Team coverage plans
Team coverage plans
When wound education specialist Rhonda Kistler travels to the 25 long-term care facilities in her region, she often works with wound care nurses on effective prevention strategies and improved interventions.
But over the last several months, the Gentell rep has seen many of the wound professionals she counts on reassigned to the floor as part of cost-saving efforts.
In some cases, that might make it more difficult to relay information on what works to staff members inundated with other responsibilities. But it also could be an opportunity to get more employees involved in the daily wound care process, a fact that Kistler says could ultimately be a plus.
Like an increasing number of wound specialists, Kistler knows that a pervasive team approach can pay dividends when it comes to spotting at-risk residents, instituting new processes and thwarting costly and painful infections or sores.
Perhaps no one knows the need for making pressure ulcer prevention a “team event” better than Janice M. Beitz, Ph.D., RN. In a presentation at the McKnight's Online Expo in March, the well-known expert called pressure ulcer prevention a critical focus for any healthcare facility. Assessment, treatment and tracking shouldn't be left to nurses alone, she emphasizes.
“Pressure ulcers are a patient problem. Therefore, they are the problem of all health disciplines,” says Beitz, a professor at the Rutgers University School of Nursing-Camden. “We want intact skin. We want quality care. It's better for the patients, and it's better for the financial health of our employers.”
Beitz says limited research, education and training materials can make it hard to achieve comprehensive care. Approaches that vary from facility to facility or downplay the role of unlicensed caregivers also can be to blame for breakdowns.
Many buildings still compartmentalize, says Mary Madison, a clinical consultant for Briggs Healthcare, who specializes in long-term care and assisted living. A nurse for 42 years — including a decade spent as a director of nursing at a 330-bed facility — she reminds her customers that administrative boundaries are there for employees. Patients, on the other hand, need a network of care that blurs lines.
“It takes a village,” Madison says. “What happens with wounds in long-term care is not about nursing care. It's the whole building that needs to get involved.”
Expressing the needs
Improving communication might be the most critical factor in creating a process that heads-off pressure ulcers or catches the inevitable ones at Stage I or II.
The Agency for Healthcare Research and Quality developed its own prototype to integrate clinical improvements into daily workflow.
The On-Time Pressure Ulcer Healing Project involves administrators, nursing directors, skin team and wound nurses, MDS staff and dietitians. They standardize documentation from CNAs, using an established set of reports and tracking tools.
The idea, according to the AHRQ, was to improve communication for “more timely referrals, treatments and changes in care plans.”
Wound Care Education Institute co-founder Nancy Morgan points to numerous studies that back the team concept, including a 2014 review by the European Wound Management Association.
The association found successful approaches centralize expertise and services, providing clinical interventions with careful attention to scientifically proven preventative measures. It notes that while wound outcome improvement can't be credited solely to a team approach, there are “no reports of negative consequences.”
The EWMA paper also calls for a “wound navigator” who can advocate for, and with, patients.
Building the team
Most experts agree a designated wound expert is a powerful resource.
“Wound care is constantly evolving with new treatments, new regulations and new guidelines,” says Morgan, whose institute offers online and onsite seminars for medical professionals and non-clinicians. “Missing out on the frequent updates in wound management could cost a facility money, reputation and worst of all, [lead to] substandard care for their residents.”
That wound expert should expect to work with everyone from doctors down to family members. Beitz noted that researchers have found critical care physicians have only “poor to fair” knowledge of pressure ulcers.
Margaret Falconio-West, BSN, senior vice president of clinical education for Medline Industries, says physicians directing care “as well as all specialty doctors like surgeons, cardiologists, oncology specialists and geriatricians, could all be involved in care and are considered part of the prevention team.”
In some facilities, nurses are essentially left on their own to take care of wounds. But they should work to get doctors involved and make them aware of facility- and patient-specific problems. Conversations need to be less adversarial, says Gentell's Kistler, who notes that reimbursement issues have created a cycle of finger-pointing by doctors and nurses at acute and long-term care facilities.
Establishing good communication channels within a facility also allows CNAs to react at the earliest signs of trouble.
“They are seeing the patient from head to toe more than the nurses or the doctors,” says
Rosalyn Jordan, RN, McKnight's “Ask the Treatment Expert” columnist and senior clinical director of post-acute clinical programs and services for Joerns RecoverCare. “They need to be educated on what to look for.”
Maryland-based chain Nexion Health took a hard look at its wound care model a few years ago, says Vice President of Rehabilitation and Wound Care Services Tara Roberts, and began involving CNAs and other clinical staff.
“With a lot of homework, organization, streamlining and investment in key resources, Nexion was able to create a clinically based, cost-effective and self-sustaining skin and wound care model that each facility/team could use as a starting point,” Roberts explains. Nexion formed a module based on the “3C's of Skin and Wound Care” that included as-needed and quarterly training sessions.
“These trainings are tailored for the education level of the employee and are offered to CNAs, nurses, therapists and to physicians/physician extenders. It was during these trainings Nexion was able to identify champions of skin and those individuals we could invest in to gain wound certification as well as become in-house experts and resources,” Roberts says.
Some of the known risks are different in long-term care, so there may be a learning curve for nurses moving over from other sectors. Falconio-West offers ulcers caused by medical devices such as oxygen tubing and poor circulation as possible red flags.
Site visits from clinical experts and onboarding sessions on wound care are a start, but prevention and treatment should be talked about routinely. Madison suggests hanging resources like a Briggs prevention poster anywhere staff members congregate; the reminders it offers on risk factors, repositioning and skin care are every bit as critical as hand-washing posters commonly spotted in break rooms or by time clocks, she says.
Observant aides needed
Most important: that CNAs recognize redness or blanching as precursors and stay especially attuned to skin changes in residents with dark skin. Their ulcers often go undiagnosed until after the initial stage.
Madison also says CNAs should record any observations on a chart — old-fashioned or electronic — and follow up with a verbal report to a supervisor.
Because malnutrition may be a factor for pressure wound development, it makes sense that dietary staff also be part of a long-term strategy. Madison asks that nutritionists help with an initial risk assessment and observe pressure ulcers that develop.
Factors such as anemia, dehydration and being under- or overweight can be addressed through individualized diets. As a director of nursing, Madison instituted a policy that anyone walking into a resident's room (including social workers and pastors) offer a glass of water to make hydration a habit.
Morgan says kitchen and dietary staff also have roles to play.
“Way before mealtime, residents start heading to the dining areas, waiting on meals to be served, securing their favorite spot,” she says. Food service staff should be empowered to offer nutrition tips and remind able residents to reposition themselves.
Morgan says these workers should be encouraged to ask for nursing help when residents slide down in a seat or are incontinent.
Similarly, housekeeping staff who enter rooms can help by reporting if a resident has not moved for an extended period. If they know when certain residents are high-risk, they might also be trained to note the absence of key equipment and aids.
MaryAnn Valente, rehab product manager for AliMed, says pieces such as gel pads for commodes and wheelchair cushions should be used routinely for anyone deemed at risk. Knowing that 1 in 10 nursing home residents will develop a wound, facilities should keep at least some therapeutic surfaces in stock, she adds.
“You need to be quick to get someone to an air mattress,” Valente says. “Make sure you have slip-on socks for heels, or sleeves and skin creams that CNAs can apply.”
Valente says she's often seen breakdowns develop overnight when patients are rotated but clothing not changed if they have an accident.
Using standard assessments (Braden, Norton and Waterlow) is also better at identifying patients at increased risk for ulcers than clinical judgments, according to an AHRQ study. Keep copies on hand, as well as “skin sheets” on which caregivers can indicate problems.
Keeping abreast of the latest innovations can help, along with choosing vendors that respond quickly to needs. Many companies have regional depots able to deliver wound care products within hours. Gentell's Fastcare wound-reporting system, for example, features a 24-hour response line, where trained experts suggest treatments and can quick-ship medications or equipment.
But it's not enough to have equipment on hand if employees aren't taught how to use it.
Gentell's Glenn Paul was once on site to witness Fastcare in use, when his wound education specialist noticed low air-loss mattresses were set to accommodate 400-pound patients. Fully inflated, they didn't give much lighter, at-risk patients a sensation of floating on air. It was more like the feeling of sleeping on a rock, Kistler explains.
Staff said they didn't adjust bed weight when crunched for time. Paul says after they relented and matched inflation to patient's weight — and instituted an overall approach to closing problem wounds — the wound rate dropped by 60%.
Even with the best team, never assume that training has been correctly relayed or that it will be remembered a month out.
“The more education, the more reminders, even bedside education for patients and their families, all those things play a role,” Jordan emphasizes.