Complex wounds require increased attention, time, and resources to treat. Certain populations, including pediatric patients, immunocompromised patients, and older adults, are at higher risk of developing complex wounds as a result of age or comorbidities. For these populations, a...
By Paula Erwin-Toth MSN, RN, CWOCN, CNS, FAAN
My last blog discussed the need to be high touch in a high-tech environment. This generated a lot of discussion among readers. Everyone agreed 'high touch' is important, but wondered what can we do to actually create that environment in all clinical settings?
The comments fell into four general classifications:
- Need to approach the management of a patient with a chronic wound with a comprehensive approach to care.
- Utilize low-tech, yet effective measures to promote wound healing rather than selecting an expensive, more high-tech device.
- Promote education and training of all clinicians involved in wound care to ensure they are selecting and applying wound therapies appropriately.
- Facilitate patient involvement and commitment to the wound care plan.
1. Need to approach the management of a patient with a chronic wound with a comprehensive approach to care.
All too often we focus on the 'hole in the patient' and not 'the whole patient'. This is not unusual in health care – or for that matter in life in general. For example, have you ever seen a person present with a foot ulcer after years of uncontrolled diabetes, tobacco use, improper footwear and poor nutrition and they are truly baffled as to why they developed an ulcer? They look to you as the expert to fix the problem as quickly as possible so they can get back to their normal life.
As wound care clinicians we know how vital comprehensive care is to improving patient outcomes. Assessing the intrinsic and extrinsic factors that led to the ulcer and those that need to be addressed in order to create an environment for healing is essential (I published a PET Model of wound management a few years ago to explain this approach). A gold standard framework in preparing the wound bed is T.I.M.E. It is absolutely essential we base our care of a person with a wound on the entire person and their overall health and environment, social support, financial issues and cultural and religious implications of care.
We have seen a shift in the approach to health care over the past decade where patients and/or inexperienced caregivers are assuming an increased role in their wound care, health care providers seeing a decrease in reimbursement for poor clinical outcomes and wound clinicians are under pressure to see a greater number of patients in a shorter period of time. This is where all of the stakeholders need to regularly sit down to address what is working and what is not working.
It is not unusual for us to be pressured from all sides – patients want the wound healed fast with the least effort on their part (that too is human nature); administrators want you to use whatever has the best reimbursement; managers want you to see patients quickly so you can see more in a day; insurers want to see low costs and good outcomes. This is where the approach to wound care comes full circle: if we do not assess and address all the factors that contributed to the wound and are impeding wound healing, we are doomed to failure. Can we correct for everything? Of course not, but the time it takes to map out a plan and assign responsibility and follow up is well worth the effort.
2. Utilize low-tech, yet effective measures to promote wound healing rather than selecting an expensive, more high-tech device as the first approach.
This is a dilemma we have all seen in clinical practice. You may work with a clinician who has had one or two successes with a high-tech, time intensive wound management device or treatment and then decides to order that device or treatment for all of their patients with wounds. Usually this person is not a wound specialist, but they may have a fair number of patients with wounds. There are indeed some occasions where the 'high-tech' device may be the best initial therapy. However, in many cases a more conservative approach will be just as effective with lower costs, and will be easier to manage – especially if the patient is going home.
In a few cases the 'high-tech' device may be contraindicated for the use they have specified. This is where your diplomatic skills as a clinician come into play. It helps if you have an interdisciplinary wound care team to support you. Ideally, you will have policies and procedures in place that provide a basic algorithm for selection and use of specific wound care therapies. When speaking with the person regarding alternative therapies, discuss patient needs and discharge planning. Try to avoid a power struggle since that will only raise your blood pressure and generally leads to a negative outcome. In some cases, it may be best to have someone on your wound care team who is a peer of the prescriber address the issue. All of us need to practice our communication skills. There are some terrific books that can help guide you. Two books I have found particularly helpful over the years are "Crucial Conversations" and "Crucial Confrontations" by Patterson, Grenny, McMillan and Switzler. As easy as it may seem to just go ahead and begin a therapy that you deem by the evidence is inappropriate, contraindicated or, for lack of a better term, overkill, address it with the clinician. Putting off the discussion will only exacerbate the problem.
3. Promote education and training of all clinicians involved in wound care to ensure they are selecting and applying wound therapies appropriately.
If we were ranking our top 10 most annoying problems in delivering wound care, inexperienced or unqualified people selecting wound therapies would probably be in the top 5. As the old saying goes, "a little knowledge is a dangerous thing," and we see it day in and day out in our clinical practices. There are many self styled experts who have taken over wound care at their facility not by virtue of their qualifications but rather by default or trial and error. In some cases, these individuals have a great deal of power—often informal power—within a group. Never underestimate the sway a person with informal power has on group dynamics and their ability to affect not only morale but outcomes. They are often respected (or feared) and speak with an air of authority when it comes to how to manage wounds. They generally have no evidence to back up what they are saying other than "I have done it this way for years." Others may have attended one wound care seminar and now proclaim they are experts. Some may have debrided a pig's foot at a conference and claim they are 'certified' to perform sharp debridement on all wounds in all settings. Those are the people that cause me to have nightmares.
I like to believe people truly mean well but as we all know something as complex as wound management requires specialized education and expertise. Base your power struggles not on the force of personality but on the force of science. Respect their passion and experience but direct them toward the advances made in the science of wound care. None of us practice nursing or medicine exactly the way we did years ago. In fact when I think of things I was taught years ago in nursing school, I shudder. At times the "Divide and Conquer" method can be effective. Some staff may be unwilling to speak up in front of a colleague who is not practicing up to current standards of wound care but may be receptive to one on one dialogue, videos or reading materials. In cases where a person has exceeded their State's Practice Act and/or is practicing substandard wound care, you will need to involve upper management, legal counsel and/or the credentialing committee at your facility. The books I recommended above can be wonderful resources to provide you direction as you navigate through these tricky waters.
4. Facilitate patient involvement and commitment to the wound care plan.
This is maybe listed last, but it is certainly not least. Patients are the chief stakeholders in wound care. Patients and their caregivers (and some health care providers) are under the impression that we, wound care clinicians, heal wounds. We may like to think we do, but in reality, we do not heal wounds. What we do is stabilize and hopefully improve the patient's overall health (e.g. manage diabetes, correct hyper/hypotension, optimize perfusion, eliminate critical colonization/infection, improve nutritional status, manage edema, offloading, etc.) By preparing the patient and the wound bed for treatment, we are attempting to set the stage to promote wound healing (assuming that is the goal – in patients with a fungating malignant wound our goals will of course be more focused on pain management, absorbing exudate, odor control, etc. ). Selection of a treatment modality that is going absorb excess moisture without dehydrating the wound bed is critical. Along the way we will modify our plan of care to help the patient and their wound as they progress along the wound healing continuum. But we cannot do it all. If we do not get the 'buy-in' from the patient and their caregiver the best wound management approach will be ineffective.
Over the years there have been different terms used to describe how receptive patients are to the plan of care we have proposed and how well they are following their plan of care. Great advances in adult learning strategies and tools, identifying whether a person has an internal versus external locus of control, addressing language, health literacy, access to care, equipment and supplies, to name only a few, have helped us devise teaching and communication methods we can tailor what works best for an individual. We often come full circle when it comes to how to best address a patient's needs. It seems as though we never have enough time to create and deliver the perfect, individualized wound management plan. On more than one occasion I have been stumped on my first, second and sometimes third try on how best to reach a patient so they will embrace their wound management plan.
I will never forget a gentleman who, after we finished reviewing his plan of care, looked at me and said. "I am not going to do any of that stuff you said I need to do." I asked him "Why not?" He said "I don't want to." I had to hand it to him – at least he was direct. That put us back to square one starting with why he sought help in the first place and what did he hope to achieve and was there a way we could revise the plan that would meet his needs? Please share your experiences and strategies with challenging patients and I will share them in my next blog.
About The Author
Paula Erwin-Toth has over 30 years of experience in wound, ostomy and continence care. She is a well-known author, lecturer and patient advocate who is dedicated to improving the care of people with wounds, ostomies and incontinence in the US and abroad.
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.