By Britney Ann Butt

A nurse and a doctor stand silently assessing their patient Lilly, an 87-year-old female. A pungent sweet sickly smell permeates the room, it is a distinct odour they have encountered before, the smell of infection. Having encountered this type of case several times before (two just this week), the nurse turns Lilly onto her side to investigate what she already knows to be true; the patient has a stage 4 infected sacral pressure injury. As the nurse and doctor assess the wound, they begin to think, “How did this wound deteriorate this significantly? Who is accountable for this? How do we prevent this? and more urgently, “Who do we call who knows how to fix this?”

Adverse events related to wound, ostomy and Continence (WOC) conditions such as Lilly’s have become common place and unnoteworthy in the medical community despite cries from health care providers. However, cases like these are being exposed and reported in the media. A CTV News article published in 2020, “Man rotting alive from bedsore dies of infection,” revealed the high incidence of pressure injuries in long term care (LTC) residents. While there has been public outcry, there has been little substantial change to our health care system to improve the lives of those suffering from WOC conditions.

Health care providers specialized in WOC care are required if we want to have a significant improvement in the health outcomes of our patients.

The need is clear, and the proof is in the numbers:

• Wound care costs Canada about $3.9 billion a year, or three per cent of the country’s total annual health spending.
• 70,000 people in Canada are living with an ostomy, and thousands more each year undergo some form of ostomy surgery and often experience complications that require treatment beyond the initial surgery, adding to already substantial care costs.
• Between one and 3.5 million incontinence cases, almost 10 per cent of the Canadian population, have been reported.

A Nurse Specialized in Wound, Ostomy, and Continence (NSWOC), formally known as an Enterostomal Therapist, is a practitioner trained specifically to provide advanced specialized care for patients with wounds, ostomies, and continence issues. NSWOCs receive a competency-based education through the Wound, Ostomy and Continence Institute. The Institute’s Wound, Ostomy and Continence – Education Program (WOC-EP) is designed for bachelors-prepared registered nurses (RN) to provide advanced, WOC consultation. NSWOCs work in a variety to health care settings including acute care, community care, LTC, clinics and private care.

In 2019, the Wound, Ostomy and Continence Institute launched the Skin Wellness Associate Nurse (SWAN^TM) Program. This was in response to the growing need in Canada for healthcare professionals with enhanced WOC knowledge and the as a means to support and empower NSWOCs and improve clinical outcomes by enhancing WOC care teams. The SWAN^TM program is designed for college prepared licensed practical nurses (LPN) or registered practical nurses (RPN) and prepares non-specialty nurses to provide basic, bedside WOC care.

NSWOCs and SWANs work collaboratively within their health care team and contribute to WOC care effectiveness and cost-efficiency by:

• Implementing best-practice approaches to the assessment and treatment of wounds, ostomies, and continence issues into their areas of care.
• Educating patients and their families about how to manage ongoing holistic health needs.
• Informing evidence-based and cost-efficient care decisions for WOC patients as interdisciplinary health team members.
• Contributing to research projects, guidelines and policies related to their specialties.
• Providing leadership within their health care teams and care setting by delivering ongoing WOC education and mentorship.

The combination of these practices leads to higher-quality care, lower costs, and better outcomes for patients.

The impact of COVID19

In December of 2019 the World Health Organization (WHO) was informed of an unknown virus causing pneumonia like symptoms in Wuhan City, Hubei Province of China. The virus, that would ultimately be known as “COVID 19” was declared a pandemic by the WHO on March 11th, 2020.  As of January 18^th, 2021, over 715,072 COVID-19 cases have been confirmed in Canada with 240,348 of those cases located in Ontario.

The pandemic has shed a light on the Ontario health care system and the need for nurses with advanced or enhanced knowledge of WOC conditions.

In the spring of 2020, the Canadian military was deployed to several Ontario LTC facilities that were identified as needing staffing support and relief. On May 14^th, 2020, the military produced a report highlighting the atrocious and inhumane living conditions of our most vulnerable population. Of note, wound care supplies meant for patient care were reported as being locked away from nursing staff, patients were found sitting in soiled linens for prolonged periods of time, there was improper catheter care, and a high incidence of pressure injuries were observed due to prolonged bed rest and improper bed positioning. The report identified a lack of resources within LTC facilities to adequately assess and treat these patients independently as they heavily relied on outside consultation which provided delayed and fragmented care. For years the concerns of residents and their families, health care practitioners and advocacy groups had been mounting but little had been done to address these concerns. This military report finally shed light on LTCs crumbling house of cards.

An internal Nurses Specialized in Wound, Ostomy and Continence Canada report confirms this gap in care as only 69 NSWOCs reported providing care support to LTC clients in Canada while only 20 of those NSWOCS are solely dedicated to work in LTC. “It is posited that with 630 LTC facilities in Ontario, the fact that the majority of which are not serviced by an NSWOC is contributing to the persistently high prevalence of patients with WOC-related conditions in Ontario LTC facilities.”

The increased burden on LTC facilities combined with a lack of resources available amplifies the strain on the Ontario health care system including the hospital sector which admits patients from LTC at an alarming rate due to the LTC facilities’ inability to adequately provide care for issues related to WOC.

There is a clear and critical need for nurses specialized in wound, ostomy, and continence care (NSWOC) which can integrate evidence-based best practises into their care setting, provide ongoing education to staff, and assess and provide recommendations on wound, WOC related issues. With the incorporation of the skin wellness associate nurses (SWAN) as a member of the WOC team, LTC facilities can have access to on-site WOC care, providing rapid assessment, bedside WOC support to staff and wisely utilize health care spending. The integration of NSWOCs and SWANs into existing health care teams will improve health care outcomes of patients and improve upon the safety and well-being of Ontario’s vulnerable LTC population and while reducing hospital admissions for WOC related issues.

Patients such as Lilly deserve better. They are your mother, your friend, your neighbour. They are you. The call to action is now, while we have the nations attention or risk another report being slipped under the rug, being pushed onto another administration and our most vulnerable population being forgotten forever.

Britney Ann Butt, MClSc-WH, BScN, RN, NSWOC, WOCC(C) is the Wound Ostomy Continence Institute Program Development Coordinator / Skin Wellness Associate Nurse Program Lead/ NSWOC Core Program Lead – SWAN Community of Practice The Wound, Ostomy & Continence Institute.