By Rosemary Kohr
Chronic wounds have never had the same level of attention as cancer care, or treatments of heart disease, yet they quietly affect a significant share of our patients; and are responsible for longer hospital stays, sepsis and amputations. What are the numbers, you might ask—and the embarrassing answer is “we don’t really know”. Consistent, accurate data collection of chronic wounds (bedsores, diabetic foot ulcers, venous leg ulcers and stalled/infected surgical wounds) has been spotty at best—the last cross-Canada estimate was in 2004. However, we can make some reasonable assumptions, based on US figures, where at any point in time, 15 per cent of the acute care population is estimated to have a pressure injury (Institute for Healthcare Improvement, 2012).
Now well into the 21st Century, patients admitted to hospital are older, sicker and often with multiple issues related to mental health, family stress, poverty, etc. What might have once been a fairly simple “throughput” experience, has become the unfortunately common scenario for many patients.
Take for example, Mrs. Ida Jackson. She’s an 86-year-old widow, living in her own home. On Saturday, she trips over a scatter rug and falls. She’s brought to the emergency department (ED) where X-rays confirm a hip fracture. Admitted for surgery, she still has to wait 24 hours in the ED for an appropriate bed to become available. The ED is busy; Mrs. Jackson is in a continence brief (adult diaper). She’s NPO (“Nothing by mouth”), with an IV running.
Her surgery goes well on Tuesday, but discharge is put on hold, due to her slow recovery. Her mobility and activity have both been limited; due to pain, she has been reluctant to get out of bed or follow the deep coughing instructions from the respiratory tech. She only picks at her food. Family visits have been sporadic, since her grown children are busy with work and other responsibilities.
The nurses have documented a Stage 2 Pressure Ulcer on her coccyx, and have notified the team. After a quick look, the doctor writes the order, Daily dressing and reposition q 2 h. The nurses use foam dressings, reinforced with a transparent film over top, but the whole dressing is often found in the continence brief. The nurses encourage Mrs. Jackson to change her position to decrease the pressure on her coccyx, but they note that she now appears to be developing a reddened spot on her “good” hip. By Friday, Mrs. Jackson is transferred to the General Medicine Unit.
There is a smell in the room, and one of the nurses suggests using an open box of kitty litter under the bed to deal with the odour. The doctor orders Betadine-soaked gauze b.i.d. By the time her daughter asks to see Mrs. Jackson’s backside on Saturday, the bedsore has oozing yellowish-gray fibrous tissue as well as a strong odour. The daughter hits the roof.
We know that elderly individuals are at higher risk of skin breakdown and slower healing, and that incontinence and poor nutritional intake are major culprits. But we also should know that appropriate prevention and treatment are available. So why do situations like this one, which unfortunately happens to be a true story, occur with such alarming frequency?
One of the basic reasons is that medical and nursing students have virtually no education regarding up-to-date, evidence informed knowledge relating to chronic wound prevention and management. Until they are in the work-force, nurses and doctors, along with other healthcare professionals, often don’t realize the magnitude and complexity of skin tears, pressure injuries, diabetic foot ulcers, venous leg ulcers and stalled surgical wounds.
And, poised over the patient’s wound, who has the time to stop and learn? It’s no surprise, then, to fall back on an out-of-date and usually inappropriate approach. If you don’t know that wounds change over time, and the order from last week is likely no longer what the wound needs, why would you question what you are doing? And if you do happen to ask, the response is likely to be, “Because that’s the way we’ve always done it”. In over 15 years of teaching wound care to nurses and doctors, and consulting on more wounds than I can remember, this is the most common situation I have seen. The sad thing is, it is far costlier and time-consuming than to actually do the right thing.
It’s time to change this paradigm. If we can’t change the academic programs to increase curriculum content on chronic wounds, at least in the clinical world, this shift can happen. The first step is to ensure all staff, physicians and students have up-to-date training in preventing and managing chronic wounds. This education (on-site, webinars, etc) must include a hands-on component to be able to confidently and quickly select appropriate treatments, particularly dressings. Everyone, from management to Personal Support Workers, needs to be on board with evidence-informed, practical and relevant education with a focus on how to work as a team to optimize patient outcomes. Zero tolerance for hospital-acquired pressure injuries can be a realistic goal, for example.
The second solution is the implementation of a consistent electronic documentation and data collection tool, that includes wound photo and measurement (apps to automatically do this are currently available), as well as tracking product utilization. I know this is a challenge. But what is needed is the recognition that this MUST happen, and the will, at the senior levels of management, to make it so. Costs to implement the technology (already developed and commercialized) will be off-set through the savings directly related to patient outcomes.
The third aspect of this change is to recognize the need for a team approach. Wounds heal from the inside out, so the patient must be an integral part of the treatment plan as much as possible. Depending on the issue, different members of the team may be key players. The team also extends to staff where the patient will be going—home, long-term care, etc. Communication is critical. In our example of the unfortunate Mrs. Jackson, the dietitian, pharmacist (re: pain medication) and occupational therapist would have been involved from the start; the home care social worker would have been connecting with the family re: home supports.
So, in summary, the “big three” components of this change are knowledge, documentation and collaboration. From this month’s special focus on wound care, you can see that information abounds regarding treatment approaches to improve wound closure/healing. As well, there are educational programs at a variety of levels, described and advertised—all designed for the needs of healthcare professionals across the continuum of care.
Consider the quiet frequency of stories like Mrs. Jackson’s. These can be avoided with a clear commitment to those values we all hold so dear: safe, effective and efficient care, with excellent outcomes for our patients, our organizations and our communities. Leaders at all levels need to be fully engaged as champions to support this sustainable approach to skin breakdown and chronic wound prevention and management. That’s you.
Rosemary Kohr RN, BScN, MScN, PhD, is a wound specialist with over 20 years providing clinical care and consultation in Acute Care (London Health Sciences Centre), long-term care and the community. She is currently Program Director, Health Leadership & Learning Network, York University and Instructor, Graduate Program, Faculty of Health Disciplines, Athabasca University.