COVID-19 and Skin Integrity: Where Are We Now?
As nursing homes continue to face the challenges posed by COVID-19, this author explores how skin programs can improve resiliency using basic building blocks to conceptualize and implement determinants of good skin health.
Today, as nursing home residents and staff become vaccinated for COVID-19, there is a palpable feeling of relief amongst the staff and residents. Infection control efforts are still required and essential, but some of the stricter confinement strategies have been relaxed, based on the community infection rates, vaccinations, testing, and regulations. As health care emerges from a unified and singular focus on COVID-19, many nursing homes are evaluating their skin integrity programs and using this time to either refresh, or even revamp, their programs.
I recently had a colleague say a wound is a physical manifestation that can occur when the body is not in homeostasis. I agree with that, and although I also feel that most pressure injuries can be prevented most of the time, the breakdown from prolonged pressure is more likely to occur when that individual’s internal reserve is shaken—whether it be from new illness, new medication, decline in mobility, change in cognition, and/or mental illness. Our ability to recognize this change in condition as a skin integrity risk factor and provide interventions before the breakdown occurs is at the heart of the CMS federal regulation for pressure injuries.1
However, COVID presented new and unreasonable challenges as staff also suffered from COVID-19 infections. The National Pressure Injury Advisory Panel (NPIAP) position paper on unavoidable pressure injuries is an essential read to help staff, residents, and families navigate and explain how new pressure injuries occurred or how an existing wound declined when their loved one was sick with COVID.2 Essentially, despite the efforts to mitigate, the pressure injury was a physical manifestation that resulted from the virus on individuals who had little to no reserve. Further, new evidence is finding a increase in frailty of those in post-acute care, supporting the notion that there is likely going to be an ongoing uptick with unavoidable pressure injuries.3,4
So, as we emerge from the devastation of COVID-19, we sadly brace for more potential scrutiny from litigation and survey for wounds that may indeed have been unavoidable.
How Can a Skin Program Maintain Resiliency in the Face of COVID?
On the positive side, there are some takeaways from COVID that may have long-term care staff address skin integrity differently than solely a nursing issue. For example, the idea that a wound on an individual is a physical manifestation of internal and/or external stressors on a human with low reserve could be applied at a macro level at the nursing home. Is it possible that a wound “outbreak” in a center is the physical manifestation of a nursing home’s significant internal stressors—like COVID-19, staffing issues, etc.—that the nursing home has little to no reserve to withstand? If so, then acknowledging how to better manage the stressors and build the reserve can help endure the next crisis.
As a wound specialist in long-term care for almost 20 years, the crisis of COVID provided me clarity on what lends to a skin program resiliency. In the past, wound programs were built on the best products and wound education, focused mostly on the nurse. Although important, there are many other determinants of a healthy skin program.
A resilient program has: (1) a skin safe environment, (2) evidence-based practices, (3) an inter-professional patient-centered team, (4) a skin program owner, (5) a team documentation platform, (6) effective leveled communication within and beyond the team, and (7) compassion. I have come to think of these constructs as building blocks that stack. Having each block in place makes your center strong enough to sustain external pressure and not fall apart easily. Removal of any one block decreases your center’s reserve and makes it easy to fall apart. Think Jenga (Figure 1).
Putting the Building Blocks into Practice
As you contemplate this with your practice and your team, it is important to brainstorm what each block entails and how, together, they build resilience.
Environment and Evidence-Based Practices. Environment—or rather, a skin-safe environment—is a key determinant for skin health. The environment includes things like viable bed surfaces for pressure redistribution. Frankly, no matter how much you turn and position an individual, you cannot out-turn a dead bed. Ensuring there is a baked-in process to annually monitor the surfaces for viability is a foundation step to good skin care. In my practice, I found most surfaces live about 4–7 years, based on the overall usage, weight, incontinence, how often the head of the bed is elevated, etc. Regardless of the manufacturer guideline, surfaces can indeed bottom out at any time, so staff need to also know the basics of what a bottomed-out surface looks or feels like so staff can report it. The safe environment also means seat cushions have both viability and easy availability. These should also be reviewed annually.
Further, the environment also implies that the products the staff need are readily available when and where they are needed. Nurses and nursing assistants do not have the time to look for turning devices, heel offloading products, skin care products, etc. When it comes to environment, good leadership will evaluate what is needed routinely and ensure a process to make it easy on the staff to do the right thing at the right time.
Program Ownership. Ownership of the skin integrity program is not a new concept but is too frequently confused with a “wound nurse.” Ownership, as defined in the Universal Wound Model, is a “wound navigator.”5 Sometimes this role is referred to as the skin champion or coordinator. This is a team leader who can model team behaviors an coordinates the team approach from prevention to management. Further, this team lead ensures that the team engages in skin health on a daily, modeling a person-centered team approach for goal setting and care planning. The owner ensures that anyone with a change of condition, like COVID-19, gets a skin check and a review of risks to ensure interventions meet the changing needs of the resident. This role is an essential piece of success, as you need someone who is willing to always take a stand for skin regardless of all the other issues that could arise on any given day in a nursing home.
Team Approach. A team approach means that all of the players on the team rise to the occasion at top of license. All members understand their role and each other’s role in wound prevention and management. Further, they recognize that the resident and family are primary members of the team. Residents are informed of “what it takes to heal” and that drives decisions regarding goals of care; goals may include maintenance or palliative care. A great framework to guide the team is the 5 M’s: what matters most; comorbidities, mobility, mentation, and medications.6,7,10
Documentation. Documentation for wound management must be transparent and available for all team members. Moving wound management into electronic medical record (EMR) systems and/or improved photo technologies and apps has improved the team approach and allowed for a more triage-forward team care, which seems to be strategic. This is significant in improving the diagnosis of wound type, evidence-based practices, and process improvement.
Communication. Communication is vital to success, but we also need to unpack the hierarchies that exist in a medical-centric model today. Communication must seek to level communication and empower those who know most about the resident, like the resident, their family, and the nursing assistant, to express concerns and ideas. Examples of different evidenced based health care team communication strategies can be explored with the TeamSTEPPS framework.8
Compassion. Last but not least is compassion, which may be the bottom building block—or maybe it is the glue that holds all the blocks together. Wounds are unique to other issues because almost every one of us has an emotional trigger. For example, the wound patient may feel fear, pain, and embarrassment; the family may feel angry and wronged or even guilty; the nurse may feel afraid of blame; the administrator may feel stressed over survey or legal scrutiny; and the provider or therapist may feel concerned about lack of knowledge about the wound type and how to best intervene.
The point is, wounds are very emotional and having a compassionate approach with our patient and with each other is a way to improve care in a just environment, building the team rather than finger pointing and breaking the team. A great resource for this is the Triple C model, which can be applied to any health care issue, or life.9,10
In Summary
Although COVID-19 was devastating, it also created a new level of a team approach, and for me, a new mental model for skin health resiliency. I now recognize the determinants of skin health and feel they can be easily conceptualized like building blocks. If each construct, or block, is solid and in place, your center will be more likely to have the reserve to withstand the next crisis. As we emerge from this part of the pandemic, an overwhelming increase in unavoidable wounds may become the next battle that stresses our residents, their families, our staff, and ultimately, the entire nursing home. Now is the time to create our internal reserve.
Jeanine Maguire, PT, MS, CWS is the Vice President for Skin Integrity & Wound Management, Genesis HealthCare. She is the President of the Post Acute Wound and Skin Integrity Council (PAWSIC).
Note: This article reflects the opinions of this author and may not reflect opinions or practices of Genesis or other members of PAWSIC.
References
1. Centers for Medicare and Medicaid Services. State Operations Manual. Appendix PP: Guidance to Surveyors for Long-Term Care Facilities, page 276. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/SOM107ap_pp_Guidelines_ltcf.pdf
2. National Pressure Injury Advisory Panel. Unavoidable pressure injury during COVID-19 pandemic: a position paper from the National Pressure Injury Advisory Panel.
3. Heyns A, Dupont J, Gielen E, et al. Impact of COVID-19: urging a need for multi-domain assessment of COVID-19 inpatients. Eur Geriatr Med. 2021; epub March 30; 1-8.
4. Heckman GA, Kay K, Morrison A, et al. Proceedings from an International Virtual Townhall: Reflecting on the COVID-19 Pandemic: Themes from Long Term Care. J Am Med Dir Assoc. 2021; epub Apr. 8. doi: https:// doi.org/10.1016/j.jamda.2021.03.029.
5. Moore Z, Butcher G, Corbett LQ, et al. Exploring the concept of a team approach to wound care: Managing wounds as a team. J Wound Care. 2014; 23 (Suppl 5b): S1–S38. https://doi-/10.12968/jowc.2014.23.Sup5b.S1
6. Schwartz AW, Hawley CE, Strong JV, et al. A workshop for interprofessional trainees using the geriatrics 5Ms framework. J Am Geriatr Soc. 2020; 66(8):1857–63. https://doi-org.ezp.waldenulibrary.org/10.1111/jgs.16574
7. Tinetti M, Huang A, Molnar F. The geriatric 5 M’s: A new way of communicating what we do. J Am Geriatr Soc. 2017; 65(9):2215.
8. Weld LR, Stringer MT, Ebertowski JS, et al. TeamSTEPPS improves operating room efficiency and patient safety. Am J Med Qual. 2016; 31(5):408–14.
9. Lown BA, McIntosh S, Gaines ME, et al. Integrating compassionate, collaborative care (the “Triple C”) into health professional education to advance the triple aim of health care. Acad Med. 2016; 91(3):310–316.
10. Lindsay E, Renyi R, Wilkie P, et al. Patient-centred care: a call to action for wound management. J Wound Care. 2017; 26(11):662–677.
