Teamwork: a winning approach to wound care. (Feature Article).

INTERVIEW WITH TRACY WIDBY

Caring for residents with pressure ulcers and other chronic wounds, as anyone involved in long-term care is painfully aware, can exact a heavy toll-not only on residents, but also on staff and on the bottom line. Doing it right is rewarding. Failure to do it right, in addition to compromising residents' quality of life and costing facilities money, can leave those facilities legally vulnerable.

It is a fact of long-term-care life that despite the best facilities' best efforts, few nursing homes will be entirely free from the occurrence of pressure ulcers and other chronic wounds. Some residents have them when they arrive. Others develop them during hospital stays or while undergoing lengthy surgical procedures. Still others, who are particularly frail or who have diseases or conditions that make them more prone to developing these hard-to-treat wounds, do so even under the most watchful eyes of the most diligent long-term care staff.

Managing Editor Linda Zinn asked Tracy Widby, RN, CWCN, wound care coordinator for Knoxville, Tennessee-based Hillcrest Healthcare's one skilled nursing and two intermediate care facilities, to describe the process that, beginning in 1996, transformed this not for-profit's once-disjointed wound care program into the collaborative, organization-wide effort it has become today. Ms. Widby discusses what has worked and what has not, and she describes some recent innovations in wound care technology.

Zinn: How did Hillcrest's wound care program, as it is structured today, begin?

Widby: I had been a long-term care nurse for about seven years when, in 1994, at the request of my director of nursing, I became a treatment nurse focusing on skin/wound care. I soaked up all the information I could find--Agency for Health Care Policy and Research (AHCPR) guidelines, textbooks and periodicals on skin and wound care--and I attended seminars to learn about the best methods and products. Having the continuity of one person in the facility who was overseeing wound care--the same person applying the same methods day after day--made the program successful.

In 1995, our ConvaTec sales representative asked if I would share my successes with Hillcrest's other two homes, suggesting that we use the same protocol for all three facilities. At that point, even though we were one organization, we had three completely different wound care programs. I took his suggestion and we began forming our skin/wound care team.

Zinn: What is the make-up of the team?

Widby: It includes treatment nurses from each of the three facilities, the DON from each facility, nurses from the skilled units and myself. We meet quarterly, unless a problem arises or an issue needs to be addressed; in that case we meet more frequently. I visit the facilities regularly to check on how the residents are doing and how the program is going.

Zinn: Do you have any words of wisdom for organizations that are putting together skin care teams--both in terms of pitfalls to avoid and approaches that have worked especially well for your organization?

Widby: In retrospect, we could have been more aggressive at the beginning, in terms of assembling the team and getting our protocol in place more quickly. It was a learning process for everyone.

What's really been successful is the collaborative nature of our approach. No one person can think of everything, so bringing everyone together and learning from each other's perspectives and experiences has been extremely helpful. Also, having a unified protocol across the entire organization has been beneficial. Initially the team discussed the protocol's components, and when we were satisfied with it, we submitted it for the medical director's approval.

Zinn: What is the primary role of each of your team members in following the wound care protocol?

Widhy: The treatment nurses evaluate and manage all wounds, considering every aspect of wound care--nutrition, infection prevention and treatment, diagnosis. Their role is to provide that continuity of care--administering the same treatment daily, measuring wounds in the same way consistently, etc.

The CNAs on the skilled units are our eyes and ears--they're the key to prevention and early detection and report to the nursing staff any problems or potential problems. While the treatment nurses might spend 20 or 25 minutes with residents a day, the CNAs are with them throughout each day. They are vitally important members of the team.

The DONs oversee the entire process and keep me informed on what's happening with the residents.

I'd like to mention that we also make residents' families part of the team, in a sense. We get them involved by keeping them informed about the development of wounds and letting them know how their loved one is progressing. This helps them understand why the wounds have occurred and what the treatment involves. Otherwise, some families think these chronic wounds can heal overnight, although sometimes healing is a long process. After all, these wounds don't occur overnight.

We also bring the occupational and physical therapists into our realm. Anytime someone has a wound, we refer that person to be evaluated for positioning devices; pillows sometimes just don't do the trick. We use a wide variety of devices.

We also have high-density foam surfaces on all our beds and low-air-loss mattresses for residents who need them. We also have purchased a specialty bed with a high-density foam overlay that conforms to the resident's body to relieve pressure. We use everything at our disposal in an effort to prevent wounds or accelerate their healing.

Zinn: How has Hillcrest's team approach affected wound treatment outcomes?

Widby: It's dramatically improved them. Healing times have been reduced, and rates of occurrence are down. When we first established the wound care team, 8 to 9% of our population was being treated for wounds. Now it's down to 5 to 6%, including community-acquired wounds. With a population the size of ours, that's a significant drop.

Zinn: With so many wound dressings on the market today, what factors guide you in choosing specific types of wound dressings to use on specific types of wounds?

Widby: First, we look at the resident when selecting products: What type of wound does he or she have? What does the exudate, or drainage, look like? What is the etiology of the wound? Then we try to choose a dressing that addresses the specific needs of that wound.

For example, calcium alginates and the new Hydrofibers[R] work well for wounds that are draining; they absorb the exudate well and provide a warm, moist environment that promotes healing. Foam dressings are good for wounds that need extra protection, such as those on the sacrum or hips or heels--basically, pressure ulcers. For venous ulcers we use Unna boots.

Wherever possible, we use cover dressings that have extra absorption and therefore require fewer changes, so that we don't have to disturb the wound bed any more often than necessary. When a dressing is changed, the wound bed temperature decreases and healing is somewhat halted. It takes a wound up to 8 hours to reach optimal temperature to begin the healing process.

Hydrogels are a good choice if the wound is pale pink and looks like it's not getting good hydration. Wounds become pale from lack of moisture and/or anemia. The hydrogels put moisture back into wound. Hydrocolloids are especially good for pressure ulcers; we've also used them at times on venous ulcers and some skin tears.

Zinn: Are there any new wound dressings or products on the market that you find useful?

Widby: The Hydrofibers, described above, are quite new. Another newproduct is a dressing that consists of a silver-impregnated, antimicrobial Telfa pad. These antimicrobial barrier dressings are useful for dealing with bacterial colonization in partial- and full-thickness wounds.

Dressings containing hyaluronic acid are also among the newer products. They are well suited for the treatment of chronic pressure ulcers and other difficult-to-treat wounds. The hyaluronic acid restores the acidic pH that wounds need for healing. When the wound bed becomes too alkaline, healing is halted.

Zinn: What protocol do you follow for wound debridement?

Widby: Whenever possible we use a collagenase product for enzymatic debridement. We try to stay away from mechanical, or sharp, debridement unless we have exhausted all other methods, because they are painful. We also do some autolytic debridement.

Zinn: What other factors have a significant impact on wound healing?

Widby: Nutrition is vitally important; that includes instituting a regimen of multivitamins. As soon as we see a wound developing, we notify nutritional services and work closely with them. They routinely look at residents' nutritional status and make sure they are getting the proper vitamins, such as vitamin C and zinc, which play a large role in healing. Nutritional staffmembers also inform us when they observe a weight loss. Often residents with chronic wounds lose weight because their bodies go into a hypermetabolic state in an attempt to heal the wounds. That is why residents need extra protein for wound healing.

Another key factor is pain management. You can manage the wound and manage the resident nutritionally, but you also have to think of his or her comfort. We bring in the medical director to assess the resident's pain and try to get him or her on pain medication--either on a prn or a routine dosing regimen. Stage II, III and some stage IV wounds, especially arterial ulcers, produce extreme pain; besides making the resident uncomfortable, this pain also increases metabolism and slows the healing process.

Finally, in residents with diabetic peripheral neuropathy, controlling their primary disease contributes to wound healing, as well.

Zinn: Howare CNAs trained, and what procedures do they follow in their day-to-day care of residents with pressure ulcers and other chronic wounds?

Widby: We provide them with frequent in-services dealing with pressure ulcers and other types of wounds. Every time they see something unusual, they are required to report it to the nurses. Some of them are exceptionally observant and know precisely what's going on with each resident. They'll report a reddening of a resident's skin at the end of their shift that wasn't there at the beginning of their shift--that's how astute they are, and how aggressive at watching for skin changes.

I also do my famous "bedpan in-service" for our CNAs. I have one CNA sit on a bedpan in a chair. I have another sit with a golf ball under her leg. I put a golf ball between another CNA's knees and wrap her knees together. And I have another one sit on a piece of plywood with her legs dangling.

Then I explain: "If you sit on a bedpan for a long time, that's how it feels." Or, "The way that golf ball under your leg feels is how it feels when residents' pads or sheets are bunched up under them." I explain that the golf ball between the knees simulates what happens when the knees are pressed together without being supported correctly with pillows or an assistive device. And I point out that when your legs dangle for extended periods without anything to prop them on, the legs get numb behind the knees. These illustrations give them a better understanding of what residents experience if they aren't given the proper attention.

Zinn: When you think back on some of your most challenging cases, what did it take to achieve a successful outcome despite the difficult-to-treat nature of the wounds involved?

Widby: I remember one difficult case very well. We had a resident in her 90s who came to us with 10 pressure ulcers on her body that she'd had for several years. With diligent and aggressive treatment, every one of those wounds was healed. It took seven years to accomplish that, and what made us successful was continuity of care. She lived for approximately another year after her wounds were healed, and she experienced no subsequent skin breakdown and no reopening of the wounds. That was a memorable case.

Zinn: I'm sure you've seen a lot of changes in wound management in your 15 years as a long-term care nurse. Would you like to comment on those changes and on other trends you've observed?

Widhy: When I first started, wound care basically consisted of the topical application of Betadine and hydrogen peroxide. We've come a long way, and today, some long-term care organizations are on the cutting edge of wound care practices. I'm proud to be associated with one of them.

Despite all the strides we have made, I see nursing homes getting a bad rap today. There's a television commercial running here in which an attorney asks in an ominous voice, "Does your family member have a pressure ulcer?" Some attorneys see long-term care as a money market.

On the positive side, the acute care facilities in this area are getting better about watching patients' skin status. In the past, hospitals typically concentrated on keeping the body running and didn't take the time to consider the skin, even though it has an impact on patients' overall outcomes. Then these patients would come to our facilities and we would have to try to get their wounds healed. I'm glad this is improving. I hope the trend continues and that it gets even better.

Tracy Widby, RN, CWCN, is the wound care and infection-control coordinator for Hillcrest Healthcare, Knoxville, Tennessee. For mare information, call [phone].