My Scope of Practice: Evidence-Based Practice in Long-Term Care

  In her role as clinical consultant for NuCare Services Corporation, Lincolnwood, Ill., Susan Langmaid, BSN, CWOCN, has oversight of staff education, standardization of protocols and policies, the development of programs, product selection, and infection control in relation to wound care.

She enjoys working with long-term care patients, a population she has served since becoming a nurse in 1995. Because wound care is a large part of her practice, she pursued and earned ET certification last year. Her educational programs, including presentations of case studies on the challenges of long-term care, are grounded in one simple principle: Evidence-based product utilization in conjunction with current standards of practice.

  "Appropriate selection and use of products must be evidence-based," Susan says. She has put her words into action. She works in many of the nine NuCare long-term care facilities all located in the Chicago area that provide skilled nursing and custodial care and services for patients with dementia. Susan's facilities receive patients from most of the major and small hospitals in Chicago. She helped standardize protocols regarding product and treatment selection across the corporation. Effective as of December 2002, the new formulary features product selections that are to be evidence-based. Best possible criteria were determined, and products are chosen according to what falls into the parameters for the two components (prevention and treatment). In addition, treatment selection should be consistent for the patient as he or she moves from facility to facility. Support, wound care, and nutritional products are included in the formulary.

  The formulary is research-based, using Agency for Health Care Policy and Research and Centers for Medicare and Medicaid Services guidelines, as well as information from the American Medical Director's Association (AMDA). "I developed the policies, which were reviewed through a corporate team that included four other nurses," says Susan. "If a product choice or treatment deviates from the advisory, research must be presented to support using the alternative."

  Susan notes that the nutrition component of the formulary differs among facilities. She explains, "The AHCPR/AHRQ guidelines recommend the use of vitamins and minerals if a deficiency is suspected. However, many clinicians promote the use of vitamin C and zinc for all patients, regardless of deficiency. In my review of the literature, no direct evidence supports using these supplements to promote healing in the absence of a noted deficiency. Our formulary eliminates the use of vitamin C and zinc unless a deficiency is noted or suspected by the dietitian or physician. It recommends obtaining prealbumin levels on all wound patients with protein supplementation provided as necessary. In addition, all wound patients without liver disease (contraindicated) receive nutritional supplements."

  The focus is on clinical outcomes as well as risk management. Wound care, and particularly, pressure ulcer prevention, is a big component. "It's the challenge of cost effectiveness," says Susan. "We must be able to show that the outcome is effective and face the on-going struggle of determining the clinical versus the cost benefit. For example, when reviewing dressing usage in the facilities, I determined that in my practice, using Aquacel® hydrofiber (ConvaTec, a Bristol-Myers Squibb Company, Princeton, NJ) as a primary dressing, with CombiDERM® ACD™ (ConvaTec, a Bristol-Myers Squibb Company, Princeton, NJ) as a secondary dressing for Stage III and Stage IV pressure ulcers and other full-thickness wounds, was clinically effective. Changing the dressings on 3-day schedule (or more often with copious exudate) proved to be cost-effective as well. The protocol prevented gastrointestinal/gastrourological contamination of trunk wounds in patients with incontinence, prevented periwound maceration, and provided a dressing regimen that decreased nursing time and costs. Clinically, I have found that leaving the dressings in place for up to 3 days provides the wound bed with a consistent temperature and moist wound environment essential to healing."

  Susan says she always wanted to be a nurse. "I started out in psychology, but I wanted to 'see' outcomes more. I have spent he last five of my 8 years as a nurse in wound care and staff education. I like training others. I like to educate people. I also enjoy the physiological and clinical aspects of care and seeing the outcomes of our efforts. But most gratifying is the contact I have with the patients and their families and my role in healing or preventing further complications or amputations."

  Susan faces the familiar obstacles of regulatory guidelines that she believes do not follow professional standards. The debate regarding the "avoidable" and "unavoidable" pressure ulcer is perhaps the best example. She says regulatory guidelines seem to acknowledge that lower extremity ulcers can and do occur despite best efforts to prevent them, yet pressure ulcers are too often perceived as evidence of neglect or abuse. The problem is compounded by a growing aged population with chronic conditions that greatly increase the risk of pressure ulceration.

  Dealing with limited resources also is an on-going dilemma. Illinois recently imposed a 6% cut in funding to long-term care facilities and no prevention dollars are available. On the federal level (prospective payment systems in the long-term care industry), Medicare does not provide reimbursement for preventative support surfaces or skin care. Susan is grateful NuCare Services Corporation, where she has been employed for almost 3 years, makes providing necessary care, regardless of reimbursement, a priority.

  Susan sees working with state surveyors on professional standards of practice as a part of her responsibility. "Survey guidelines and clinical practices do not necessarily reflect current best standards of care," she says. She hopes her role will evolve to allow her to impact professional standards of long-term care on a national scope and plans to continue to research and develop preventive and treatment protocols.

  Susan points out that most research in terms of nursing is hospital-based. "I want to do research specific to long-term-care," she says. "I want to study issues such as support surface effectiveness and turning schedules. My statistical background will help, but I am interested in taking a course on clinical trials management, as well as courses on the ethical consideration of research and its outcomes. Retrospective as well as original research can impact and change current revered standards - for example, requiring a modification of the Braden scale and assessing comorbidities identified by the AHRQ that represent additional situations that put a patient at risk for pressure ulcers. Through all of my research, however, it will be important for me to maintain patient contact, not just be an administrator."

  She continues, "It is crucial to include education for all level of care providers as a fundamental basis for any skin care program. I have developed an 8-hour seminar that is presented quarterly regarding pressure ulcer prevention and treatment in long-term care. The seminar has been attended by nursing assistants, nurses, skin care nurses, and dietitians, as well as administrative personnel. It focuses on prevention and all of the comorbid conditions that can impact the risk of wound development and lead to delayed healing or failure to heal. I also am developing a 6-hour program on lower extremity ulcers that also will be offered on a quarterly basis. Providing information to caregivers that illustrates the importance of their role positively impacts standards of care." Comfortable with sharing the results of her research, Susan presented two posters at the 2002 Symposium on Advanced Wound Care.   "Long-term care is a challenging and rewarding, if underserved, area of healthcare," Susan says. "But knowing I can rise to those challenges makes me proud to say it's my scope of practice."

 My Scope of Practice is made possible through the support of ConvaTec, A Bristol-Myers Squibb Company, Princeton, NJ.