John visits his father, who resides in a nursing home, and is an invalid since his stroke left him incapacitated. During one of his visits, he sees a large bandage on his father’s back, and subsequently sees a nurse change the dressing. To his shock, he sees a large and raw wound that is cleaned by the nurse and then covered with a new dressing. By the end of the day, John has not only given a piece of his mind to the manager of the nursing home, but is considering moving his father to a new location as well as contacting authorities as well as an attorney to report elder abuse.
Wound Care and the Elderly
While wound care is concerned with treatment of surgical wounds, pressure and stasis ulcers, as well as problems with both bowel and urinary incontinence, it should be noted that the second leading cause of litigation in nursing homes is due to skin and wound allegations.1 It is not uncommon for legal claims against a facility in regards to wound care issues costing $250,000, and multiple wound care cases can make it difficult for a facility to obtain insurance, endangering both the patients as well as the facility’s livelihood.2 As a result, a jury will often find in favor of the plaintiff, when the appearance of incompetence or malpractice on behalf of the nursing home, due to the apparent indifferent treatment of the patient’s wound issues.3 As a result, the lack of a Certified Wound Care professional allows for the false perception that all facility-acquired wound problems are preventable.4 In fact, it has been proven repeatedly with statistically valid studies that properly trained nursing staffs is one of the key factors in influencing patient safety and livelihood and reduced mortality.5
Wound Care Patient Demographics
The most common wounds to be discussed are pressure ulcers (decubitus ulcers or bedsores), vascular ulcers (arterial and venous), and neuropathic ulcers.
Approximately 70% of all pressure ulcers occur in the geriatric population. Their skin has a decrease in water content, tensile strength, and junctional integrity between the dermis and the epidermis. Atrophy of the apocrine and sebaceous glands causes drying of the skin. A loss of subcutaneous tissue, vascularity, and diminishing stability of small blood vessels add other factors to compromise skin integrity.6
Pressure ulcers, also known as bed sores, pressure sores, or decubitus ulcers, are wounds caused by unrelieved pressure on the skin.7 They usually develop over bony prominences, such as the elbow, heel, hip, shoulder, back, and back of the head.8 Pressure ulcers are serious medical conditions and one of the important measures of the quality of clinical care in nursing homes. The most common system for staging pressure ulcers classifies them based on the depth of soft tissue damage, ranging from the least severe (stage 1) to the most severe (stage 4).9
Approximately one out of every 10 nursing home residents (11%) had pressure ulcers. Furthermore,
- Residents aged 64 years and under were more likely than older residents to have pressure ulcers.
- Residents of nursing homes for a year or less were more likely to have pressure ulcers than those with longer stays.
- One in five nursing home residents with a recent weight loss had pressure ulcers.
- Thirty-five percent of nursing home residents with stage 2 or higher (more severe) pressure ulcers received special wound care services in 2004.
Vascular ulcers result from deficits in either quality of arterial flow or derangement of the venous system. The prevalence of peripheral arterial and peripheral venous disease is increased in the geriatric population. Evaluation must include both systems because these problems are not mutually exclusive. Arterial ulcers are a result of restriction of flow or occlusion of an artery. They have a discrete “punched out” appearance, a pale wound bed and minimal exudate. Gangrene or necrotic tissue is common. Due to the ischemia underlying the development of these ulcers, they are often very painful and difficult to treat or heal.10 The most frequent locations for these ulcers are the tips of or between the toes, over the phalangeal heads, or over the lateral malleolus. Even a bump or scrape can precipitate an ulceration.11
Venous ulcers are generally shallow with irregular wound margins. The ulcer base tends to be beefy red and granulation is frequent with exudates most often moderate to heavy. If there is an arterial component, the color and amount of exudates may be muted. These wounds may have a strong odor that may be concerning to the patient and must be addressed when providing wound care. Venous ulcers are classically located over the medial malleolus although sometimes they can be near the lateral malleolus. In severe cases they may encircle the entire ankle. Other disease processes such as vasculitis, pyoderma gangrenosum, or neoplasms may be mistaken for venous ulcers. Ulcers that do not respond to standard treatment should be referred for further evaluation, i.e., dermatology, vascular or plastic surgery.12
Neuropathy is most often associated with diabetes, but may result from other diseases. Neuropathy falls into three categories: sensory, motor, and autonomic. The most common is sensory neuropathy resulting in an insensate foot. Ulcer causality is multifactorial, the presence of sensory neuropathy, peripheral occlusive vascular disease and the presence of bony deformities increase the incidence of foot ulcers.13 Diabetic foot ulcers may be classified in stages according to the natural history progression:14
- Normal foot
- High risk foot
- Ulcerated foot
- Infected foot
- Necrotic foot
Patients with loss of protective sensation have been shown to have a 15-fold increase in the risk of developing a foot ulcer.15 When the protective sensory threshold is lost, patients may continue to experience tissue damaging pressure or trauma. The ulcers are typically located in areas exposed to repetitive pressure and the precursor of callus or blister formation can alert patients and providers alike to an impending ulcer. Callus formation is a normal response to the stress of elevated pressures on an area of the foot. The callus can act like a stone in the shoe.16
Accreditation for Wound Care Treatment
One of the issues wound care faces is the lack of standardization regarding educational level within the specialty, where a medical professional may claim a level of expertise based on his or her total years in medicine, not necessarily in time dedicated to wound care. As a result, many providers feel justified in portraying themselves as experts in wound care due to a course they undertook and achieved a certificate, or by joining an organization that included a designation implying competency in wound care as part of the benefit of paying dues. However, expertise and competency in wound care are derived from both years of study and an application of knowledge in the clinical setting.
Two major organizations offer formally recognized accredited certifications in regards to Wound Care:
- The Wound, Ostomy and Continence Nursing Certification Board (WOCNCB)
- American Board of Wound Management (ABWM)
Two other organizations offer educational services and certificates in regards to Wound Care, but are not formally accredited, and in fact, the WCEI offers a certification:
- National Alliance of Wound Care and Ostomy (NAWCO)
- Wound Care Education Institute (WCEI)
Benefits to Medical Facilities of Accredited Wound Care Professionals
Wounds have become the focus of government regulations for long-term-care, home care, and acute care. They are among the most often-litigated health issues. The Nursing Home Quality Initiative, a Medicare program designed to help nursing homes improve their quality of care in key areas, lists “pressure sores” as one of five quality measures for post-acute care; “low risk pressure sores,” “high risk pressure sores,” and “pressure ulcers-short stay” are three of the 15 quality measures for chronic care. In home health:17
- 73.1% of patients are reported to have a wound or lesion
- 34% have surgical wounds
- 6.8% have pressure ulcers. Under pay-for-performance in home care, pressure ulcer development will negatively affect an agency’s reimbursement.18
When the Montefiore Home Health Agency (New York) implemented the hiring and training of wound care by accredited wound care professionals, patient costs for wound care problems dropped significantly:
- The percentage of non-healing wounds (not healed 12 weeks after admission) decreased from 33% to 20%.
- Post-surgery healing rates reached 95% in 2013. That compared to an average of 88% in New York State and 89% nationally.
- It is especially impressive given the rise in the diabetes rate — from 12.1% in 2010 to 13.1% in 2011 — in the Bronx, where most of the wound program’s patients live.
- Before implementing the home-care wound program in 2008, the hospital’s post-surgery healing rates were 86%.
These figures show that this home care innovation for wound patients can lower costs and improve healing outcomes.19
As an added motivation, the Centers for Medicare and Medicaid Services (CMS) cite the development of pressure ulcers as one of eight conditions that became subject to payment reductions as of October 1, 2008. The CMS considers the development of a Stage III or Stage IV pressure ulcer to be a preventable event. The update also notes that, compared to many other conditions, a pressure ulcer is a high-cost, high-volume condition. In fiscal year 2006, 322,946 Medicare patients with pressure ulcer as a secondary diagnosis were reported and their average hospital stay charge was $40,381. Therefore, healthcare professionals specializing in wound prevention and management have become sought-after employees in all areas of patient care and wound care is becoming recognized as a specialty area of practice.20
Benefits to Patients
The greatest and most important benefit of an accredited certification is for the wellness and livelihood of the patients that the healthcare professional serves. A recent study has shown than a 10% increase in certified baccalaureate (Bachelor of Science in Nursing with certification) decreased inpatient 30-day mortality by 6%.21 In regards to those nurses who are formally accredited by a certifying body for wound care, these individuals were found to more accurately state pressure ulcers and access lower extremity vascular status than their non-certified counterparts.22 With mounting focus on patient safety and outcome performance, job opportunities for certified wound nurses are increasing in hospitals, skilled nursing facilities, home care, and outpatient wound centers.23
Finally, the % of improvement of patients with select wound care related conditions showed a higher marked improvement among those patients who had their wound care treatment managed by nurses who had an accredited certification in wound care:24
Clinical condition No Wound Care Nurse Accredited Certified Wound Care Nurse
Pressure Ulcers 5.7% 5.0%
Stasis Ulcers 1.8% 1.5%
Surgical Wounds 36.3% 27.5%
Urinary Incontinence 49.4% 43.3%
Bowel Incontinence 16.4% 16.5%
Urinary Tract Infections 10.4% 8.2%
Elderly wounds do not have to become more severe in most cases, greatly reducing both the mortality of nursing home patients as well as reducing both liability and healthcare costs to elderly care institutions. Proper training and care can eliminate this; as well as the encouragement of better and consistent training of nurses for wound care rehabilitation.
1Chizek, Margaret, “Wound Care and Lawsuits,” Advance Healthcare Network for Nurses, Volume 5, Issue 7, page 31, March 17, 2003.
2O’Conner, John, “Documentation is critical in wound care lawsuits: expert,” McKnight’s, May 1, 2012.
3Fowler, Elaine, “Deposed: A Personal Perspective,” Legal Issues in the Care of Pressure Ulcer Patients: Key Concepts for Healthcare Providers, Medline.
4Caroline E. Fife, MD, & Kevin Yankowsky, JD, “Avoiding Legal Pitfalls for Home Health Services in Wound Care,” Today’s Wound Clinic, Volume 7, Issue 4, May 2013.
5Van den Heede, K., “The relationship between inpatient cardiac surgery mortality and nurse numbers and educational level: Analysis of administrative data,” International Journal of Nursing Studies, 2009 Jun; 46(6): 796–803.
6 Thomas DR. Issues and dilemmas in prevention and treatment of pressure ulcers: a review. J Gerontol. 2001;56A:M328–M340.
7 Agostini J, Baker D, Bogardus Jr S. Prevention of pressure ulcers in older patients. In: Shojania K, Duncan B, McDonald K, et al., eds. Making health care safer: A critical analysis of patient safety practices Evidence Report/Technology Assessment No. 43, AHRQ Publication No. 01-E058. Rockville, MD: Agency for Health Care Research and Quality, 2001.
8Cuddigan J, Berlowitz DR, Ayello EA. Pressure ulcers in America: Prevalence, incidence and implications for future: An executive summary of the National Pressure Ulcer Advisory Panel Monograph. Advances in Skin & Wound Care 14:208-15. 2001.
9 Institute of Medicine. Improving the quality of long-term care. Washington, DC: National Academy Press, 2001.
10 Paquette D. Leg ulcers. Clinics Geri Med. 2002;18:77–88.
11 Wipke-Tevis DD. Management of vascular leg ulcers. Adv Skin Wound Care. 2005;18:437–445.
12 Brill LR. New treatments for lower extremity ulcers. Patient Care for the Nurse Practitioner. 2001;12:9–20.
13 Kravitz SR. The treatment of diabetic foot ulcers: Reviewing the literature and a surgical algorithm. Adv Skin Wound Care. 2007;20:227–237.
14 Edmonds M. A natural history and framework for managing diabetic foot ulcers Br J Nurs 200817S20, S22,S24–S29.S29
15 Mulder GD. Management of the diabetic foot ulcer in the elderly population. Clin Geriatrics. 2003;11:46–53.
16 Inlow S. Best practices for the prevention, diagnosis and treatment of diabetic foot ulcers. Ostomy Wound Manage. 2000;46:55–68.
17 Nursing home enhanced quality measures, Centers for Medicare and Medicaid Services.
182007 Home Health Line’s PPS Benchmarks Handbook, 6th Edition. Rockville, Md., 2007.
19Poliey, Lorraine, “The Benefits of Dedicated Home Nursing for Treating Wounds,” Harvard Business Review, September 19, 2013.
20 Zaratkiewicz, S., “Development and Implementation of a Hospital-Acquired Pressure Ulcer Incidence Tracking System and Algorithm,” Journal of Healthcare Quality, 2010, Nov-Dec, 32(6), pp. 44-51.
21 Kendall-Gallagher D. Aiken LH. Sloane DM. Cimiotti JP., “Nurse specialty certification, inpatient mortality, and failure to rescue,” Nurse Scholarship, 2011;43:188.
22 Zulkowski K, et al. “Certification and education: do they affect pressure ulcer knowledge in Nursing? “Advanced Skin and Wound Care Journal, 2007;20:34.
23 Henderson-Everhardus MC. “Does nursing expertise contribute to the accuracy of vascular assessment in the detection of peripheral arterial disease?” Texas Woman’s University; Denton, Texas: 2004.
24Westra, Bonnie, “Effectiveness of Wound, Ostomy, and Continence Nurses on Agency-Level Wound and Incontinence Outcomes in Home Care,” Journal of Wound Ostomy Continence Nursing, 2013;40(1):25-33.