Senior care facilities place a high priority on person-centered care and attending to the body, mind, and spirit of the whole resident. One critical facet of that care is skin health and wound management. The good news is that there are more technologies and treatments, as well as certification and training programs, to help maximize outcomes and quality of life.
The Skinny on Skin Breakdown
Diabetes, malnutrition, vascular disease, immobility, incontinence, and even dry, itchy skin are among the things that can lead to the development of wounds in older adults. Chronic wounds affect up to 10.5 million Medicare beneficiaries, and the incidence of pressure injuries and other chronic wounds increases with age, frailty, and disability. These wounds can lead to various complications, including infections and amputations. It is harder for wounds to heal in nursing home residents who are frail with multiple comorbidities and nutritional challenges. At the same time, aging skin is less resilient and more fragile. It can bruise and tear easily.
Essential to effective skin care and wound management in long term care is a strong wound management program. “Wound management is such a complex issue. A good program needs to address numerous elements and have a focus on prevention and improving quality of life,” said Amin Setoodeh, BSN/RN, senior vice president of skin health solutions and clinical services at Medline. He added, “Staff need to know what they’re striving for—zero tolerance of preventable pressure injuries. There needs to be a check and balance system to consistently review staff performance, revise plans, and provide feedback and additional training and support.”
Developing a Team Approach
Like so much in long term care, wound management is a team activity that requires the involvement of everyone—from housekeeping and dietary staff to nursing and physical therapy practitioners. All these individuals need to know the basics of wound prevention, as well as red flags and signs of skin issues to watch for. If they notice any sign of a possible wound—such as red or discolored skin, especially at bony prominences—they should know how to document this and who to report their observations or concerns to.
Setoodeh said, “Everyone who comes in contact with residents should have training. This starts with certified nurse aides (CNAs) and families. Then the dietitian should be involved to help ensure the resident is getting the right nutrition; and physical and occupational therapists could be monumental in preventing wounds.” He urged, “Don’t wait until there is an issue to do training. Good programs should be based on assessing staff’s knowledge gaps and developing education from prevention to treatment.”
Not only does everyone need to know their role in wound prevention, assessment, and management, but they need to know how to document their findings and observations, as well as who to communicate with and how. This is essential to guide care, set goals, and track outcomes, but it also is key to showing surveyors that you have taken all necessary and appropriate steps to keep residents safe, prevent wounds, and avoid hospitalizations and exacerbations when wounds are unavoidable.
However, while everyone has a role in wound care, Jeffrey Levine, MD, a New York-based geriatrics and palliative medicine specialist and recognized expert in wound care and pressure injuries, stressed the need for every facility to have a certified wound care expert. This can be a nurse or other clinical team member, but there needs to be someone who can champion skin care and wound management and serve as a source of information, guidance, and answers. “There are many options to become certified. Some are better than others, so it is important to do the research before choosing one.” He also noted that different certifications have different requirements, such as some experience in the field.
“It is extremely important to have an expert on your team to audit the wound management process and provide ongoing feedback to frontline caregivers,” said Setoodeh, stressing that this is especially significant where there are staffing shortages or a proliferation of agency nurses who may have limited experience in geriatrics and skilled nursing care. For instance, he observed that up to 80 percent of residents have some incontinence issues. “Staff need to know the importance of keeping residents dry, and they need to have adequate training and time to deal with incontinence issues and make regular checks of skin condition. The same is true of turning and repositioning immobile residents or those with limited mobility,” he said.
Ensuring Expertise
It is important not to assume that members of your clinical team have wound management expertise. Setoodeh said, “Looking at our curricula, most medical and nursing schools don’t include wound care. This is such a comprehensive, technical science, and it requires a specialized expertise.”
Levine agrees. He said, “Wound management is an important medical issue that physicians haven’t been taught in medical school. Unfortunately, this has created a gap in training where practitioners often don’t know how to assess wounds or identify appropriate treatment options. I think this training should be mandatory for licensure.” Ultimately, he stressed, “Everyone needs to be involved and educated. You can’t afford to have one weak link.”
Don’t forget families in this education equation, Levine urged, noting, “People often don’t know the basics of skin assessment and care. Families need to be counseled. I hear stories about how families weren’t informed until discharge or even death. They need transparent information up front.” This requires consistency, he noted. Everyone on the team needs to be providing the same information about staging, location, etc. “You can’t have one physician saying it’s a stage 4 wound, another saying it’s stage 3, and the nurse saying it’s a skin tear,” he said.
There also is a role for telemedicine in providing access to experts, Setoodeh observed. “This took off during the pandemic, and the technology enables remote practitioners to examine and assess wounds and capture data. There is a great opportunity for telemedicine and technology for improving assessment, product selection, treatment course, and staff and family education,” he said.
Steps to Healthy Wound Management
First, suggested Setoodeh, “Look at wound care from a 30,000-feet perspective. You need to look at skin health holistically, and the number one focus should be on prevention.” At the same time, Levine stressed, “Become familiar with the federal regulations, particularly F-tag 686. This is a very detailed document with guidance for surveyors, and it provides an excellent summary of everything you need for wound care in long term care.” Then, he said, establish a system of care based on this guidance.
Jeanine Maguire, MPT, CWS, a wound prevention and management specialist, stressed that wound prevention and management needs to start as soon as residents enter the facility, with a prompt skin assessment. “Skin breakdown can happen fast in older, vulnerable people. A stage 1 or 2 ulcer can happen in a couple of hours. But with prompt attention, it is healable in 30-60 days. It is much harder and more costly to heal a stage 3 or 4 wound.” An integrated team approach with alignment and collaboration, not fear or blame, is also important. “It is important to have photo documentation. All wounds should be visible to the team on a HIPAA-compliant app.” At the same time, skin and wound care should be an essential piece of Quality Assurance and Performance Improvement (QAPI), and there should be a culture of communication and transparency.
With limited budgets, product choice to support wound care is key. Levine said, “Wound care is a vast multi-
billion-dollar market, and there are always innovations and new products, including diagnostics being developed to detect early injuries.” However, he cautioned that many products haven’t been subjected to research to establish healing efficacy in the long term care population.
Maguire noted, “There are no standard guidelines for treatment, and there are thousands of treatments. There is a need for some framework for nursing home operators to understand what is happening in centers across the country, including best practices. Toward this end, we are trying to build a national wound team.”
Providers need to be closely intertwined with processes of care so their decision-making is appropriate for each individual, according to Levine. He noted that one big development in the field is the availability of third-party wound care providers who can come in with expert teams and conduct consults. These, he said, can help provide training, documentation, and back-end functions for more effective prevention and treatment efforts.
A report in Science Advances earlier this year1 identified the three key principles of wound management as moisture balance, infection prevention, and medical optimization of comorbidities. The authors pointed to advancements such as biomaterials that mimic extracellular biophysical cue to resolve inflammation, therapies to promote healing and reduce scarring (using a cell-penetrating RNA), and new peptide formulas designed to treat venous leg and diabetic foot ulcers. At the same time, however, the report noted that some of these innovations are still being studied and that there is a need for additional strategies, particularly for healing complex wounds.
From Care to Costs to Accountability
Clearly, all the staffing time, education and training, treatments, and technology for wounds come with a cost. However, Setoodeh said, “Wounds are a huge issue that can have tremendous adverse effects. If wounds aren’t assessed properly, the course of treatment won’t be accurate. And wounds, particularly if they progress, take significant nursing time and present a risk for infection, sepsis, and hospital readmissions. At the same time, the risk of mortality increases for patients with wounds, and they can impact the quality of life and the family experience.” He said, “The average facility spends about 3-5 percent of supply costs on preventive skin care, and preventive efforts cost about $115 per day. Compare this to the cost of treating a stage 3 or 4 wound, which is about $3000-4000 per day. Organizations can’t afford not to invest in skin care and wound management.”
Accountability is key, said Setoodeh. “This starts with looking in the mirror and determining what you can do. It means a common vision and the assurance that staff have the resources, tools, and time to provide good care. And it means being transparent, doing the best we can, and celebrating positive outcomes.”
References
1. https://medicalxpress.com/news/2023-06-breakthrough-treatments-wound.html