Wound care feature: Team players

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Wound care has taken on a new status in long-term care, and like many celebrities, an entourage now often accompanies it.

A quarterback can make all the great throws in the world, but if he doesn't have someone to catch the ball, the point is moot.
A softball pitcher needs her catcher, not to mention teammates to field and hit the ball.
A soccer player? She goes nowhere without someone to defend her net or with whom she can attack offensively.
And so it is with wound care in nursing homes. The days of naming a wound care specialist and letting her "do her thing" are long over, or at least should be, experts say. The growth and specialization of wound care teams has been one of the most significant developments recently in resident care, they agree.
"Unless we have a team approach, things get missed," says Dr. Karen Zulkowski, RN, DNS, an associate professor in the school of nursing at the University of Montana–Bozeman. "You see lawsuits for pressure ulcers. It's kind of scary."
A rise in litigation is only one reason for providers' collective caregiving approach. Residents experience less pain and enjoy better outcomes when more eyes are on the chart, Zulkowski notes.
"People go from a nursing home, to the hospital, back to home. They transition around so much that unless we have teamwork, not only in the facility but between levels of service, patients get lost," she says.
"If we don't have a team approach, we're losing a part of the necessary care," adds Zulkowski, a diplomat in the American Academy of Wound Management. "No two people are the same, regardless if the wound is the same size, shape and stage. Unless we understand the person underneath the wound, and not just the wound, we lose an essential element of care."
A standard wound care team should have at least a handful of members. Just how many will depend on the size, budget and location of a given operator. But experts agree that wound care, no matter how clinically oriented it might seem, must be a "transdisciplinary" pursuit.
That means corralling not only the medical director and various nurses, but also dietary, social services, activities and therapy staff members, among others, if possible.
In her roles as teacher, consultant and researcher, Zulkowski has noticed that larger nursing facilities generally develop better wound care teams than smaller or more isolated operations.
"They have the resources. They may have a podiatrist, plastic surgeon and wound care nurse – and they can get everyone together," she says. "It's the smaller facilities in rural communities who don't have the specialists available, who really need creative ways to provide care and get these teams together."
She said discussions could be conducted by e-mail, for example, noting that team members don't always have to meet face-to-face.

Not all together
For some, it's still a learning process. While wound care teams are not new to the long-term care scene, the phrase still means different things to different people.
"I don't think the concept is fully matured," says Connie Phillips-Jones, RN, MSN, the director of clinical support for Longport Inc., an ultrasound imaging company.
While some facilities don't have the resources to devote to a team, others may not have buy-in from important leaders such the administrator or medical director. Others may have the makings of a team, only to see it not meet often enough to be effective, she said.
"The administrator ideally should be part of the team and provide leadership to support its mission and function. In the absence of that leadership, the wound care team would waffle," she noted. "It would be less effective and not necessarily goal directed or respected by the rest of the organization. It might be seen as a task, rather than a mission."
Medical directors may be tough to get on board simply because most don't work full-time at a facility and therefore don't get fully integrated into operations.
Even team members may frequently misunderstand the team's mission or goals, Phillips-Jones acknowledges.
"It's important that the wound care team not look at just preventing and treating wounds but also whether there is a continuous quality improvement process in place, where a root-cause analysis is part of the process," she says. "So when a wound occurs or someone's admitted with a wound, there's an analysis to find out exactly what the root cause of that wound is, and then create a process to address that."
At a minimum, there must be an organized process for the management of wounds, care experts say. This should include steps for prevention and continuous improvement, not just the documentation and treatment of wounds.

Correct positioning
Any team must have good communication, both internally and externally, Phillips-Jones emphasized.
"In facilities where I've seen wound care teams, there have been failures to communicate activities, goals, objectives and findings to everyone in a facility, in a formal way," she observed. "Sometimes I think wound care teams are too introverted. They get together, do what they do, follow their mission and objectives and then fail to communicate. It's a real issue and a real problem.
"After communicating the goals, objectives and activities of the team to others, results will become a self-fulfilling prophecy, because everyone will be aware of what they're doing."
Phillips-Jones says the things she finds missing most often from wound team work are assessments and evaluation.
"The teams I'm aware of are heavily into the process but what's missing is looking back, outcome analysis and evaluation of their program. If you look at the healthcare and nursing processes, it's the step most forgotten," she says. "It's looking back and analyzing, seeing how we're doing, what we're doing well and what we need to improve and modify."
The biggest need for teams today is "objective assessment tools" because "wound care right now is somewhat subjective," Phillip-Jones said. The use of ultrasound scanning, like what her company promotes, dovetails with that thought. "Long-term care will probably remain more 'high-touch' than 'high-tech,' but it needs to build a comfort zone with tech," she added.

Brighter spotlight
Wound care was not always the focal point that it is today. Although the issues have been around for centuries, some stakeholders say wound care's profile has grown most noticeably over the last handful of years.
"When I started with KCI in 2002, wound care was just not as glamorous as it is today," observed Steven Tolleson, a Portland, OR-based account executive for KCI's extended care division. "It was there, and there were always a few nurses who loved to do wound care. But there certainly wasn't the focus and attention it's given today."
There are two main reasons for the change, he feels.
"Companies, both local and nationwide realized how costly a bad wound can be," he said. "Facilities are always looking to minimize costs. There's also been a rise in the prevalence of F-314 enforcement. And surveyors, both state and national, have been given incentive to do so."
The heightened sensitivity to wound care programs has opened doors for providers, Tolleson believes. Operators with strong wound care teams can market themselves as something special, he said.
A broad-based approach gets noticed, agrees Arnold Silverman, president of geriatric product supplier Skil-Care Corp.
"Sales used to be totally through the DON or nurse assigned to wound care," he said. "Now, when sales people go in, it's common that therapists or others are there. It's a good thing. Each discipline brings its unique perspective. Often, the synergy of perspectives brings more than one individual would."
The industry gets a pat on the back for continuing to develop new products, Tolleson added.
"Wound care is making great strides," he said. "Back in the 1970s and '80s and '90s, in large part, we didn't have the myriad treatment options for wounds we have today, from hydrocolloid dressings to wound vacs."
Overall, there is a more holistic view toward healing, he added.
"You don't just look at the hole in the patient, but look at the whole patient," he said, crediting an oft-repeated phrase in the business. "You tie it in with therapy and mental state and see if treatment is going to increase in those areas."
'War on the sore'
Wound care teams have been given a variety of challenges around the country. In New York, for example, a state mandate mirrors a federal initiative to improve pressure ulcer care. It's called "The War on the Sore" and carries a goal of improving care by 2% by September.
Some providers have taken it even further, creating partnerships between various levels of care in Saratoga County, said Cindy Labish, director of nursing at Wesley Health Care Center in Saratoga Springs. Nursing homes, hospice, home health and a hospital are among those coordinating efforts.
It all starts on-site, however.
"Our team can be ready to address risk factors upon admission," Labish said. "They need to do a total skin assessment within an hour of admission. Studies show that most residents, if they're going to develop a pressure ulcer, will do so in the first four weeks after admission. If someone has an existing wound, we need to do an assessment on it once a week. Other team members, such as the dietitian, have to be kept informed of the whole treatment protocol."
Critical on that list, but often overlooked, are nurses aides, she noted.
"You can have all the experts help and put things together, but if you're not carrying on at the bedside with prevention, you're not going to be successful," she said. "We're on top of it, but the challenge is to get the CNAs part of the team. Everybody looks to the top-tier, but you have to make sure the CNAs know the importance of the work they do."

Getting it in writing

Two national wound care credentialing organizations for healthcare professionals are:

The Wound, Ostomy and Continence Nurses Society (WOCN)
Founded in 1968, the Wound, Ostomy and Continence Nurses Society (WOCN) is a professional, credentialing, international nursing society of more than 4,000 nurse professionals who are experts in the care of patients with wound, ostomy and continence problems.

The American Academy of Wound Management
The American Academy of Wound Management (AAWM) is a voluntary, not-for-profit organization established for the purpose of credentialing interdisciplinary practitioners in the field of wound management.