Skilled nursing facilities must treat both pressure ulcers and surgical site wounds, and never has there been more focus on treating them successfully to minimize infection.
The profession is also under immense pressure to reduce its use of antibiotics thanks to revised federal rules, the threat of financial penalty and the all-too-real increase in drug-resistant organisms.
What happens when all of these pressures collide in the real world?
The answer, it turns out, is better care.
“Many times patients with wounds, regardless of the setting of care, need antibiotic management, but it is often not the case,” says Kim McCarthy, MSN, RN, clinical director for post-acute care at Mölnylke. “Long-term care settings are tasked with managing a mix of chronic and acute wounds and can successfully meet these needs when leaning on the clinical processes of wound management while also taking the lead in antibiotic stewardship.”
Getting ahead of the antibiotic curve today may mean the development of fewer resistant organisms later.
A review published by Medscape earlier this year found 20% of wounds will become infected with Staphylococcus aureus, and the danger may be higher in nursing homes. Studies have indicated that more than half of all nursing home residents are already colonized with Methicillin-resistant Staphylococcus aureus.
More bacteria types likely will learn to battle back against widely available and inexpensive antibiotics if exposed to them again and again.
Long-term care providers seem to have gotten the message on using antibiotics more sparingly for common infections of the urinary tract or sinus cavity. Broad-spectrum prescriptions can make residents more susceptible to Clostridium difficile and VRE, and widespread colonization can even put future residents at risk.
But playing wound care more conservatively hasn’t really been a tenet of early antibiotic stewardship efforts.
“I don’t see many conversations involving wounds and antibiotics,” says Rachel Sprinkle, RN, BSN, CWOCN, a Gentell wound and product specialist. “I work with a lot of newer nurse practitioners, and they seem less likely to prescribe antibiotics. But many of the other providers still overprescribe antibiotics or prescribe antibiotics to appease the patient or the family.”
Experts say the conversation should begin before wound patients arrive, with written and universally understood antibiotic policies.
“Think outside the box when developing educational offerings aimed at infection prevention,” urges Steven Antokal, RN, director of clinical education for DermaRite Industries.
He says interactive online sessions can be part of the solution, resulting in successful survey outcomes.
But long-term care providers don’t have complete control over prescriptions for all of their wound patients. In the case of surgical site incisions, surgeons dictate post-operative care.
Creating wound and antibiotic stewardship policies that acknowledge all the players, from infection preventionists, wound care champions and physicians to certified nursing assistants, may help everyone get on the same page.
Preventing wounds from becoming infected also should get more interest. Sterile practices, exemplary wound cleansing techniques and the appropriate application of antimicrobials can help stave off infections or control some localized ones.
“Treating the wound correctly to begin with, that’s how we avoid antibiotics,” says Dea J. Kent, DNP, RN, former national board member of the Wound, Ostomy and Continence Nurses Society.
Kent resists the call for antibiotics unless there’s a compelling reason to give them. Her view is gaining momentum.
In Minnesota this summer, health officials rolled out new guidance on wound care infection prevention in long-term care that never once mentions bacteria or antibiotics.
But they do call for more single-use equipment, disposable gowns worn for all wound care, and wound care sprays and other products dedicated to one patient.
Many of the more recent product development efforts have been driven by the recognition of biofilm and infections as inhibitors of healing. Some 90% of diabetic foot ulcers have been shown to have biofilm, says Sarah Isakson, APRN, an advanced technical service specialist for 3M.
Even though picking the right solution is critical, culturing for the right antibiotic isn’t necessarily the best step to take early on.
“A culture is only going to give you a tiny snapshot of how much biofilm is there and exactly what’s in it,” Isakson says. “Even though you’re doing your best to pick the right antibiotic, you might not get everything. Using a broad-acting antiseptic can be more effective.”
Wound care providers must stay on top of emerging treatment trends. While silver-infused products remain popular, some have shown signs of resistance in the lab. Residents should not be given them as a one-size-fits-all prophylactic.
“Honey has emerged as an alternative,” notes David Navazio, founder and chief operating officer of Gentell, which plans to launch a honey product line by early next year. “Both silver and honey are effective in combination with hydrogels, alginates and foams, and allow providers to treat wounds in a way that takes into account the sensitivities of the patient.”
If Kent suspects a wound is on its way to infection, she reaches for quarter-strength Dakin’s solution as a chemical debrider. Although once thought to be deadly to new skin cells, she says recent research has shown hypochlorite solution is safe.
Sprinkle has been watching the development of branded products with hyphochlorous acid. One of her clients uses one on every wound and reports improved outcomes. She advises keeping a variety of wound care and infection prevention products available, and reminding nurses about hand hygiene often.
Another important reminder: The presence of bacteria alone is natural and doesn’t demand treatment if residents aren’t showing other infection symptoms such as swelling more than 3 centimeters from the wound, fever or purulent drainage.
“There are pretty clear guidelines of when we really do need to reach for those systemic antibiotics,” Isakson says, pointing to the International Wound Infection Institute’s 2016 consensus update to best practices. “A 50-year-old with an open belly wound is going to have a lot more of the classic signs of infection. It can be a lot more subtle and takes a more patient approach with an 80-year-old patient who has a chronic wound.”
Poor nutritional status and co-morbidities can make wounds appear to be stuck.
“These residents require increased care and staff time, in addition to the potential cost of antibiotics and contact precautions,” says Ann Meyer, RN, BSN, clinical manager for antiseptics at Mölnylke. The company’s
HIBICLENS®/4% CHG bathing product is one option. In one study, daily use of it led to lowered microbial counts on the skin and decreased the occurrence of infection symptoms, antibiotic use and hospital visits, she notes.
Not all wound care alternatives are right for skilled nursing residents.
In acute settings, surgeons might prefer locally applied antiseptics like iodine, silver sulfadiazine or hydrogen peroxide. A 2018 review of pressure ulcer management by Veteran Affairs- and Stanford-affiliated surgeon George P. Yang, M.D., reported that those solutions can slow wound healing by killing living cells, if relied upon for too long.
Yang and his research partners also caution against the overuse of IV antibiotics, finding they are best suited to wound patients with significant cellulitis or other signs of severe infection. Even with osteomyelitis, Yang says there is little evidence that supports antibiotic use over debridement.
Adopting best practices in debridement and cleansing are two major ways facilities can improve the odds of keeping infection at bay, Kent says.
Last year, she designed a grant for three Indiana skilled nursing facilities following protocols developed by the Agency for Healthcare Research and Quality. It focused on staff nurse training, pharmacy-coordinated medication management and routine stewardship reminders to reduce the use of antibiotics. Overall, she estimates orders for antibiotics dropped by 80% to 90%.
Kent urges clinicians to consider a timeout. When physicians automatically order an antibiotic after surgery, nursing staff should be encouraged to ask them to reconsider if there are no signs of infection. Further, when giving antibiotics, the clinician should consult the local hospital’s antibiogram.
While there’s no question that wounds and infections are bad from a clinical viewpoint, they are also bad for business in other ways.
“Avoiding infection by practicing good infection control techniques and using antimicrobial products as directed, for the shortest amount of time possible, is key to controlling costs,” notes Eula Reynolds, RN, MSN, director of clinical education for DermaRite.