Wound Care: 10-year progress report

The practice of wound care has undergone tremendous changes in the past few years-from new Centers for Medicare & Medicaid Services (CMS) guidelines that have renewed the emphasis on the proper prevention, identification, and treatment of pressure ulcers, to new research that suggests some pressure ulcers that manifest at the end of life may be unavoidable.

Long-Term Living Consulting Editor Richard L. Peck recently discussed these and other developments in the rapidly changing field of wound care with Dr. Thomas Stewart, founder of the National Pressure Ulcer Advisory Panel (NPUAP) and president and chief clinical officer of Gaymar Industries, as well as Cynthia Sylvia, MSc, MA, RN, CWOCN, program manager, educational development for Gaymar.

Peck: How has wound care changed for the better in the past decade?

Stewart: One of the positive developments in long-term care over the past 10 years has been the progress we have seen in the treatment and prevention of pressure ulcers. From preventive awareness to advanced technology to organized intervention, a great deal has occurred over that time period to justify hope for better outcomes for our immobile residents.

Sylvia: With respect to technology, dressings have evolved from the simple gauze to the technologically advanced. Ten years ago the alginates and the bioengineered skin replacements were lacking, as were the commercially available honey products with antibacterial properties. Bioelectric wound care dressings, constructed using a thin pad with a minielectric circuit embedded to stimulate skin growth at the cellular level, have also appeared relatively recently. Growth factors and the biochemistry of chronic wounds are much better understood today than they were then. Negative-pressure wound treatment has been a major advance, and new debriding techniques have been developed using ultrasound technology.

Stewart: Support surfaces have improved, including mattresses with features such as lateral rotation and percussion/vibration that improve pulmonary toilet, as well as low-air loss mattresses that address microclimate, including temperature and humidity, and help maintain a constant low interface pressure. Gaymar has been involved for some years in the Support Surface Standards Initiative, which evolved from a research committee connected with the NPUAP to a full-fledged subcommittee for the International Standards Organization (ISO). Members are seeking to develop standardized terminology and testing for support surfaces, with protocols emerging within the next year or so. In sum, wound care products have continued to grow in variety, efficacy, and sophistication.

Peck: How have professional organizations advanced the practice of wound care?

Stewart: In 2008, the American Medical Directors Association (AMDA) issued updated guidelines for pressure ulcer treatment and prevention, while the Wound Ostomy & Continence Nurse Society published their Guidelines for Prevention and Treatment of Pressure Ulcers in 2003. Perhaps one of the most significant recent developments has been a certification examination for physicians, scheduled to begin this September. These and other efforts demonstrate all-important physician interest and involvement in managing residents at risk in the long-term care setting.

We are also encouraged by the growth in collaborative efforts between skilled nursing facilities (SNFs) and hospitals. There has been a long-standing joke that since neither SNFs nor hospitals claim responsibility for the initiation of pressure ulcers, then they must develop in ambulances. But the days of finger-pointing are coming to a close. A more collaborative spirit has been inspired in part by new Medicare regulations prohibiting reimbursement for nosocomial wounds, as well as more recent regulations focusing on reducing rehospitalization.

Peck: What role do federal and state regulatory agencies play in the evolution of wound care?

Sylvia: CMS has been working with quality improvement organizations in various states to develop the Care Transition Theme. The Continuity Assessment Record and Evaluation (CARE) Tool, a patient assessment instrument, is currently part of the demonstration project. It is hoped that this extremely important communications system will be commonly available to professional caregivers as soon as 2012.

Individual states have become involved in upgrading wound care as well. For example, team efforts in New Jersey and Indiana have encouraged provider collaboration in various demonstration projects, culminating in the New Jersey and Indiana Pressure Ulcer Collaboratives.

Peck: What are the challenges in wound care that still must be overcome?

Stewart: The unfortunate Minimum Data Set (MDS) remains an issue. SNFs are required to report healing pressure ulcers in a sequence of “downstages,” but there is no scientific rationale for downstaging. Wounds do not heal in this manner, but SNFs currently have no other option for presenting clinical documentation. The revised report of the MDS 3.0 was posted online in April 2008 and a final version is slated for October 2009. It is commonly believed that MDS 3.0, slated for introduction in the fall of 2010, will do away with downstaging.

As the reimbursement situation for long-term care becomes ever more challenging, the possibility has been raised that certain SNFs might specialize in wound care, developing sufficient expertise to be recognized as a referral center for neighboring acute care providers. The model for the wound care center already exists at the acute care level, which offers stand-alone or attached specialized facilities. Since pressure ulcers and diabetic ulcers are chronic problems of the elderly, SNFs are a logical venue to serve as Centers of Excellence for wound care. It would be very important, however, for the management of SNFs to have the necessary business acumen to function in this manner.

Peck: How is scientific research contributing to a better understanding of pressure ulcers?

Stewart: Studies have shown that pressure ulcers may actually develop in reverse sequence from what is commonly thought. Investigators are advancing the theory that pressure first manifests in the underlying deep tissues, such as fatty tissues and muscle tissues, rather than at the skin surface, and that certain enzymes released by this process produce the damage on the skin. This may help explain, for example, why Stage 3 and Stage 4 wounds sometimes appear seemingly overnight, causing shock and dismay for nurses, physicians, and other caregiving personnel, not to mention patients and families. There are also indications that this process can occur naturally toward the end of life, no matter what best practices are employed. We will be convening a Consensus Panel to address this issue possibly later this year.

Sylvia: This research has profound implications for providers. It remains essential, of course, for providers to use best practices to prevent wound occurrence and progression, but the development of deep wounds cannot always be blamed on provider neglect and does not justify the guilt and anger that providers might experience. An expert group called Consensus Panel: Skin Changes At Life’s End (SCALE) is now using a modified Delphi process to publish a Consensus Document of the evidence on SCALE, due this fall. Meanwhile, the key for providers is to educate patients, families, and staff that this potential exists and that everything possible will be done to keep patients comfortable during this inevitable process.

Stewart: In sum, while significant progress has been made in the practice of wound care over the past decade, there is still much more work that must be done. We believe additional technological advances, increased professional participation, regulatory guidelines better aligned with effective diagnosis and treatment, and continued research will all contribute to better wound care in the next decade and beyond.

Visit https://www.gaymar.com for more information. To send your comments to the editor, e-mail mhrehocik@iadvanceseniorcare.com.

Long-Term Living 2009 August;58(8):23-25