Ka-Ching!

Are wound care costs clouding clinical judgment?

Glenburn Home, a not-for-profit nursing facility in Linton, Indiana, uses state-of-the-art wound care treatments and care plans, says Susan Perigo, director of rehabilitation. But pressed for details, she begins by describing what the facility doesn't do.

"We don't use Betadine, hydrogen peroxide, or heat lamps on wounds. We rarely use whirlpools," she reports. "We use wet-to-dry dressings if a physician insists, but only for a short time."

If these treatments sound familiar, it's no surprise. They represent routine wound care practice in many nursing facilities today.

Clinical experts, however, claim that such outdated modalities are jeopardizing wound care in nursing facilities. Prompted in part by the high cost of some more advanced wound care products--and a misunderstanding of how they can be used cost-efficiently-providers' reliance on yesterday's arsenal can equal poor outcomes and dismal survey results. Add to that cuts in payment and staffing shortages, and SNFs' efforts at preventing and treating wounds effectively are being seriously undermined.

"One hundred percent of nursingi facilities should be using the latest in wound care protocols," says Michael Miller, DO, program medical director for chronic wound and skin care at HealthSouth Rehabilitation Hospital and medical director of Wound and Skin Care Consultants in Terre Haute, Indiana. "There's no lock on modern wound care. But using it effectively requires education and breaking the mold of old time thinking."

Practitioners at many facilities, for example, still use surface swabs to culture a wound for infection, a method that can lead to false positive cultures and unnecessary antibiotic therapy. A much more reliable method is the Agency for Health Care Policy and Research's (AHCPR) current treatment protocol: using actual wound tissue samples.

The physician-ordered wet-to-dry dressing is another ineffective treatment still being used by many nursing homes. Nurses apply a wound dressing wet with Betadine of saline and remove it when dry in an attempt to debride the wound Studies show, however, that removal of the dressing also removes healing tissue. The dressings also leave more dry tissue, which does not heal well and provides a good medium for infection," notes Miller.

Instead, practitioners can debride stage II pressure sores that have a small amount of superficial necrotic tissue by using coarse mesh gauze moistened with saline (removing and reapplying moist dressings every six to eight hours). Hydrocolloid dressings or enzymatic debriding agents are other options, according to wound care recommendations provided by the Mayo Clinic. Surgical debridement is usually required for stage IV ulcers and large stage III lesions.

According to the 1994 AHCPR treatment guidelines for pressure ulcers, once a wound it clean and granulating moist dressings can be used to promote healing.

Whirlpools are another poor choice when it comes to cleaning or debriding wounds. "Whirlpools are typically dirty--despite efforts to keep them clean," Perigo says. "Also, the agitation of the water will wash away any new granulating cell in the wound." Cleaning the wound can be achieved other ways, such as a moist-to-moist saline soak, rinsing with a syringe, or using [pulsed water, such as] a WaterPik on a low setting."

PPS regression

Though clinical myths help perpetuate many of the outdated treatments, Medicare's prospective payment system hasn't helped, many consultants say.

Under the former cost-based system. SNFs could bill Medicare separately for many wound care items. But now that these products are all included in the PPS per diem, many providers are opting for treatments with a cheaper price tag, explains Glenda Motta, president of GM Associates, a clinical and reimbursement consulting firm in Mitchellville, Maryland, and past president of the Wound, Ostomy and Continence Nurses Society (WOCN).

Linda R. Jones, RN, a clinical nurse in Gainesville, Florida, who specializes in wound care, says that facilities' use of appropriate wound care products took a nosedive when PPS kicked in "[Providers] regressed to using Betadine packings ordered by unknowing physicians and woundered why the wounds weren't healing," she reports.

Some state Medicaid programs are adding to providers' woes by covering outdated wound care items while refusing to pay for more current approaches.

Policies like these aren't in the best interest of patients or providers. In many cases, using less expensive--but less effective--products will only drive up total costs, perpetuating the spiral of cost containment.

SNFs will pay half price for a lotion that's not formulated for at-risk skin and therefore, doesn't work," says Motta. "Or they buy gauze dressings, when wound products, such as hydrogels, put the moisture back in a Wound if it gets too dry."

Conversely, notes Miller, "even though some of the newer therapies are more expensive initially, they heal wounds much faster and produce a better type of healing. With respect to overall costs, you have less nursing time, less supplies, less paperwork, less everything."

Some products even manage the wound exudate, keeping it from spreading to and breaking down the surrounding, healthy skin.

"Unit cost is not the issue. The total cost is always less because the wounds respond faster," reminds Motta, adding that numerous studies show that products that facilitate moist wound healing produce better patient outcomes, form faster healing to lower infection rates. "The control treatment in these studies is almost always gauze, which is the cheapest [type of dressing] available," she notes.

Still, others note that, at least in some ways, PPS may actually he promoting better wound care. Beth Klitch, principal, Survey Solutions in Columbus, Ohio, and a member of a HCFA expert technical panel that helped the agency test a quality medical review process for PPS, notes that because "many of the wound care items and care are included on the MDS used for the PPS, there's an incentive to identify and treat pressure ulcers under the new system. PPS should be causing SNFs to focus more on prevention."

PPS also allows SNFs to classify some residents in the higher paying rehab RUGs where rehab therapists can provide multidisciplinary wound care--a strategy used by Glenbum Home. "If the patient is in a higher RUG category for a primary diagnosis and also has a wound, then we plan the treatment with the therapy minutes that are available" based on the physician orders and assigned RUG, Perigo reports.

The right diagnosis

What's the most basic step in treating a wound effectively? Determining why it developed, Miller advises. "There are wounds, such as diabetic ulcers or venous stasis ulcers, that won't respond to pressure ulcer protocols no matter what," he says.

Wounds caused by diabetes or circulatory problems may be mistaken for pressure sores. "An ulcer on the heel of the foot may really be arterial in nature; ulcers on the toes or the feet may actually be diabetic," Motta says.

Arterial wounds may require surgery to correct the circulation problem. Venous stasis ulcers, which occur from the ankle to the shin, are another common wound treated by SNFs, according to Miller. "The treatment for these ulcers is compression. There are several three- and four-layer wrap systems on the market that maximize how veins work in returning blood to the heart."

Yet one rarely sees compression therapy used in nursing facilities, Motta observes, even though the new four-layer wraps don't come with an especially high price tag, about $20. "But you do have to teach staff how to apply these effectively. so there is a learning curve," she notes.

Prevention measures

But the best--and ultimately most cost-effective--medicine is preventing pressure sores and other wounds from occurring in the first place. That can be difficult today, however, when patients entering nursing facilities tend to be sicker than those of years past, with existing wounds or at high risk of developing them. At the same time, many facilities are struggling with staffing shortages tied to inadequate Medicare and Medicaid rates and a tight labor market.

"Staffing, in terms of numbers and consistency, has a direct effect on pressure ulcer development," emphasizes Clare Hendrick, RN, a certified registered nurse practitioner and PPS consultant in San Clemente, California. If you don't turn immobile or at-risk patients every two hours, at least, they will develop pressure ulcers. So you have to have enough staff to do that and they have to be consistent in turning patients. That's why HCFA's new survey interpretive guidelines link staffing issues to pressure sores: If a facility has too many pressure sores compared with its peers (a quality indicator), then the surveyors may assess the adequacy of staffing."

Echoes Motta: "You have to combat the idea that patients with certain problems are going to get pressure sores no matter what. That may be true to some extent--but you can always minimize that risk."

First, be familiar with the risk factors. A recent study by The National Pressure Ulcer Long-Term Care Study, funded by the Ross Products Division of Abbott Laboratories, identified patient and care practices associated with the development of new pressure sores in a nursing home. Be alert to the following:

* Male gender

* Overall severity of illness

* History of tobacco use

* History of recent pressure sore

* Dependency in seven or more activities of daily living

* Diabetes

* Weight loss

* Dehydration

* Use of catheters

The MDS and resident assessment protocols (RAPs) can also help caregivers identify at-risk residents, says Hendrick, who recommends, at minimum, a risk assessment upon admission and weekly body checks, which can be done as part of the bath routine. "Patients at risk need to be checked daily, especially incontinent residents," she adds.

Don't underestimate malnutrition and dehydration as major risk factors for pressure sores and delayed wound healing--especially since HCFA apparently isn't, as evidenced by the new survey focus on nutrition, hydration, and pressures sores.

Involving more disciplines

Every clinical discipline can play a role in wound prevention and management, Stresses Pam Unger, a certified wound specialist and partner in the Center for Advanced Wound Care in Redding, Pennsylvania, who serves as a liaison to the National Pressure Ulcer Advisory Panel. "For example, the pharmacist can review the patient's medications" to see if any of them could be causing cognitive problems, poor appetite, depression, lethargy, dehydration, or incontinence, all of which contribute to pressure sores," she says. Depression, for example, "can contribute to immobility and impaired healing."

Therapeutic support surfaces can also help prevent ulcers. Studies show that they help prevent skin breakdown in high-risk patients. For example, while someone paralyzed on one side by a stroke who has chronic malnutrition and poor peripheral circulation must be turned every 30 minutes to prevent skin breakdown, "that's just not realistic in a nursing facility setting with today's staffing problems," Motta notes. "Put that patient on a therapeutic mattress that effectively reduces pressure--approximate cost: $200--and the staff could turn her every two hours and prevent pressure sores to a large extent."

Karen Lusky is a contributing writer for Contemporary Long Term Care.

1999 Wound Care Study

Late last year, Contemporary conducted a random survey of readers on the subject of wound care. Of 236 responding most--31 percent--reported providing some type of wound care at their facility. The charts accompanying this article give a glimpse of a few key findings. To view the full results, visit our Web site at [less than]www.cltcmag.com[greater than].

                               Which wounds?
                        Types of wounds cared for:
Pressure ulcers          95%
Venous ulcers            74%
Arterial leg/foot ulcers 67%
Neuropathic ulcers       44%
Burns                    33%
Source: CLTC
                                 Who says?
       Person responsible for assessment of wounds at your facility:
Other RN          52%
DON/Assistant DON 38%
LPN               27%
ET nurse           9%
Nursing assistant  4%
Other             21%
Source: CLTC
                                 why buy?
 Percent of providers who said the following factors were "very important"
       or "important" in deciding which wound care products to buy.
Effectiveness       93%
Ease of use         84%
Availability        83%
Price               73%
Helpful sales force 44%
Brand name          13%
Source: CLTC

Getting up to speed

Is it time to revamp your wound care program? Consider the following strategies:

* Review wound care protocols and recommendations from AHCPR, the National Pressure Ulcer Advisory Panel, and professional groups such as the American Medical Directors Association and WOCN. You can use such materials to develop care plans, clinical pathways, or protocols.

* Consult regularly with someone who has expertise in the field of wound care. This person could be a geriatric nurse practitioner with certification in the area, whose patient care services are billable under Medicare Part B (separately from the SNFs' Part A per diem). "Perhaps the SNF can get physicians to agree to sign off on wound care orders written by a wound care nurse practitioner," Motta suggests.

* Educate physicians about protocols and products.

* Use state-of-the-art products and techniques, but in the most cost-effective way. For example, Glenburn Home tries to select high-tech dressings that don't have to be changed every day. They then teach the nurses and CNAs how to clean the area in a way that keeps the dressings intact.

* Recognize when a treatment is not working and switch to another accepted approach.