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Teach nurses basics of alternatives to gauze, saline
There are thousands of choices of products to dress patients’ wounds. So how does an agency teach its nurses which to use and recommend? At Johns Hopkins Home Care in Baltimore, nurses have focused on a few categories of important wound care products and learned to look for the best alternative to the traditional gauze and saline order given by physicians.
The need for more potent alternatives stems from the difference between wound care in a hospital setting and under the very different conditions of home care, explains Brenda J. Hensley, MSN, RN, CETN, clinical nurse specialist at Johns Hopkins Home Care. She says hospitals are sending home patients earlier with more complex wounds that can take longer to heal.
"We’re doing more extensive surgeries on people who are more and more debilitated, compared to maybe 10 years ago," she says. "Of course, the older you are and the more compromised you are, the more difficult and slower the healing process."
Meanwhile, she says, hospital physicians are not always as knowledgeable about the more technologically advanced — and substantially more expensive — wound care supplies now available. "At the hospital, you have a wonderful nurse who goes to change dressings three times a day. You also have medical residents and interns, and they all want to look at the wounds. The newer products are designed not to be changed very often, so if you’re in a hospital, it’s not going to be cost-effective to use these dressings. They don’t have a reason to use them [in the hospital], so they don’t know that much about them."
But in home care, where a nurse’s time is at a premium, the added expense of the newer dressings can be more than offset by the savings due to fewer visits. Most importantly, Hensley says, the use of newer dressings can actually help wounds heal more quickly. "Wounds heal faster when the dressings are changed less often. The less you disturb them, the faster the cells can regenerate. It makes sense, if you can maintain a good environment, to only change them two or three times a week."
At Johns Hopkins Home Care, all new employees take a three-hour wound class. The agency also has a trained group of resource nurses, including one on each of its geographically defined teams. Those resource nurses receive an extra one-hour training session every month. The program consists of case studies and product reviews, so the resource nurses can go back to their regions and serve as a resource for other staff.
At the next level of training are six certified wound, ostomy, and continence nurses (WOCN), wound care specialists such as Hensley who meet monthly to sort through the vast array of new products on the market. "We are introduced to new products in different ways," she says. "In our system, we have an outpatient wound healing center. That’s all they do is treat chronic wounds. They get a lot of the newer products, and we get them and try them that way, too."
Some successful products are added to the agency’s inventory. Others are dropped after proving to be less than effective.
When teaching nurses to deal with different wounds of varying complexity, the agency has tried to reduce the number of dressings to four major types that Johns Hopkins Home Care calls its primary dressings:
• The gauze and saline combination typically ordered by physicians.
• Calcium alginate, which Hensley says is the most common dressing recommended for home care patients with draining wounds such as pressure ulcers and surgical wounds. She says the seaweed-based dressing absorbs 10 times its weight in wound drainage while lowering the pH in the wound bed, which retards the growth of bacteria.
"So it actually decreases the incidence of infection in the wounds, and, therefore, we don’t need to change it so often," she explains. "If you use a traditional gauze dressing, it’s very much compatible with bacterial growth. If you use calcium alginate dressings, because you’re not going to have that problem with bacteria, it’s safe to change it two or three times a week instead of two or three times a day, which is what the traditional gauze dressing requires."
• Wound hydrogels, used on drier wounds that aren’t draining as much, where the goal is to continue healing. "[The wound] is clean, it’s pink, it’s healing, and we just want to keep it that way," Hensley says. The gel comes in tubes or sheets or is impregnated in gauze. It absorbs a small amount of drainage but won’t stick to the wound bed and promotes healing. It generally requires daily dressing changes.
• Dry hypertonic solutions for wounds that are grossly necrotic, infected, or malodorous. This is a solution that’s placed on gauze then dehydrated. When placed in the wound, it pulls drainage out of the wound through osmotic pressure and helps debride dead tissue. Hensley says such dressings clean up infections faster than traditional gauze dressings. The most common such product used at Johns Hopkins Home Care is called Mesalt.
She says nurses are taught that when they assess a new patient with a standard order for gauze and saline, they should look for signs that another type of dressing might be more effective and to call the physician for an order change.
"Our nurses know automatically to call the physician or the nurse practitioner, whoever is sending the patient, and immediately try to make an order change for one of these three products, depending on what the wound sounds like. If we’re not sure what we have to deal with, we might just leave it with the original saline and gauze until somebody gets out to the house to evaluate it," she explains.
After changing to a new type of dressing, the nurse continues to reevaluate the wound, to look for improvement or for signs of infection. If after a week to 10 days there are no signs of healing, the nurses can request that a WOCN come out and look at the patient to determine what to do next. In those cases, the agency can turn to an arsenal of secondary dressings, usually much more intensive and expensive than the first, to see if they will do a better job. Some of those options include the following:
• Regranex gel, specifically used to treat diabetic foot ulcers that won’t heal.
• Iodasorb gel, which Hensley describes as a favorite first choice for wounds that aren’t healing using the normal primary dressings. Iodasorb gel has a small amount of iodine in it and has some antiseptic properties, while also keeping the wound bed moist and absorbing wound drainage.
"You’re combining a hydrogel with an antiseptic with absorptive properties, so you get kind of three effects," she says. "You don’t want to dry your wound out, and a lot of traditional dressings we used in the past are very drying to the wound bed. In the olden days, we thought that was good, but now we know you want it to stay moist."
Iodasorb gels have been found to work quite well on lower leg wounds, diabetic foot wounds, or post-op surgery wounds that aren’t healing properly.
• Collagens, which promote wound healing through the stimulation of fibroblasts. Used in a gel or sheet form, they can sometimes jump-start healing in a chronic or non-healing wound when nothing else is working, Hensley says. "The collagens need to be applied twice a day, but you teach the families how to do that. If you don’t have a compliant patient or an individual that’s caring for them, you might not even be able to use some of these products. Everything kind of gets weighed when you’re trying to decide what to use."
• Vacuum-assisted closure (VAC). In this procedure, a sponge is inserted into the wound, connected through tubing to low-level, continuous suction through a portable suction machine. "This actually will increase the amount of red blood cells that are feeding the wound, speed up the healing process," Hensley says. "What I’ve learned is that it works really well on wounds that have tunnels, steep tracks that take forever to heal. If you’ve got a lot of wound drainage you can’t control with any other type of dressing — the family tells you they’re changing dressings three times a day, it’s draining everywhere, and you’re having nurses going in more frequently — those are reasons we might try the VAC."
That high-tech relief comes with a high price tag — Hensley estimates that it costs about $3,500 a month to operate the VAC. But the dressing only needs to be changed twice a week.
"Think about an insurance company that is paying for 14 nursing visits a week, and the wound isn’t healing," she says. "If we go down to two a week, even though the treatment is much more expensive, if you cost out the visit, the cost of the nurse, $100 a visit, that’s $200 a day. The VAC is still cheaper. Plus, it will help the wound to heal faster. There’s nothing more expensive than a wound that won’t heal."
Such intensive efforts are discontinued if they don’t make a significant impact on the wound in up to two weeks, Hensley says. Knowing that, insurance companies have been agreeable to paying for the pricier options, if it results in reduced visits. "That’s exactly what they’re interested in: How can we heal the wound, prevent infection, prevent complications, and have as few nursing visits as possible? Those are everybody’s goals."
Fortunately, doctors have become more knowledgeable in recent years about the benefits of newer dressings and are more willing to order them. "Some of the physicians will say, It doesn’t matter what I order. One of your nurses is going to call me to change the order,’" Hensley says with a laugh.
Even with the use of more advanced dressings and wound treatments, Hensley stresses that every wound is different, and the same products won’t work for every patient. When evaluating a patient with a wound, nurses should look at a number of other factors, such as nutrition, since bodies need calories and protein to promote healing; resources, including caretakers and the money or insurance coverage to afford the dressings; and the cleanliness and safety of the home.