Better staff education can translate into better care for wounds
February 1, 1998 6 minutes read
Better staff education can translate into better care for wounds
Instruction results in better outcomes, fewer visits
Teaching wound care is a difficult, time-consuming task, but educating staff in proper techniques can go a long way toward decreasing wound-healing time and improving outcomes, according to the experience of a couple of home health care organizations.To cut down on home health nursing visits and to keep bedsores from resulting in hospital readmission, nurses at agencies in Ohio and Kentucky have developed wound care education programs, assessments, and protocols that have reduced patient infection rates and improved the quality of care.
University MEDNET Home Care of Eastlake, OH, which serves three counties in northeastern Ohio, spent a year developing a wound care protocol. The protocol was taught in a mandatory inservice that provided continuing education credits.
"We had some chronic wounds that were taking a very long time to heal and required two or three visits a day," recalls Donna Schott, RN, BSN, continuous quality improvement and staff development supervisor with University MEDNET Home Care. (For a case study of how another agency provides inservice education, see story, p. 20.)
Since the nonprofit agency implemented its new process in the spring of 1996, the wound infection rate has decreased from 9% to about 3%, Schott says. "We don’t have enough data right now to show a trend in the number of days it takes to heal a wound, but that’s what we’re checking for right now, and we expect that to decrease."
The program revisions at University MEDNET Home Care began with the formation of a skin care task force that developed a wound assessment form. The assessment was used as a guideline during the training program, says Connie Kless, RN, BSN, CETN, leader of the task force. "We went through each aspect of the form and taught nurses what to look for when examining a wound and how to make a thorough assessment," Kless says.
A need for standardized assessments
Family Home Health Care of Somerset, KY, also was looking for faster healing rates when the agency’s quality improvement coordinator focused on wound outcomes as a performance improvement area.The full-service agency, which serves south central and northeastern Kentucky, held a two-hour wound care inservice for nurses that included instruction on how to do a thorough wound assessment, says Dinah Burton, RN, BSN, CNA, quality improvement coordinator. So far, it seems to be working. "We’re still in the initial phases," Burton says. "But we can already tell the wounds are healing much more quickly."
Burton and the agency’s quality improvement specialists started the program by researching literature related to current standards of practice and trends in wound treatment and assessment. Then they compared the findings with their own assessment and treatments.
"We found that wound assessment was one of the things that needed improving because staff didn’t always assess the wounds in the same way or in a way that would help determine appropriate treatment," Burton explains.
Based upon the research findings and analysis of the data collected within the agency, a more specific standardized assessment was developed. The assessment covers the physical state of the wound, a nutritional analysis, infection control issues, identification of risk factors, and the type of treatment and care that is appropriate.
Burton says a chief purpose of the initial phase of the program was to make nurses familiar with measuring wound outcomes, and to answer this question: "What do we need to assess about patients with wounds to be consistent and to be able to identify the most appropriate treatment in order to improve outcomes?"
The next step was to impart the findings to staff members for implementation. Schott, Burton, and Kless offer the following advice on how to teach nurses a wound assessment and treatment program, as well as tips to promote faster healing:
1. Begin by covering the basic types of wounds and their healing characteristics.
Family Home Health Care has divided the different types of wounds into three basic types for the purposes of data collection and analysis, Burton says. "Different types of wounds generally have different healing times, and we wanted our data to be as precise as possible," she explains. The organization’s wound stages and definitions fall in line with most assessment scales, as follows:
• Stage 1 pressure ulcers are those in which the skin hasn’t broken yet. Skin tears are grouped together as the easiest to treat because they generally heal more quickly than complicated wounds.
• Stages 2-4 pressure ulcers are the wounds Family Home Health Care has made its primary focus. These types of ulcers have the following characteristics: In stage 2 the first layer of skin is affected. In stage 3 the wound penetrates the skin, but doesn’t reach muscle or bone. By stage 4, it can affect the muscle and bone; therefore, stage 4 ulcers usually take the longest to heal.
Venous stasis ulcers are the result of poor circulation in the lower extremities. This causes the skin to break down, sometimes giving it a purplish-red coloring on the lower half of the leg. These types of wounds leave the skin dry and often covered with small sores. "They take a long time to heal because of the circulatory problems," Burton says. "If something isn’t done to improve the circulation, those wounds may never heal."
2. Give tips on how to properly clean a wound and change its dressing.
"Whenever you clean a wound, you need to use enough force to get all the debris out without hurting or traumatizing the new tissue that’s starting to develop," Kless advises. "New tissue is very fragile, but if you just clean without pressure, you won’t get out all the debris. So a good cleansing is very important."
Kless recommends that nurses use a 19 gauge angiocath and 35 cc syringe to obtain adequate pressure for cleaning the wound. She uses normal saline as a cleaning fluid in the syringe because it is nontoxic.
Kless shows nurses slides of healthy and dead tissue to help them identify their differences. She also explains the correct process for changing wound dressings, noting that the first step is usually to use wet-to-dry dressings that will help with the removal of dead tissue from the wound. She explains to her students the need for a moist environment for most wounds, and goes on to explain the proper use and the biomechanics of placing a wet-to-dry dressing on a wound.
"Once all the dead issue is removed, you have to stop using the wet-to-dry dressing because if you don’t, you will take off healthy tissue, and this will prolong the healing time," Kless says.
3. Explain the latest trends and standards in wound care, and make sure nurses know which products are to be used.
"For the most part, they’ve all done wound care at one time or another, and if the nurses come from a nursing home, then obviously they’ve done a lot of it," Burton says. "But people have gotten out of the habit of keeping up with the current trends and standards in wound care." Burton still encounters physicians who use treatment protocols considered outdated according to current research. Nurses who are aware of proper protocols can at least point out errors.
Helping nurses use the right product
Nurses also need to learn how to sort through the vast selection of wound care products and how to use them appropriately. Burton uses 4-by-4 gauze as an example of a product that has been around a long time and still is used frequently, although it may not be the most appropriate product in many situations.For instance, she points out to her nurses that a hydrocolloid dressing will keep the wound bed moist and allow some types of wounds to heal faster. She also covers the wide array of dressing types, such as films, hydrogels, and calcium alginates. Burton brought the various types of dressings into the classes and passed them around for the nurses to examine.
4. Develop a protocol or standard for assessing patients’ wounds.
Education managers can make sure nurses are assessing wounds in a consistent manner by putting the process in writing. Burton says she has spent a lot of time during wound care training programs discussing standardized wound assessment.
She familiarizes her students with a range of assessment criteria, all contained in the organization’s newly developed assessment form. Primary characteristics include location, size, drainage, odor, condition of surrounding skin, presence of eschar or slough, and signs of infection.
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