Trouble afoot

Because nurses are professional healers, they commit themselves every day to providing comfort to their patients. They do everything in their power to ensure that every person in their care is as free of pain as possible.

That is why it is so discouraging to them when a pressure ulcer refuses to heal. The notorious stubbornness these wounds can display has been an age-old source of frustration for long-term care nurses and the topic of endless discourse at conferences.

Yet concerted effort from the clinical, technological and manufacturing sectors has produced some encouraging breakthroughs in treating and healing these wounds in recent years. With that progress comes optimism that the industry has turned a critical corner in providing greater relief to patients. Even so, significant challenges remain, wound-care specialists note.

“The statistics indicate that pressure-ulcer incidence is rising in all environments, and, obviously, long-term care will acquire some of this population from home and hospitals,” says Susan Girolami, RN, an account representative with Cincinnati-based Therapy Support. “Patients are living longer, with more complex conditions and thus become more at risk for complications.”

Because wounds can take a long time to completely heal, perhaps the most crucial stage of treatment is when they look like they’ve gone away, notes Diane Heasley, RN, vice president of clinical services for Paterson, NJ-based DermaRite Industries.

“This is why completion of the healing process is the toughest phase—because even though we ‘think’ it may be healed due to visualized assessment, the tissue, due to tensile strength issues, is still very fragile,” she explains. “Our bodies only recover to, at best, 80% of the tissue strength we were born with and that is if all conditions are ideal. Let’s face it, [wound relapses] aren’t due to disease processes. Many homes remove the bed, increase sitting and fail to toughen the tissues, which leads to a reopening of the area.”

The manufacturing community has heeded the call for more sophisticated wound-care products. The treatment process, nursing specialists say, has helped tremendously. Hydrogel dressings, for instance, are effective in hydrating dry wounds, and creating a moist environment for proper healing. They are also used to perform autolytic debridement.

“This dressing category is important to wound healing as a primary treatment when these conditions exist, but they can create negative results when used in moderate or heavily exuding wounds,” Girolami says.

The long-term care industry is starting to embrace newer modalities of care, such as silver therapies, negative pressure, non-contact ultrasound and bioengineered skin grafting. Ionic silver not only jumpstarts a wound, it provides pain management, making it a more cost effective option, Heasley says.

“Most silver dressings have more longevity so that even though the dressing may cost more initially, in the long run it costs less due to a decrease in the need for nursing time.”

Government oversight has forced the industry to focus more attention on wound-care procedures, Heasley notes. She refers specifically to the 2004 regulation enforcing a two-to-six-hour time frame for skilled nursing facilities to become responsible for all residents’ preventive care.

She maintains, however, that the requirement “can be pretty scary” because most facilities receive their residents in the late-afternoon hours.

“When I was a DON, the hardest shift was 3 to 11 [p.m.],” she recalls. “It used to be that hospice residents were not even considered as having an avoidable wound – it was a given that they would. Now, any pressure area with no proof of preventative care within the two-to-six-hour time frame is considered a reason for a citation. This means that the tide may change, once again putting skilled care’s back to the wall since many of CMS’ requirements are not easily understood.”

Modifications to wound-care terminology are another source of anxiety for the nursing corps because they contradict some traditional methods taught in nursing school, Heasley notes.

“The Stage I ulcer has been redefined, as well as clarifications for other existing stages,” she says. “Now, Stage I could be not only what we visually see, but what the resident ‘feels.’ Painfulness and itchiness of a specified area may herald a Stage I, along with darkening, shadowing bogginess. And it doesn’t have to be a bony prominence: Tissue-to-tissue contact now counts. Many nurses were taught to stage by depth and the new consensus addresses the shallow nature of a wound and how it may be a Stage III or IV.”

Finally, a new stage called Suspected Deep Tissue Injury has been added to the wound care vernacular. It refers to an area that typically appears as purple or red and is closed but may eventually open up, revealing damage to subcutaneous tissue. Blood blisters are included in this category.

Although the National Pressure Ulcer Advisory Council instructs nurses to treat this wound as a Stage IV, the Medicare Minimum Data Set does not allow staff to report whether the wound was facility- or community-acquired, which can lead to skewed quality indicator reports, Heasley notes.

“That means a facility may have 10 community-acquired and one facility-acquired areas, and because all are reported in the same fashion, it may flag the facility as having a wound issue,” she says.

“Additionally, we are forced to ‘back stage’ the wound on the MDS, meaning that as the wound heals, less money is rendered for care, even though a Stage IV is always a Stage IV. Hopefully, this will soon change.”

The optimal scenario is effective skin protection to prevent wounds from forming in the first place, says Micki Bell, RN, national clinical director for Philadelphia-based SCA Tena.

“For instance, incontinent residents are at the highest risk for skin breakdown, so it is vital that staff use a high quality perineal care product every time an absorbent garment is changed,” she says. “It is important that the skin maintain its acidic mantle, so three-in-one products that are pH-balanced, that cleanse and moisturize while protecting the skin are highly useful in promoting skin health. This greatly helps prevent the risk for wound development.”

Typically, the wound is initially caused by a deep tissue injury or by an environment that is not properly managed, allowing for pressure, shear or friction to take hold of the skin, Girolami adds. Pressure ulcer prevention and treatment are best managed, she explains, by optimizing mobility, frequent position changes, and support surfaces on all beds and chairs.

While Girolami says there is no single approach to healing wounds, there are several key principles that offer the best hope for success, including debriding devitalized tissue, preventing infection, managing the cause of the wound, controlling the co-morbidities that affect healing and proper wound cleansing. Moreover, there are various dressing types that facilitate healing, she says.

“There are three phases of treatment and any phase can stall if the principles of healing are not followed or issues are not recognized, including soft tissue or bone infection, poor nutrition or dehydration, improper patient off-loading or poor perfusion,” she notes.

Industry knowledge about effective wound treatment can be advanced only through continued clinical research and devotion to ongoing training, say wound care authorities. More intensive training is needed to broaden perspectives of nurses in long-term care, according to Girolami.

“Staging wounds is largely misunderstood, as is measuring, so I find nursing staff benefits from education in these areas,” she says. “CNAs could benefit from more education on posturing techniques and equipment utilization.”

DermaRite, for example, has created a program called “The War on Sores – The Beginning of Co-Collaboration,” to navigate the labyrinth of CMS rules across the healthcare spectrum.

“It forces everyone to take their boxing gloves off and respect each other for the jobs they perform,” Heasley says. 

_____