Wound management programs can be tough to maintain but should be a point of pride for providers.
One of the most lucrative new business opportunities for long-term care facilities is expected to be the proliferation of post-surgical patients discharged by hospitals for recuperative care. Competition for these new clients is sure to be tight, so providers need to have a plan for promoting their effectiveness in areas such as wound prevention.
Because their specialty is dealing with wounds and infection control, skilled nursing facilities are a natural destination for post-surgical patients. However, all SNFs do not operate in the same way.
Some facilities, such as Harbert Hills Academy Nursing Home in Savannah, TN, can say they haven't had a pressure ulcer develop in-house for years. It is a record that is a source of pride for Administrator Randall Dickman.
“We have a five-star rating from Medicare because they recognize the work we do,” he says about his 49-bed facility. “We haven't had a single pressure ulcer originate in our facility for 10 years, so contrary to what some people think, wounds are not inevitable in long-term care. We are able to do it through proper staffing and strict attention to basics.”
Harbert Hills' success in preventing wounds gets down to diligence on fundamentals, Dickman says — keeping skin clean and dry, keeping pressure off specific areas, keeping patients hydrated and persistent infection control.
“Just do the job you've been trained to do,” he says.
Though the facility hasn't had any wounds originate there for a prolonged period, some residents do come in with them, and they can be difficult to manage.
“We had a patient come in here last year with several wounds, including one that went to the bone,” Dickman says. “We healed most of them and the really bad one shrank to a fraction of its original size.”
Keeping the facility adequately staffed is necessary to provide a high level of care. Dickman says Harbert Hills has the same staffing challenges faced by many operators. Even in small-town Tennessee, where jobs are scarce, personnel stability is a challenge, he says.
“Long-term care is a very hard job from both physical and emotional standpoints,” he says. “Turnover is higher than I'd like it to be among CNAs, but we do have stability among our DONs and LPNs. We are focusing on keeping our CNAs longer, and one way to do that is to make sure they are not overworked. Exhaustion leads to carelessness.”
Pressure on SNFs
The healthcare landscape is changing to discourage the costly process of emergency room visits and hospital readmissions based on complications from surgeries and chronic diseases. To reduce readmissions, Medicare has implemented a fiscal penalty for hospitals if their patients with certain conditions come back within 30 days of discharge. This means skilled nursing partners must also share the risk in caring for post-surgical cases.
Peggy Naas, M.D., orthopedic surgeon and vice president of physician strategies for Texas-based VHA, says that while SNFs might specialize in wound prevention, they need to provide the outcomes data to back it up.
“It is not just about avoiding readmissions, but providing the most effective care at the lowest-cost site of care,” she says. “Decisions are being made about which site is most appropriate, which means there is growing pressure on SNFs to come up with a solid value equation.”
The key to attracting a hospital partner is solid documentation of wound care value, Naas says. This includes compiling the organization's value per unit of cost, which she says demonstrates how partners can share the risk on cost-of-care issues and bundled payment contracts. She says it comes down to managing the process in order to identify “unexplained and unnecessary variation” so that there is predictability with cost and outcomes.
“We're seeing SNFs justify their participation in narrow networks with acute care organizations, so if there is anything the facility can do to document value, it will enable them to create a multitude of customers with hospitals, patients, families and payers,” Naas says.
SNFs have been handling post-acute patients as short-term admissions for some time. Facilities ahead of the curve also have completed renovations to attract the under 30-day Medicare patient, says Judy Bolhuis, vice president of acute care at Ferris Manufacturing.
These upgrades include private rooms, Internet services and separate rehab areas.
“Provision of these services is now an expectation, not an amenity, and the focus needs to move to a customer service model that includes the patient, the surgical practice and the primary physician,” Bolhuis says. “Skilled nursing facilities need to take advantage of these opportunities, working not only with the hospitals, but also with primary care physicians to capture as many admissions as possible. It will be vital for the SNF to become the fundamental source of knowledge and the primary support network for hospital case management and primary care providers.”
As partners with hospitals on post-surgical care, SNFs must prepare for patients who have a higher acuity level, says Margaret Falconio-West, RN, senior vice president of clinical education for Medline Industries.
“Faced with this situation, long-term care staff needs to be educated about these challenges,” she says. “This should include some of the basic principles of wound closure, such as understanding primary versus secondary versus tertiary intention of closure. Staff should be taught the role of co-morbidities in the healing process, signs of infection, wound dehiscence and evisceration of the surgical incision.”
Wound dehiscence is a complication that occurs when a wound appears at the point of incision. It can be caused by inadequate undermining of the wound during surgery, excessive tension on wound edges caused by lifting or straining, or the wound being on a mobile or high tension area such as shoulders or legs. Prevention steps include reducing stress on wound edges, speeding healing through nutrition therapy and using sterile strips on sutures.
Evisceration is an emergency situation caused when the incision opens and internal protrusion occurs. It can range from the inside becoming visible and slightly extended, to very severe, when organs threaten to spill out.
Triple check method
With an orthopedic surgery background, Naas is a specialist in post-operative complications. She refers to a wound care method called “wind-water-wound.”
Typically, if a fever develops, Naas says the patient's respiratory status should be checked, then urinary status. Finally, the wound should be checked for infection.
“Staff needs to accurately determine the patient populations with increased risk of infections and wounds,” she says.
Wound prevention is a team function comprising clinicians, discharge planners, case managers and family members in order to gain the complete context for determining wound vulnerability, Naas says. For instance, information about whether a patient is diabetic, asthmatic, arthritic or has related co-morbidities could provide clues as to that patient's susceptibility to wounds.
“If a patient has difficulty ambulating, it could lead to incision infections or pressure ulcers,” she says.
To minimize the risk of wound development, Naas says staff must focus on activities of daily living, skilled care, medication administration and proper assessment of patients coming out of the acute care environment. Because of these necessities, “we've seen increasing recruitment of geriatric professionals by hospitals to manage post-surgical patients at SNFs,” Naas says.
Given its rural location, Harbert Hills hasn't yet seen a migration of post-surgical patients to its skilled nursing site. But if and when it does happen, Dickman says he is confident that adding more patients won't taint the facility's record of wound prevention.
“We just don't allow wounds around here,” he says. n