The practice of wound care has undergone tremendous changes in the past few years-from new Centers for Medicare & Medicaid Services (CMS) guidelines that have renewed the emphasis on the proper prevention, identification, and treatment of pressure ulcers, to new research that suggests some pressure ulcers that manifest at the end of life may be unavoidable.
Long-Term Living Consulting Editor Richard L. Peck recently discussed these and other developments in the rapidly changing field of wound care with Dr. Thomas Stewart, founder of the National Pressure Ulcer Advisory Panel (NPUAP) and president and chief clinical officer of Gaymar Industries, as well as Cynthia Sylvia, MSc, MA, RN, CWOCN, program manager, educational development for Gaymar.
Peck: How has wound care changed for the better in the past decade?
Stewart: One of the positive developments in long-term care over the past 10 years has been the progress we have seen in the treatment and prevention of pressure ulcers. From preventive awareness to advanced technology to organized intervention, a great deal has occurred over that time period to justify hope for better outcomes for our immobile residents.
Sylvia: With respect to technology, dressings have evolved from the simple gauze to the technologically advanced. Ten years ago the alginates and the bioengineered skin replacements were lacking, as were the commercially available honey products with antibacterial properties. Bioelectric wound care dressings, constructed using a thin pad with a minielectric circuit embedded to stimulate skin growth at the cellular level, have also appeared relatively recently. Growth factors and the biochemistry of chronic wounds are much better understood today than they were then. Negative-pressure wound treatment has been a major advance, and new debriding techniques have been developed using ultrasound technology.
Stewart: Support surfaces have improved, including mattresses with features such as lateral rotation and percussion/vibration that improve pulmonary toilet, as well as low-air loss mattresses that address microclimate, including temperature and humidity, and help maintain a constant low interface pressure. Gaymar has been involved for some years in the Support Surface Standards Initiative, which evolved from a research committee connected with the NPUAP to a full-fledged subcommittee for the International Standards Organization (ISO). Members are seeking to develop standardized terminology and testing for support surfaces, with protocols emerging within the next year or so. In sum, wound care products have continued to grow in variety, efficacy, and sophistication.
Peck: How have professional organizations advanced the practice of wound care?
Stewart: In 2008, the American Medical Directors Association (AMDA) issued updated guidelines for pressure ulcer treatment and prevention, while the Wound Ostomy & Continence Nurse Society published their Guidelines for Prevention and Treatment of Pressure Ulcers in 2003. Perhaps one of the most significant recent developments has been a certification examination for physicians, scheduled to begin this September. These and other efforts demonstrate all-important physician interest and involvement in managing residents at risk in the long-term care setting.
We are also encouraged by the growth in collaborative efforts between skilled nursing facilities (SNFs) and hospitals. There has been a long-standing joke that since neither SNFs nor hospitals claim responsibility for the initiation of pressure ulcers, then they must develop in ambulances. But the days of finger-pointing are coming to a close. A more collaborative spirit has been inspired in part by new Medicare regulations prohibiting reimbursement for nosocomial wounds, as well as more recent regulations focusing on reducing rehospitalization.
Peck: What role do federal and state regulatory agencies play in the evolution of wound care?
Sylvia: CMS has been working with quality improvement organizations in various states to develop the Care Transition Theme. The Continuity Assessment Record and Evaluation (CARE) Tool, a patient assessment instrument, is currently part of the demonstration project. It is hoped that this extremely important communications system will be commonly available to professional caregivers as soon as 2012.
Individual states have become involved in upgrading wound care as well. For example, team efforts in New Jersey and Indiana have encouraged provider collaboration in various demonstration projects, culminating in the New Jersey and Indiana Pressure Ulcer Collaboratives.
Peck: What are the challenges in wound care that still must be overcome?
Stewart: The unfortunate Minimum Data Set (MDS) remains an issue. SNFs are required to report healing pressure ulcers in a sequence of “downstages,” but there is no scientific rationale for downstaging. Wounds do not heal in this manner, but SNFs currently have no other option for presenting clinical documentation. The revised report of the MDS 3.0 was posted online in April 2008 and a final version is slated for October 2009. It is commonly believed that MDS 3.0, slated for introduction in the fall of 2010, will do away with downstaging.