe wounds, the National Pressure Ulcer Advisory Panel (NPUAP) recently replaced the term “pressure ulcer” with “pressure injury” in its revised staging system.

According to the organization, “The change in terminology more accurately describes pressure injuries to both intact and ulcerated skin. In the previous staging system, Stage 1 and Deep Tissue Injury described injured intact skin, while the other stages described open ulcers. This led to confusion because the definitions for each of the stages referred to the injuries as ‘pressure ulcers.’”

In addition to the terminology change, stages are referred to with Arabic numbers, instead of Roman numerals, and the term “suspected” has been removed from the “Deep Tissue Injury” diagnostic label. The updated staging system includes the definitions included in Figure 1 (see Figure One).

While many organizations have adopted the new terminology, some have expressed concerns. For example, this past March AMDA—The Society for Post-Acute and Long-Term Care Medicine House of Delegates passed a resolution opposing the change in nomenclature from “pressure ulcer” to “pressure injury” for ICD-10 diagnoses and “other diagnostic catalogues and classification systems.” However, the society continues to explore the NPUAP terminology.

The Centers for Medicare & Medicaid Services (CMS) and the Minimum Data Set still use the term pressure ulcers, “so we are staying with that for the time being,” says Gary Brandeis, MD, CMD, medical director of the New Jewish Home and clinical professor of geriatrics at the Icahn School of Medicine at Mount Sinai in New York. “If CMS adopts the new terminology, that will change everything. We will see how it plays out.”

More Sinister Applications

At the same time, many practitioners are concerned about the new nomenclature.

“I understand the rationale for the terminology change. However, there have been issues with lawsuits related to language,” says Jonathan Musher, MD, CMD, medical director of The Village at Rockville in Maryland and chair of Family Medicine for Suburban Hospital/Johns Hopkins Medicine. “When you say ‘injury,’ it implies that something has been damaged. Attorneys may wrongly suggest or conclude that injury implies fault—that someone did something wrong.”

While some practitioners are concerned about the litigation-related implications of the new terminology, an article in The National Law Review published earlier this year called the new staging system a “much needed clarification for medical professionals.” The authors said, “It is important that providers of pressure injury treatment take note of these recent changes and incorporate this new terminology and staging system into their diagnoses and treatment documentation moving forward.”

Promising Products

Wound care is a large and fast-growing market. In 2016, $17 billion was spent on wound care products, and this is expected to grow to $20 billion by 2021. Factors such as rising awareness regarding new technologies for wound care, government funding, and rising diabetic and aging populations are driving market growth.

Researchers are constantly looking for new, innovative ways to manage wounds, and new products are always in development. Among some of the innovations currently being studied are:
Crab-shell bandages. These involve the use of alginate, derived from seaweed, to create effective, strong bandages used as wound dressings. Researchers studying crab-shell bandages say it not only heals wounds faster but also contains powerful antimicrobial agents that kill several strains of bacteria.
Vacuum-esque bandages. Created by Australian researchers, these fast-acting vacuum plasters are small and lightweight and connect to a vacuum pump that is small and portable (about the size of the average Smart phone). It creates an area of negative pressure that removes dead tissue and other debris while encouraging increased blood flow that can help the wound heal quicker.
Bacteriophages. While keeping bacteria away from wounds typically has been a goal of wound care, some researchers are using microbials as part of treatment. A bacteriophage is a virus that infects bacteria, essentially a virus consisting of DNA or RNA that is enclosed in a protein shell. They use this DNA or RNA to kill targeted bacteria. While this technology has been around for years, it is fairly new to wound care.
Biomarkers of chronic wound tissue. One researcher has developed a biomarker profile of chronic wound tissue that can be measured against normal tissue and used to determine if a wound requires further debridement and measure the success of previous debridement.
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From Silver to Silicone: Options Abound

In addition to interventions in the works and on the horizon, there are many products and interventions that are available and useful today. For example, “skin substitutes,” a group of substances that help with the closure of wounds, may promote healing by absorbing, retaining, and protecting bioactive molecules from the wound area.

Ultrasound technology has proven effective in recent years. High-resolution ultrasound can help detect soft tissue damage and edema even before the wound sets off visual alarms for the care team. Additionally, hyperbaric oxygen therapy has shown promise to help heal recalcitrant wounds. Topical Radiant Heating, using a temperature-related bandaging system, has shown to be useful in healing infections and increasing local dermal blood flow.

Elsewhere, “smart” adhesive bandages, approved by the U.S. Food and Drug Administration (FDA), release a multi-compound therapeutic substance—which may include anticoagulants, antibiotics, and antifungals—onto a sterile pad.

Jeffrey LevineSilicone dressings are gaining popularity. Basically, these are coated with soft silicone and adhere to the surface of dry skin. They can be used to reduce friction and protect vulnerable areas from breakdown. Their advantage is that they can be used with very frail individuals, and they don’t have to be changed every day, says Mary Sieggreen, MSN, APRN, BC, CVN, a nurse practitioner and wound care specialist at Harper University Hospital, Detroit Medical Center.

Silver-containing dressings have also become popular in recent years to assist in managing infected wounds and those at risk of infection. However, these dressings have varied responses in clinical use because of technological differences in the nature of their silver content and release characteristics and in the properties of the dressings themselves.

Some newer products contain lower concentrations of silver and are not deactivated by saline, which offers some advantages. At least one silver-containing product has an FDA-approved indication for treating methicillin-resistant Staphylococcus aureus, and some have an anti-inflammatory component to reduce pain. In choosing a silver product, considerations include cost, efficacy, and ease of use.

New Therapies

Gaining some attention in recent years is negative pressure wound therapy, or NPWT. This treatment uses controlled subatmospheric pressure to assist with healing. It is designed to remove necrotic debris materials, promote perfusion and granulation tissue formation, and reduce edema.

Support surfaces can make a difference, although they are not all created equal. According to AMDA’s clinical practice guideline, Pressure Ulcers and Other Wounds, “A systematic review of support surfaces for pressure ulcer prevention found that ordinary foam mattresses (less than 4 inches thick) presented a higher risk for pressure-ulcer development than did higher-specification mattresses and that the use of real sheepskin overlays reduced pressure ulcer incidence.”

The guideline suggests, “Patients at risk of skin breakdown should be placed on a static support surface (for example, foam overlay, foam mattress, static flotation device) rather than on a standard mattress.”

Air-fluidized beds have been shown to improve pressure ulcer healing, although there is little evidence that alternating-pressure surfaces have the same effect. Nancy Overstreet, DNP, GNP-BC, CWOCN, CDP, a geriatric nurse practitioner with a Post-Masters certificate in wound, continence, and ostomy nursing, recommends selecting a support surface that meets the individual patient’s needs.

She advises clinicians to factor in the person’s mobility/activity level, size and weight, existing wounds (number, severity, and location), and risk for developing new wounds.

Follow a Plan

There are so many products out there, it can be hard to choose, Musher says. “Having a wound care formulary is helpful. You work with your team to identify products you prefer, and practitioners can choose from those.” Of course, physicians can go off the formulary if they have a good reason, but this is an effective, straightforward process that will prevent using inappropriate or inordinately expensive products, he says. “It provides checks and balances.”

Rogers observes, “I don’t think there is much difference between dressings in the same category. It’s often challenging for providers to get past the corporate biases to make choices.” He adds, “I recommend that providers prescribe dressings based on categories, not brand name. This streamlines the process and prevents call-backs when a particular brand isn’t available.”

Overall, says Levine, “There have been numerous products in the past two decades to assist in healing wounds, but there is little evidence to support one over the other.” However, he says, “The concept of ‘wound bed preparation’ calls attention to the basics of wound healing and gives greater order and rationale to the use of these products to address a specific aspect of healing.” Examples include moisture balance, reduction of bacterial load, and removal of slough and dead tissue.

“There is also recent acknowledgement that some wounds will not heal, and palliative care principles need to be applied,” Levine says. In such cases, expensive treatments and aggressive or invasive procedures can be replaced with symptom control and comfort care, allowing for better quality of life and possible cost savings, he says.

Bring the Team On

Often, says Sieggreen, the answer isn’t always a breakthrough product or innovative treatment but common sense.
“We want to have a high degree of observance among the entire team,” she says. For example, “We gave out pocket mirrors to caregivers that say ‘Prevent Injury’ on them. Every time they pull the mirror out, they are reminded to watch for signs of skin breakdown or irritation and to be cognizant of managing and monitoring existing wounds.”
Moving forward, says Overstreet, “science is helping us. We understand more about what happens in wounds, especially pressure-related wounds.”

This information needs to be shared with all team members, and everyone needs to be able to report concerns about skin integrity without fears of retribution. “When everyone is empowered, you will see people taking this responsibility seriously,” she says. “We often having housekeeping staff, for example, tell us that someone isn’t eating or is sitting in the same position for hours. That is powerful.”

Document it All

Be sure to document everything, says Overstreet. “Document all appropriate discussions about the wound, what it looks like—measurement, location, drainage, etc. It should be apparent from this information if a wound is progressing or has stalled. If it has stalled, document what is being done to resolve it.” The documentation should include what all team members are doing, including dietary staff and frontline caregivers.

Electronic health records can help streamline documentation. However, they also can make it more challenging. “Most have standard, templated language, which can cause a legal issue if these notes ever end up in court since there are often contradictions with what is free-texted,” says Rogers. “Create policies and procedures that include guidelines for documentation and communication and what terminology and language to use.”

Levine notes that CMS is working on rendering quality measures uniform across systems. In preparation, he suggests all health care settings improve documentation standards, implement flow sheets that may include photographs, and train wound care personnel to regularly write notes that describe the wound as well as the patient’s underlying conditions.

“Wound documentation has to include notification of the family about what is happening with the wound and collaboration with various disciplines, including dietary, physical therapy, and nursing,” he says.
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Communicate Clearly

“We see people going to the hospital and coming out with serious wounds. We should be addressing this problem,” says Sieggreen. The reason generally is because the risk of wounds is “low on the totem pole” in the hospital, where staff are focusing on addressing and resolving an acute condition and releasing the patient as quickly as possible. However, when a wound does develop, “it can be devastating,” she says.

Practitioners can take the lead on ensuring effective communication between settings.

“I’ve told my physicians that when they send a patient out, they should call the emergency room doctor,” Musher says. “Nurse-to-nurse communication also can be helpful.” During these conversations, it is important to highlight any skin issues and any conditions or problems that put the patient at risk of skin breakdown, he says.

Mary SieggreenSieggreen says specialists are concerned with their areas of care and often aren’t thinking about issues such as skin integrity. However, when they understand the impact of wounds, it can be eye-opening.

She recalls a thoracic surgeon with a patient who developed a pressure ulcer, and the doctor was motivated to do something about it. He went on to develop a pressure-reduction surface with a company that made airbag sensors, thus raising awareness and developing prevention interventions with people who may never have been exposed to the problem of pressure ulcers.

“Heighten awareness,” advises Sieggreen. For example, use National Pressure Injury Awareness Day, held the third Thursday in November, as an opportunity to educate staff and reinforce the role they play in wound prevention and management by sharing human interest stories and relevant research and articles from the literature, she says.

Promoting consistent use of tools, assessments, and interventions across settings is key, Sieggreen says. “Make sure you have a risk assessment scale being used on a regular basis. I’m trying to get people here to include Braden Scale scores as part of the handover when patients are transferred.”

Transfer information also should highlight conditions such as kidney disease, diabetes, or malnutrition that can contribute to risk and complicate the healing of existing wounds.

When the patient comes to a facility from the hospital, the admission team should ask some questions, says Sieggreen, including:
■ Does the person have any risk factors for skin issues/breakdown?
■ How long was the patient in the hospital and for what procedures and treatments?
■ Were any medications added to their regimen that could impact appetite or other issues that might contribute to skin breakdown?

Transfer Challenges

A full assessment on admission should include an examination of body parts that were dependent for hours. “Look for redness, anything that looks like a bruise. Have someone who knows about wounds assess the patients,” says Sieggreen. Ensuring that skin integrity and wound care are priorities on transfer is essential. “Once the patient comes into the hospital, it only takes about three days before an otherwise healthy individual loses muscle mass and becomes more debilitated—even more so with frail elders,” she says. Educating patients on discharge back to the home also is necessary.

“Often I see problems because patients haven’t done what they’re supposed to do after they go home. They don’t weigh themselves, they sit or recline without moving for hours, and they eat poorly. We need to help patients and families learn what role they can play in preventing wounds and maintaining healthy skin,” Sieggreen says. This requires education, including what red flags and warning signs to look for and the importance of maintaining weight and a healthy diet.

The Family Factor

In the world of person-centered care, family involvement is a must. With wound care, the collaboration between family and caregivers can lead to greater satisfaction but, most important, it can influence the patient’s quality of care and clinical outcomes.

Long term care centers need to educate family members about the risk of wounds, as well as the goals of wound care for existing problems. “If the patient is very ill and the wound isn’t going to heal, you need to tell the family,” says Nancy Munoz, DCN, MHA, RDN, FAND, a registered dietitian. “Let people know that malnutrition is not part of the aging process and needs to be recognized and addressed as early as possible.”

Involving families in patient care is important, but care teams need to assess their ability and willingness to help in various ways. For example, Munoz says, “Not everyone can come in and help feed their family members. But they can recommend favorite foods or bring in recipes.”

Munoz suggests, “Establish partnerships with families from the start.” She admits that this can be challenging.

“Facilities are focusing on more urgent issues on admission. However, without social support, you can’t help the resident as you should.”

Be Honest

Overstreet agrees. “We need to have frank, honest conversations with families. Be specific about what you’re doing to prevent or treat wounds. Pick up the phone and call them after wound rounds and give them an update.” Wound care is complex, and it takes a village, she says. “Everyone, including the family, should be involved.”

These conversations can be difficult, Musher admits, but families usually appreciate the honest sharing of information. “Tell families up front in a positive way. Explain the risk and tell them how you are working to prevent it.” When a wound develops despite the team’s best efforts, Musher says, “It’s okay to say that you’re sorry this happened. Then involve them in your efforts to manage the wound and keep them informed every step of the way.”

Rogers adds, “The best way to ensure family satisfaction is to make them feel involved and empowered. If their loved one is at risk for a pressure ulcer, talk to them about it.” Otherwise, a wound can come as a complete surprise, which could contribute to eroded confidence and concerns about the care the center is providing.

Don’t forget the patient’s “family” at the facility—the certified nurse assistants (CNAs) who care for them every day.
“CNAs are critical in wound care. They’re with the patients more than anyone,” Rogers says. “They make sure the person eats, gets turned, and is as mobile as possible. They know their residents’ bodies and are the first to see changes in skin integrity and what is happening with existing wounds. They also can tell if someone is feeling pain or discomfort.”

It takes a team to provide quality care, and when it comes to wound prevention and care, the players are lined up and ready to go.

The key is providing everyone with current clinical knowledge, tools, support, and ongoing education and ensuring that all team members feel engaged and empowered.
 
Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.
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