Wound Care Feature: Pressure point
The 'shock and awe' of stark, new guidelines on wound care have not yet hit, but providers can expect some changes.One can excuse Roberta White if she sounds a bit blasÃ© about fallout from the new surveyor emphasis on F-Tag 314. Wound care, after all, has been a point of emphasis for her nursing and rehab facility for a long time.
She and her colleagues would be entitled to a bit of "been there, done that" type of line of thinking. But White doesn't take that route.
She's truly impressed with the new survey protocols and the greater attention paid to treatment processes.
"The biggest impact is when F-Tag 314 came out. I think it's a wonderful regulation. It can drive you crazy with all the regulations they give out, but this was written by experts in the field. It tightened up everything," said White, a registered nurse, certified geriatric nurse practitioner, and wound care specialist. She is the rehabilitation coordinator for the Stern Family Center for Extended Care and Rehabilitation in Manhasset, NY.
Because the new guidance for surveyors was issued in November 2004, annual surveys have not yet revealed much comparison data. White said inspectors found no problems at her facility during their most recent visit.
"Surveyors are still learning how to approach this," she said. "Maybe on this year's survey they'll be a little more into it. You can never exhale. You have to continually keep things going."
And that's just what White and her wound-care colleagues within the North Shore-Long Island Jewish Health System have been doing.
"It's always been an issue in our system, long before the F-tag every came out," she said. "Way back in the 1990s, we had decided that as a system — tertiary hospitals and other hospitals, nursing homes — we wanted [product] uniformity."
They held discussions for a "couple" of years, tested about a "million" products and made unified shopping lists.
"As a system, we get good pricing, but we're feeling it, too," White says. "We don't know how some of these other facilities do it with the costs."
Materials keep evolving, she said, noting the rise of silver dressings, antimicrobials and "all kinds of products to cut down on bioburdens."
Some of them, including vacuum-assisted wound closing tools, are helpful but expensive. Funding is always a central concern. "If we can't afford it, we can't do it," she noted.
The end result, however, has been positive for White and colleagues. Recently, they've had zero nosocomial pressure ulcers reported.
"We had a poster saying, 'Let's go for 0,' and then the F-Tag came along and really had an impact," she explained. "Quality improvement drives it all. But it's like anything: You have to sit on it and pull them (staff) into it."
The new emphasis on wound-care practices, along with revisions to other F-Tags concerning incontinence care and medical directors, have federal health officials touching providers in new ways.
"The importance of current standards of practice have never been higher in the nursing home industry than right now," said Diane Johnson, of product manufacturer Smith & Nephew. "Prevention is no longer an option. Best practice will be the standard. Documentation around preventing, healing and treating wounds, including infected wounds and non-pressure related wounds, will be a focus."
"You find all kinds of treatment methods and approaches for wound care the world over. But now they're only going to be looking at whether you are using best practices like those of the National Pressure Ulcer Advisory Panel (NPUAP) and WOCN (Wound, Ostomy and Continence Nurses Society)."
Johnson thinks the tougher instructions in the new F-Tag 314 are good for providers.
"I think it empowers them to work with surveyors because it gives them the opportunity to make the right choices to treat and decrease wounds, and put prevention in place. Those who are really educated, have good documentation and understand advanced wound care have opportunities."
Time and research
There is no denying that wound care remains a complicated topic. Providers are being held accountable on multiple fronts, from nutrition to hydration, positioning and turning, and more.
Then, there is always the money question.
"There are many, many solutions, but it depends on what state you are in, and what a resident qualifies for," said Gabe Anderson, a product manager for Direct Supply's line of therapy products, as well as clinical and support surface lines. "You may have success with a treatment but have to use another."
It's always about choosing what will help the body facilitate wound healing, Anderson said. The array of new products hitting the market has made that tougher than in the past, he said.
"It's becoming very difficult for someone dealing with staff and residents day-to-day to evaluate everything out there. How do you decide with some of the new things on the market, like wound vacs. Which one is better? It takes time and research."
Anderson said wound vacs are starting to rise in prominence in the nursing community. He lauded their use, especially models that nursing directors can operate. His views are particularly valid, he said, because he doesn't even sell the apparatus.
"There are all sorts of cutting-edge type things that are opportunities and exciting but may be too expensive for nursing homes," he said. Skin grafts grown in petri dishes, for example, fit that description. Silver nitrate products have also proven effective, he pointed out.
Sometimes other factors might block effective, less painful approaches, like the use of live maggots.
"They really only focus on necrotic tissue," Anderson said, acknowledging a big hurdle to their widespread use: "The psychological issue — residents might actually feel them moving around doing their thing. It's kind of the 'creepy' factor."
The key is to set goals, and remember they won't be the same for every resident. The skin is a human organ and if it's failing, perhaps the main goal of treating a pressure ulcer should be to manage pain or control odor, he said.
"If nursing homes are missing out on anything, it might be bringing in outside consultants to help them evaluate things," according to Anderson.
"That's going to kind of ruffle some feathers if you say they're missing out on something, but consultants are great resources. They've seen many things. It may cost a few hundred dollars to have them in and evaluate a program, but the value can be enormous."
Pressure ulcer incidence actually rose slightly, according to the otherwise cheery results from the first round of Nursing Home Quality Initiative (NHQI) comparative data.
"There's not been a real reduction in pressure ulcer incidence in a number of years, partly because the process is very subjective," maintains Connie Phillips-Jones, RN, MSN, the director of clinical support for Longport Inc., a firm that manufactures a scanner to detect pre-emergent pressure sores.
"The ultrasound scanner may be the tool to define avoidable vs. unavoidable," she continued. "If you can show a person had signs of a deep skin problem and nursing did everything it could but it broke down anyway, wouldn't that help categorize it as unavoidable?"
She thinks fallout from the updated F-Tag 314 will be significant, eventually.
"The boom has been lowered, but the reason you're not hearing a lot of shock and awe is nursing homes are surveyed only once a year. The new surveyor guidelines raise the bar, and we're going to hear more and more about nursing homes being held accountable. But that's going to take a while to show."
Pervasive, costly problem
Pressure ulcers and wound care are assured of staying in the spotlight.
There were 3 million pressure ulcers reported through the National Pressure Ulcer Advisory Panel in 2001. That's not including the 1.5 million diabetic ulcers, 1 million venous ulcers and other wounds that were also reported.
Aging demographics all but assure the numbers will remain high. As a result, cost, resident care, regulatory and liability concerns will continue to captivate stakeholders.
"This is a sad saga: Nothing has improved basically in about 20 to 25 years," said Arnold Gans, president of Medical Nutrition USA Inc. "The incidence of pressure ulcers goes up and the nursing home population gets older. NAPUAC says there has been no significant improvement in the incidence of pressure ulcers in 30 years."
Gans cited statistics that said treatment costs for wound care in acute and senior living settings totaled $1.3 billion in 2004. There were 17,000 lawsuits filed against nursing homes.
He agreed providers' biggest wound-care challenge is adhering to requirements in the new F-Tag 314.
"Diagnose immediately from head to toe," he advised, endorsing the use of scanners that can assess beneath the skin. Nutrition intervention also is a critical step to promote healing, he said, advocating high doses of protein in things like his Pro-Stat supplement.
Gans also agreed with Direct Supply's Anderson about the use of consultants: "Facilities must hire wound care nurses or physicians. It's not necessary for them to be full-time. They need to diagnose, document and see the underlying conditions of this wound.
"I've seen nursing homes treat a Stage II ulcer with a wet to dry gauze. That can cause infection and is probably the worst thing to do."
Staff education is undoubtedly one of the most needy areas, he and others agree. NPUAP now is setting up educational programs for a variety of provider chains.
"If I were a nursing home owner, I would spend money on education. That's money well spent," said Dr. James Spahn, CEO of EHOB Inc., a manufacturer of support surfaces. "You need to have qualified people caring for those at risk. They need to understand what to do, and why. This idea of, 'Just let the next shift worry about it,' isn't going to work now.'"
Spahn urged caution when buying products. Some can be good but only if accompanied by good care.
"You have to have proper protocols in place: Turning schedules, eating, ambulation, getting out of bed. You don't have to spend a lot of money on surfaces. You can do it for a dollar a day," he said. "I think expectations have been falsely made. Some are told, 'If you use this, you don't have to turn them or get them out of bed.' Well, that's wrong. It's not going to work."
Easy as 1, 2, 3?
That National Pressure Ulcer Advisory Panel gives the following descriptions for "grading" wound beds.
1. Closed/resurfaced: The wound is completely covered with epithelium (new skin).
2. Epithelial tissue: For superficial ulcers, new pink or shiny tissue (skin) that grows in from the edges or as islands on the ulcer surface.
3. Granulation tissue: Pink or beefy red tissue with a shiny, moist, granular appearance.
4. Slough: Yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous.
5. Necrotic tissue (eschar): Black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges and may be either firmer or softer than surrounding skin.
Source: NPUAP's PUSH tool