Educating Staff: What Wound Clinicians Need To Know

  You have been asked by your facility’s administrative team to train a staff for the new Wound Center that is to open in a few short months or even weeks. That should be fairly simple, right? After all, seasoned nurses, physical therapists, and other clinicians from multiple disciplines have been hired. Or maybe it’s not so easy. Often, staff members hired for hospital outpatient wound centers are pulled or transferred from the acute care setting — folks who enjoy caring for patients with wounds who have worked with the general hospital population, not exclusively with wound patients. This can present challenges in the educational process. Hiring an experienced wound care practitioner will require specificity in outpatient clinic training.

  A systematic approach to staff training can result in a positive outcome for you, your staff, your clinic and most importantly, your patients. Staff should be knowledgeable regarding basic general care as well as assessment, treatment, and documentation specific to wound management.

Basic Patient Care in an Outpatient Setting

  Patients receiving care in an outpatient clinic will require full nursing or physical therapy assessments.Vital signs (blood glucose, function, nutritional status, bowel and bladder control, cognitive status, sensation, and level of independence) must be evaluated at each visit.This may include interviewing the patient’s caregiver or family members.

  Outpatient and inpatient assessments differ in that much of this information may come via report rather than direct observation (eg, diet and nutritional status). In the clinic, we can rely only on what we are told and by what we observe in the hour or so the patient is present, unlike the hospital where a constant monitoring system is in place. The clinician must learn to interpret subtle signs. For example, a patient or family member may report performing daily dressing changes but displays poor eyesight and/or lacks the hand dexterity necessary. Changes in that patient’s plan of care will be required to accommodate appropriate wound care in the home.

Wound Assessment

  In assessing wounds, standardization and accuracy among staff members are imperative — assessing wounds is what we are expected to do best. Clinicians need to be proficient in recognizing the signs and symptoms of basic and atypical types of wounds that may present in the clinic. If staff members are unable to identify specific atypical wounds, they should at least identify what is abnormal so the physician can be alerted and treatment plans altered if necessary. All clinical staff members should be knowledgeable regarding pressure ulcers (including staging), arterial ulcers, venous insufficiency ulcers, diabetic neuropathic ulcers, and burns as well as ulcers related to shear, friction, and moisture.

  Wound measurement and description are key to documenting progress and altering the plan of care. Ulcers should be accurately staged and described in all documentation, including appearance of wound bed and periwound tissue, anatomic location, odor, and pain level, as well as color and consistency of exudate. Clinicians must not forget that wound assessment extends beyond the actual wound. Staff proficiency in assessing skin turgor, pulses, edema, circumferential measurements, ankle-brachial indices (ABIs), mobility of affected joints, and integrity of periwound skin is integral to appropriate evaluation and will dictate treatment options.

Wound Treatment

  Patients come to wound centers expecting state-of-the-art wound treatment. Many have exhausted all other options in treating chronic wounds and are anticipating rapid and complete healing rendered by persons who are familiar with all of the latest techniques. The ability to appropriately select and apply dressings are two of the most basic skills staff members should possess. Again, because we provide care in an outpatient environment, patients live at home or in some sort of skilled or assisted facility, a fact that differentiates from acute care the types of dressings and mode of application available. Dressings conducive to a patient’s lifestyle and that can be easily changed by the patient, caregiver, or home healthcare (HHC) provider need to be selected. Because the patient is not in clinic every day, the dressing application needs to be easily duplicated by the person who actually applies it. Wound center staff must be able to teach the caregiver or patient the appropriate application of the dressing selected.

  Staff must be well trained in applying various types of compression therapies, wound cleansing, offloading techniques, and debridement (if within the parameters of their state practice act and part of their expected duties), as well as in the adjunctive physical modalities offered at your facility, including ultrasound treatments, pulsed lavage with suction, electric stimulation, negative pressure wound therapy, biotherapy, vasopneumatic compression, ultraviolet therapy, and monochromatic infrared radiation.

  The clinicians providing treatment must be credentialed to do so. Physical therapists do not need to learn infusion therapy and nurses do not need to pass competencies on estim but both clinician groups should be aware of what the other has to offer and support their efforts.

Documentation and Reimbursement

  Documentation is critical in all healthcare settings but must be “spot on” and specific to diagnosis when working in the outpatient clinic, both to meet regulatory guidelines and to ensure the payment that sustains operations. Although we would all like to believe that our clinics exist simply for the benefit of the ever-expanding number of wound patients, the truth is that our clinics can serve their populations only if they are able to stay in the black — perhaps financially benefiting the hospital as a whole. If your clinic is a stand-alone (not hospital-owned) facility, the only way to survive is to make sure that income exceeds expenditure (ie, creates a profit).

  Concise, exact. Our current payment systems mandate appropriate documentation to support the care rendered our patients per diagnosis. Simply documenting treatment of a “wound” will not guarantee reimbursement for the assessment and treatment of clinic patients. Appropriate and accurate diagnoses are critical; they must be documented both by staff members and the physician treating the patient. The exact anatomical location must be denoted and must include specific and consistent measurements — eg, specifically where on the left lower extremity, the depth and type of tissue exposed, and most importantly, whether more than one ulcer was treated, as well as if one or both extremities were treated.

  Treatment parameters, including time and dressing specifics, must be recorded. Many treatment modalities and dressings are reimbursed based on the size of the affected area. Reimbursement rates also differ according to treatment — eg, dermal substitutes, negative pressure wound therapy, and debridement. Of note: staff member and physician documentation must support one another. Conflicting documentation (eg, differing extremities, numbers of wounds, measurements, or diagnosis) will almost guarantee no reimbursement for that visit.

  The hazards of paper. Many clinics still use paper documentation. Although this initially may appear staff-friendly, it actually can be more labor-intensive in the long run and prove ineffective in terms of tracking outcomes and benchmarking. In addition, handwriting is conducive to mistakes when being re-read, as is often the case when physicians dictate from staff or their own notes. Multiple electronic documentation systems are available that help eliminate these problems and offer national benchmarking, trend reports, tracking statistics, and updates that keep pace with changing reimbursement guidelines.

Case Management

  Supplies. Outpatient clinics differ from other healthcare facilities with regard to case management. Staff members need to understand the nuances of care outside the walls of their own facility. Dressing selection must be tailored not just to the patient’s needs, but also to what will be available from various home health care agencies and long-term care facilities. Liaisons from these agencies can inservice your staff on contracts and product lines available to them in order to suit the treatment plan to what the caregiver can actually provide. When more advanced dressings or treatments are ordered that are not available or easily substituted, patients may arrive at the clinic for follow-up with traditional wet-to-dry dressings because no equivalent was available. In addition, thorough clinician knowledge of surgical dressing policy will enable you to help your patients get the most appropriate dressing for their healthcare dollar. Nationwide, many companies offer dressing and diabetic care supplies. Staff members need to understand how supplies are provided and how to work with the company (including completion of all pertinent paperwork) to ensure timely delivery of correct products to your patient.

  Continuity of care. Continuity of care improves if clinic practitioners have a basic understanding of skilled nursing facility (SNF) and HHC reimbursement issues. Ongoing dialogue with relevant liaisons and administrators helps ensure the patients served by the clinic receive the best and most cohesive treatment possible, eliminating gaps caused by regulatory issues and funding. By fostering basic understanding and relationships among care institutions, open referral lines from the SNF and HHC agencies will be maintained — the realization is that working together in the most cost efficient way is of the most benefit to the patient.

  Support services. Outpatient care should include referral to and use of other community services. Everyone in the clinic should be familiar with local transportation companies, durable medical equipment (DME) companies, orthotists, prosthetists, physician’s offices, labs, and other hospital departments. Understanding the requirements of these ancillary services lessens the burden of trial and error for your staff and improves time to treatment for the patient.

  Reimbursement. Beyond the clinic’s profit/loss statement, knowledge of the reimbursement system will help clinic staff navigate payment issues that include patients who need but cannot afford compression hose or advanced dressings. Such obstacles may seem insurmountable but clinicians armed with knowledge of the reimbursement system and the services available often are able to find payment assistance for the patient or alter treatment plans to provide less expensive options. Learning the art of writing a letter of medical necessity can ease these battles.

The Clinic's Limits

  Most importantly in an outpatient setting, staff members need to realize that they can only control limited chapters of a patient’s life. According to Tere Sigler, Director of the Archbold Center for Wound Management, Thomasville, Ga, “The patient’s problem is the patient’s problem” — that is, in an outpatient clinic, we can help provide the best care possible and instruct the patient on a healthier lifestyle but if the patient refuses or is unable to follow practical healthcare advice, we must let go. One could easily spend several hours a day or week trying to fix everything in a patient’s life. Nurses and therapists need to know what is and what is not within their control. This is often the most difficult lesson to learn in the outpatient wound center.

Conclusion

  Staff education must be an ongoing task. Wound care changes rapidly, clinically, and logistically. Membership in wound care organizations, continuing education programs, online education, journal articles, collegial relationships with other wound care professionals, and ongoing dialogue between staff, physicians, and patients will help keep your staff up-to-date and aware of changes in the healthcare climate.

  You must learn day by day, year by year, to broaden your horizon. The more things you learn, the more you are interested in, the more you enjoy, the more you are indignant about, the more you have left when anything happens. — Ethel Barrymore

Val Sullivan is Clinical Manager of Advanced Wound Care Services, Capital Regional Medical Center, Tallahassee, Fla.