Wound care feature — Topical issues

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Proper skin care often comes down to good old-fashioned common sense. To avoid pressure ulcers, stick to the basics.

Investing just a little bit in wound care prevention goes a long way, experts say.
"If everyone did one more small thing everyday for skin care we'd have better outcomes," notes Debra Lewis, a clinical consultant for Kinetic Concepts Inc. (KCI).
Thankfully, nursing homes today have more tools in their arsenal to protect residents' skin against costly pressure ulcers. There is more awareness today about the importance of good nutrition, repositioning and maintaining the pH balance of older skin. Specially trained wound care nurses are fast becoming the norm in long-term care. And the still relatively new F-tag 314 on pressure ulcers has forced nursing homes to stay on top of risk factors and assessment protocols.
But even with these developments, many nursing homes still fall short in the prevention department, some officials say. Education about proper skin care is still lacking. And because of staffing shortages and other pressures, there often are system-wide failures, such as poor communication between nurses and frontline staff.
Experts agree that tweaking a skin care program – such as installing a quality assessment tool and investing in education – can add up to big savings down the road.
Prevention pays
Tight budgets are no excuse for good prevention.
"A dollar spent in skin care is better than a dollar spent in wound care," said Judye Reed, group product manager for Smith & Nephew Inc., which makes barrier creams, lotions and skin moisturizers. "Spending a little on skin care can offset a lot of the cost and risk associated with wounds."
And they are costly. It is estimated that the price tag of a pressure ulcer can run up to $70,000. That includes increased length of stay, more expensive treatment options and nursing time. When you factor in fines and possible litigation, the costs can soar into the unknown.
Beyond the dollar amount, wounds also have a system-wide impact, negatively affecting outcomes, staff retention and morale, patient satisfaction and safety.
"You have to look at what you are paying for in the future," Reed stresses. "Prevention is not an option anymore."
Simple solutions
The good news is that a good skin care program is not necessarily expensive.
And making minor changes to a skin care program can yield positive results. Start with your soap, suggests Donna Sardina, president of the Wound Care Education Institute and an expert columnist for McKnight's. A pH-balanced soap that moisturizes the skin is critical for older residents who have dry, cracked skin, she says.
A high-quality soap can play a major role in offsetting the incidence of skin care breakdowns.
"Of all the things that I could do, that's the one thing I would – make sure they have a good soap," Sardina says.
It's especially important to pay attention to incontinent residents. Nurses must use perineal skin cleansers and moisture barrier creams on residents' backsides after every episode of incontinence to protect the skin from other external materials.
Often, facilities skimp and use an all-purpose soap to clean residents. Bad idea, Sardina says.
"It causes patients' skin to get dryer and then they can bump into something that will cause a skin tear," she says.
There are other basic nursing strategies that will be effective in preventing skin breakdowns. Strong support surfaces are an important component. Replacement mattresses, which contain a special foam, should take the place of all standard hospital mattresses, Sardina says.
"The standard now is everyone in a nursing home should be sleeping on a pressure management device," agrees Doug Callant, corporate accounts manager for Gaymar Industries Inc.
Other small changes could result in positive outcomes. Properly fitting cushions for wheelchairs is an overlooked but key task for avoiding pressure ulcers, Sardina notes. Sitting in a poorly fitted wheelchair causes hips to fold inward and puts pressure on bony areas. A fitted cushion will help to avoid that unneeded pressure.
The benefits of appropriate hydration and nutrition also have been well documented.
"If the resident isn't eating enough or taking enough protein in, we can do all the topical measures we can, but optimally, it's not going to be as effective," says Sue Bell, clinical director for Medical Nutrition USA Inc., maker of the protein supplement Pro-Stat.
Providers also need to remember tried-and-true assessment tools such as the Braden and Norton scales. These are still the best way to assess residents for risk factors associated with pressure ulcers, nurses say.
Nursing knowledge
While basic skin care procedures are nothing new, wound care, nonetheless, has improved over the years, nurses say.
"It has come a long way. With more products out there and specialized nursing care, wounds are being cared for more than they used to be," says Kathy Solari, a registered nurse and member of the clinical support team for Longport Inc., maker of the Episcan, an ultrasound device used to detect pressure ulcers.
The government and wound care organizations have recently published key guidance that supports up-to-date wound care protocols. The most prevalent is F-tag 314, the surveyor guidance from the Centers for Medicare & Medicaid Services that pertains to the care and prevention of pressure ulcers.
Also new, the National Pressure Ulcer Advisory Panel earlier this year released terms and definitions related to support surfaces. The organization also updated the staging of pressure ulcers. (For more sources of proper skin care protocols, see sidebar on previous page.)
Keeping the pressure on
Despite the knowledge now readily available concerning wound care, problems in skin care programs persist in nursing homes across the country. Who is to blame?
Some feel the Medicare and Medicaid programs are in part responsible. If daily reimbursements are too low, nursing homes cannot upgrade on products, such as soap, that will make a difference in preventing ulcers.
There are other factors in play besides reimbursement, however. Even though F-tag 314 has been updated for nearly three years, many charge nurses have not seen it, according to Janet L. Jones, vice president of clinical services for Medline Industries Inc.
She attributes poor wound care protocols in many facilities to system-wide flaws. One common problem is poor communication between the charge nurse and direct caregiver.
When there is a lack of communication, there is a lack of expectation, she notes. As a result, frontline caregivers under-perform. Besides transmitting information, communication also helps boost morale among the frontline staff who then feel others are noticing their work.
Morning focus groups are a great way to keep the staff on track in terms of wound care protocols, Jones says. The task entails calling the whole staff together – clinical and non-clinical members alike – and reminding them of skin care basics – such as turning and repositioning residents, emolliating arms and legs, and using a peri-wash and barrier for residents' bottoms.
Also at the morning meeting, the director of nursing can remind caregivers to see her if supplies are needed. Often, staff can toil all day without enough supplies, Jones notes.
"It's pulling people together and reminding them of the importance of their job," she says of morning meetings.
A big part of turning around a wound care program is implementing a quality assessment mechanism so that a caregiver is always accountable to someone else, she adds.
Often there is an ingrained idea of what is acceptable, even though it is not always right, Jones said.
"Unless someone is following up behind us, we are going to do what we have always done," she says.
To implement a quality assurance mechanism, delegate various tasks to various people during the course of their daily routine. For example, while a caregiver is doing a med pass, she can observe if the resident's skin is moisturized. If it is not, she would be responsible for communicating it to a head nurse.
"The beautiful part about picking up a quality assurance tool is these people don't have to be nurses," Jones says.
The key to a quality assurance tool is that it is user-friendly.
"The follow-through should not be more encompassing than the actual work," Jones says.
Creating reliable systems is critical for maintaining a knowledge base amid fluctuations in staffing levels at a facility, experts say.
"Teaching is one thing, but there is such (high) turnover that you need to have something built in and embedded in the culture of the organization," says Diane Maydick, director of clinical affairs for Derma Sciences Inc., and a veteran skin- and wound-care nurse.
"They need to know that prevention is paramount," Maydick says. "Once you have a team who knows how to do this, you pass it on to the people who come in."
A team effort
Workers at The Wisconsin Veterans Home at King can attest to the impact of of a collective effort.
The 750-bed skilled nursing facilities has 19 wound care certified (WCC) nurses.
These nurses, who received a certificate through the Wound Care Education Institute, are largely responsible for the facility's low 2.7% pressure ulcer rate, nursing managers say. Nurses were trained for the certificate starting in 2003.
"Having them in the building is when we had the biggest drop in our percentage," says Kate Pieper, the facility's assistant director of nursing for nursing ancillary services. "That is our major asset — having so many wound care nurses that can address the problem before it begins."
The nurses' specialized education pays off on a daily basis, whether it be pinpointing the best products to use or knowing the proper way to change dressings, Pieper says. The specialized nurses also help to disseminate information through regular in-services.
"Investment in a certified nurse is well worth it," Pieper says. "When you look at the cost benefit, it is a minimal cost."

Bathing without bugs
Infection control is serious business for bathing equipment companies.
Because so many nursing home residents are incontinent, the threat of contracting
c. diff or other dangerous bacteria from tubs and showers has increased.
"Showering is really the future of nursing homes and long-term care because of
the incontinence issue," believes David Storm, owner of Storm Showers, located in Cookeville, TN.
Infection control has played a big role in the creation of The Melanie, a showering system named after Storm's youngest daughter. The sit-down unit contains all the water that circulates in the shower in a shower caddy. After the shower, the caregiver backs the caddy, which is connected to the shower, into the toilet.
A containment shower "contains any waste and keeps it away from the floor to be spread around or from the shoes of CNAs to be spread around," Storm says.
The possibility of spreading infection has led some bathing companies in the last five years to replace conventional pumps and motors with blowers.
"If not disinfected properly, pumps can be sources of cross-contamination because you can't kill bugs," notes Kirk Penner, vice president of Penner Manufacturing, which now uses blower systems in its tubs.
Still, disinfecting a bathing system between sessions is imperative no matter what system you use, stresses Brian Amato of Invacare Continuing Care Group.

Skin care tips
- Push fluids unless fluid is restricted.
- Topically emolliate arms and legs.
- Apply barrier cream to the perineal area after every episode of incontinence.
- Clean with a no-rinse, pH-balanced cleaning product that doesn't strip the acid mantle off the skin.
- Place residents on pressure-reducing mattresses.
For more on skin care protocols and procedures, consult these sources:
Centers for Medicare & Medicaid Services, www.cms.hhs.gov
National Pressure Ulcer Advisory Panel, www.npuap.org
The Wound, Ostomy and Continence Nurses Society, www.wocn.org
National Database of Nursing Quality Indicators, www.nursingquality.org
Agency of Healthcare Research and Quality, www.ahrq.org

Severity of damages: Pressure ulcers
Not-for-profit LTC facilities
Number of Total paid Average
closed (indemnity total
claims and expenses) paid
14 $1,902,582 $135,899

For-profit LTC facilities
Number of Total paid Average
closed (indemnity total
claims and expenses) paid
109 $21,646,190 $198,589

Source: CNA Healthpro, "Comparison of Claims Data in Long Term Care, January 1996 through March 2005," September 2005