July / August 2005
Promoting Quality Outcomes
Keeping Patients Safe and Promoting Quality Outcomes
Wound, Ostomy, and Continence Care Management
Wound, ostomy, and continence (WOC) nurses provide improved outcomes for patients needing WOC care management. They add value (improved quality, access, satisfaction, and reduced cost) by:
- Participating in best practice and interdisciplinary wound guideline development, testing, research, and implementation to advance evidence-based care (www.wocn.org).
- Diffusing evidence-based practice: Clinician tools and resource team development (Dailey, 2001 and 2005).
- Modeling interdisciplinary collaboration facilitating patient-centered, safe care (IOM, 2003b; Dailey, 2005).
- Promoting patient, caregiver, and interdisciplinary team satisfaction: Develop effective education programs and patient self-care guides.
- Improving safety: Performance improvement (PI) to prevent adverse events (e.g., avoidable pressure ulcer incidence and surgical site infection [SSI]) and reducing liability (Dailey and Newfield, 2005).
- Leading curative and palliative WOC programs.
- Consulting for complex WOC care management.
- Implementing interdisciplinary pain guidelines (e.g., Alvarez et al., 2002).
- Developing policies, procedures, and protocols.
- Participating/leading product formularies and evaluation (e.g., supplies, specialty bed/surfaces, and advanced wound modality equipment) (Dailey, M., Jasper, A. & Regan, S., 2000).
- Reducing excessive, inappropriate cost (e.g., appropriate LOS and inpatient specialty bed/mattress use and timely placement in home care).
- Partnering with other disciplines, expert nursing societies, and advocacy groups.
- Advocating for public policy (e.g., reimbursement and safety standards).
WOC nurses contribute to organizations achieving strategic quality, satisfaction, and cost goals. Leadership roles include: PI, telehealth, research, disease management (DM), and other roles to improve outcomes at the population level. They also focus on crucial patient-level outcomes. For example, in home-care agencies (HCAs), appropriate reduction in pressure ulcer risk, and management of urinary incontinence (UI) is pivotal in reducing premature/avoidable institutionalization. This dramatically impacts quality of life (QOL) and cost on an individual level for patients and families.
Serving Populations with Complex WOC Needs
There are approximately 4,000 WOC nurses in the Wound, Ostomy, and Continence Nurses Society (WOCN) who are certified via the Wound, Ostomy and Continence Certification Board (WOCNCB). They were originally known as enterostomal therapy (ET) nurses focusing on ostomy (or stoma) care. A stoma means an opening into the body. WOC nurses still provide advanced ostomy care management. Their certification and scope of practice now includes wound and incontinence care management to meet their patient populations’ needs. The BSN is a certification requirement. A growing percentage are advanced practice nurses. They may focus on one, two, or all three areas in their scope of practice to meet patient population and organizational needs. WOCNCB individual certification is an option for each of the three WOC areas (e.g., wound certification for skin care resource team members). WOCN is in preliminary discussions to become multidisciplinary (subject to membership approval if proposed).
Increased Demand for WOC Nurses
Multiple forces are impacting increased demand for WOC nurses across practice settings:
- Reimbursement (e.g., prospective payment system).
- Market and regulatory/accrediting body standard changes (e.g., magnet status).
- Changing demographics (growing chronically ill and frail elderly populations).
- Rising in-patient acuity level related to increased frail, “old old” (> 80 is the fastest growing population), and chronically ill (living longer into their disease trajectory) populations.
- Increased outcomes transparency and consumerism reflecting need for WOC. For example, in Home Care Outcomes reported by the Centers for Medicare & Medicaid Services (CMS) across all 50 states, the most prevalent “weakest” average benchmarked outcomes are for wound and incontinence care (CMS, 2005).
- Increased focus on benchmarking and reduction of healthcare acquired infections (HAI) across practice settings. (e.g., urinary tract infections and SSIs are responsible for 50% of hospital infections, [CDC, 2005]).
- New roles and options for revenue streams involving WOC nurses (e.g. outpatient settings).
Increased demand has resulted in additional WOC nurse capacity in most organizations. Exponential growth in demand is predicted, perhaps resulting in a “perfect storm,” with concurrent increased population and reduced nursing workforce capacity. In past decades it was rare to see these nurses in HCAs, but now it is common for some of the following reasons:
- Hospitals and nursing homes are discharging patients “quicker and sicker.”
- HCAs are admitting patients who need complex care management directly from the community (no prior hospitalization).
- Care is increasingly complex in HCA populations: complex co-morbidities and advanced symptom/palliative care needs.
Safe WOC Staffing Capacity
A formula based on population and acuity needs to be developed and tested regarding a safe staffing of “expert” nurses as well as “generalist” nurses. This research is similar to nursing-sensitive outcomes research and standards regarding inpatient nursing staffing levels (Aiken, et al., 2003; Kovener, 2000; Needleman & Buerhaus, 2003; NQF, 2004; and Stanton & Rutherford, 2004). This research would inform organizations regarding appropriate WOC staffing and enhance their reputation for quality, safety, and customer satisfaction. These decisions are more important during an environment of demographic changes and increased outcomes scrutiny in the public domain (e.g., CMS Hospital, Nursing Home and Home Care Compare, etc.). The level of expertise that nurses have makes a difference (Benner, 1984). In one HCA, the director of the Center of Excellence developed population-based thresholds for each advanced-practice nursing specialty including WOC nurses (Dailey, 2005b). Upstream PI was possible due to appropriate WOC staffing (e.g., implementation of a continuum-of-care protocol led by WOC professionals resulted in aggregate pressure ulcer incidence reduction).
Wound Prevention and Care Management
The estimated cost related to wounds in the U.S. is $20 billion (Ablaza & Fisher, 1998). Chronic complex wounds that don’t heal in an expected trajectory (e.g., pressure ulcers or some classes/types of complex leg ulcers) can last for extended lengths of time. They can require multiple acute-care inpatient stays, emergent care, surgeries, exorbitant dressings, and labor costs (e.g., nursing and family care giving time, etc.). Wounds can lead to serious morbidity such as amputation or loss of life (e.g., related to sepsis).
Wounds addressed by WOC professionals fall into the following categories: surgical, pressure, leg ulcers (arterial, venous, arterial/venous mix, neuropathic etc.); dermatological or immune-related (e.g., vasculitis); and less common “catastrophic” types (e.g., fistula or severe parastomal around the stoma, cancer, etc.). Complex and catastrophic wounds are costly and can lead to severe morbidity or even mortality if not managed appropriately and in a timely fashion.
WOC nurses direct acute/chronic wound programs and address identified safety issues, (e.g., pressure ulcer prevention [NQF, 2003; WOCN, 2004] and SSI [HAI, 2005]). They provide consults for complex cases (Dailey, 2003); and manage projects such as pressure ulcer incidence reduction or more realistically, reducing upward trend with changing demographics, increased risk and end-of-life care, telehealth and evidence-based population/DM focus programs.
Telehealth innovation (real time and store and forward) has improved WOC efficiency (capacity to consult) and increased the demand for consultation. Outcomes include improved wound categorization and use of evidence-based care protocols, healing rates and times, QOL and reduced cost, and adverse events in PI projects, case studies and research (Bolton, et al., 2004; Kaufman, 2000). Upon looking at before-and-after photos from one HCA, the physician director of a CMS-funded telehealth project noted, “These photos speak volumes about the power of WOC nurse telehealth consultations to improve outcomes.” This patient was 5’7″ and weighed 77 lbs. when referred with a gastrocutaneous fistula that required more than 400 dressings per week. Consultation resulted in interdisciplinary collaboration and appropriate medical interventions (hyperalimentation changes and corrective surgery) and wound healing.
Ostomy Care Management
Improved outcomes occur when WOC nurses are involved in preoperative stoma marking (essential for QOL and self-care independence) and ostomy care (Bass, et al., 1997; Hearn & Dailey, 2000; and Marquis, Marrel, & Jambon, 2003). Often an ostomy is related to chronic illness (e.g., inflammatory bowel disease (IBD), cancer, diverticulitis or multiple sclerosis, etc.) or functional loss (e.g., post spinal cord injury). Complex management includes primary diagnosis and co-morbidities as well as the new ostomy. These nurses develop protocols and educate novice and experienced staff to provide competent ostomy teaching and care.
Populations with an ostomy are not prevalent, but the potential for physical and emotional harm as well as excessive cost is great. Two prominent patients with complex chronic illnesses requiring an ostomy have written about their devastating experiences (Cohen, 2001; Donabedian, 2001). They had to negotiate their own care, safety issues related to a lack of pre/postoperative ostomy care, and access to a WOC nurse. These nurses problem-solve uncommon complications (e.g., stomal prolapse or parastomal hernia) that can be frightening, even devastating, to patients without appropriate care management (e.g., avoidable surgeries occur). Necessary, complex, expensive surgeries can have poor outcomes without competent pre- and postoperative ostomy care and teaching (e.g., devastating loss of bowel for a patient with IBD).
Self-care and caregiver educational materials are developed for each ostomy (e.g., colostomy, ileostomy, urostomy) or “continent” versus “incontinent” (meaning an external pouch must be worn). Inpatient LOS reductions has reduced teaching time. Safe care includes appropriate discharge planning and education continuity to ensure patient/caregiver satisfaction. It is crucial that an ostomate and his or her parent understand the signs and symptoms of complications and timely actions to prevent avoidable adverse events upon inpatient and home care discharge. Safe transition information must include which education goals have been met and what if any further teaching is needed. Left unaddressed, minor complications can impact QOL (e.g., impact of “leaking pouch” causing embarrassment or skin discomfort), and may become more serious and complex, involving morbidity and mortality (e.g., intestinal obstruction or unaddressed “pouchitis” [reservoir] in a “continent diversion” that could jeopardize the pouch). The importance of access to an inpatient facility and HCA that has adequate WOC staffing is clear for an ostomate.
Whether it is temporary or permanent, or occurs in acute, chronic, or terminal illness, body image change occurs with an ostomy. Risk for isolation and depression increases. WOC nurses are skilled and knowledgeable in QOL and psychosocial issues such as sexuality. Patients and caregivers are guided in appropriate therapeutic clinical and psychosocial interventions. Most patients successfully negotiate their body image and any functional changes (e.g., loss of bladder and/or bowel control). Patients with baseline depression may be at serious risk, and behavioral referrals are made appropriately.
The National Institute of Health (NIH) has identified inequitable access to cancer care (prevention and timely care) in underserved populations. Development of evidence-based interdisciplinary protocols and staff education promotes the IOM six “aims of care:” safe, effective, timely, patient-centered, efficient, and equitable (IOM, 2003a).
Urinary incontinence (UI) is prevalent, increases with age, and is costly. An estimated 3.4 million males suffer from UI, costing $18.8 billion (Stothers, Thom, & Calhoun, 2005). For females, much prevalence and cost data for all age groups is missing for many reasons. But we do know that the rate among female soldiers is 31%, (Davis et al., 1999), and the cost is increasing. The 1998 cost was $234.4 million tracked for female Medicare beneficiaries ages 65 or older (Thom, Nygaard, & Calhoun, 2005).ÝFecal incontinence (FI) is less prevalent, but can be costly and complex to manage. Both FI and UI can be acute (transient), chronic, and devastating. Trauma, such as childbirth, can precipitate FI and UI. Both impact QOL and are risk factors for pressure ulcers, premature/avoidable institutionalization, rehospitalization, falls and other adverse events. WOC nurses provide:
- UI and FI assessment, evidence-based skin and continence care, management/therapies and collection strategies.
- Expert consultation regarding short- and long-term medical and surgical management options and specialist referrals to maximize outcomes (e.g., QOL), testing (urodynamics or anal manometry) and counseling to ensure patient-centered surgical options, etc.
- Evidence-based tube management (e.g., foley, cystotube, nephrostomy and external catheters) and strategies to reduce costly UTIs.
WOC nurses have sometimes been called “master plumbers.” While humorous, this term doesn’t do justice to the expert knowledge, care, and impact these nurses provide in varied roles. They are adept at managing the most complex clinical problems and projects. Access to these nurses facilitates the best interdisciplinary care across geographic disparities and practice settings to reduce care inequity and avoidable adverse events. Interdisciplinary guidelines, best practice sheets, and other essential materials are available at: www.wocn.org.
Maureen Dailey (firstname.lastname@example.org) has 25 years experience in home care and disease management (DM). She has directed the planning, piloting, and implementation of multiple DM and wound care programs. Dailey is the current president of the Metro NY Affiliate of the Wound, Ostomy, and Continence Nursing Society (WOCN) Northeast region (www.nerwocn.org). She is a founding member of the Disease Management Association of America’s Quality and Research Committee’s Safety Workgroup and has lead successful performance improvement initiatives to improve evidence-based practice and care outcomes. Dailey is the vice president of clinical operations at Vista Chronic Care Solutions, providing innovative solutions for rare complex diseases.
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