Nursing home-based skin care: where we are and where we're headed: an overview.

Nursing home-based skin and wound care have come a long way. With an unprecedented focus on prevention and innovative therapies, the future promises to hold equally impressive changes. In a recent interview with Nursing Homes, John Zone, MD, Donna Miller, DO, and Gerit Mulder, DPM, shared their thoughts about the challenges posed by nursing home skin care and the directions it may take in the future.

What is the State of Skin and Wound Care in Today's Nursing Home?

Dr. Miller: The incidence of pressure sores has decreased in many acute and long-term care facilities because of a more sophisticated, aggressive approach to skin care and prevention. Nursing teams are specially trained to manage pressure ulcers and risk is identified and minimized on admission.

Dr. Zone: Twenty years ago, a resident lying in the same position for days at a time wasn't an uncommon sight. The vast improvement we see can be attributed almost entirely to prevention. And it's the increased awareness of the associated problems and chronic morbidity caused by pressure ulcers that makes caregivers more likely to implement preventive measures.

Dr. Mulder: Care and product availability has significantly improved over the last decade. Nursing homes are doing the best they can under the limitations imposed by the new Medicare Act and the policies of private insurance that reimburse for basic care and make adjunctive treatment impractical. More wound care education is needed in nursing homes.

Which Areas Need Improvement? What Steps Should We Take?

Dr. Mulder: We should inundate HCFA with letters demanding policy changes, especially regarding prophylactic care. Currently, there is no reimbursement for preventive care. Facilities aren't reimbursed for many of the newer therapies still deemed investigational, frequently because the companies don't provide the substantiating data needed to change that status.

Dr. Zone: I agree that prevention is what we need. Unfortunately, prevention isn't a money-maker. Federal agencies won't reimburse for an expensive preventive measure but you can be sure that some sophisticated new dressing will become reimbursable. This places a disproportionate amount of emphasis on treating the existing wound rather than preventing its development. In the meantime, nursing homes should be performing exams for incipient lesions more frequently. This doesn't mean every resident needs to be examined daily. But measures to prevent major problems can't be taken unless those problems are identified in their early stages.

Dr. Miller: We also need to pay more attention to nutritional status which is so closely linked with wound healing. Patients with pressure sores need protein-calorie and vitamin C supplements, as well as a daily multiple vitamin. Staff morale is an important issue as well. Treating chronic conditions can be extremely demoralizing and nursing schools still tend to equate pressure ulcers with poor nursing care. But despite our best efforts, pressure sores aren't always preventable in very debilitated or terminally ill residents.

Dr. Mulder: The nurses do an excellent job. However, most are operating without a standard of education in wound care. A newsletter to keep the staff up to date on products and treatments would be helpful. I've seen only minimal willingness of physicians to learn about what many still view as "a nursing task." More extensive skin and wound care education is needed in medical school curriculums.

What About Dressings and Topical Agents?

Dr. Mulder: Many of the new products are duplicates of existing products. Changes made have been primarily to improve minor features of existing products.

Some of the skin replacement products really do qualify as major advances. One group of dressings that I consider innovative are the hydrogels. I also think we're going to see a positive shift toward dressings used as flexible delivery systems, for biologicals and antimicrobials.

Dr. Miller: We tend to stay away from topical antibiotics, except in infected wounds, because they may retard healing. The topical antibiotic metronidazole (Metrogel) may be useful for anaerobic wound infections, particularly those with strong odors. We are also very cost conscious, and find that wet-to-moist saline dressings usually are effective and easy to use.

Dr. Zone: I think wet-to-moist dressings are great. They keep the area hydrated and significantly facilitate debridement. Without doubt, the most common error I see is the use of wet-to-dry dressings: applying a wet dressing, allowing it to dry, and debriding by ripping the dressing from the wound. Not only is it archaic and unnecessarily painful, but my own bias is that it impedes healing by ripping the fibroblasts from the base of the wound. Unfortunately, it's still done because it's easy and because it's been the traditional way to use dressings for decades.

I strongly believe that a wound requiring debridement should be anesthetized or debrided by softening the tissue with continuous soaks and moist dressings. They hydrocolloid (hydrogel) dressings accomplish just that. By occluding the wound with gelatin-like materials, they keep it moist and prevent the excessive dryness that makes debridement so difficult. At the same time, the dressings cushion the tissue by preventing direct pressure to focal areas of the skin.

I use the dressings on any depth ulcer that's fairly clean and not grossly infected. The only time they're contraindicated is in a wound with an obvious area of infection that needs to drain.

With respect to topical antibiotics, we usually use mupirocin (Bactroban) ointment in areas where we're concerned about secondary infection. It's preferable to polymyxin B sulfate-neomycin sulfate (Neosporin) because of a relatively high incidence of allergic contact dermatitis.

What Are Your Impressions of Investigational Wound Treatments Such as Biological Response Modifiers and Electrostimulation?

Dr. Zone: There are two areas on the horizon with respect to biological response-modifiers: growth factors and matrix proteins. I don't think growth factors have panned out as well as anticipated.

We conducted a leg ulcer study with fibroblast growth factors last year, applying them directly into the ulcers. The results are a bit equivocal and my impression is that they may require some type of adjunctive treatment. We've had some good results with diabetic foot ulcers but I'm not sure how well that's been documented. Growth factor also seemed to work well on venous insufficiency ulcers, but again, additional agents are probably required for optimal results.

Dr. Mulder: I'm not at all impressed with the results of past growth factor trials. They don't appear to be cost-effective and many products have no significant advantage over traditional therapy. Current trials with tri-peptides and PC1020 do appear to have potential.

Dr. Zone: If it becomes widely available, growth factor will be quite expensive. But I agree that the real question remains one of efficacy. The biological response-modifiers that seem to be quite promising are the matrix proteins. They are essentially synthetic matrix proteins put into wounds to facilitate the cell migration that occurs during normal healing. We've had some promising early results in a trial of matrix proteins used in venous insufficiency ulcers of the lower extremities in elderly patients.

Dr. Miller: Some of the treatments on the horizon are really quite interesting. But I'm not sure how feasible they are for the nursing home. The cost of some may simply be prohibitive. And technologies like electrostimulation require special equipment and skills. So while I'm very much in favor of continuing research, I think it will be a while before some of these modalities are used routinely in long-term care.

I hope the research will focus on identifying candidates for these treatments. Some of the newer technologies may actually be more beneficial to younger patients, such as paraplegics.

It's important that the treatment we employ is appropriate for the underlying condition as well as the pressure ulcer. All the technology in the world won't heal an ulcer if we haven't dealt with the causal factors.

Dr. Mulder: Electrostimulation seems to have great potential but we need to know more about its mechanism and be able to reproduce results. I'm sure we'll be seeing an increasing number of collagen-containing products on the market. But we need more data with respect to collagen's efficacy in chronic wounds.

Are You Optimistic About the Future of Skin and Wound Care in the Nursing Home?

Dr. Miller: I'm convinced that things are much better than they were 5 or 10 years ago: recognizing and dealing with skin problems and keeping up with the latest developments in prevention and therapy. We're also finding that with good, consistent care, many people with pressure ulcers can be successfully treated at the nursing home without hospitalization.

Dr. Mulder: The numbers of people requiring wound care are increasing. Despite the appearance of freestanding wound care facilities, I think nursing homes will still be the primary administrator of wound care. If I'm at all optimistic, it's because nurses will be providing that care. They need to be given more authority and responsibility.

Dr. Zone: With the possible exception of hydrogels, we really haven't been handed any magic new treatments. So, the difference between the wound care of today and that of 20 years ago is prevention. Overall, we're heading in the right direction; better nursing care, closer monitoring of skin status. Unfortunately, the nature of the business world is such that prevention will always be valued less than therapy, and resources will be directed at high-tech drugs and devices to heal what could have been prevented. So my hope is that the value of prevention will be more universally recognized and the emphasis will continue to shift toward aggressive preventive care.

What Are Some of the Latest Developments in Pressure-Relieving Devices?

Dr. Miller: There is a wide array of specialty beds available: low air loss beds, water mattresses; and very specific protocols for their use. Because of the expense involved, we use these products in a stepwise fashion, starting with a specialized foam overlay, moving up to a first step air mattress and going on to something like a KinAir bed if the mattress isn't adequate. With so many companies, it's important to establish a protocol, select good products, learn how to use them, and prioritize their use to control cost.

Donna Miller, DO, is Assistant Staff Physician, Section of Geriatric Medicine, Cleveland Clinic Foundation, Cleveland.

Gerit D. Mulder, DPM, is Director of the Wound Healing Institute, Denver.

John Zone, MD, is professor of Medicine and Head of the Division of Dermatology, University of Utah School of Medicine, Salt Lake City.