OASIS Alert

Published on Thu Jun 15, 2006 PDF

Use these expert tips for getting wound healing back on track.
 
When your agency experiences poor wound outcomes, you'll find that adverse events and increases in acute care hospitalizations won't be far behind. Develop an action plan to quickly address non-healing wounds.
 
Emergent care for wound infections and deteriorating wound status is a Tier 1 adverse event. If your agency experiences this event, the Centers for Medicare & Medicaid Services requires surveyors to spend extra time on this with focused review and an automatic home visit -- either to the patient involved or to a similar patient.
 
Another problem: About 45 percent of chronic wound care patients are hospitalized at some point during their episode, says wound care consultant Patti Johnston with Woodlands, TX-based Healthcare Quality Solutions. This gives affected agencies poor results in the acute care hospitalization quality measure, she says.

How To Know It's Non-Healing

A non-healing wound is a wound that is not progressing despite appropriate treatment, says consultant Lisa Selman-Holman with Denton, TX-based Selman-Holman & Associates. It may have separated edges or show signs of infection.
 
The Laguna Beach, CA-based Wound Ostomy & Continence Nurses Society defines a non-healing wound as "a wound with >25 percent avascular tissue OR signs/symptoms of infection OR clean but non-granulating wound bed OR closed/hyperkeratotic wound edges OR persistent failure to improve despite appropriate comprehensive wound management."

3 Reasons For Wound Deterioration

If a wound stalls or deteriorates in the healing process, it usually does so for one of three reasons, which wound experts sometimes refer to as the "three-legged stool," according to Joyce Black, associate professor of nursing at the University of Nebraska in Omaha:
 
1. Support surface. The person may need better pressure-relief in the chair or bed or he may need to be constantly off the wound -- for example, turning only onto the right or left side, says Black. "The patient can sit on the ulcer to eat, but he can only sit for one hour three times a day and on a pressure redistribution cushion."
 
2. Poor nutrition. This is a common reason for a wound to stall in healing, says Black. A good rule of thumb: Whatever the patient ate before he developed the wound won't be enough to promote optimal healing, she notes. So consider a dietary consult to see if he needs more calories and protein.
 
3. Infection. Assess the wound for exudate (drainage), erythema (redness) and odor. If you suspect infection, get the physician involved immediately. Black has seen wounds go from healing to stalled over a two-week period where the resident has clear signs of infection, wound pain and a fever. "And no one has [changed the plan of care]. People can get septic and die from an infected pressure ulcer," she warns.

Check Your Action Plan

If wound healing stalls or deteriorates -- or the patient develops symptoms of infection or pain -- clinicians need a protocol to follow, experts say. Be sure your care and documentation include the following:

 • Accurate wound descriptions. Describe the wound in a standard way, says Peggy Dotson, a nurse and the principal of Healthcare Reimbursement Strategy in Yardley, PA.
 
Example: Compare the size of the wound to a quarter or a dime, describe the color, odor, amount of necrotic tissue and appearance of wound edges. "As the wound heals, you should be looking at nice red vascular tissue that's clean," she says.

 • Helpful photos. Don't bother to take photos if they don't provide good information. They could be used against you, experts say.
 
Imagine a jury viewing a series of fuzzy pictures of a serious wound where you can't tell it's improving, warned medical director Mark Heard, who spoke on the topic at a regional meeting of the American Medical Directors Association. "If you're going to chronicle wound healing with pictures, take good color pictures that actually show the wound's progress," he advised AMDA attendees.

 • Appropriate actions. If a patient's wound doesn't show signs of healing within two weeks, give the physician a heads up to re-evaluate and change the plan of care, advises Dotson -- and document this.