Which Comes First: The Patient or the Formulary?

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by Diana L. Gallagher MS, RN, CWOCN, CFCN

I have always prided myself on my ability to place patients' needs as a top priority. Patients are people and each and every one is an individual. They have unique needs and desires. Their levels of education, both formal and life lessons, varies greatly. They relate to me and communicate with me on different levels. They may have the same need for education, but they each learn differently. Although there are commonalities, the differences are significant. All people appreciate knowing that they are a priority and that they matter. Admittedly, making every patient a priority is a juggling act at times. It clearly takes extra time and effort but going the extra mile has always been worth it. I believe that doing the right thing the first time saves time and effort in the long run.

What Does Putting in the Extra Effort Look Like?

Sometimes that extra effort is taking the time to research an unusual wound or ostomy presentation. Other times, it may be developing a different approach to teaching to engage a patient. It may be working with their insurance provider to authorize the right equipment or the right volume of necessary supplies. Occasionally, it is working as a conduit between other providers to make certain that everyone is working together to help the patient reach their goals. Perhaps it is remembering the individual on their birthday or on the anniversary of a significant event. It may be as simple as taking the time to sit and listen attentively to their concerns. The "extra" can vary with each and every individual. After all, we are all unique.

Because I am an optimist, I like to believe that everyone in health care shares my sense of responsibility to patients. Because I am an optimist, the disappointment that I feel when I encounter providers who do not is profound. I understand that for some, health care is simply a job, or a means to an end. Health care should be more than just a job; it is a career and hopefully a calling. Passion for the role and the people we serve provides the greatest and most memorable rewards.

A Case Study in Going the Extra Mile

Last month, I encountered one of those situations that left me profoundly disappointed. I received a call from a home health nurse who lived and practiced in another state. I was so proud of this dedicated nurse who was reaching out to help a patient in her care. Over several months, she had cared for this particular patient and was clearly going beyond her basic responsibility of applying the ordered dressings. Month after month, the prescribed care was being done with very little improvement in the wound. She was hoping that there was something more that could be offered.

Without sharing any HIPPA sensitive information, she provided me an excellent description of the type of wound, treatments that had been tried, and the lack of results with each different treatment. She was clearly knowledgeable and was able to answer questions about the assessment and testing that had been done. She confirmed my impression that this was an arterial wound. None of the dressings that had been attempted were inappropriate but they had not been successful and it was time to consider something more.

After listening to information about this challenging patient, I suggested a different wound approach based on new research that had been presented at the SAWC/WHS Spring Meeting.1 I had been amazed and intrigued by research done by researchers at The Ohio State University.

The research study clearly showed improved healing in avascular wounds. After wounding the back of pigs and interrupting all normal blood flow, a modified collagen gel was applied. The avascular status was verified by laser doppler. The control was standard wound care using a transparent dressing. The results of the study clearly showed that the experimental wounds healed faster in spite of not having any blood flow. The modified collagen gel triggered an exaggerated inflammatory response that quickly resolved. On a cellular level, Macrophage I cells, which are pro inflammatory, were activated. Once they had completed their role in clearing dead and dying cells from the wound base, they were then converted into Macrophage II cells which are anti-inflammatory. These cells continued to clean up the wound base and when their role was complete they then turned into cells that grow new and functional blood vessels.

It was truly "game-changing" research. More importantly it addressed the need of this particular patient who was seemingly not healing because of a lack of blood flow. Unlike some research that is limited to the laboratory settings, this research was done using a product that is already on the market and readily available. The product is Stimulen® Gel by Southwest Technologies, Inc. Since learning about this new research, I had used the product several times and each and every time, I have been amazed by the rate of healing in compromised wounds.

I explained this research and the home health nurse was as excited as I had been. We were both very hopeful for this particular patient and so many future patients who could be helped. My excitement was dashed a day later when the dedicated home health nurse called me back. She had called the director of the local wound care center who had been providing the orders for home health to provide care, and had shared the information about the product and the research that supported adding it to the treatment plan.

Sadly, the director at the wound care center did not share our excitement. The home health nurse was told that not only was this product not going to be ordered but that she was not to discuss it with anyone else at the wound care center. She explained that they had a formulary and only products on the formulary were going to be used. There was no room for exceptions and no space for individualizing treatments. The formulary mattered but not the needs of any particular patient.

Dealing with Disappointment

I was disappointed; my normal optimism was crushed. It was hard to imagine any health care provider could place adherence to a formulary and treatment algorithms over the needs of a patient. We all know that formularies normally have some room to make an exception. I suggested encouraging the patient to seek a second opinion but there was only one wound care center in their community. The nurse was justifiably concerned about the political ramifications of having the patient seek another opinion. I encouraged the nurse to stay in touch but have not heard anything new.

Over the month, my disappointment for a patient that I have never met and the home health nurse who was so dedicated to doing a great job has been tempered. I am most sad for the director of the wound care clinic who was not willing to deviate from a set formulary or treatment algorithms. She is depriving herself from the satisfaction that is to be gained when you are able to place a patient first.

Even for an optimist, there are disappointments. I am disappointed that emerging research takes time to become a standard of care. I am disappointed to know that so many patients suffer during this interim. I am disappointed that not every nurse has the opportunity and support to attend an annual conference to stay abreast of new research to help their patients and refuel their passion. I am disappointed that not every nurse or health care provider practices with passion. That disappointment is perhaps the saddest of all. Work without passion truly is work. Nursing should become so much more.

1. WHS Poster Presentations. Abstract ID WHS20140226. Emerging Technologies. April 26, 2014.

About the Author
Diana Gallagher has over 30 years of nursing experience with a strong focus in wound, ostomy, continence, and foot care nursing. As one of the early leaders driving certification in foot care nursing, she embraces a holistic nursing model. A comprehensive, head to toe assessment is key in developing an individualized plan of care.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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Great attitude, but of course we have had the privilege of knowing it and you for a long time.

Administration's insistence upon adhering to a limited list of products, usually from one large corporation, is my single greatest frustration as a wound nurse educator. Often a patient would clearly benefit from continuously cleansing dressings, or from subduing the nociceptor response and focusing it with polymeric membrane dressings, but the wound clinicians are unable to provide them because they are made by a small, family-owned company that is not on the formulary.

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