In the current healthcare environment, wound care practitioners need to capitalize on all available reimbursement avenues for care delivery and wound care supplies and dressings. And when it comes to reimbursement, there’s one constant: The rules change constantly. Whether these changes always benefit the patient is questionable. Nowhere is this more evident than in acute-care settings. Clinicians constantly are challenged to make sure their patient-care decisions comply with current Medicare reimbursement guidelines. (And if you’re not sure about today’s guidelines, be prepared for the guidelines to change tomorrow.) (more…)
Necrotizing fasciitis (NF) results from an infection that attacks the fascia and subcutaneous tissues. The primary bacterial etiology is group A streptococcus, a facultative anaerobic bacterium. However, other bacteria may contribute. Sometimes called the “flesh-eating” disease because of the potentially devastating effect on the afflicted patient, NF can be monomicrobial or polymicrobial.
The four typical settings for NF are:
surgical bowel or abdominal trauma surgery
pressure ulcer and perianal abscess
injection sites (especially in drug users)
Bartholin abscess or minor vulvovaginal infection.
Because of the rapid course and ravaging nature of acute NF, clinicians must maintain a high index of suspicion if the patient has suggestive signs and symptoms. In 1990, puppeteer Jim Henson (best known for creating the Muppets) died from NF. At that time, little was known about the progression of group A streptococcal infection.
The disease can quickly cause death, so starting immediate treatment is even more crucial than confirming the diagnosis. Once the disease is suspected, antibiotics must be given immediately and the patient must be prepared for surgery at once. NF spreads rapidly, capable of progressing from a small lesion to death in days to weeks. Thus, delayed diagnosis increases the risk of death. Lack of knowledge about the disease and inability to recognize it promptly are the main reasons many victims die. This article can improve your knowledge base.
Overview
NF was discovered in 1871 by Joseph Jones, a Confederate Army surgeon. At that time, it was called hemolytic streptococcal gangrene, nonclostridial gas gangrene, nonclostridial crepitant cellulitis, necrotizing or gangrenous erysipelas, necrotizing cellulitis, bacterial synergistic gangrene, or synergistic necrotizing cellulitis.
NF involves the fascia, muscle compartments, or both. It can affect not only the muscle fascia but the superficial fascia. NF and cellulitis differ in the amount of tissue involved and extent of tissue involvement.
The most common areas of infection are the abdominal wall, perineum, and extremities. When NF affects the perineum and scrotum, it’s called Fournier gangrene, after the French dermatologist and virologist Alfred Jean Fournier.
The most common causes are trauma, surgery, and insect bites. The disease can affect persons of any age. Such comorbidities as diabetes, chronic renal failure, immunosuppressive therapy, hypertension, obesity, and malnutrition increase susceptibility.
Pathophysiology
NF falls into four classifications based on wound microbiology. Type 1, the most common, involves polymicrobial bacteria. Type 2 results from trauma and is associated with comorbidities. Type 3, rare in this country, stems from gram-negative marine bacteria. Type 4 is a fungal infection occurring mostly in immunocompromised persons. (See Comparing types of necrotizing fasciitis by clicking the PDF icon above.)
Disease progression
The four types of NF progress in a similar way. Bacteria secrete pyrogenic exotoxin A, which stimulates cytokines. These cytokines damage the endothelial lining; fluid then leaks into the extravascular space.
M proteins in streptococci and β-hemolytic streptococci exacerbate the immune reaction by inhibiting phagocytosis of polymorphonuclear leukocytes and normal neutrophil chemotaxis. As the immune reaction increases, blood vessels dilate, allowing toxins to leak through vessel walls, which in turn decreases blood flow. As the cascade continues, hypoxic conditions cause facultative aerobic organisms to grow and become anaerobic. These bacteria exacerbate destruction of surrounding cells and lead to release of carbon dioxide, water, hydrogen, nitrogen, hydrogen sulfide, and methane. As the infection continues to progress, toxins spread throughout the bloodstream and the patient becomes septic.
Assessment
Obtain the patient’s medical history and description of the wound. Determine when the changes first appeared and whether the affected area seemed to get worse recently.
In all NF types, patients commonly present with a small, painful area (possibly with entry marks) but no other signs or symptoms. The wound may appear as a bulla, cellulitis, or dermatitis, representing an infection developing in underlying tissues. The skin may have a wooden-hard feel as the infection progresses to the subcutaneous space and causes necrosis. The wound becomes discolored and necrotic; drainage is rare until surgical debridement begins. The patient quickly develops fever, chills, nausea, and vomiting. As NF progresses, bullae become dark purple with darkened edges; the patient grows disoriented and lethargic, and organ failure and respiratory failure
ensue. Without treatment, the patient dies.
Diagnosis
Diagnostic tests usually include magnetic resonance imaging, complete blood count with differential, comprehensive metabolic panel, and cultures. (See Diagnostic findings in necrotizing fasciitis by clicking the PDF icon above.)
Treatment
Immediate surgical debridement and broad-spectrum antibiotics are needed to stop the immune response to infection. Clindamycin, gentamicin, penicillin, or metronidazole may be given alone or in combination until culture results are available. Supportive care includes total parenteral nutrition for nutritional support, I.V. fluids, and oxygen. Limb amputation should be done only as a last resort.
Surgical debridement involves penetrating deep into the fascia and removing all necrotic tissue. After the first debridement, release of “dishwater fluid” may occur.
Administering hyperbaric oxygen therapy (HBOT) after the first debridement increases tissue oxygenation, thus reducing tissue destruction by anaerobic bacteria. During HBOT (usually given as a 90-minute treatment), the patient breathes 100% oxygen in an environment of increasing atmospheric pressure.
HBOT should be given in conjunction with surgical debridement (usually after each debridement) and should continue until necrotic tissue ceases and cell destruction stops. HBOT also promotes collagen synthesis and neoangiogenesis (new blood vessel growth), which boosts blood supply and oxygen to tissues.
Adverse effects of HBOT include ear pain, oxygen toxicity, and seizures. Ear pain can be minimized by swallowing or yawning. If the patient continues to have ear pain, ear tubes may be inserted by an otolaryngologist. During HBOT, air breaks (intervals of breathing room air) are important in controlling oxygen toxicity (the main cause of seizures).
Throughout the HBOT treatment period, wound dressings must be simple. Well-moistened gauze dressings and an abdominal pad provide good support. Once necrotic destruction occurs, dressings depend on wound size and the need to fill cavities. The patient may require a diverting colostomy, depending on wound
location and the amount of uncontrolled diarrhea. Blood glucose levels must be monitored before and after HBOT, as this treatment affects blood glucose.
Supportive care and follow-up treatment
During initial treatment, patients need supportive care and monitoring. Once they’re out of danger, begin teaching them how to prevent NF recurrences. Advise them to control blood glucose levels, keeping the glycated hemoglobin (HbA1c) level to 7% or less. Caution patients to keep needles capped until use and not to reuse needles. Instruct them to clean the skin thoroughly before blood glucose testing or insulin injection, and to use alcohol pads to clean the area afterward.
Before discharge, help arrange the patient’s aftercare, including home health care for wound management and teaching, social services to promote adjustment to lifestyle changes and financial concerns, and physical therapy to help rebuild strength and promote the return to optimal physical health. One helpful patient resource is the National Necrotizing Fasciitis Foundation. The Centers for Disease Control and Prevention section on necrotizing fasciitis includes “Common sense and great wound care are the best ways to prevent a bacterial skin infection.”
The life-threatening nature of NF, scarring caused by the disease, and in some cases the need for limb amputation can alter the patient’s attitude and viewpoint, so be sure to take a holistic approach when dealing with the patient and family. Today, NF has a much better survival rate than 2 decades ago when Jim Henson died. In my practice, I’ve seen four NF cases. Thanks to early identification, good wound care, and HBOT, these patients suffered only minimal damage.
Selected references
Boyer A, Vargas F, Coste F, et al. Influence of surgical treatment timing on mortality from necrotizing soft tissue infections requiring intensive care management. Intensive Care Med. 2009;35(5):847-853. doi:10.1007/s00134-008-1373-4.
Cain S. Necrotizing fasciitis: recognition and care. Practice Nurs. 2010;21(6):297-302.
Centers for Disease Control and Prevention. Notes from the field: fatal fungal soft-tissue infections after a tornado—Joplin, Missouri, 2011. MMWR. 2011;60(29):992.
Chamber AC, Leaper DJ. Role of oxygen in wound healing: a review of evidence. J Wound Care. 2011; 20(4):160-164.
Christophoros K, Achilleas K, Vasilia D, et al. Postraumatic zygomycotic necrotizing abdominal wall fasciitis with intraabdominal invasion in a non immunosuppressed patient. Internet J Surg. 2007;11(1). doi:10.5580/17a8.
Ecker K-W, Baars A, Topfer J, Frank J. Necrotizing fasciitis of the perineum and the abdominal wall-surgical approach. Europ J Trauma Emerg Surg. 2008;
34(3):219-228. doi:10.1007/s00068-008-8072-2.
Hunter J, Quarterman C, Waseem M, Wills A. Diagnosis and management of necrotizing fasciitis. Br J Hosp Med. 2011;72(7):391-395.
Magel DC. The nurse’s role in managing necrotizing fasciitis. AORN J. 2008;88(6):977-982.
Phanzu MD, Bafende AE, Imposo BB, Meyers WM, Portaels F. Under treated necrotizing fasciitis masquerading as ulcerated edematous Mycobacterium ulcerans infection (Buruli ulcer). Am J Trop Med Hyg. 2012;82(3):478-481.
Ruth-Sahd LA, Gonzales M. Multiple dimensions of caring for a patient with acute necrotizing fasciitis. Dimens Crit Care Nurs. 2006;25(1):15-21.
Stevens DL, Bisno AL, Chambers HF, et al; Infectious Diseases Society of America. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. 2005;41(10):1373-1406.
Su YC, Chen HW, Hong YC, Chen CT, et al. Laboratory risk indicator for necrotizing fasciitis score and the outcomes. ANZ J Surg. 2008;78(11):968-972.
Taviloglu K, Yanar H. Necrotizing fasciitis: strategies for diagnosis and management. World J Emerg Surg. 2007;2:19.
Lydia Meyers is a medical reviewer for National Government Services in Castleton, Indiana, and a clinical liaison at CTI Nutrition in Indianapolis. She has 11 years of wound care experience in nursing homes, wound clinics, and home health.
Complex wound failures are costly and time-consuming. They increase length of stay and contribute to morbidity and mortality in surgical patients. Negative-pressure wound therapy (NPWT)—a common adjunct to wound-care therapy—is used to accelerate wound healing in all fields of surgery. Using a vacuum device and wound-packing material, it applies subatmospheric pressure to complex wounds.
But NPWT alone doesn’t ensure adequate wound healing. Many physiologic factors—including infection, excessive moisture, nutrition, and medications—influence wound-healing success. Failure to account for these factors or improper application of NPWT can limit patient outcomes and cause debilitating complications.
For clinicians, applying and establishing an airtight seal on a complex wound is among the most dreaded, time-consuming, and challenging NPWT-related tasks. Simply applying NPWT material under layers of transparent drape may delay wound healing or exacerbate the wound. This article provides tips on safe application of NPWT to enhance the outcomes of patients with complex wounds.
Consider wound location
Wounds on the body’s anterior surfaces are less susceptible to the forces of pressure, friction, and shear than those on posterior and lateral surfaces. Posterior and lateral wounds commonly require posterior offloading or repositioning the patient in bed to reduce or eliminate direct pressure. This can be done with judicious and frequent patient turning using a specialty bed or support surface.
Bridge a posterior or lateral wound to an anterior surface by placing the drainage collection tubing to a nonpressure-bearing surface away from the wound. Bridging keeps the tubing from exerting pressure on intact skin and decreases the risk of a pressure ulcer. To create the bridge, cut foam into a single spiral of 0.5 to 1 cm, or if using gauze, fold gauze into 8 single layers.
Place the spiraled foam or gauze layers onto the drape, ensure the bridge is wider than the collection tubing disc, and secure it with an additional drape. Next, apply the NPWT collection tubing on the end of the bridge away from the wound. A wide bridge under the collection tubing disc will minimize the potential for periwound breakdown when negative pressure is initiated. You may modify this spiraling technique by varying the width of the foam to fill undermining and wounds of irregular configuration and depth.
Protect the periwound
An intact periwound may break down from exposure to moisture, injury from repetitive removal of a transparent drape, or NPWT material coming in contact with skin. Skin protection is critical in preventing additional breakdown stemming from contact with potentially damaging material.
Transparent drapes are designed to permit transmission of moisture vapor and oxygen. Avoid using multiple layers of transparent drapes to secure dressings over intact skin, as this can decrease the transmission of moisture vapor and oxygen, which in turn may increase the risk of fungal infection, maceration, and loss of an intact seal.
Periwound maceration also may indicate increased wound exudate, requiring an increase in negative pressure. Conversely, an ecchymotic periwound may indicate excessively high negative pressures. If either occurs, assess the need to adjust negative pressure and intervene accordingly. Reassess NPWT effectiveness with subsequent dressing changes.
Apply a protective liquid skin barrier to the periwound and adjacent healthy tissue to help protect the skin surface from body fluids. The skin barrier also helps prevent stripping of fragile skin by minimizing shear forces from repetitive or forceful removal of transparent drapes. Excessive moisture can be absorbed by using a light dusting of ostomy powder sealed with a skin barrier. A “window pane” of transparent drape or hydrocolloid dressing around the wound also can protect surface tissue from contactwith NPWT material and prevent maceration.
Avoid creating rolled wound edges
In the best-case scenario, epithelial tissue at the wound edge is attached to the wound bed and migrates across healthy granulation tissue, causing the wound to contract and finally close. With deep wound environments that lack moisture or healthy granulation tissue, the wound edges may roll downward and epibole may develop. Epibole is premature closure of the wound edges, which prevents epithelialization and wound closure when it comes in contact with a deeper wound bed. (See Picturing epibole by clicking the PDF icon above.)
Materials used in NPWT are primarily air-filled. Applying negative pressure causes air removal, leading to wound contraction by pulling on the wound edges—an action called macrostrain. Without sufficient NPWT material in the wound, macrostrain can cause the wound to contract downward and the wound edges to roll.
Ensure that enough NPWT material has been applied into the wound to enhance wound-edge approximation and avoid creating a potential defect as the wound heals. Before NPWT begins, material should be raised 1 to 2 cm above the intact skin. Additional material may be needed with subsequent changes if the NPWT material compresses below the periwound. The amount of NPWT material needed to remain above the periwound once NPWT starts varies with the amount of material compressed and the wound depth.
Reduce the infection risk
To some degree, all wounds are contaminated. Usually, the body’s immunologic response is able to clear bacterial organisms and wound healing isn’t delayed. But a patient who has an infection of a complex wound needs additional support.
Systemic antibiotics alone aren’t enough because they’re selective for specific organisms and don’t reach therapeutic levels in the wound bed. In contrast, topical antimicrobial adjuncts, such as controlled-release ionic silver, provide broad-spectrum antimicrobial coverage against fungi, viruses, yeasts, and gram-negative and gram-positive bacteria, including methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci.
Consider using controlled-release ionic silver for a wound known to be infected or at risk for infection due to its location or potential urine or fecal contamination. To be bactericidal, ionic silver must be in concentrations of at least 20 parts per million; also, it must be kept moist and must come in direct contact with infected wound bed. At lower concentrations, organisms may develop resistance. Ionic silver has no known resistance or contraindications. Dressings using it come in several forms, including a hydrogel sheet, perforated sheet, cavity version, and semiliquid hydrogel. Be sure the form you choose doesn’t occlude the NPWT material and compromise therapy. (See NPWT for a patient with necrotizing fasciitis by clicking the PDF icon above.)
One of the most daunting aspects of NPWT is obtaining and maintaining a good seal—in other words, avoiding the dreaded leak. Preventive skin measures may contribute to a poor seal; skin-care products containing glycerin, surfactant, or dimethicone may prevent adequate adhesion of NPWT drapes. Body oil, sweat, and hair may need to be minimized or removed.
To avoid leaks, don’t overlook the obvious—loose connections, a loose drainage collection canister, exposed NPWT material, and skinfolds extending beyond the transparent drape. Tincture of benzoin (with or without a thin hydrocolloid dressing) increases tackiness to enhance the adhesive property of a transparent drape on the diaphoretic patient and on hard-to-drape areas, such as the perineum. But be sure to use tincture of benzoin with discretion, as it may remove fragile periwound tissue when the dressing is removed.
Ostomy paste products can serve as effective filler. These pliable products can be spread into position to obtain a secure seal under the transparent drape in hard-to-seal areas, such as the perineum. Pastes remain flexible and can be removed without residue. Temporarily increasing NPWT pressure to a higher setting may help locate a subtle leak or provide enough negative pressure to self-seal the leak. Once the leak resolves, remember to return the pressure to the ordered setting.
Knowledge optimizes healing
It’s important to be aware of potential complications of NPWT (See Take care with NPWT by clicking on the PDF icon above). However, when applied correctly, NPWT is an effective option for managing complex wounds. Recognizing and managing potential complications at the wound site, ensuring periwound protection, minimizing epibole formation, and preventing wound infection can result in a better-prepared wound bed and promote optimal healing.
Selected references
Baranoski S, Ayello EA. (2012). Wound Care Essentials: Practice Principles. 3rd ed. Springhouse, PA; Lippincott Williams & Wilkins.
Bovill E, Banwell PE, Teot L, et al. Topical negative pressure wound therapy: a review of its role and guidelines for its use in the management of acute wounds. Int Wound J. 2008;5:511-529.
Sussman C, Bates-Jensen B. Wound Care: A Collaborative Practice Manual for Health Professionals. 4th ed. Baltimore, MD; Lippincott Williams & Wilkins; 2011.
Ronald Rock is an Adult Health Clinical Nurse Specialist in the Digestive Disease Institute at the Cleveland Clinic in Cleveland, Ohio.
Jim, a 52-year-old patient with colon cancer, received a new ostomy. He needed a custom fit for his appliance, which took 10 days. During this time, trying to obtain a good seal and treat the peristomal area wasn’t easy. Despite my best efforts, Jim’s skin was denuded from contact with stool. Although he was in great discomfort, he wanted to wait until my next visit to tell me about the problem. Fortunately, his wife was worried and contacted me directly.
Jim lives in a neighborhood with a low crime rate, so I’m able to see him within a few hours of his wife’s call, even though it’s late at night. As it turns out, I make extra visits to help him manage his stoma until the customized appliance is ready.As with any home care situation, I’m ready to do my best for my patient.
Many home-care patients like Jim benefit from the interventions of a wound care clinician (WCC). More than one-third of all home-care admissions are wound related, and home wound care has become one of the fastest growing needs and skills in home-care services. So if you’re a WCC, you may want to consider home care as a practice option.
Delivering wound care in the home differs dramatically from delivering it in the hospital. Given the complexity of wound care and the multiple factors that affect healing, home wound care is a challenge. Some patients have chronic conditions, such as diabetes or wounds or open sores that don’t heal easily. In other cases, the patient or caregiver is unable to change dressings. That’s where the WCC comes in.
Special needs of home-care patients
Like other patients across the continuum of care, home-care wound patients require accurate and thorough wound assessment, as well as documentation that provides information about wound status and aids development of a plan that supports healing.
Of course, the plan of care must address the whole patient, not just the “hole” in the patient. The WCC must take into account comorbidities, individual wound-care requirements, assistance the patient may need due to physical or mental deficits, and nutritional support. Additional factors that affect wound-care strategies include wound characteristics, family support, and insurance guidelines and reimbursement.
Role of the WCC
The WCC’s role in home care includes providing clinical expertise, working with other healthcare team members, and providing education.
The WCC provides clinical expertise regarding wound and ostomy care to ensure delivery of the highest quality of care. This expertise helps reduce the need for readmissions to the emergency department (ED) for wound-related complications. The WCC also plays a vital role in product awareness, formu-lary development, and maintenance of cost-effective, evidence-based practice in the agency.
Working with other healthcare team members, the WCC serves as patient advocate, strengthening the relationship between patient and healthcare team members while promoting care coordination to help the patient achieve goals. Effective communication with the patient’s primary care provider is essential to delivering the best-quality, research-based wound care. A tool for strengthening such communication is the SBAR (Situation-Background-Assessment-Recommendation) technique. SBAR structures conversations so all parties provide complete yet concise information. (See SBAR wound and skin provider communication record by clicking the PDF icon above).
The WCC educates patients and family members about wound healing, dressing applications, and other interventions. Teaching families allows them to be involved in the patient’s care and start to take ownership of it. The WCC also educates home health aides, who can play a vital role in preventing such problems as pressure ulcers and may be responsible for ensuring staff members are aware of the products, procedures, and dressings available.
Challenges of home care
If you’re a WCC and considering home care as a career option, know that practicing in the home can be a real eye opener. For starters, consider geography. Shortly after I started as a wound care nurse/consultant in home care, I was visiting patients all over New Jersey, some days driving 200 miles. As I quickly discovered, once you enter the home, don’t assume you’ll simply change a dressing and then be on your way. Instead, you may find you are, in essence, the family case manager who’s expected to “fix everything.” This role requires equal doses of planning and creativity.
What’s more, expect to do some improvising. In acute-care settings, all the supplies you may need to prevent infection—gowns, gloves, masks—usually are within arm’s reach. But in home care, these supplies may be absent, meaning you’ll need to set up the cleanest environment you can under the circumstances. That might mean using disposable drapes and dressings. Be sure to carry large amounts of hand sanitizer.
Dressing selection is perhaps the biggest challenge in home wound care because
it involves not just wound-specific issues but financial and practical considerations. The ideal dressing in the home is one that needs to be changed only every other day, at most. Evidence shows it’s not practical to try to change dressings two or three times daily at home unless the family is providing care.
Develop a checklist
Because the home environment may lack all the resources you need, remembering everything you need to do before you leave the patient’s home may be challenging. To help keep things on track, develop a checklist of reminders that covers these points:
Have necessary medical appointments been arranged? Does the patient have transportation to appointments?
Are there sufficient supplies in the home?
Is there enough medicine? If not, who will pick up the medicine?
Are consults needed, such as social worker or physical therapist?
Who will help with any activities of daily living that the patient is unable to do?
Does the patient with diabetes have a glucometer?
Hours and safety concerns
Typical home wound-care hours are 8:30 a.m. to 4:30 p.m. But realistically, expect variations. For instance, as you’re about to leave, the patient might say, “My wife isn’t feeling well. Could you take her blood pressure?” This means you’ll stay a little longer.
When planning home visits, be aware of safety concerns. If visiting after hours could put you in danger, it’s safer to instruct the patient to call an ambulance and go to the local ED.
Reimbursement
Reimbursement is an important factor in wound care in the home. To be eligible for home care through Medicare, patients must be homebound—meaning they don’t routinely travel to run errands or visit or they’re not able to obtain or receive needed medical services. (With private insurance and workers’ compensation, eligibility requirements may be less restrictive.)
Know that a Medicare patient receives home care as an “episode.” Episodes are 60-day periods; within each 60-day episode, a $592 cap is allotted should a patient require supplies for wound or ostomy care needs. Except for negative-pressure wound therapy, a home care agency can’t bill Medicare for products used; instead, the home-care agency is responsible for the cost of all topical wound-care products and dressings. Agencies may keep patients on service even if they exceed the allowed amount, although patients reaching maximum benefits commonly are discharged from service. Home-care agencies have no choice but to discharge Medicare patients they find aren’t truly homebound.
Also, be aware that Medicare views home health service as an interim service. When a patient is no longer making progress, Medicare expects that the family will provide the patient’s care or the patient will enter a skilled care facility. So it’s important to work hard to obtain good outcomes—not just for the patient but to maintain Medicare reimbursement. Like many private insurance companies, Medicare reimbursement is based on pay for performance; if an agency doesn’t deliver optimal outcomes, it receives lower reimbursement, increasing its financial burden.
A worthwhile option
WCCs use their knowledge and clinical expertise to improve patient outcomes and teach patients, families, and other healthcare team members. They also give the agency recommendations for care and supplies that are evidence based and reflect current best practices in wound care. Accomplishing these goals in a timely fashion under various constraints can be challenging. But if you choose to work in the home, try to keep a smile on your face and joy in your voice for each patient and family. If you like challenges and want a job where you can apply your creativity and function independently, becoming a home-care WCC might be the right choice for you.
Connie Johnson provides wound care in the home and in acute-care settings.
Venous leg ulcers are the most common cause of lower extremity ulcers, affecting 1% of the U.S. population (approximately 3 million people). Annual treatment costs for venous disease in this country range from $1.9 to $3.5 billion.
The gold standard for venous ulcer treatment includes moist wound healing and compression therapy. But before compression wraps are applied, we must determine if adequate arterial blood flow exists—or consequences could be life-threatening.
Raise your hand if you know what ABI is. Now raise your hand if you routinely obtain ABIs for patients. I’ve been asking these questions at wound care seminars around the country for the last 10 years, and the answers are always the same:
Between 50% and 95% of the audience know what an ABI is, but only 1% to 2% say they perform the ABI test. My next question is “Why not?”
The ABI (ankle brachial index) is a noninvasive screening test performed with a handheld vascular Doppler and a blood pressure cuff. This simple test helps determine if you can safely apply compression therapy, aids diagnosis of peripheral arterial disease, and even helps monitor the efficacy of therapeutic interventions.
Numerous standard practice guidelines from various organizations recommend obtaining ABIs to determine arterial blood flow. These organizations include the American College of Cardiology, American Heart Association, American Diabetes Association, Society for Vascular Nursing, Wound Ostomy Continence Nurses, Society for Vascular Medicine, U.S. Preventive Services Task Force, and World Union of Wound Healing Societies.
Instructions for most compression therapy products include indications for Doppler ABI readings above 0.8. So if you don’t get an ABI reading, how can you safely apply these products? A report by Allie and colleagues found that more than 50% of lower extremity amputations occur without previous vascular testing of any type, including ABI.
So why aren’t more practitioners obtaining ABIs? The leading answer: “We don’t have a Doppler.” I understand the dilemma of not having equipment or the funds to get the equipment. But do we want to tell a patient who has just lost her leg, “Oh, sorry. We didn’t have a Doppler”?
It’s our responsibility and duty as WCCs, wound care experts, and health care clinicians to ensure we provide the highest standard of care for patients with venous leg ulcers. So communicate with management, explaining what you need and why you need it. Work with your medical supply company for an extended payment plan. Hold a fundraiser. Consider using the alternative Lanarkshire Oximetry Index procedure. Or send the patient to a wound clinic or other healthcare provider who can perform the test.
It’s time to step it up and take greater accountability—and to no longer use the excuse “We don’t have a Doppler.”
Donna Sardina, RN, MHA, WCC, CWCMS, DWC Editor-in-Chief Wound Care Advisor
Cofounder, Wound Care Education Institute
Plainfield, Illinois
Selected references
Allie DE, Hebert CJ, Lirtzman MD, et al. Critical limb ischemia: a global epidemic. A critical analysis of current treatment unmasks the clinical and economic costs of CLI. EuroIntervention. 2005; 1(1):75-84. http://www.ncbi.nlm.nih.gov/pubmed/
19758881. Accessed June 4, 2012.
Lazarus GS, Cooper DM, Knighton DR, et al. Definitions and guidelines for assessment of wounds and evaluation of healing. Arch Dermatol. 1994; 130(4):489-493. http://www.ncbi.nlm.nih.gov/pubmed/8166487. Accessed June 4, 2012.
Olin JW, Allie DE, Belkin M, et al. ACCF/AHA/ACR/SCAI/SIR/SVM/SVN/SVS 2010 performance measures for adults with peripheral artery disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures, the American College of Radiology, the Society for Cardiac Angiography and Interventions, the Society for Interventional Radiology, the Society for Vascular Medicine, the Society for Vascular Nursing, and the Society for Vascular Surgery (Writing Committee to Develop Performance Measures for Peripheral Artery Disease). J Am Coll Cardiol. 2010;56(25):2147-2181. http://content.onlinejacc
.org/cgi/content/full/j.jacc.2010.08.606. Accessed June 4, 2012.
O’Meara S, Al-Kurdi D, Ologun Y, Ovington LG. Antibiotics and antiseptics for venous leg ulcers. Cochrane Database Syst Rev. 2010;(1):CD003557. http://www.ncbi.nlm.nih.gov/pubmed/20091548. Accessed June 4, 2012.
Rooke TW, Hirsch AT, Misra S, et al; Society for Cardiovascular Angiography and Interventions; Society of Interventional Radiology; Society for Vascular Medicine; Society for Vascular Surgery. 2011 ACCF/AHA focused update of the guideline for the management of patients with peripheral artery disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2011;58(19):2020-2045. http://
content.onlinejacc.org/cgi/content/full/j.jacc.2011.08.023v1. Accessed June 4, 2012.
Valencia IC, Falabella A, Kirsner RS, Eaglstein WH. Chronic venous insufficiency and venous leg ulceration. J Am Acad Dermatol. 2001;44(3):401-421. http://www.ncbi.nlm.nih.gov/pubmed/11209109. Accessed June 4, 2012.
World Union of Wound Healing Societies. Principles of best practice:. Compression in venous leg ulcers: a consensus document. London: MEP Ltd; 2008. www.woundsinternational.com/pdf/content_25.pdf. Accessed June 4, 2012.
This chart (please click the PDF icon to download) explains the differences among ischemic, neuropathic, and neuroischemic diabetic foot ulcers, making it easier for you to select the best treatment for your patient.
The alarm clock goes off too early, and you jump-start the day with a cup of coffee and a short stack of reasons why you hate your job. Sound familiar? Although you can’t expect to love every aspect of your job, you should expect to get some degree of fulfillment from your career. If you don’t, maybe your job isn’t the problem. Maybe you just need a little career resuscitation to turn things around. First, let’s be clear. I’m not urging you to stay in a job that exposes you to unsafe conditions, a toxic environment, or a toxic boss. Call the code and get out, because emotional and physical well-being comes first. However, know that blaming our jobs for our dissatisfaction may be easier than taking a closer look at the chaos in our lives. It’s even easier not to fix what’s wrong, instead consoling ourselves with the company of like-suffering people. And misery does love company.
If you can’t have the job you love, love the job you have. The daily grind of Herculean demands can wear down even the most conscientious clinicians—to the point where we’re no longer seeking job satisfaction but struggling just to make it through the day. But you can turn things around. To enhance your job satisfaction, try these sure-fire methods. (Okay, maybe they’re not sure-fire, but they’re sure worth a try.)
Know when to say no
When your life feels out of balance, any demand will feel as if it’s sucking the living daylights out of you. You’ll be tempted to blame your job, when the truth is you’re giving in to a bottomless pit called “trying to please everyone else.” Learn to say no to the things you don’t want and say yes to more of what you do want. Say no to anything that’s not a priority (making cupcakes for the second-grade class). Say yes to quality time with your family and quality time for you (that painting class you’ve always wanted to take). Key question: How would the quality of your life improve if you started to say no to demands that don’t enhance its quality, and say yes to the things you want more of?
Learn to see the big picture again
Recognize that, in ways you can’t see or perhaps even imagine, you’ve forever touched and changed the lives of the patients you’ve cared for. The ability to touch and heal another person is a gift that’s available to few people in other professions, who struggle to find meaning in what they do. Key questions: In what ways have you helped your patients? What special qualities and skills are uniquely yours to give? How can you make the most of the opportunity to make a difference in patients’ lives?
Attract the positive
When we’re miserable, other miserable people gravitate to us. Soon a collective mindset takes root and the negative “group think” becomes a life-form unto
itself, festering and insatiable. So be careful of the company you keep. Surround yourself with positive people—clinicians committed to making a difference. This will reenergize you and give you a new perspective on your job.
Learn to be what you want
To be more passionate about your job,
focus on the aspects of the job that excite you the most. Passion is an energy form that attracts more of the same. Say, for instance, you’d love to buy a red convertible. One day you go out for a drive and you see red convertibles everywhere! Have more red convertibles suddenly driven off the assembly line? No; your mind is preselecting, or noticing the convertibles, for you. In the same way, you can preselect either more passion or more misery.
Pay it forward
Keep in mind that novice clinicians proceed through a learning curve. Rather than moan about how inexperienced they are, take one under your wing and turn her or him into the sort of clinician you’d want at your bedside if you were ill. You’ll rediscover your profession through this clinician’s eyes.
Communicate cleanly and ask for what you want
People can’t read your mind. To get more of what you want and less of what you don’t want, learn to communicate in a clean, neutral way. Let’s say you consistently wind up with the more difficult patient assignments. And let’s assume your boss does that because you’re the most clinically experienced clinician—not because she’s the devil incarnate. You can respond in one of two ways.
• Gripe to a coworker: “Can you believe she gave me that workload again?”
• Communicate with your boss cleanly and neutrally: “Lately it seems you’ve given me the more difficult patient assignments, and I appreciate your faith in me. Is there some way we can give other clinicians a chance to gain more experience caring for difficult patients? I’d be happy to act as a resource for them.”
See the difference? The first response does nothing to change the situation; it simply fuels the collective misery mindset. The second response communicates to the boss in a respectful, appreciative way (yes, bosses need appreciation, too!) and seeks a solution that pleases everyone.
Take action and follow your STAR
Using the mnemonic device “STAR” can guide you toward actions that increase your job satisfaction.
Success on your terms. We all define success differently. If you grew up in a family of college professors, chances are the healthcare field didn’t fit your family’s definition of success; your job dissatisfaction may stem from your inner turmoil over not meeting your family’s expectations. To key into these expectations, recall the “you should” and “you ought to” messages you heard as a child.
Key question: Take a moment to think about what success in your career would look and feel like. Then complete this sentence: “I know I will be successful when I have/I am _________.”
True north as your guide. A large part of how we judge ourselves, our worth, our success, and our happiness hinges on how other people see us. But true success, true happiness, and true job satisfaction are determined from within, by your inner compass. The captain of a ship must always know where true north is, because it never changes (much like our core values). He must know the difference between true north and compass north. Unlike true north, compass north is affected by the earth’s magnetic pull. In life, compass north is the magnetic pull of “you should do this” and “you ought to do that” messages. For instance, if you’re a skilled wound care clinician but have always been particularly passionate about lymphedema, you may dislike your job. That’s because you’ve ignored your true north (inner truth) and given in to compass north (fear of walking away from those current skills, and so forth). Don’t be afraid to follow your true north.
Key question: What steps can you take right now that will move you closer to your true north?
Assess and understand who you are. Most of us can articulate what our strengths are. But that’s not enough. To get more enjoyment from your job, you must stretch and exercise your strengths and look for ways to use them. If the opportunities aren’t there, create them.
Let’s say you’re the one everyone turns to for help when there’s a patient with a lower extremity ulcer. To leverage that strength, offer to hold an education program.
Key questions: List your strengths, and then ask yourself: How can I leverage these? If you’re too humble to recognize your strengths, give yourself 20 lashes (figuratively speaking); then ask a trusted colleague, “What do you see as my strengths?”
Risk it all (within reason). When we play it safe, our lives and careers can be pretty dull. We’re meant to push the envelope and stretch our capabilities. It puts the juice back in our lives and helps us grow and feel more alive. Nothing shakes out the cobwebs and brings excitement back to your career more than taking a risk. With every risk comes the threat of failure, but know that failure is just another form of data that helps you readjust and move forward. Don’t give failure more power than your successes.
Key questions: If you weren’t afraid, what risks would you consider taking to enhance your career? What’s holding you back?
Embrace change
An Eastern saying goes something like this: You can stand by a river, but you can never put your feet in the same place twice. The river is your life. It’s not stagnant; it’s ever changing. Nothing in life stays the same—not personal circumstances, relationships, or careers. You aren’t the clinician you were 10 years ago or even last year. So tweak your professional life to better reflect the clinician you are today. With a little attention, you could make your job the career of your dreams.
Joan C. Borgatti, MEd, RN, is the owner of Borgatti Communications in Wellesley Hills, Mass., which provides writing, editing, and coaching services. You may e-mail her at [email protected].
Looking for resources related to diabetes? See below.
National Diabetes Education Program
This excellent site for patients and providers is a partnership of the National Institutes of Health, the Centers for Disease Control and Prevention (CDC), and more than 200 public and private organizations.
Sections of the site include:
I Have Diabetes
Am I at Risk?
Health Care Professionals, Businesses & Schools
Partners & Community Organizations
An important feature is the ability to create a customized search to find publications particular to an individual’s situation—age, diabetes status, ethnicity/race, and language. You can also search by topic.
The Health Care Professionals section of the website contains clinical practice tools and patient education materials to help you identify and counsel patients with prediabetes and work with patients with diabetes.
Making Systems Changes for Better Diabetes Care is a National Diabetes Education Program website that provides information, links, resources, and tools to help healthcare professionals assess needs for system changes, develop plans, implement tools for action, and evaluate the change process.
Tools include links to clinical practice recommendations, patient education materials, algorithms, and risk assessments.
One section of particular interest is Diabetes Self-Management Education, which provides a four-step patient empowerment model.
