Protein change explains why pressure ulcers are 'not entirely preventable' among seniors, researcher

Considering the prevalence of chronic wounds and pressure ulcers in long-term care—and the physical and financial toll that these wounds take on residents and providers—few could deny the potential benefits of having more wound care specialists on hand. Better management of existing wounds while preventing new ones from forming can be invaluable.

Although certified wound care nurses exist in some skilled nursing facilities, they still tend to be few and far between. Wound care experts cite several key factors for the scarcity, beginning with an ongoing, widespread nursing shortage that has led to more limited access to nursing specialists.

Also, while nurses desire to broaden skill sets, resources often are too limited to make certification a reality. Even though the knowledge and advanced skills gained through certification can undoubtedly can pay big dividends, wound care certification tuition and ancillary course fees range from roughly $2,000 to more than $7,000, depending upon the type of wound specialist certification sought and the provider of the accredited program.

“In an ideal world, all wound care would be provided by a nurse clinician who is certified as a wound care specialist,” acknowledged Sherrie Dornberger, RNC, CDONA, president of the National Association Directors of Nursing Administration in Long-Term Care and McKnight’s Long-Term Care News’ “Ask The Care Expert” columnist.

“If nurses or facilities have the resources to make that happen, then that’s terrific, but we know that often isn’t the case,” she said.

‘Possible and necessary’

That’s not to say long-term care nurses shouldn’t strive to become more specialized in their wound care abilities. On the contrary, most would agree that there’s never been a better time to commit to wound care knowledge advancement—with or without the pursuit of certification.

“It’s important that caregivers and [LTC providers] realize that it is both possible and necessary to become knowledgeable about wound care and prevention, even in the absence of certification,” notes certified wound specialist Robert Warriner, III, MD, chief medical officer for Diversified Clinical Services in Jacksonville, FL. “There are many different [wound care-related] educational tools and resources available that can broaden skill sets, and many of them cost very little money.”

Because having practical, up-to-date wound care information readily available is essential for effective wound management and prevention, Warriner recommends long-term care providers look to wound care textbooks as a first line of attack.

“There are a number of great books that are readily available and filled with good content and practical information that can lead to immediate improvements, and they are really quite inexpensive,” he said. Two he routinely recommends are Wound Care Essentials, Practical Principles, Second Edition, a comprehensive handbook that addresses all aspects of wound care, from quality of life issues and legal and regulatory aspects to skin integrity and treatment options; and Wound Care Made Incredibly Easy, a user-friendly reference guide that covers wound assessment, monitoring and wound care procedures. It is geared toward virtually any caregiver, including certified nursing assistants (a group that Warriner stresses should not be overlooked).

Subscribing to professional journals, trade publications and wound care organization newsletters is another important way to keep caregivers—and administrators—informed.

“Some of it may be more top-level, but it’s still a great way to know what’s going on. That’s very important, especially in wound care, where regulations and requirements are changing and new techniques [and protocols] are surfacing,” said Diane Heasley, RN, CNS, MSN, vice president of clinical services for DermaRite Industries LLC.

The information super highway is another avenue worth taking, although sources pointed out that not all Web-related information is created equal (or is as reliable). Some content could be too advanced for new nurses or CNAs, for example, while other information could be too basic, and some might even be outdated or inaccurate.

“The Web has made it much easier to access information—and for free—but there’s so much information out there that it’s important to know where to go for the most reliable [material],” Warriner noted.

The National Pressure Ulcer Advisory Panel’s Web site ( is a useful resource for current guidelines, regulatory requirements and pressure ulcer prevention initiatives. The site also provides free access to wound staging illustrations, the NPUAP newsletter and an extensive resource directory.

The Advancing Excellence in American Nursing Homes Campaign Web site ( also provides substantial pressure ulcer-related educational material, including guidelines and protocols for applying dressings and barriers, Dornberger added.

The Wound Care Information Network (, another forum for unbiased, practical guidance, ranks at the top of Warriner’s list of useful, high-quality online portals.

Ask more of vendors

Providers seeking a wealth of low- or no-cost instructional wound care materials also should turn to their vendors. Unfortunately, vendors frequently remain a largely untapped resource, often because long-term care providers fear they’ll receive biased, marketing-driven information.

“Vendors are also under-utilized because [getting the educational resources] can take some work and coordination,” said Jayne Clark, strategic account manager for Frost & Sullivan’s healthcare consulting group. “But it’s definitely worth the effort.”

She reasoned that vendors should be integrally involved in the care process and willing to work directly with facilities to promote high level, quality care–regardless of whether a facility uses their products.

“It’s in a vendor’s best interest to provide quality wound care education because if a nursing home is [well informed about wound care and prevention] and knows how to use products correctly, then they’ll be more satisfied with that vendor,” she pointed out.

Facilities should ask their vendors for in-services and other educational offerings, being sure to recruit their support on specific issues or concerns that caregivers are currently facing.

“The more specific you are, the better able these vendor experts will be to help you,” Clark explained. “It’s also a good idea to ask a vendor outright if they’ll be offering a true in-service or just a sales pitch. You should be able to expect continuing education credits, too. If they’re offering CEUs, then you can be sure it’s not marketing spin.”

Asking each wound care vendor partner to provider a packet of introductory wound care-related materials (including any non-product-specific, standards-based resources) that the facility can distribute to staff during initial orientation and training is another wise move, according to Clark. Many vendors, she says, will offer educational DVDs—a particular plus for rural or outlying facilities that may have more limited direct access to vendor representatives.

Regardless of the material provided, sources stressed that facilities should review it carefully before distributing, ensuring that the information is targeted to caregivers’ current knowledge and skill sets, and is relevant to the facility’s own practices and protocols.

“If your facility does one thing and the educational tools you hand out aren’t consistent with that [practice], then it’s going to lead to confusion,” Heasley said.

She ensures that the educational materials she distributes are converted to Word documents to allow customers to make necessary changes and keep information consistent with their facility’s unique practices. DermaRite takes a holistic approach to education, offering not only wound-specific material but also resources on nutrition, hydration, pain assessment and management, diabetes, incontinence, and other factors that can contribute to skin breakdown, according to Heasley.

“There are many pieces that need to be factored in, so we think it’s more effective to break education into digestible parts, rather than throwing it all out there at once,” Heasley reasoned, adding that the idea is to provide education in layers, with each lesson building upon a previous one.

Facilities will find that some of the wound care tools that they previously had to pay for, such as wound measuring guides, illustrated pocket references and even consultative support, currently can be obtained from some of their vendors at no cost.

Medline Industries’ Compass programs, for example, provide clinical direction for every level of wound care and prevention, and incontinence and diabetes care. The program contains a wound care handbook and pocket guides, patient education brochures and a CD with 225 images organized by wound categories. Compass also assists caregivers with the survey process by offering clarification of surveyor guidelines and providing detailed clinical tools and protocols that relate directly to the Center for Medicare & Medicaid Services’ F-tags.

“Whether it’s formal or informal, we believe that education will empower the customer and help them make better [clinical] decisions,” said Margaret Falconio-West, BSN, RN, APN/CNS, CWOCN, vice president of clinical education for Medline Industries.

Medline offers a range of formal and informal wound care educational resources, from full-day educational programs and Web seminars to DVD series, in-service training, home study courses and a toll-free clinical hotline for one-on-one support. The vendor also publishes its own Healthy Skin publication, which offers practical clinical information on wound prevention and treatment, guidelines and national quality initiatives, survey readiness tools, transdisciplinary flow sheets and algorithms, and continuing education lesson plans offered through Medline University.

“All of this is offered as a free service and it’s not just limited to our current customers,” Falconio-West explained.

Adopt the buddy system

Sometimes, the best educational resource is just a facility or phone call away. Nurses and other frontline caregivers should be encouraged to network with their peers and reach out to a wound care specialist for mentorship as well as support.

“Educational seminars and symposiums provide a terrific opportunity for [caregivers] to mingle and network with industry experts and peers,” Warriner said, adding that caregivers also can greatly benefit by reaching out to a certified wound care specialist in their community.

“Peer-to-peer relationships can be very beneficial. If your own facility lacks a wound care specialist, look to a nearby wound care institute or hospital, or another long-term care facility and ask if they would be willing to share their knowledge and take your calls if you have a question or concern,” he continued.

“There’s no sense in reinventing the wheel and, by and large, it’s been my experience that CWOCNs are very open about sharing their knowledge and experience with others.

“We all share the same goal, which is to provide the very best care possible. I believe that information sharing plays a key part in reaching that goal,” Warriner maintained.