By Melinda Young
EXECUTIVE SUMMARY
Warm handoffs and better patient/caregiver education on wound care can improve healing when patients are discharged.
- One way is to ask the patient for permission to take photos of the wound to show caregivers and community providers what it looked like at discharge.
- Case managers also can send patients home with inexpensive, portable waffle mattresses that can prevent pressure ulcers.
- Training caregivers and community clinicians on wound care and ensuring they know about a patient’s wound also are important in preventing readmissions and emergency department visits.
A picture is worth 1,000-word discharge instructions when it comes to educating patients, caregivers, and community providers about wound care.
Case managers and care coordinators can improve care coordination and transitions of wound care patients by showing them photos of the ulcer and providing warm handoffs between hospitals and community providers.
Ways to Improve Wound Care
• Show patients photos of their wounds. For example, some patients who are repeatedly hospitalized because of pressure ulcers return so frequently because they refuse to allow family members to help them turn in their beds, or they sit in their wheelchairs too long. A case manager could show patients and their caregivers a photo of the wound and explain that it will worsen if they do not move and turn their bodies at regular intervals. “Discuss the risks of turning and benefits of turning,” suggests Holly Kirkland-Kyhn, PhD, FNP, CWCN, FAANP, an assistant clinical professor at the University of California, Davis Betty Irene Moore School of Nursing. “How can the family say, ‘I never knew,’ when it’s written in the chart, and you have the photo there? Transparency helps a lot.”
The way to do this and stay within privacy rules is to ask the patient and family’s permission to take the wound photos with the patient’s own cellphones. Then, show them the pictures to obtain their buy-in on follow-up care at home. “Let them know we’re doing the best we can and be transparent,” she adds.
Kirkland-Kyhn offers this tip for how to take the best picture of the patient’s wound: “Get far enough back from the wound to show where it’s located,” she says. “People want to move close and don’t include the location of the wound in the photo. You can always zoom out, so get far enough back so I know what it is.”
• Clearly communicate wound care information to community providers and caregivers. “It’s really important to have communication with people in the community,” Kirkland-Kyhn says.
Case managers can identify home health agencies that can provide wound care nursing or help them educate their nurses on how to provide this care.
“We’re working on a program for educating people about wounds,” she says. “I’m trying to educate physicians and home health nurses and certified nursing assistants.”
Patients with wounds often return to their homes or residential settings after they are discharged. It is important for their caregivers to learn more about wound care because they will be the ones helping them turn their bodies and ensure their wounds heal properly, says Ron Ordona, DNP, FNP-BC, GS-C, WCC, clinical director of Senior Care Clinic House Calls and administrator and health services director of Care Home By RNs Congregate Living Health Facility, both in Sacramento.
Residential facilities, regulated in California, care for people who cannot live alone but who might not need 24-hour nursing care, such as they would receive in a skilled nursing facility. Typically, these residential care facilities are run by caregivers with a minimum requirement of a high school education. They receive 40 to 80 hours of training, but they are not necessarily licensed and do not need to be certified nursing assistants, Ordona explains.
“They do a good job and try to do what they can,” he says. “But they [typically] cannot take anyone with a stage 3 or 4 wound.”
Ordona works with people in the community with wounds that need a higher level of care after they are discharged from the hospital. Providers and clinicians trained in wound care may take a medical van to homeless encampments to provide follow-up wound care.
“I’ve started to see [patients] in a mobile clinic,” Ordona says. “With stage 3 or 4 vascular wounds, they go back and forth to the emergency room.”
When patients return to homeless encampments, clinicians can visit them to assist with wound care and to help them find housing or return to the hospital when needed.
“What we’ve learned — and this is anecdotal — is some people would rather stay where they are vs. going to the hospital, for many different reasons,” Ordona adds.
• Send wound care patients home with portable waffle mattresses. This is a cost-effective tactic that could save thousands of dollars in healthcare costs.
Patients will be less active when they return home and are not turned regularly by hospital staff or are not engaged in therapy, Kirkland-Kyhn notes. They will need a special mattress to prevent their wounds from worsening, but pressure mattress rentals can cost $100 per day, and not all payers cover the full cost.
An alternative is to give them the $60 waffle (static air) mattress that goes on top of the bed, along with its pump. “The waffle mattresses aren’t used by anyone else, so send them home with the patient and show them how to use them. They’re cheap,” Kirkland-Kyhn suggests. “We have videos from the AARP on how to use the waffle mattress.”
Research suggests the waffle mattress might be even better for pressure redistribution than the expensive pressure mattresses. A study of available research found the static air mattress overlay had a comparable or lower incidence of pressure ulcers than the high-technology supported surface.1
“It redistributes the pressure,” Kirkland-Kyhn explains. “What you want in a surface is something with a larger surface area and lowest peak pressure for that weight.”
Kirkland-Kyhn compares it to wearing stiletto shoes, which place the peak pressure on the ball of the foot, while wedge or flat shoes spread peak pressure throughout the foot. “I used that analogy in Alaska, and they said, no one uses stilettos there,” she recalls. “They used the analogy of snowshoes. While a regular shoe will sink in the snow, putting on snowshoes distributes the weight so it doesn’t sink.”
Waffle mattresses can handle up to 300 pounds of weight, and there are larger static air support surfaces for people who weigh more than 300 pounds.
The key is for case managers and other staff to make it routine to send this home with patients. Even when this is the plan, it can be forgotten. Someone should tell the patient that they will receive this waffle mattress to use at home — and should show them how to use it, Kirkland-Kyhn says.
• Teach low-resource wound care techniques. Pressure ulcer patients and others with wounds treated in emergency departments and hospitals often come from low-resource settings. It might be unrealistic to expect the patients to use the newest products or technology to prevent recurrence of wounds.
A more pragmatic approach would be to teach these patients, caregivers, and community providers how to treat wounds with dressings that do not cost hundreds of dollars, Ordona notes. “We’ve been trying to teach community-based nurses and physician assistants to do the low-resource approach to wound care,” he says. “There are cheaper types of materials that are effective that people can use.”
This approach can be started at homeless encampments, where people will not buy dressings that cost $300 but possibly could change a wound dressing daily for just $5.
“The same thing goes for those who are in other home settings,” Ordona says. “As much as we can, we try not to burden them or take $100 a month out of their Social Security benefit for expensive wound dressing.”
Instead, clinicians working with these low-resource populations will find inexpensive materials that will help prevent wounds from worsening or becoming infected.
REFERENCE
- Serraes B, van Leen M, Schols J, et al. Prevention of pressure ulcers with a static air support surface: A systematic review. Int Wound J 2018;15:333-343.
Warm handoffs and better patient/caregiver education on wound care can improve healing when patients are discharged. One way is to ask the patient for permission to take photos of the wound to show caregivers and community providers what it looked like at discharge.
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